hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|WV,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Mon Health Medical Center,2024-09-11,2.0.0,Mon Health Medical Center,"1200 J D Anderson Dr Morgantown, WV 26505",35,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|ACPN|COMMERCIAL|negotiated_dollar,standard_charge|ACPN|COMMERCIAL|negotiated_percentage,standard_charge|ACPN|COMMERCIAL|negotiated_algorithm,estimated_amount|ACPN|COMMERCIAL,standard_charge|ACPN|COMMERCIAL|methodology,additional_payer_notes|ACPN|COMMERCIAL,standard_charge|ACPN_MEDICARE_ADVANTAGE|MEDICARE|negotiated_dollar,standard_charge|ACPN_MEDICARE_ADVANTAGE|MEDICARE|negotiated_percentage,standard_charge|ACPN_MEDICARE_ADVANTAGE|MEDICARE|negotiated_algorithm,estimated_amount|ACPN_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|ACPN_MEDICARE_ADVANTAGE|MEDICARE|methodology,additional_payer_notes|ACPN_MEDICARE_ADVANTAGE|MEDICARE,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|AETNA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|AETNA_MEDICARE|MEDICARE,standard_charge|AETNA_MEDICARE|MEDICARE|methodology,additional_payer_notes|AETNA_MEDICARE|MEDICARE,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|GATEWAY_HEALTH|MEDICAID|negotiated_dollar,standard_charge|GATEWAY_HEALTH|MEDICAID|negotiated_percentage,standard_charge|GATEWAY_HEALTH|MEDICAID|negotiated_algorithm,estimated_amount|GATEWAY_HEALTH|MEDICAID,standard_charge|GATEWAY_HEALTH|MEDICAID|methodology,additional_payer_notes|GATEWAY_HEALTH|MEDICAID,standard_charge|GEHA|COMMERCIAL|negotiated_dollar,standard_charge|GEHA|COMMERCIAL|negotiated_percentage,standard_charge|GEHA|COMMERCIAL|negotiated_algorithm,estimated_amount|GEHA|COMMERCIAL,standard_charge|GEHA|COMMERCIAL|methodology,additional_payer_notes|GEHA|COMMERCIAL,standard_charge|GEHA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|GEHA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|GEHA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|GEHA_MEDICARE|MEDICARE,standard_charge|GEHA_MEDICARE|MEDICARE|methodology,additional_payer_notes|GEHA_MEDICARE|MEDICARE,standard_charge|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL|negotiated_dollar,standard_charge|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL|negotiated_percentage,standard_charge|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL|negotiated_algorithm,estimated_amount|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL,standard_charge|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL|methodology,additional_payer_notes|HEALTH_PAYORS_ORGANIZATION|COMMERCIAL,standard_charge|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE|negotiated_dollar,standard_charge|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE|negotiated_percentage,standard_charge|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE|negotiated_algorithm,estimated_amount|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE,standard_charge|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE|methodology,additional_payer_notes|HEALTH_SOUTH_MOUNTAIN_VIEW|MEDICARE,standard_charge|HIGHMARK_BCBS_ACA|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_BCBS_ACA|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_BCBS_ACA|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_BCBS_ACA|MEDICARE,standard_charge|HIGHMARK_BCBS_ACA|MEDICARE|methodology,additional_payer_notes|HIGHMARK_BCBS_ACA|MEDICARE,standard_charge|HIGHMARK_BCBS_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_BCBS_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_BCBS_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_BCBS_MEDICARE|MEDICARE,standard_charge|HIGHMARK_BCBS_MEDICARE|MEDICARE|methodology,additional_payer_notes|HIGHMARK_BCBS_MEDICARE|MEDICARE,standard_charge|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE,standard_charge|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE|methodology,additional_payer_notes|HIGHMARK_BCBS_PPO_POS_FEP|MEDICARE,standard_charge|HIGHMARK_BCBS_TRADITIONAL|MEDICARE|negotiated_dollar,standard_charge|HIGHMARK_BCBS_TRADITIONAL|MEDICARE|negotiated_percentage,standard_charge|HIGHMARK_BCBS_TRADITIONAL|MEDICARE|negotiated_algorithm,estimated_amount|HIGHMARK_BCBS_TRADITIONAL|MEDICARE,standard_charge|HIGHMARK_BCBS_TRADITIONAL|MEDICARE|methodology,additional_payer_notes|HIGHMARK_BCBS_TRADITIONAL|MEDICARE,standard_charge|HUMANA|COMMERCIAL|negotiated_dollar,standard_charge|HUMANA|COMMERCIAL|negotiated_percentage,standard_charge|HUMANA|COMMERCIAL|negotiated_algorithm,estimated_amount|HUMANA|COMMERCIAL,standard_charge|HUMANA|COMMERCIAL|methodology,additional_payer_notes|HUMANA|COMMERCIAL,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|HUMANA_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA_MEDICARE|MEDICARE,standard_charge|HUMANA_MEDICARE|MEDICARE|methodology,additional_payer_notes|HUMANA_MEDICARE|MEDICARE,standard_charge|MARYLAND_PHYSICIANS_CARE|COMMERCIAL|negotiated_dollar,standard_charge|MARYLAND_PHYSICIANS_CARE|COMMERCIAL|negotiated_percentage,standard_charge|MARYLAND_PHYSICIANS_CARE|COMMERCIAL|negotiated_algorithm,estimated_amount|MARYLAND_PHYSICIANS_CARE|COMMERCIAL,standard_charge|MARYLAND_PHYSICIANS_CARE|COMMERCIAL|methodology,additional_payer_notes|MARYLAND_PHYSICIANS_CARE|COMMERCIAL,standard_charge|MON_COUNTY_COMMISSION|COMMERCIAL|negotiated_dollar,standard_charge|MON_COUNTY_COMMISSION|COMMERCIAL|negotiated_percentage,standard_charge|MON_COUNTY_COMMISSION|COMMERCIAL|negotiated_algorithm,estimated_amount|MON_COUNTY_COMMISSION|COMMERCIAL,standard_charge|MON_COUNTY_COMMISSION|COMMERCIAL|methodology,additional_payer_notes|MON_COUNTY_COMMISSION|COMMERCIAL,standard_charge|MULTIPLAN_PHCS|COMMERCIAL|negotiated_dollar,standard_charge|MULTIPLAN_PHCS|COMMERCIAL|negotiated_percentage,standard_charge|MULTIPLAN_PHCS|COMMERCIAL|negotiated_algorithm,estimated_amount|MULTIPLAN_PHCS|COMMERCIAL,standard_charge|MULTIPLAN_PHCS|COMMERCIAL|methodology,additional_payer_notes|MULTIPLAN_PHCS|COMMERCIAL,standard_charge|MUTUAL_OF_OMAHA|COMMERCIAL|negotiated_dollar,standard_charge|MUTUAL_OF_OMAHA|COMMERCIAL|negotiated_percentage,standard_charge|MUTUAL_OF_OMAHA|COMMERCIAL|negotiated_algorithm,estimated_amount|MUTUAL_OF_OMAHA|COMMERCIAL,standard_charge|MUTUAL_OF_OMAHA|COMMERCIAL|methodology,additional_payer_notes|MUTUAL_OF_OMAHA|COMMERCIAL,standard_charge|PARAMOUNT_ELITE|MEDICARE|negotiated_dollar,standard_charge|PARAMOUNT_ELITE|MEDICARE|negotiated_percentage,standard_charge|PARAMOUNT_ELITE|MEDICARE|negotiated_algorithm,estimated_amount|PARAMOUNT_ELITE|MEDICARE,standard_charge|PARAMOUNT_ELITE|MEDICARE|methodology,additional_payer_notes|PARAMOUNT_ELITE|MEDICARE,standard_charge|SEVEN_CORNERS|MEDICARE|negotiated_dollar,standard_charge|SEVEN_CORNERS|MEDICARE|negotiated_percentage,standard_charge|SEVEN_CORNERS|MEDICARE|negotiated_algorithm,estimated_amount|SEVEN_CORNERS|MEDICARE,standard_charge|SEVEN_CORNERS|MEDICARE|methodology,additional_payer_notes|SEVEN_CORNERS|MEDICARE,standard_charge|THE_HEALTH_PLAN|COMMERCIAL|negotiated_dollar,standard_charge|THE_HEALTH_PLAN|COMMERCIAL|negotiated_percentage,standard_charge|THE_HEALTH_PLAN|COMMERCIAL|negotiated_algorithm,estimated_amount|THE_HEALTH_PLAN|COMMERCIAL,standard_charge|THE_HEALTH_PLAN|COMMERCIAL|methodology,additional_payer_notes|THE_HEALTH_PLAN|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL|negotiated_dollar,standard_charge|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL|negotiated_percentage,standard_charge|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL|negotiated_algorithm,estimated_amount|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL|methodology,additional_payer_notes|THE_HEALTH_PLAN_MURRAY_ENERGY_COMMERCIAL_ASO|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_PEIA|COMMERCIAL|negotiated_dollar,standard_charge|THE_HEALTH_PLAN_PEIA|COMMERCIAL|negotiated_percentage,standard_charge|THE_HEALTH_PLAN_PEIA|COMMERCIAL|negotiated_algorithm,estimated_amount|THE_HEALTH_PLAN_PEIA|COMMERCIAL,standard_charge|THE_HEALTH_PLAN_PEIA|COMMERCIAL|methodology,additional_payer_notes|THE_HEALTH_PLAN_PEIA|COMMERCIAL,standard_charge|THREE_RIVERS|COMMERCIAL|negotiated_dollar,standard_charge|THREE_RIVERS|COMMERCIAL|negotiated_percentage,standard_charge|THREE_RIVERS|COMMERCIAL|negotiated_algorithm,estimated_amount|THREE_RIVERS|COMMERCIAL,standard_charge|THREE_RIVERS|COMMERCIAL|methodology,additional_payer_notes|THREE_RIVERS|COMMERCIAL,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|UHC_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|UHC_MEDICARE|MEDICARE,standard_charge|UHC_MEDICARE|MEDICARE|methodology,additional_payer_notes|UHC_MEDICARE|MEDICARE,standard_charge|UHC_ONENET_PPO|MEDICARE|negotiated_dollar,standard_charge|UHC_ONENET_PPO|MEDICARE|negotiated_percentage,standard_charge|UHC_ONENET_PPO|MEDICARE|negotiated_algorithm,estimated_amount|UHC_ONENET_PPO|MEDICARE,standard_charge|UHC_ONENET_PPO|MEDICARE|methodology,additional_payer_notes|UHC_ONENET_PPO|MEDICARE,standard_charge|UHC_OPTIONS_PPO|MEDICARE|negotiated_dollar,standard_charge|UHC_OPTIONS_PPO|MEDICARE|negotiated_percentage,standard_charge|UHC_OPTIONS_PPO|MEDICARE|negotiated_algorithm,estimated_amount|UHC_OPTIONS_PPO|MEDICARE,standard_charge|UHC_OPTIONS_PPO|MEDICARE|methodology,additional_payer_notes|UHC_OPTIONS_PPO|MEDICARE,standard_charge|UHC_VA|MEDICARE|negotiated_dollar,standard_charge|UHC_VA|MEDICARE|negotiated_percentage,standard_charge|UHC_VA|MEDICARE|negotiated_algorithm,estimated_amount|UHC_VA|MEDICARE,standard_charge|UHC_VA|MEDICARE|methodology,additional_payer_notes|UHC_VA|MEDICARE,standard_charge|UMWA|MEDICARE|negotiated_dollar,standard_charge|UMWA|MEDICARE|negotiated_percentage,standard_charge|UMWA|MEDICARE|negotiated_algorithm,estimated_amount|UMWA|MEDICARE,standard_charge|UMWA|MEDICARE|methodology,additional_payer_notes|UMWA|MEDICARE,standard_charge|UNISON|MEDICAID|negotiated_dollar,standard_charge|UNISON|MEDICAID|negotiated_percentage,standard_charge|UNISON|MEDICAID|negotiated_algorithm,estimated_amount|UNISON|MEDICAID,standard_charge|UNISON|MEDICAID|methodology,additional_payer_notes|UNISON|MEDICAID,standard_charge|UPMC|COMMERCIAL|negotiated_dollar,standard_charge|UPMC|COMMERCIAL|negotiated_percentage,standard_charge|UPMC|COMMERCIAL|negotiated_algorithm,estimated_amount|UPMC|COMMERCIAL,standard_charge|UPMC|COMMERCIAL|methodology,additional_payer_notes|UPMC|COMMERCIAL,standard_charge|UPMC_MEDICARE|MEDICARE|negotiated_dollar,standard_charge|UPMC_MEDICARE|MEDICARE|negotiated_percentage,standard_charge|UPMC_MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|UPMC_MEDICARE|MEDICARE,standard_charge|UPMC_MEDICARE|MEDICARE|methodology,additional_payer_notes|UPMC_MEDICARE|MEDICARE,standard_charge|ZELIS_GROUP_OTHER|MEDICARE|negotiated_dollar,standard_charge|ZELIS_GROUP_OTHER|MEDICARE|negotiated_percentage,standard_charge|ZELIS_GROUP_OTHER|MEDICARE|negotiated_algorithm,estimated_amount|ZELIS_GROUP_OTHER|MEDICARE,standard_charge|ZELIS_GROUP_OTHER|MEDICARE|methodology,additional_payer_notes|ZELIS_GROUP_OTHER|MEDICARE,standard_charge|ZELIS_OTHER|MEDICARE|negotiated_dollar,standard_charge|ZELIS_OTHER|MEDICARE|negotiated_percentage,standard_charge|ZELIS_OTHER|MEDICARE|negotiated_algorithm,estimated_amount|ZELIS_OTHER|MEDICARE,standard_charge|ZELIS_OTHER|MEDICARE|methodology,additional_payer_notes|ZELIS_OTHER|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
10004 - PF Fine Needle Aspiration Bx w/o Imaging Guidance Each Additional Lesion,4315547,CDM,960,RC,10004,HCPCS,Outpatient,,,89.1,44.55,,80.19,90,,,percent of total billed charges,90% of total Billed charges,92.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,65.13,155,,,Fee Schedule,155% of CMS OPPS Rate,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,65.13,155,,,Fee Schedule,155% of CMS OPPS Rate,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.72,155,,,Fee Schedule,155% of CMS OPPS Rate,142.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.52,142.72,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,510,RC,10005,HCPCS,Outpatient,,,348.93,174.47,,314.04,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,279.14,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.04,90,,,Percent of total Billed charges,90% of total billed charges,65.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,338.46,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,321.02,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.04,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,244.25,70,,,percent of total billed charges,70% of total billed charges,314.04,90,,,percent of total billed charges,90% of total billed charges,331.48,95,,,percent of total billed charges,95% of total billed charges,331.48,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.08,86,,,percent of total billed charges,86% of total billed charges,279.14,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,338.46,97,,,percent of total billed charges,97% of total billed charges,314.04,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.46,97,,,percent of total billed charges,97% of total billed charges,324.5,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,338.46,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.78,3163.8,
10005-PF FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION,4321298,CDM,981,RC,10005,HCPCS,Outpatient,,,145.6,72.80,,131.04,90,,,percent of total billed charges,90% of total Billed charges,203.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.18,155,,,Fee Schedule,155% of CMS OPPS Rate,316.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,316.18,
US add Needle Aspiration non breast,645160,CDM,320,RC,10005,HCPCS,Outpatient,,,338.88,169.44,,304.99,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,271.1,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.99,90,,,Percent of total Billed charges,90% of total billed charges,65.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,328.71,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,311.77,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,304.99,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,237.22,70,,,percent of total billed charges,70% of total billed charges,304.99,90,,,percent of total billed charges,90% of total billed charges,321.94,95,,,percent of total billed charges,95% of total billed charges,321.94,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,291.44,86,,,percent of total billed charges,86% of total billed charges,271.1,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,328.71,97,,,percent of total billed charges,97% of total billed charges,304.99,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.71,97,,,percent of total billed charges,97% of total billed charges,315.16,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.71,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.78,3163.8,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,361,RC,10006,HCPCS,Outpatient,,,156.74,78.37,,141.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,125.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,141.07,90,,,Percent of total Billed charges,90% of total billed charges,44.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,152.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,144.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,100.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,123.28,78.65,,,percent of total billed charges,78.65% of total billed charges,140.02,89.33,,,percent of total billed charges,89.33% of total billed charges,141.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.72,70,,,percent of total billed charges,70% of total billed charges,141.07,90,,,percent of total billed charges,90% of total billed charges,148.9,95,,,percent of total billed charges,95% of total billed charges,148.9,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.8,86,,,percent of total billed charges,86% of total billed charges,125.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,152.04,97,,,percent of total billed charges,97% of total billed charges,141.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,152.04,97,,,percent of total billed charges,97% of total billed charges,145.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,152.04,
US add Needle Asp non breast each add,3348377,CDM,320,RC,10006,HCPCS,Outpatient,,,154.47,77.24,,139.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,123.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,139.02,90,,,Percent of total Billed charges,90% of total billed charges,44.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,149.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,142.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,98.65,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,121.49,78.65,,,percent of total billed charges,78.65% of total billed charges,137.99,89.33,,,percent of total billed charges,89.33% of total billed charges,139.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,108.13,70,,,percent of total billed charges,70% of total billed charges,139.02,90,,,percent of total billed charges,90% of total billed charges,146.75,95,,,percent of total billed charges,95% of total billed charges,146.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.84,86,,,percent of total billed charges,86% of total billed charges,123.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,149.84,97,,,percent of total billed charges,97% of total billed charges,139.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,149.84,97,,,percent of total billed charges,97% of total billed charges,143.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,149.84,
10007- PF FNA Bx w/ Fluoro Gdn 1st Lsn,4347140,CDM,960,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,164.79,90,,,percent of total billed charges,90% of total Billed charges,270.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,135.7,155,,,Fee Schedule,155% of CMS OPPS Rate,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,135.7,155,,,Fee Schedule,155% of CMS OPPS Rate,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,419.51,155,,,Fee Schedule,155% of CMS OPPS Rate,419.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.74,419.51,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,164.79,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,146.48,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.79,90,,,Percent of total Billed charges,90% of total billed charges,84.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,177.61,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,168.45,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,164.79,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,128.17,70,,,percent of total billed charges,70% of total billed charges,164.79,90,,,percent of total billed charges,90% of total billed charges,173.95,95,,,percent of total billed charges,95% of total billed charges,173.95,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,157.47,86,,,percent of total billed charges,86% of total billed charges,146.48,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,177.61,97,,,percent of total billed charges,97% of total billed charges,164.79,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.61,97,,,percent of total billed charges,97% of total billed charges,170.28,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.61,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.74,3163.8,
DR Fluoro Fine Needle Aspiration/Bx,3348363,CDM,361,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,164.79,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,146.48,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.79,90,,,Percent of total Billed charges,90% of total billed charges,84.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,177.61,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,168.45,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,164.79,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,128.17,70,,,percent of total billed charges,70% of total billed charges,164.79,90,,,percent of total billed charges,90% of total billed charges,173.95,95,,,percent of total billed charges,95% of total billed charges,173.95,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,157.47,86,,,percent of total billed charges,86% of total billed charges,146.48,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,177.61,97,,,percent of total billed charges,97% of total billed charges,164.79,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.61,97,,,percent of total billed charges,97% of total billed charges,170.28,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.61,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.74,3163.8,
10008- PF FNA Bx w/ Fluoro Gdn Ea Addl,4347141,CDM,960,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,96.45,90,,,percent of total billed charges,90% of total Billed charges,160.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,70.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.42,155,,,Fee Schedule,155% of CMS OPPS Rate,248.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,248.42,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,96.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,85.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,96.45,90,,,Percent of total Billed charges,90% of total billed charges,55.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,98.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,68.44,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,84.29,78.65,,,percent of total billed charges,78.65% of total billed charges,95.74,89.33,,,percent of total billed charges,89.33% of total billed charges,96.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.02,70,,,percent of total billed charges,70% of total billed charges,96.45,90,,,percent of total billed charges,90% of total billed charges,101.81,95,,,percent of total billed charges,95% of total billed charges,101.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.17,86,,,percent of total billed charges,86% of total billed charges,85.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,103.95,97,,,percent of total billed charges,97% of total billed charges,96.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,103.95,97,,,percent of total billed charges,97% of total billed charges,99.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,103.95,
10009-MSA FNA BIOPSY W/ CT GD 1ST LESION,3428650,CDM,361,RC,10009,HCPCS,Outpatient,,,1045.83,522.92,,941.25,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,836.66,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,941.25,90,,,Percent of total Billed charges,90% of total billed charges,102.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1014.46,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,962.16,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,941.25,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,732.08,70,,,percent of total billed charges,70% of total billed charges,941.25,90,,,percent of total billed charges,90% of total billed charges,993.54,95,,,percent of total billed charges,95% of total billed charges,993.54,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,899.41,86,,,percent of total billed charges,86% of total billed charges,836.66,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1014.46,97,,,percent of total billed charges,97% of total billed charges,941.25,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.46,97,,,percent of total billed charges,97% of total billed charges,972.62,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1014.46,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.03,3163.8,
10010-MSA FNA BIOPSY W/ CT GD ADD LESION,3428651,CDM,361,RC,10010,HCPCS,Outpatient,,,580.65,290.33,,522.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,464.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,522.59,90,,,Percent of total Billed charges,90% of total billed charges,74.79,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,563.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,534.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,370.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,456.69,78.65,,,percent of total billed charges,78.65% of total billed charges,518.7,89.33,,,percent of total billed charges,89.33% of total billed charges,522.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,406.46,70,,,percent of total billed charges,70% of total billed charges,522.59,90,,,percent of total billed charges,90% of total billed charges,551.62,95,,,percent of total billed charges,95% of total billed charges,551.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.36,86,,,percent of total billed charges,86% of total billed charges,464.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.23,97,,,percent of total billed charges,97% of total billed charges,522.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,563.23,97,,,percent of total billed charges,97% of total billed charges,540,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,563.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.99,563.23,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,100.78,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,89.58,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.78,90,,,Percent of total Billed charges,90% of total billed charges,68.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,108.62,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,103.02,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,100.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,78.39,70,,,percent of total billed charges,70% of total billed charges,100.78,90,,,percent of total billed charges,90% of total billed charges,106.38,95,,,percent of total billed charges,95% of total billed charges,106.38,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,96.3,86,,,percent of total billed charges,86% of total billed charges,89.58,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,108.62,97,,,percent of total billed charges,97% of total billed charges,100.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.62,97,,,percent of total billed charges,97% of total billed charges,104.14,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108.62,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.24,1818.76,
10021-PF FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION,4321299,CDM,981,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,100.78,90,,,percent of total billed charges,90% of total Billed charges,150.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,65.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.2,155,,,Fee Schedule,155% of CMS OPPS Rate,233.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.31,289.68,
Read,3370903,CDM,972,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,100.78,90,,,percent of total billed charges,90% of total Billed charges,150.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,65.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.2,155,,,Fee Schedule,155% of CMS OPPS Rate,233.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.31,289.68,
Read,3370905,CDM,972,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,100.78,90,,,percent of total billed charges,90% of total Billed charges,150.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,65.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.2,155,,,Fee Schedule,155% of CMS OPPS Rate,233.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.31,289.68,
10030 I&D Abscess,3428313,CDM,983,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,246.63,90,,,percent of total billed charges,90% of total Billed charges,407.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,206.18,155,,,Fee Schedule,155% of CMS OPPS Rate,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,206.18,155,,,Fee Schedule,155% of CMS OPPS Rate,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.93,155,,,Fee Schedule,155% of CMS OPPS Rate,630.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,811.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.28,811.73,
CT Drainage Soft Tissue,3319651,CDM,350,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,246.63,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,219.22,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.63,90,,,Percent of total Billed charges,90% of total billed charges,137.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,265.81,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,252.11,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,246.63,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,191.82,70,,,percent of total billed charges,70% of total billed charges,246.63,90,,,percent of total billed charges,90% of total billed charges,260.33,95,,,percent of total billed charges,95% of total billed charges,260.33,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,235.67,86,,,percent of total billed charges,86% of total billed charges,219.22,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,265.81,97,,,percent of total billed charges,97% of total billed charges,246.63,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.81,97,,,percent of total billed charges,97% of total billed charges,254.85,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,265.81,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.28,3163.8,
Read,4181182,CDM,972,RC,10030,HCPCS,Outpatient,,,274.03,137.02,,246.63,90,,,percent of total billed charges,90% of total Billed charges,407.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,206.18,155,,,Fee Schedule,155% of CMS OPPS Rate,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,206.18,155,,,Fee Schedule,155% of CMS OPPS Rate,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.93,155,,,Fee Schedule,155% of CMS OPPS Rate,630.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,811.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.28,811.73,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,510,RC,10035,HCPCS,Outpatient,,,926.11,463.06,,833.5,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,740.89,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,833.5,90,,,Percent of total Billed charges,90% of total billed charges,77.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,898.33,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,852.02,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,833.5,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,648.28,70,,,percent of total billed charges,70% of total billed charges,833.5,90,,,percent of total billed charges,90% of total billed charges,879.8,95,,,percent of total billed charges,95% of total billed charges,879.8,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,796.45,86,,,percent of total billed charges,86% of total billed charges,740.89,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,898.33,97,,,percent of total billed charges,97% of total billed charges,833.5,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.33,97,,,percent of total billed charges,97% of total billed charges,861.28,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,898.33,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.26,3163.8,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,287.12,143.56,,258.41,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,229.7,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.41,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,278.51,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,264.15,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,258.41,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,200.98,70,,,percent of total billed charges,70% of total billed charges,258.41,90,,,percent of total billed charges,90% of total billed charges,272.76,95,,,percent of total billed charges,95% of total billed charges,272.76,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,246.92,86,,,percent of total billed charges,86% of total billed charges,229.7,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,278.51,97,,,percent of total billed charges,97% of total billed charges,258.41,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.51,97,,,percent of total billed charges,97% of total billed charges,267.02,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,278.51,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,880.35,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,166.89,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.75,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.35,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,191.92,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.75,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,146.03,70,,,percent of total billed charges,70% of total billed charges,187.75,90,,,percent of total billed charges,90% of total billed charges,198.18,95,,,percent of total billed charges,95% of total billed charges,198.18,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.4,86,,,percent of total billed charges,86% of total billed charges,166.89,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.35,97,,,percent of total billed charges,97% of total billed charges,187.75,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.35,97,,,percent of total billed charges,97% of total billed charges,194.01,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.35,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,880.34,
"10060- Incision and Drainage, Simple",3428468,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,980.65,
"10060- PF Incision and Drainage, Simple",4311917,CDM,960,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,215.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.73,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.66,155,,,Fee Schedule,155% of CMS OPPS Rate,334.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,334.66,
10060-PF INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE,4321292,CDM,981,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,215.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.73,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.66,155,,,Fee Schedule,155% of CMS OPPS Rate,334.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,334.66,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,293.3,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.97,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,355.63,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,337.3,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,329.97,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,256.64,70,,,percent of total billed charges,70% of total billed charges,329.97,90,,,percent of total billed charges,90% of total billed charges,348.3,95,,,percent of total billed charges,95% of total billed charges,348.3,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,315.3,86,,,percent of total billed charges,86% of total billed charges,293.3,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,355.63,97,,,percent of total billed charges,97% of total billed charges,329.97,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.63,97,,,percent of total billed charges,97% of total billed charges,340.97,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,355.63,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1818.76,
"10061- PF Incision and Drainage, Complex",4311918,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,378.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.66,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.85,155,,,Fee Schedule,155% of CMS OPPS Rate,586.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.5,586.85,
10061-PF INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE,4321293,CDM,981,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,378.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.66,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.85,155,,,Fee Schedule,155% of CMS OPPS Rate,586.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.5,586.85,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,187.65,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,166.8,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.65,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.25,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,191.82,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.65,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,145.95,70,,,percent of total billed charges,70% of total billed charges,187.65,90,,,percent of total billed charges,90% of total billed charges,198.08,95,,,percent of total billed charges,95% of total billed charges,198.08,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.31,86,,,percent of total billed charges,86% of total billed charges,166.8,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.25,97,,,percent of total billed charges,97% of total billed charges,187.65,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.25,97,,,percent of total billed charges,97% of total billed charges,193.91,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.25,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,3163.8,
10080-PF INCISION & DRAINAGE PILONIDAL CYST SIMPLE,4321294,CDM,981,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,187.65,90,,,percent of total billed charges,90% of total Billed charges,307.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.95,155,,,Fee Schedule,155% of CMS OPPS Rate,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.95,155,,,Fee Schedule,155% of CMS OPPS Rate,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.12,155,,,Fee Schedule,155% of CMS OPPS Rate,477.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36,477.12,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,312.74,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,277.99,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.74,90,,,Percent of total Billed charges,90% of total billed charges,123.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,337.07,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,319.69,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,312.74,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,243.24,70,,,percent of total billed charges,70% of total billed charges,312.74,90,,,percent of total billed charges,90% of total billed charges,330.12,95,,,percent of total billed charges,95% of total billed charges,330.12,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,298.84,86,,,percent of total billed charges,86% of total billed charges,277.99,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,337.07,97,,,percent of total billed charges,97% of total billed charges,312.74,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.07,97,,,percent of total billed charges,97% of total billed charges,323.17,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.07,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.5,3163.8,
10081-PF INCISION & DRAINAGE PILONIDAL CYST COMPLICATED,4321295,CDM,981,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,312.74,90,,,percent of total billed charges,90% of total Billed charges,494.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,258.14,155,,,Fee Schedule,155% of CMS OPPS Rate,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,256.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,256.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,302.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,198.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,258.14,155,,,Fee Schedule,155% of CMS OPPS Rate,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,766.51,155,,,Fee Schedule,155% of CMS OPPS Rate,766.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,524.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.5,766.51,
10120 - PF I&D Foreighn Body Subq Tiss Simple,4311464,CDM,960,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,186.73,90,,,percent of total billed charges,90% of total Billed charges,239.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,108.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.16,155,,,Fee Schedule,155% of CMS OPPS Rate,371.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,276.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,371.16,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,186.73,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,165.98,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.73,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,201.26,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,190.88,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,186.73,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,145.24,70,,,percent of total billed charges,70% of total billed charges,186.73,90,,,percent of total billed charges,90% of total billed charges,197.11,95,,,percent of total billed charges,95% of total billed charges,197.11,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,178.43,86,,,percent of total billed charges,86% of total billed charges,165.98,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,201.26,97,,,percent of total billed charges,97% of total billed charges,186.73,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.26,97,,,percent of total billed charges,97% of total billed charges,192.96,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.26,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,1818.76,
10120-PF INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE,4321296,CDM,981,RC,10120,HCPCS,Outpatient,,,207.48,103.74,,186.73,90,,,percent of total billed charges,90% of total Billed charges,239.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,108.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.16,155,,,Fee Schedule,155% of CMS OPPS Rate,371.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,276.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,371.16,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,332.68,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,295.71,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.68,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,340.07,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.68,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,258.75,70,,,percent of total billed charges,70% of total billed charges,332.68,90,,,percent of total billed charges,90% of total billed charges,351.16,95,,,percent of total billed charges,95% of total billed charges,351.16,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.89,86,,,percent of total billed charges,86% of total billed charges,295.71,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.55,97,,,percent of total billed charges,97% of total billed charges,332.68,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.55,97,,,percent of total billed charges,97% of total billed charges,343.77,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,7310.49,
10121-PF INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL,4321297,CDM,981,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,332.68,90,,,percent of total billed charges,90% of total Billed charges,429.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.33,155,,,Fee Schedule,155% of CMS OPPS Rate,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,277.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,277.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,214.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.33,155,,,Fee Schedule,155% of CMS OPPS Rate,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.42,155,,,Fee Schedule,155% of CMS OPPS Rate,666.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,539.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,666.42,
10140 - PF Incision and Drainage Hematoma Seroma/Fluid Collection,4333236,CDM,960,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,273.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.62,155,,,Fee Schedule,155% of CMS OPPS Rate,423.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,319.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,423.62,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.06,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,164.93,70,,,percent of total billed charges,70% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.63,86,,,percent of total billed charges,86% of total billed charges,188.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.55,97,,,percent of total billed charges,97% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.55,97,,,percent of total billed charges,97% of total billed charges,219.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7310.49,
10140-Defibrillation Hematoma Evacuation,3431745,CDM,360,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.06,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,164.93,70,,,percent of total billed charges,70% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.63,86,,,percent of total billed charges,86% of total billed charges,188.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.55,97,,,percent of total billed charges,97% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.55,97,,,percent of total billed charges,97% of total billed charges,219.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7310.49,
10140-Pacemaker Hematoma Evacuation,3431746,CDM,481,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.06,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,164.93,70,,,percent of total billed charges,70% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.63,86,,,percent of total billed charges,86% of total billed charges,188.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.55,97,,,percent of total billed charges,97% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.55,97,,,percent of total billed charges,97% of total billed charges,219.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7310.49,
10140-PF I&D HEMATOMA SEROMA/FLUID COLLECTION,4321301,CDM,981,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,273.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.62,155,,,Fee Schedule,155% of CMS OPPS Rate,423.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,319.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,423.62,
Defibrillation Hematoma Evacuation,3427152,CDM,960,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,273.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.62,155,,,Fee Schedule,155% of CMS OPPS Rate,423.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,319.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,423.62,
Nail Bed Hematoma Evacuation,3428487,CDM,761,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.06,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,164.93,70,,,percent of total billed charges,70% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.63,86,,,percent of total billed charges,86% of total billed charges,188.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.55,97,,,percent of total billed charges,97% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.55,97,,,percent of total billed charges,97% of total billed charges,219.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7310.49,
Pacemaker Hematoma Evacuation,,,761,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.06,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.55,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,216.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,164.93,70,,,percent of total billed charges,70% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,223.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.63,86,,,percent of total billed charges,86% of total billed charges,188.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.55,97,,,percent of total billed charges,97% of total billed charges,212.06,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.55,97,,,percent of total billed charges,97% of total billed charges,219.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.55,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7310.49,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,172.2,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,153.06,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.2,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.59,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,176.02,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.2,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,133.93,70,,,percent of total billed charges,70% of total billed charges,172.2,90,,,percent of total billed charges,90% of total billed charges,181.76,95,,,percent of total billed charges,95% of total billed charges,181.76,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.54,86,,,percent of total billed charges,86% of total billed charges,153.06,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.59,97,,,percent of total billed charges,97% of total billed charges,172.2,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.59,97,,,percent of total billed charges,97% of total billed charges,177.94,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.59,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,1818.76,
10160-PF PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST,4321303,CDM,981,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,172.2,90,,,percent of total billed charges,90% of total Billed charges,214,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.7,155,,,Fee Schedule,155% of CMS OPPS Rate,331.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,255.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24,331.7,
CT add Perc Aspiration or abscess,645108,CDM,360,RC,10160,HCPCS,Outpatient,,,323.12,161.56,,290.81,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,258.5,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.81,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.43,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,297.27,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,290.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,226.18,70,,,percent of total billed charges,70% of total billed charges,290.81,90,,,percent of total billed charges,90% of total billed charges,306.96,95,,,percent of total billed charges,95% of total billed charges,306.96,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,277.88,86,,,percent of total billed charges,86% of total billed charges,258.5,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,313.43,97,,,percent of total billed charges,97% of total billed charges,290.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.43,97,,,percent of total billed charges,97% of total billed charges,300.5,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.43,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,1818.76,
Read,4181226,CDM,972,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,172.2,90,,,percent of total billed charges,90% of total Billed charges,214,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.7,155,,,Fee Schedule,155% of CMS OPPS Rate,331.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,255.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24,331.7,
10180 - PF I&D Comple PO Wound Infection,4311465,CDM,960,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,424.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.29,155,,,Fee Schedule,155% of CMS OPPS Rate,658.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,483.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.41,658.29,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,288.98,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.11,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,350.39,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,332.33,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,325.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,252.86,70,,,percent of total billed charges,70% of total billed charges,325.11,90,,,percent of total billed charges,90% of total billed charges,343.17,95,,,percent of total billed charges,95% of total billed charges,343.17,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,310.66,86,,,percent of total billed charges,86% of total billed charges,288.98,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,350.39,97,,,percent of total billed charges,97% of total billed charges,325.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.39,97,,,percent of total billed charges,97% of total billed charges,335.94,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,350.39,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,12593.67,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,288.98,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.11,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,350.39,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,332.33,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,325.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,252.86,70,,,percent of total billed charges,70% of total billed charges,325.11,90,,,percent of total billed charges,90% of total billed charges,343.17,95,,,percent of total billed charges,95% of total billed charges,343.17,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,310.66,86,,,percent of total billed charges,86% of total billed charges,288.98,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,350.39,97,,,percent of total billed charges,97% of total billed charges,325.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.39,97,,,percent of total billed charges,97% of total billed charges,335.94,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,350.39,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,12593.67,
10180-PF 10140-PF INCISION & DRAINAGE COMPLEX PO WOUND INFECTION,4321305,CDM,981,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,424.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.29,155,,,Fee Schedule,155% of CMS OPPS Rate,658.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,483.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.41,658.29,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,50.81,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,45.17,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.81,90,,,Percent of total Billed charges,90% of total billed charges,32.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,54.77,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,51.94,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,50.81,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,39.52,70,,,percent of total billed charges,70% of total billed charges,50.81,90,,,percent of total billed charges,90% of total billed charges,53.64,95,,,percent of total billed charges,95% of total billed charges,53.64,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,48.56,86,,,percent of total billed charges,86% of total billed charges,45.17,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,54.77,97,,,percent of total billed charges,97% of total billed charges,50.81,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.77,97,,,percent of total billed charges,97% of total billed charges,52.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,54.77,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.3,2832.2,
11000-PF DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF,4321307,CDM,981,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,50.81,90,,,percent of total billed charges,90% of total Billed charges,81.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.26,90,,,Percent of total Billed charges,90% of total billed charges,29.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,41.4,155,,,Fee Schedule,155% of CMS OPPS Rate,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,41.4,155,,,Fee Schedule,155% of CMS OPPS Rate,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.5,155,,,Fee Schedule,155% of CMS OPPS Rate,126.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,126.5,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,30.19,15.10,,27.17,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.15,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.17,90,,,Percent of total Billed charges,90% of total billed charges,16.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,29.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,27.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,19.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,23.75,78.65,,,percent of total billed charges,78.65% of total billed charges,26.97,89.33,,,percent of total billed charges,89.33% of total billed charges,27.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.13,70,,,percent of total billed charges,70% of total billed charges,27.17,90,,,percent of total billed charges,90% of total billed charges,28.68,95,,,percent of total billed charges,95% of total billed charges,28.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.96,86,,,percent of total billed charges,86% of total billed charges,24.15,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.28,97,,,percent of total billed charges,97% of total billed charges,27.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.28,97,,,percent of total billed charges,97% of total billed charges,28.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,29.28,
11001-PF DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4321308,CDM,981,RC,11001,HCPCS,Outpatient,,,30.19,15.10,,27.17,90,,,percent of total billed charges,90% of total Billed charges,40.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.92,155,,,Fee Schedule,155% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,21.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,21.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,16.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,22.92,155,,,Fee Schedule,155% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.29,155,,,Fee Schedule,155% of CMS OPPS Rate,62.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.9,62.29,
11004- Debride skn/sq/musc/ext genit/peri,3431480,CDM,510,RC,11004,HCPCS,Outpatient,,,1530.74,765.37,,1377.67,90,,,percent of total billed charges,90% of total Billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1224.59,80,,,Percent of total Billed charges,80% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1377.67,90,,,Percent of total Billed charges,90% of total billed charges,480.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1484.82,97,,,Percent of total billed charges,97% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1408.28,92,,,Percent of total billed charges,92% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1377.67,90,,,percent of total billed charges,90% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1071.52,70,,,percent of total billed charges,70% of total billed charges,1377.67,90,,,percent of total billed charges,90% of total billed charges,1454.2,95,,,percent of total billed charges,95% of total billed charges,1454.2,95,,,percent of total billed charges,95% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1316.44,86,,,percent of total billed charges,86% of total billed charges,1224.59,80,,,percent of total billed charges,80% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1484.82,97,,,percent of total billed charges,97% of total billed charges,1377.67,90,,,percent of total billed charges,90% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1484.82,97,,,percent of total billed charges,97% of total billed charges,1423.59,93,,,percent of total billed charges,93% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,437.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1484.82,97,,,percent of total billed charges,97% of total billed charges,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1530.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,437.26,1530.74,
11004-PF DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR,4321300,CDM,981,RC,11004,HCPCS,Outpatient,,,1179.14,589.57,,1061.23,90,,,percent of total billed charges,90% of total Billed charges,1144.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,881.8,155,,,Fee Schedule,155% of CMS OPPS Rate,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,568.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,869.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,899.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,899.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,464.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1061.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,743.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,881.8,155,,,Fee Schedule,155% of CMS OPPS Rate,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1773.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1773.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,602.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1182.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.26,1773.98,
11005- Debride skn/sq/musc/abd wall,3431481,CDM,510,RC,11005,HCPCS,Outpatient,,,2101.66,1050.83,,1891.49,90,,,percent of total billed charges,90% of total Billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1681.33,80,,,Percent of total Billed charges,80% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1891.49,90,,,Percent of total Billed charges,90% of total billed charges,654.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2038.61,97,,,Percent of total billed charges,97% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.53,92,,,Percent of total billed charges,92% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1891.49,90,,,percent of total billed charges,90% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1471.16,70,,,percent of total billed charges,70% of total billed charges,1891.49,90,,,percent of total billed charges,90% of total billed charges,1996.58,95,,,percent of total billed charges,95% of total billed charges,1996.58,95,,,percent of total billed charges,95% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1807.43,86,,,percent of total billed charges,86% of total billed charges,1681.33,80,,,percent of total billed charges,80% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2038.61,97,,,percent of total billed charges,97% of total billed charges,1891.49,90,,,percent of total billed charges,90% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2038.61,97,,,percent of total billed charges,97% of total billed charges,1954.54,93,,,percent of total billed charges,93% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,594.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2038.61,97,,,percent of total billed charges,97% of total billed charges,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,594.74,2101.66,
11006 - Dbrdmnt skn subq T/M/F necro infct gent/abdl,4241823,CDM,983,RC,11006,HCPCS,Outpatient,,,1491.21,745.61,,1342.09,90,,,percent of total billed charges,90% of total Billed charges,1414.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,548.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1090.25,155,,,Fee Schedule,155% of CMS OPPS Rate,703.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,703.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1067.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1067.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1107.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1107.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,566.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1406.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1306.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,929.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1090.25,155,,,Fee Schedule,155% of CMS OPPS Rate,703.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,2192.49,155,,,Fee Schedule,155% of CMS OPPS Rate,2192.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,703.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,867.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,703.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1445.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1445.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,548.28,2192.49,
11008 - PF Remove Prosth Matrl Abdl Wall for Infection,4311466,CDM,960,RC,11008,HCPCS,Outpatient,,,654.65,327.33,,589.19,90,,,percent of total billed charges,90% of total Billed charges,554.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,222.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,427.34,155,,,Fee Schedule,155% of CMS OPPS Rate,275.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,275.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,416.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,433.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,433.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,221.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,511.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,374.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,427.34,155,,,Fee Schedule,155% of CMS OPPS Rate,275.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.61,155,,,Fee Schedule,155% of CMS OPPS Rate,859.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,275.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,309,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,275.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,561,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,561,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221.87,859.61,
11008- Rmv prosth mat/mesh/abd wall/infec,3431482,CDM,510,RC,11008,HCPCS,Outpatient,,,741.69,370.85,,667.52,90,,,percent of total billed charges,90% of total Billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,593.35,80,,,Percent of total Billed charges,80% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,667.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,719.44,97,,,Percent of total billed charges,97% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,682.35,92,,,Percent of total billed charges,92% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,667.52,90,,,percent of total billed charges,90% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.18,70,,,percent of total billed charges,70% of total billed charges,667.52,90,,,percent of total billed charges,90% of total billed charges,704.61,95,,,percent of total billed charges,95% of total billed charges,704.61,95,,,percent of total billed charges,95% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,637.85,86,,,percent of total billed charges,86% of total billed charges,593.35,80,,,percent of total billed charges,80% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,719.44,97,,,percent of total billed charges,97% of total billed charges,667.52,90,,,percent of total billed charges,90% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,719.44,97,,,percent of total billed charges,97% of total billed charges,689.77,93,,,percent of total billed charges,93% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,719.44,97,,,percent of total billed charges,97% of total billed charges,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,741.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.18,741.69,
11010-PFDBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS,4321309,CDM,981,RC,11010,HCPCS,Outpatient,,,539.82,269.91,,485.84,90,,,percent of total billed charges,90% of total Billed charges,702.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,250.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,418.35,155,,,Fee Schedule,155% of CMS OPPS Rate,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,269.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,414.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,416.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,416.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,491.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,418.35,155,,,Fee Schedule,155% of CMS OPPS Rate,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1089.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,398.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,976.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,228.86,1089.11,
Debridement with Fracture or Dislocation,3428413,CDM,981,RC,11010,HCPCS,Outpatient,,,1150.82,575.41,,1035.74,90,,,percent of total billed charges,90% of total Billed charges,702.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,250.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,418.35,155,,,Fee Schedule,155% of CMS OPPS Rate,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,269.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,414.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,416.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,416.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,491.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,418.35,155,,,Fee Schedule,155% of CMS OPPS Rate,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1089.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,398.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,269.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,976.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,228.86,1089.11,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,610.39,305.20,,549.35,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,488.31,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,549.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.08,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,561.56,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,549.35,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,427.27,70,,,percent of total billed charges,70% of total billed charges,549.35,90,,,percent of total billed charges,90% of total billed charges,579.87,95,,,percent of total billed charges,95% of total billed charges,579.87,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,524.94,86,,,percent of total billed charges,86% of total billed charges,488.31,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,592.08,97,,,percent of total billed charges,97% of total billed charges,549.35,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.08,97,,,percent of total billed charges,97% of total billed charges,567.66,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,592.08,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,427.27,3163.8,
11011-PF DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC,4321311,CDM,981,RC,11011,HCPCS,Outpatient,,,610.39,305.20,,549.35,90,,,percent of total billed charges,90% of total Billed charges,771.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,453.64,155,,,Fee Schedule,155% of CMS OPPS Rate,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,452.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,461.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,461.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,240.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,544.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,376.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,453.64,155,,,Fee Schedule,155% of CMS OPPS Rate,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1195.7,155,,,Fee Schedule,155% of CMS OPPS Rate,1195.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,268,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,474.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1054,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,240.82,1195.7,
"11012- Debride Skin/Muscle/Bone, FX",3428666,CDM,510,RC,11012,HCPCS,Outpatient,,,1661.66,830.83,,1495.49,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.33,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1611.81,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.73,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.49,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.16,70,,,percent of total billed charges,70% of total billed charges,1495.49,90,,,percent of total billed charges,90% of total billed charges,1578.58,95,,,percent of total billed charges,95% of total billed charges,1578.58,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.03,86,,,percent of total billed charges,86% of total billed charges,1329.33,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1611.81,97,,,percent of total billed charges,97% of total billed charges,1495.49,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1611.81,97,,,percent of total billed charges,97% of total billed charges,1545.34,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1611.81,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.16,12593.67,
11012-PF DBRDMT FX&/DISLC SUBQ T/M/F BONE,4321313,CDM,981,RC,11012,HCPCS,Outpatient,,,821.06,410.53,,738.95,90,,,percent of total billed charges,90% of total Billed charges,1035.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,410.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,392.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,636.32,155,,,Fee Schedule,155% of CMS OPPS Rate,410.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,410.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,629.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,640.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,640.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,342.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,755.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,518.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,636.32,155,,,Fee Schedule,155% of CMS OPPS Rate,410.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1604.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1604.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,410.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,685.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,410.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1402.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1402.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,342.61,1604.82,
11042 - PF Deb Subq Tiss 20 sq cm/ <,4311467,CDM,960,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,110.02,90,,,percent of total billed charges,90% of total Billed charges,179.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.92,155,,,Fee Schedule,155% of CMS OPPS Rate,277.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,277.92,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,110.02,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,97.79,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.02,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,118.57,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,112.46,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,110.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,85.57,70,,,percent of total billed charges,70% of total billed charges,110.02,90,,,percent of total billed charges,90% of total billed charges,116.13,95,,,percent of total billed charges,95% of total billed charges,116.13,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,105.13,86,,,percent of total billed charges,86% of total billed charges,97.79,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,118.57,97,,,percent of total billed charges,97% of total billed charges,110.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.57,97,,,percent of total billed charges,97% of total billed charges,113.68,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,118.57,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1818.76,
11042-PF DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/<,4321315,CDM,981,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,110.02,90,,,percent of total billed charges,90% of total Billed charges,179.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.92,155,,,Fee Schedule,155% of CMS OPPS Rate,277.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,277.92,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,313,156.50,,281.7,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,250.4,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.7,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,303.61,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,287.96,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,281.7,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,219.1,70,,,percent of total billed charges,70% of total billed charges,281.7,90,,,percent of total billed charges,90% of total billed charges,297.35,95,,,percent of total billed charges,95% of total billed charges,297.35,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,269.18,86,,,percent of total billed charges,86% of total billed charges,250.4,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,303.61,97,,,percent of total billed charges,97% of total billed charges,281.7,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,303.61,97,,,percent of total billed charges,97% of total billed charges,291.09,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.61,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,2832.2,
11043-PF DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/,4321317,CDM,981,RC,11043,HCPCS,Outpatient,,,313,156.50,,281.7,90,,,percent of total billed charges,90% of total Billed charges,374.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,188.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.43,155,,,Fee Schedule,155% of CMS OPPS Rate,580.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,381.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,580.43,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,416.67,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,370.38,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.67,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,449.08,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,425.93,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,416.67,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,324.08,70,,,percent of total billed charges,70% of total billed charges,416.67,90,,,percent of total billed charges,90% of total billed charges,439.82,95,,,percent of total billed charges,95% of total billed charges,439.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,398.15,86,,,percent of total billed charges,86% of total billed charges,370.38,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,449.08,97,,,percent of total billed charges,97% of total billed charges,416.67,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.08,97,,,percent of total billed charges,97% of total billed charges,430.56,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,449.08,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,7310.49,
11044-PF DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/<,4321319,CDM,981,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,416.67,90,,,percent of total billed charges,90% of total Billed charges,523.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,412.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.32,155,,,Fee Schedule,155% of CMS OPPS Rate,811.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,811.32,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,47.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,48.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,33.39,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,41.12,78.65,,,percent of total billed charges,78.65% of total billed charges,46.7,89.33,,,percent of total billed charges,89.33% of total billed charges,47.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.6,70,,,percent of total billed charges,70% of total billed charges,47.05,90,,,percent of total billed charges,90% of total billed charges,49.67,95,,,percent of total billed charges,95% of total billed charges,49.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.96,86,,,percent of total billed charges,86% of total billed charges,41.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.71,97,,,percent of total billed charges,97% of total billed charges,47.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.71,97,,,percent of total billed charges,97% of total billed charges,48.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,50.71,
11045-PF DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM,4321302,CDM,981,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,47.05,90,,,percent of total billed charges,90% of total Billed charges,64.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.39,155,,,Fee Schedule,155% of CMS OPPS Rate,100.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.45,100.39,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,102.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,90.89,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,102.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,110.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,104.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,72.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,89.36,78.65,,,percent of total billed charges,78.65% of total billed charges,101.49,89.33,,,percent of total billed charges,89.33% of total billed charges,102.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.53,70,,,percent of total billed charges,70% of total billed charges,102.25,90,,,percent of total billed charges,90% of total billed charges,107.93,95,,,percent of total billed charges,95% of total billed charges,107.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.7,86,,,percent of total billed charges,86% of total billed charges,90.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,110.2,97,,,percent of total billed charges,97% of total billed charges,102.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,110.2,97,,,percent of total billed charges,97% of total billed charges,105.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.55,110.2,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,180.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,160.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,180.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,194.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,184.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.38,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.11,78.65,,,percent of total billed charges,78.65% of total billed charges,179.57,89.33,,,percent of total billed charges,89.33% of total billed charges,180.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,140.71,70,,,percent of total billed charges,70% of total billed charges,180.92,90,,,percent of total billed charges,90% of total billed charges,190.97,95,,,percent of total billed charges,95% of total billed charges,190.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.88,86,,,percent of total billed charges,86% of total billed charges,160.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.99,97,,,percent of total billed charges,97% of total billed charges,180.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,194.99,97,,,percent of total billed charges,97% of total billed charges,186.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,194.99,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,31.86,15.93,,28.67,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,25.49,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.67,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,30.9,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29.31,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,28.67,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22.3,70,,,percent of total billed charges,70% of total billed charges,28.67,90,,,percent of total billed charges,90% of total billed charges,30.27,95,,,percent of total billed charges,95% of total billed charges,30.27,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,27.4,86,,,percent of total billed charges,86% of total billed charges,25.49,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,30.9,97,,,percent of total billed charges,97% of total billed charges,28.67,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.9,97,,,percent of total billed charges,97% of total billed charges,29.63,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.9,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,880.35,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,44.99,22.50,,40.49,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,35.99,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.49,90,,,Percent of total Billed charges,90% of total billed charges,32.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.64,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,41.39,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.49,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,31.49,70,,,percent of total billed charges,70% of total billed charges,40.49,90,,,percent of total billed charges,90% of total billed charges,42.74,95,,,percent of total billed charges,95% of total billed charges,42.74,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.69,86,,,percent of total billed charges,86% of total billed charges,35.99,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.64,97,,,percent of total billed charges,97% of total billed charges,40.49,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.64,97,,,percent of total billed charges,97% of total billed charges,41.84,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.64,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,880.35,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,58.72,29.36,,52.85,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,46.98,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.85,90,,,Percent of total Billed charges,90% of total billed charges,42.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,56.96,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,54.02,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,52.85,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,41.1,70,,,percent of total billed charges,70% of total billed charges,52.85,90,,,percent of total billed charges,90% of total billed charges,55.78,95,,,percent of total billed charges,95% of total billed charges,55.78,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,50.5,86,,,percent of total billed charges,86% of total billed charges,46.98,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,56.96,97,,,percent of total billed charges,97% of total billed charges,52.85,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.96,97,,,percent of total billed charges,97% of total billed charges,54.61,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,56.96,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.94,880.34,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,75.62,37.81,,68.06,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,60.5,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.06,90,,,Percent of total Billed charges,90% of total billed charges,35.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,73.35,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,69.57,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,68.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,52.93,70,,,percent of total billed charges,70% of total billed charges,68.06,90,,,percent of total billed charges,90% of total billed charges,71.84,95,,,percent of total billed charges,95% of total billed charges,71.84,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,65.03,86,,,percent of total billed charges,86% of total billed charges,60.5,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,73.35,97,,,percent of total billed charges,97% of total billed charges,68.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.35,97,,,percent of total billed charges,97% of total billed charges,70.33,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.35,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.23,880.34,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,43.84,21.92,,39.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,35.07,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.46,90,,,Percent of total Billed charges,90% of total billed charges,20.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,40.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,34.48,78.65,,,percent of total billed charges,78.65% of total billed charges,39.16,89.33,,,percent of total billed charges,89.33% of total billed charges,39.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.69,70,,,percent of total billed charges,70% of total billed charges,39.46,90,,,percent of total billed charges,90% of total billed charges,41.65,95,,,percent of total billed charges,95% of total billed charges,41.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.7,86,,,percent of total billed charges,86% of total billed charges,35.07,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.52,97,,,percent of total billed charges,97% of total billed charges,39.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.52,97,,,percent of total billed charges,97% of total billed charges,40.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,42.52,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,94.4,47.20,,84.96,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,75.52,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.96,90,,,Percent of total Billed charges,90% of total billed charges,44.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,91.57,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,86.85,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.96,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,66.08,70,,,percent of total billed charges,70% of total billed charges,84.96,90,,,percent of total billed charges,90% of total billed charges,89.68,95,,,percent of total billed charges,95% of total billed charges,89.68,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81.18,86,,,percent of total billed charges,86% of total billed charges,75.52,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,91.57,97,,,percent of total billed charges,97% of total billed charges,84.96,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.57,97,,,percent of total billed charges,97% of total billed charges,87.79,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.57,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.43,1818.76,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,51.75,25.88,,46.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,46.58,90,,,Percent of total Billed charges,90% of total billed charges,24.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,50.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,47.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,33.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,40.7,78.65,,,percent of total billed charges,78.65% of total billed charges,46.23,89.33,,,percent of total billed charges,89.33% of total billed charges,46.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.23,70,,,percent of total billed charges,70% of total billed charges,46.58,90,,,percent of total billed charges,90% of total billed charges,49.16,95,,,percent of total billed charges,95% of total billed charges,49.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.51,86,,,percent of total billed charges,86% of total billed charges,41.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.2,97,,,percent of total billed charges,97% of total billed charges,46.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.2,97,,,percent of total billed charges,97% of total billed charges,48.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,50.2,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,114.16,57.08,,102.74,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,91.33,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.74,90,,,Percent of total Billed charges,90% of total billed charges,54.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,110.74,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,105.03,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,102.74,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,79.91,70,,,percent of total billed charges,70% of total billed charges,102.74,90,,,percent of total billed charges,90% of total billed charges,108.45,95,,,percent of total billed charges,95% of total billed charges,108.45,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,98.18,86,,,percent of total billed charges,86% of total billed charges,91.33,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,110.74,97,,,percent of total billed charges,97% of total billed charges,102.74,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.74,97,,,percent of total billed charges,97% of total billed charges,106.17,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.74,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.21,2832.2,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,61.9,30.95,,55.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,49.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,55.71,90,,,Percent of total Billed charges,90% of total billed charges,28.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,60.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,56.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,39.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,48.69,78.65,,,percent of total billed charges,78.65% of total billed charges,55.3,89.33,,,percent of total billed charges,89.33% of total billed charges,55.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.33,70,,,percent of total billed charges,70% of total billed charges,55.71,90,,,percent of total billed charges,90% of total billed charges,58.81,95,,,percent of total billed charges,95% of total billed charges,58.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.23,86,,,percent of total billed charges,86% of total billed charges,49.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,60.04,97,,,percent of total billed charges,97% of total billed charges,55.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,60.04,97,,,percent of total billed charges,97% of total billed charges,57.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,60.04,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,134.11,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,119.21,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.11,90,,,Percent of total Billed charges,90% of total billed charges,34.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,144.54,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,137.09,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,134.11,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,104.31,70,,,percent of total billed charges,70% of total billed charges,134.11,90,,,percent of total billed charges,90% of total billed charges,141.56,95,,,percent of total billed charges,95% of total billed charges,141.56,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,128.15,86,,,percent of total billed charges,86% of total billed charges,119.21,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,144.54,97,,,percent of total billed charges,97% of total billed charges,134.11,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.54,97,,,percent of total billed charges,97% of total billed charges,138.58,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.54,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31,880.35,
11200-PF REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15,4321320,CDM,981,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,134.11,90,,,percent of total billed charges,90% of total Billed charges,156.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.15,155,,,Fee Schedule,155% of CMS OPPS Rate,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.15,155,,,Fee Schedule,155% of CMS OPPS Rate,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.91,155,,,Fee Schedule,155% of CMS OPPS Rate,241.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31,241.91,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,32.48,16.24,,29.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.23,90,,,Percent of total Billed charges,90% of total billed charges,16.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,31.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,29.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,25.55,78.65,,,percent of total billed charges,78.65% of total billed charges,29.01,89.33,,,percent of total billed charges,89.33% of total billed charges,29.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.74,70,,,percent of total billed charges,70% of total billed charges,29.23,90,,,percent of total billed charges,90% of total billed charges,30.86,95,,,percent of total billed charges,95% of total billed charges,30.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.93,86,,,percent of total billed charges,86% of total billed charges,25.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,31.51,97,,,percent of total billed charges,97% of total billed charges,29.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31.51,97,,,percent of total billed charges,97% of total billed charges,30.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,31.51,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,68.48,34.24,,61.63,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,54.78,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.63,90,,,Percent of total Billed charges,90% of total billed charges,27.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.43,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,63,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.63,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,47.94,70,,,percent of total billed charges,70% of total billed charges,61.63,90,,,percent of total billed charges,90% of total billed charges,65.06,95,,,percent of total billed charges,95% of total billed charges,65.06,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.89,86,,,percent of total billed charges,86% of total billed charges,54.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,66.43,97,,,percent of total billed charges,97% of total billed charges,61.63,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.43,97,,,percent of total billed charges,97% of total billed charges,63.69,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.43,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25,1818.76,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,92.56,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,82.27,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.56,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,99.75,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,94.61,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,92.56,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,71.99,70,,,percent of total billed charges,70% of total billed charges,92.56,90,,,percent of total billed charges,90% of total billed charges,97.7,95,,,percent of total billed charges,95% of total billed charges,97.7,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,88.44,86,,,percent of total billed charges,86% of total billed charges,82.27,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,99.75,97,,,percent of total billed charges,97% of total billed charges,92.56,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.75,97,,,percent of total billed charges,97% of total billed charges,95.64,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.75,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,880.35,
11301-PF SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM,4321322,CDM,981,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,92.56,90,,,percent of total billed charges,90% of total Billed charges,152.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.41,155,,,Fee Schedule,155% of CMS OPPS Rate,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.41,155,,,Fee Schedule,155% of CMS OPPS Rate,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.81,155,,,Fee Schedule,155% of CMS OPPS Rate,236.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,185.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,236.81,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,119.57,59.79,,107.61,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,95.66,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.61,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,115.98,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,110,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,107.61,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,83.7,70,,,percent of total billed charges,70% of total billed charges,107.61,90,,,percent of total billed charges,90% of total billed charges,113.59,95,,,percent of total billed charges,95% of total billed charges,113.59,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.83,86,,,percent of total billed charges,86% of total billed charges,95.66,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,115.98,97,,,percent of total billed charges,97% of total billed charges,107.61,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.98,97,,,percent of total billed charges,97% of total billed charges,111.2,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.98,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,880.35,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,142.8,71.40,,128.52,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,114.24,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.52,90,,,Percent of total Billed charges,90% of total billed charges,51.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,138.52,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,131.38,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,128.52,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,99.96,70,,,percent of total billed charges,70% of total billed charges,128.52,90,,,percent of total billed charges,90% of total billed charges,135.66,95,,,percent of total billed charges,95% of total billed charges,135.66,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.81,86,,,percent of total billed charges,86% of total billed charges,114.24,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,138.52,97,,,percent of total billed charges,97% of total billed charges,128.52,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.52,97,,,percent of total billed charges,97% of total billed charges,132.8,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.52,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47,1818.76,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,76.36,38.18,,68.72,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,61.09,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.72,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.07,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,70.25,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,68.72,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,53.45,70,,,percent of total billed charges,70% of total billed charges,68.72,90,,,percent of total billed charges,90% of total billed charges,72.54,95,,,percent of total billed charges,95% of total billed charges,72.54,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,65.67,86,,,percent of total billed charges,86% of total billed charges,61.09,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.07,97,,,percent of total billed charges,97% of total billed charges,68.72,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.07,97,,,percent of total billed charges,97% of total billed charges,71.01,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.07,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,880.35,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,98.9,49.45,,89.01,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,79.12,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.01,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,95.93,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,90.99,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,89.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,69.23,70,,,percent of total billed charges,70% of total billed charges,89.01,90,,,percent of total billed charges,90% of total billed charges,93.96,95,,,percent of total billed charges,95% of total billed charges,93.96,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,85.05,86,,,percent of total billed charges,86% of total billed charges,79.12,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,95.93,97,,,percent of total billed charges,97% of total billed charges,89.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.93,97,,,percent of total billed charges,97% of total billed charges,91.98,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.93,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,880.35,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,126.12,63.06,,113.51,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,100.9,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.51,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,122.34,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,116.03,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,113.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,88.28,70,,,percent of total billed charges,70% of total billed charges,113.51,90,,,percent of total billed charges,90% of total billed charges,119.81,95,,,percent of total billed charges,95% of total billed charges,119.81,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,108.46,86,,,percent of total billed charges,86% of total billed charges,100.9,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,122.34,97,,,percent of total billed charges,97% of total billed charges,113.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.34,97,,,percent of total billed charges,97% of total billed charges,117.29,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.34,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,880.34,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,142.1,71.05,,127.89,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,113.68,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.89,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,137.84,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,130.73,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,127.89,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,99.47,70,,,percent of total billed charges,70% of total billed charges,127.89,90,,,percent of total billed charges,90% of total billed charges,135,95,,,percent of total billed charges,95% of total billed charges,135,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.21,86,,,percent of total billed charges,86% of total billed charges,113.68,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,137.84,97,,,percent of total billed charges,97% of total billed charges,127.89,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.84,97,,,percent of total billed charges,97% of total billed charges,132.15,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.84,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1818.76,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,91.39,45.70,,82.25,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,73.11,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.25,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,84.08,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,82.25,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,63.97,70,,,percent of total billed charges,70% of total billed charges,82.25,90,,,percent of total billed charges,90% of total billed charges,86.82,95,,,percent of total billed charges,95% of total billed charges,86.82,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.6,86,,,percent of total billed charges,86% of total billed charges,73.11,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.65,97,,,percent of total billed charges,97% of total billed charges,82.25,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.65,97,,,percent of total billed charges,97% of total billed charges,84.99,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,880.34,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,125.76,62.88,,113.18,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,100.61,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.18,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.99,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,115.7,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,113.18,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,88.03,70,,,percent of total billed charges,70% of total billed charges,113.18,90,,,percent of total billed charges,90% of total billed charges,119.47,95,,,percent of total billed charges,95% of total billed charges,119.47,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,108.15,86,,,percent of total billed charges,86% of total billed charges,100.61,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.99,97,,,percent of total billed charges,97% of total billed charges,113.18,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.99,97,,,percent of total billed charges,97% of total billed charges,116.96,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.99,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,880.34,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,148.68,74.34,,133.81,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,118.94,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.81,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,144.22,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,136.79,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,104.08,70,,,percent of total billed charges,70% of total billed charges,133.81,90,,,percent of total billed charges,90% of total billed charges,141.25,95,,,percent of total billed charges,95% of total billed charges,141.25,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.86,86,,,percent of total billed charges,86% of total billed charges,118.94,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,144.22,97,,,percent of total billed charges,97% of total billed charges,133.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.22,97,,,percent of total billed charges,97% of total billed charges,138.27,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.22,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1818.76,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,192.84,96.42,,173.56,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,154.27,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.56,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,187.05,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,177.41,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.56,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,134.99,70,,,percent of total billed charges,70% of total billed charges,173.56,90,,,percent of total billed charges,90% of total billed charges,183.2,95,,,percent of total billed charges,95% of total billed charges,183.2,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.84,86,,,percent of total billed charges,86% of total billed charges,154.27,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,187.05,97,,,percent of total billed charges,97% of total billed charges,173.56,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.05,97,,,percent of total billed charges,97% of total billed charges,179.34,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.05,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,1818.76,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,148.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,132.1,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.62,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.18,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,151.92,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,115.59,70,,,percent of total billed charges,70% of total billed charges,148.62,90,,,percent of total billed charges,90% of total billed charges,156.87,95,,,percent of total billed charges,95% of total billed charges,156.87,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.01,86,,,percent of total billed charges,86% of total billed charges,132.1,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.18,97,,,percent of total billed charges,97% of total billed charges,148.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.18,97,,,percent of total billed charges,97% of total billed charges,153.57,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.18,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,3163.8,
11400-PF EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/<,4321304,CDM,981,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,148.62,90,,,percent of total billed charges,90% of total Billed charges,198.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,122.54,155,,,Fee Schedule,155% of CMS OPPS Rate,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,122.54,155,,,Fee Schedule,155% of CMS OPPS Rate,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.21,155,,,Fee Schedule,155% of CMS OPPS Rate,307.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,307.21,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,208.37,104.19,,187.53,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,166.7,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.53,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.12,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,191.7,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.53,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,145.86,70,,,percent of total billed charges,70% of total billed charges,187.53,90,,,percent of total billed charges,90% of total billed charges,197.95,95,,,percent of total billed charges,95% of total billed charges,197.95,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.2,86,,,percent of total billed charges,86% of total billed charges,166.7,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.12,97,,,percent of total billed charges,97% of total billed charges,187.53,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.12,97,,,percent of total billed charges,97% of total billed charges,193.78,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.12,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1818.76,
11402 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L 1.1-2.0 cm,4311468,CDM,960,RC,11402,HCPCS,Outpatient,,,261.28,130.64,,235.15,90,,,percent of total billed charges,90% of total Billed charges,272.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,170.55,155,,,Fee Schedule,155% of CMS OPPS Rate,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,124.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,170.55,155,,,Fee Schedule,155% of CMS OPPS Rate,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,421.79,155,,,Fee Schedule,155% of CMS OPPS Rate,421.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54,421.79,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,228.94,114.47,,206.05,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,183.15,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.05,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.07,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,210.62,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,160.26,70,,,percent of total billed charges,70% of total billed charges,206.05,90,,,percent of total billed charges,90% of total billed charges,217.49,95,,,percent of total billed charges,95% of total billed charges,217.49,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,196.89,86,,,percent of total billed charges,86% of total billed charges,183.15,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.07,97,,,percent of total billed charges,97% of total billed charges,206.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.07,97,,,percent of total billed charges,97% of total billed charges,212.91,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.07,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,3163.8,
11403 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L 2.1-3.0 cm,4311469,CDM,960,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,267.24,90,,,percent of total billed charges,90% of total Billed charges,329,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,220.3,155,,,Fee Schedule,155% of CMS OPPS Rate,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,118.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,220.3,155,,,Fee Schedule,155% of CMS OPPS Rate,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,509.95,155,,,Fee Schedule,155% of CMS OPPS Rate,509.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,173.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,509.95,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,267.24,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,237.54,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.24,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,288.02,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,273.18,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,267.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.85,70,,,percent of total billed charges,70% of total billed charges,267.24,90,,,percent of total billed charges,90% of total billed charges,282.08,95,,,percent of total billed charges,95% of total billed charges,282.08,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,255.36,86,,,percent of total billed charges,86% of total billed charges,237.54,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,288.02,97,,,percent of total billed charges,97% of total billed charges,267.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.02,97,,,percent of total billed charges,97% of total billed charges,276.14,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,288.02,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,3163.8,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,329.05,164.53,,296.15,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,263.24,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,296.15,90,,,Percent of total Billed charges,90% of total billed charges,88.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,319.18,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,302.73,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,296.15,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,230.34,70,,,percent of total billed charges,70% of total billed charges,296.15,90,,,percent of total billed charges,90% of total billed charges,312.6,95,,,percent of total billed charges,95% of total billed charges,312.6,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,282.98,86,,,percent of total billed charges,86% of total billed charges,263.24,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,319.18,97,,,percent of total billed charges,97% of total billed charges,296.15,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.18,97,,,percent of total billed charges,97% of total billed charges,306.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,319.18,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.5,7310.49,
11406 - PF Exc B9 Lesion Mrgn XCP SK TG T/ A/ L >4.0 cm,4311470,CDM,960,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,453.13,90,,,percent of total billed charges,90% of total Billed charges,548.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.55,155,,,Fee Schedule,155% of CMS OPPS Rate,241,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,369.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,436.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,293.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,373.55,155,,,Fee Schedule,155% of CMS OPPS Rate,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.88,155,,,Fee Schedule,155% of CMS OPPS Rate,849.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,616.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,849.88,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,453.13,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,402.78,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.13,90,,,Percent of total Billed charges,90% of total billed charges,129.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,488.38,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,463.2,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,453.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,352.44,70,,,percent of total billed charges,70% of total billed charges,453.13,90,,,percent of total billed charges,90% of total billed charges,478.31,95,,,percent of total billed charges,95% of total billed charges,478.31,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,432.99,86,,,percent of total billed charges,86% of total billed charges,402.78,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,488.38,97,,,percent of total billed charges,97% of total billed charges,453.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.38,97,,,percent of total billed charges,97% of total billed charges,468.24,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,488.38,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.5,7310.49,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,145.39,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,129.23,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.39,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.69,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,148.62,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.39,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,113.08,70,,,percent of total billed charges,70% of total billed charges,145.39,90,,,percent of total billed charges,90% of total billed charges,153.46,95,,,percent of total billed charges,95% of total billed charges,153.46,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.92,86,,,percent of total billed charges,86% of total billed charges,129.23,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.69,97,,,percent of total billed charges,97% of total billed charges,145.39,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.69,97,,,percent of total billed charges,97% of total billed charges,150.23,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.69,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,7310.49,
11420-PF EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<,4321324,CDM,981,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,145.39,90,,,percent of total billed charges,90% of total Billed charges,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.6,155,,,Fee Schedule,155% of CMS OPPS Rate,305.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,305.6,
11420PF Exc h-f-nk-sp benign+marg 0.5/<,4267403,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,145.39,90,,,percent of total billed charges,90% of total Billed charges,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.6,155,,,Fee Schedule,155% of CMS OPPS Rate,305.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,305.6,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,194.87,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,173.22,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.87,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,210.02,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,199.2,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,194.87,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,151.56,70,,,percent of total billed charges,70% of total billed charges,194.87,90,,,percent of total billed charges,90% of total billed charges,205.69,95,,,percent of total billed charges,95% of total billed charges,205.69,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,186.21,86,,,percent of total billed charges,86% of total billed charges,173.22,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,210.02,97,,,percent of total billed charges,97% of total billed charges,194.87,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.02,97,,,percent of total billed charges,97% of total billed charges,201.36,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,210.02,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,3163.8,
11421-PF EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM,4321325,CDM,981,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,194.87,90,,,percent of total billed charges,90% of total Billed charges,255.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.16,155,,,Fee Schedule,155% of CMS OPPS Rate,396.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,310.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,396.16,
11422 - PF Exc B9 Lesion Mrgn XCP SK TG S/ N/ H/ F/ G 1.1-2.0 cm,4311471,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,241.46,90,,,percent of total billed charges,90% of total Billed charges,298.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.97,90,,,Percent of total Billed charges,90% of total billed charges,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.81,155,,,Fee Schedule,155% of CMS OPPS Rate,462.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,462.81,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,241.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,214.63,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.46,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,260.24,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,246.83,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,241.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,187.8,70,,,percent of total billed charges,70% of total billed charges,241.46,90,,,percent of total billed charges,90% of total billed charges,254.88,95,,,percent of total billed charges,95% of total billed charges,254.88,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,230.73,86,,,percent of total billed charges,86% of total billed charges,214.63,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,260.24,97,,,percent of total billed charges,97% of total billed charges,241.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.24,97,,,percent of total billed charges,97% of total billed charges,249.51,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.24,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,7310.49,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,312.19,156.10,,280.97,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,249.75,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.97,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,302.82,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,287.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,280.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,218.53,70,,,percent of total billed charges,70% of total billed charges,280.97,90,,,percent of total billed charges,90% of total billed charges,296.58,95,,,percent of total billed charges,95% of total billed charges,296.58,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,268.48,86,,,percent of total billed charges,86% of total billed charges,249.75,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,302.82,97,,,percent of total billed charges,97% of total billed charges,280.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.82,97,,,percent of total billed charges,97% of total billed charges,290.34,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,302.82,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,7310.49,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,326.3,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,290.05,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.3,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,351.68,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,333.56,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,326.3,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,253.79,70,,,percent of total billed charges,70% of total billed charges,326.3,90,,,percent of total billed charges,90% of total billed charges,344.43,95,,,percent of total billed charges,95% of total billed charges,344.43,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,311.8,86,,,percent of total billed charges,86% of total billed charges,290.05,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,351.68,97,,,percent of total billed charges,97% of total billed charges,326.3,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.68,97,,,percent of total billed charges,97% of total billed charges,337.18,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,351.68,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,7310.49,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,487.87,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,433.66,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,487.87,90,,,Percent of total Billed charges,90% of total billed charges,133.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,525.82,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,498.71,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,487.87,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,379.46,70,,,percent of total billed charges,70% of total billed charges,487.87,90,,,percent of total billed charges,90% of total billed charges,514.98,95,,,percent of total billed charges,95% of total billed charges,514.98,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,466.19,86,,,percent of total billed charges,86% of total billed charges,433.66,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,525.82,97,,,percent of total billed charges,97% of total billed charges,487.87,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.82,97,,,percent of total billed charges,97% of total billed charges,504.13,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.82,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121,12593.67,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,186.78,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,166.02,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.78,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,201.3,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,190.93,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,186.78,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,145.27,70,,,percent of total billed charges,70% of total billed charges,186.78,90,,,percent of total billed charges,90% of total billed charges,197.15,95,,,percent of total billed charges,95% of total billed charges,197.15,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,178.48,86,,,percent of total billed charges,86% of total billed charges,166.02,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,201.3,97,,,percent of total billed charges,97% of total billed charges,186.78,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.3,97,,,percent of total billed charges,97% of total billed charges,193,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.3,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,3163.8,
11440-PF EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<,4321306,CDM,981,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,186.78,90,,,percent of total billed charges,90% of total Billed charges,232.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.18,90,,,Percent of total Billed charges,90% of total billed charges,54.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.25,155,,,Fee Schedule,155% of CMS OPPS Rate,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.25,155,,,Fee Schedule,155% of CMS OPPS Rate,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.22,155,,,Fee Schedule,155% of CMS OPPS Rate,360.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,123.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.5,360.22,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,262.35,131.18,,236.12,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,209.88,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.12,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,254.48,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,241.36,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,236.12,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,183.65,70,,,percent of total billed charges,70% of total billed charges,236.12,90,,,percent of total billed charges,90% of total billed charges,249.23,95,,,percent of total billed charges,95% of total billed charges,249.23,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.62,86,,,percent of total billed charges,86% of total billed charges,209.88,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.48,97,,,percent of total billed charges,97% of total billed charges,236.12,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.48,97,,,percent of total billed charges,97% of total billed charges,243.99,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.48,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3163.8,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,290.48,145.24,,261.43,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,232.38,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.43,90,,,Percent of total Billed charges,90% of total billed charges,86.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,281.77,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,267.24,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.43,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,203.34,70,,,percent of total billed charges,70% of total billed charges,261.43,90,,,percent of total billed charges,90% of total billed charges,275.96,95,,,percent of total billed charges,95% of total billed charges,275.96,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,249.81,86,,,percent of total billed charges,86% of total billed charges,232.38,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,281.77,97,,,percent of total billed charges,97% of total billed charges,261.43,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.77,97,,,percent of total billed charges,97% of total billed charges,270.15,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,281.77,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.5,3163.8,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,356.01,178.01,,320.41,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,284.81,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.41,90,,,Percent of total Billed charges,90% of total billed charges,97.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,345.33,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,327.53,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,320.41,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,249.21,70,,,percent of total billed charges,70% of total billed charges,320.41,90,,,percent of total billed charges,90% of total billed charges,338.21,95,,,percent of total billed charges,95% of total billed charges,338.21,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,306.17,86,,,percent of total billed charges,86% of total billed charges,284.81,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,345.33,97,,,percent of total billed charges,97% of total billed charges,320.41,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.33,97,,,percent of total billed charges,97% of total billed charges,331.09,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,345.33,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89,7310.49,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,451.24,225.62,,406.12,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,360.99,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.12,90,,,Percent of total Billed charges,90% of total billed charges,128.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,437.7,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,415.14,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,406.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,315.87,70,,,percent of total billed charges,70% of total billed charges,406.12,90,,,percent of total billed charges,90% of total billed charges,428.68,95,,,percent of total billed charges,95% of total billed charges,428.68,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,388.07,86,,,percent of total billed charges,86% of total billed charges,360.99,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,437.7,97,,,percent of total billed charges,97% of total billed charges,406.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.7,97,,,percent of total billed charges,97% of total billed charges,419.65,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.7,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117,7310.49,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,638.48,319.24,,574.63,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,510.78,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.63,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,619.33,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,587.4,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,574.63,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,446.94,70,,,percent of total billed charges,70% of total billed charges,574.63,90,,,percent of total billed charges,90% of total billed charges,606.56,95,,,percent of total billed charges,95% of total billed charges,606.56,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,549.09,86,,,percent of total billed charges,86% of total billed charges,510.78,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,619.33,97,,,percent of total billed charges,97% of total billed charges,574.63,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.33,97,,,percent of total billed charges,97% of total billed charges,593.79,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,619.33,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,12593.67,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,530.15,265.08,,477.14,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,424.12,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.14,90,,,Percent of total Billed charges,90% of total billed charges,201.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,514.25,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,487.74,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,477.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,371.11,70,,,percent of total billed charges,70% of total billed charges,477.14,90,,,percent of total billed charges,90% of total billed charges,503.64,95,,,percent of total billed charges,95% of total billed charges,503.64,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,455.93,86,,,percent of total billed charges,86% of total billed charges,424.12,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,514.25,97,,,percent of total billed charges,97% of total billed charges,477.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.25,97,,,percent of total billed charges,97% of total billed charges,493.04,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,514.25,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.24,12593.67,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,673.08,336.54,,605.77,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,538.46,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.77,90,,,Percent of total Billed charges,90% of total billed charges,277.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,652.89,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,619.23,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,605.77,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,471.16,70,,,percent of total billed charges,70% of total billed charges,605.77,90,,,percent of total billed charges,90% of total billed charges,639.43,95,,,percent of total billed charges,95% of total billed charges,639.43,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,578.85,86,,,percent of total billed charges,86% of total billed charges,538.46,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,652.89,97,,,percent of total billed charges,97% of total billed charges,605.77,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,652.89,97,,,percent of total billed charges,97% of total billed charges,625.96,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,652.89,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,252.67,12593.67,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,503.35,251.68,,453.02,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,402.68,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.02,90,,,Percent of total Billed charges,90% of total billed charges,191.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,488.25,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,463.08,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,453.02,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,352.35,70,,,percent of total billed charges,70% of total billed charges,453.02,90,,,percent of total billed charges,90% of total billed charges,478.18,95,,,percent of total billed charges,95% of total billed charges,478.18,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,432.88,86,,,percent of total billed charges,86% of total billed charges,402.68,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,488.25,97,,,percent of total billed charges,97% of total billed charges,453.02,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.25,97,,,percent of total billed charges,97% of total billed charges,468.12,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,488.25,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.95,12593.67,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,674.75,337.38,,607.28,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,539.8,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.28,90,,,Percent of total Billed charges,90% of total billed charges,283.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,654.51,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,620.77,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,607.28,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,472.33,70,,,percent of total billed charges,70% of total billed charges,607.28,90,,,percent of total billed charges,90% of total billed charges,641.01,95,,,percent of total billed charges,95% of total billed charges,641.01,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,580.29,86,,,percent of total billed charges,86% of total billed charges,539.8,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,654.51,97,,,percent of total billed charges,97% of total billed charges,607.28,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.51,97,,,percent of total billed charges,97% of total billed charges,627.52,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,654.51,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,257.76,12593.67,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,580.73,290.37,,522.66,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,464.58,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.66,90,,,Percent of total Billed charges,90% of total billed charges,234.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,563.31,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,534.27,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,522.66,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,406.51,70,,,percent of total billed charges,70% of total billed charges,522.66,90,,,percent of total billed charges,90% of total billed charges,551.69,95,,,percent of total billed charges,95% of total billed charges,551.69,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,499.43,86,,,percent of total billed charges,86% of total billed charges,464.58,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,563.31,97,,,percent of total billed charges,97% of total billed charges,522.66,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.31,97,,,percent of total billed charges,97% of total billed charges,540.08,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,563.31,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.98,12593.67,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,712.09,356.05,,640.88,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,569.67,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,640.88,90,,,Percent of total Billed charges,90% of total billed charges,305.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,690.73,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,655.12,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,640.88,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,498.46,70,,,percent of total billed charges,70% of total billed charges,640.88,90,,,percent of total billed charges,90% of total billed charges,676.49,95,,,percent of total billed charges,95% of total billed charges,676.49,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,612.4,86,,,percent of total billed charges,86% of total billed charges,569.67,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,690.73,97,,,percent of total billed charges,97% of total billed charges,640.88,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,690.73,97,,,percent of total billed charges,97% of total billed charges,662.24,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,690.73,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.14,12593.67,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,243.02,121.51,,218.72,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,194.42,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.72,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,235.73,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,223.58,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,218.72,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,170.11,70,,,percent of total billed charges,70% of total billed charges,218.72,90,,,percent of total billed charges,90% of total billed charges,230.87,95,,,percent of total billed charges,95% of total billed charges,230.87,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,209,86,,,percent of total billed charges,86% of total billed charges,194.42,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,235.73,97,,,percent of total billed charges,97% of total billed charges,218.72,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.73,97,,,percent of total billed charges,97% of total billed charges,226.01,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,235.73,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,3163.8,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,294.28,147.14,,264.85,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,235.42,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.85,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,285.45,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,270.74,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,264.85,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,206,70,,,percent of total billed charges,70% of total billed charges,264.85,90,,,percent of total billed charges,90% of total billed charges,279.57,95,,,percent of total billed charges,95% of total billed charges,279.57,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,253.08,86,,,percent of total billed charges,86% of total billed charges,235.42,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,285.45,97,,,percent of total billed charges,97% of total billed charges,264.85,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.45,97,,,percent of total billed charges,97% of total billed charges,273.68,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,285.45,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,3163.8,
11602 - PF Excision MAL Lesion Trunk/ Arm/ Leg 1.1-2.0 cm,4311472,CDM,960,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,287.04,90,,,percent of total billed charges,90% of total Billed charges,383.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,238.39,155,,,Fee Schedule,155% of CMS OPPS Rate,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,175.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,238.39,155,,,Fee Schedule,155% of CMS OPPS Rate,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.36,155,,,Fee Schedule,155% of CMS OPPS Rate,594.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,214.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,493,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,493,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81,594.36,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,287.04,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,255.14,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.04,90,,,Percent of total Billed charges,90% of total billed charges,89.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,309.36,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,293.42,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,287.04,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,223.25,70,,,percent of total billed charges,70% of total billed charges,287.04,90,,,percent of total billed charges,90% of total billed charges,302.98,95,,,percent of total billed charges,95% of total billed charges,302.98,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,274.28,86,,,percent of total billed charges,86% of total billed charges,255.14,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,309.36,97,,,percent of total billed charges,97% of total billed charges,287.04,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.36,97,,,percent of total billed charges,97% of total billed charges,296.6,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,309.36,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81,1818.76,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,383.4,191.70,,345.06,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,306.72,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.06,90,,,Percent of total Billed charges,90% of total billed charges,94.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,371.9,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,352.73,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,345.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,268.38,70,,,percent of total billed charges,70% of total billed charges,345.06,90,,,percent of total billed charges,90% of total billed charges,364.23,95,,,percent of total billed charges,95% of total billed charges,364.23,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,329.72,86,,,percent of total billed charges,86% of total billed charges,306.72,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,371.9,97,,,percent of total billed charges,97% of total billed charges,345.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.9,97,,,percent of total billed charges,97% of total billed charges,356.56,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,371.9,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.5,3163.8,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,424.06,212.03,,381.65,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,339.25,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.65,90,,,Percent of total Billed charges,90% of total billed charges,138.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,411.34,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,390.14,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,381.65,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,296.84,70,,,percent of total billed charges,70% of total billed charges,381.65,90,,,percent of total billed charges,90% of total billed charges,402.86,95,,,percent of total billed charges,95% of total billed charges,402.86,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,364.69,86,,,percent of total billed charges,86% of total billed charges,339.25,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,411.34,97,,,percent of total billed charges,97% of total billed charges,381.65,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.34,97,,,percent of total billed charges,97% of total billed charges,394.38,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,411.34,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.5,3163.8,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,642.59,321.30,,578.33,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,514.07,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,578.33,90,,,Percent of total Billed charges,90% of total billed charges,270.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,623.31,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,591.18,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,578.33,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,449.81,70,,,percent of total billed charges,70% of total billed charges,578.33,90,,,percent of total billed charges,90% of total billed charges,610.46,95,,,percent of total billed charges,95% of total billed charges,610.46,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,552.63,86,,,percent of total billed charges,86% of total billed charges,514.07,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,623.31,97,,,percent of total billed charges,97% of total billed charges,578.33,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.31,97,,,percent of total billed charges,97% of total billed charges,597.61,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,246,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,623.31,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246,7310.49,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,245.22,122.61,,220.7,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,196.18,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.7,90,,,Percent of total Billed charges,90% of total billed charges,100.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,237.86,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,225.6,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.7,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,171.65,70,,,percent of total billed charges,70% of total billed charges,220.7,90,,,percent of total billed charges,90% of total billed charges,232.96,95,,,percent of total billed charges,95% of total billed charges,232.96,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,210.89,86,,,percent of total billed charges,86% of total billed charges,196.18,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,237.86,97,,,percent of total billed charges,97% of total billed charges,220.7,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.86,97,,,percent of total billed charges,97% of total billed charges,228.05,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.86,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.5,7310.49,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,295.91,147.96,,266.32,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,236.73,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.32,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,287.03,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,272.24,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,266.32,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,207.14,70,,,percent of total billed charges,70% of total billed charges,266.32,90,,,percent of total billed charges,90% of total billed charges,281.11,95,,,percent of total billed charges,95% of total billed charges,281.11,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,254.48,86,,,percent of total billed charges,86% of total billed charges,236.73,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,287.03,97,,,percent of total billed charges,97% of total billed charges,266.32,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.03,97,,,percent of total billed charges,97% of total billed charges,275.2,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,287.03,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,3163.8,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,335.96,167.98,,302.36,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,268.77,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.36,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,325.88,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,309.08,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,302.36,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,235.17,70,,,percent of total billed charges,70% of total billed charges,302.36,90,,,percent of total billed charges,90% of total billed charges,319.16,95,,,percent of total billed charges,95% of total billed charges,319.16,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,288.93,86,,,percent of total billed charges,86% of total billed charges,268.77,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,325.88,97,,,percent of total billed charges,97% of total billed charges,302.36,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.88,97,,,percent of total billed charges,97% of total billed charges,312.44,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,325.88,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,3163.8,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,416.86,208.43,,375.17,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,333.49,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.17,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,404.35,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,383.51,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,375.17,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,291.8,70,,,percent of total billed charges,70% of total billed charges,375.17,90,,,percent of total billed charges,90% of total billed charges,396.02,95,,,percent of total billed charges,95% of total billed charges,396.02,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,358.5,86,,,percent of total billed charges,86% of total billed charges,333.49,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,404.35,97,,,percent of total billed charges,97% of total billed charges,375.17,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,404.35,97,,,percent of total billed charges,97% of total billed charges,387.68,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,404.35,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,7310.49,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,477.13,238.57,,429.42,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,381.7,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.42,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,462.82,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,438.96,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,429.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,333.99,70,,,percent of total billed charges,70% of total billed charges,429.42,90,,,percent of total billed charges,90% of total billed charges,453.27,95,,,percent of total billed charges,95% of total billed charges,453.27,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,410.33,86,,,percent of total billed charges,86% of total billed charges,381.7,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,462.82,97,,,percent of total billed charges,97% of total billed charges,429.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.82,97,,,percent of total billed charges,97% of total billed charges,443.73,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,462.82,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,7310.49,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,589.34,294.67,,530.41,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,471.47,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,530.41,90,,,Percent of total Billed charges,90% of total billed charges,264,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,571.66,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,542.19,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,530.41,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,412.54,70,,,percent of total billed charges,70% of total billed charges,530.41,90,,,percent of total billed charges,90% of total billed charges,559.87,95,,,percent of total billed charges,95% of total billed charges,559.87,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,506.83,86,,,percent of total billed charges,86% of total billed charges,471.47,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,571.66,97,,,percent of total billed charges,97% of total billed charges,530.41,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,571.66,97,,,percent of total billed charges,97% of total billed charges,548.09,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,571.66,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,240,12593.67,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,250.84,125.42,,225.76,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,200.67,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.76,90,,,Percent of total Billed charges,90% of total billed charges,84.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.31,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,230.77,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225.76,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,175.59,70,,,percent of total billed charges,70% of total billed charges,225.76,90,,,percent of total billed charges,90% of total billed charges,238.3,95,,,percent of total billed charges,95% of total billed charges,238.3,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215.72,86,,,percent of total billed charges,86% of total billed charges,200.67,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,243.31,97,,,percent of total billed charges,97% of total billed charges,225.76,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.31,97,,,percent of total billed charges,97% of total billed charges,233.28,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.31,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77,3163.8,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,308.46,154.23,,277.61,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,246.77,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.61,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.21,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,283.78,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.61,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,215.92,70,,,percent of total billed charges,70% of total billed charges,277.61,90,,,percent of total billed charges,90% of total billed charges,293.04,95,,,percent of total billed charges,95% of total billed charges,293.04,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.28,86,,,percent of total billed charges,86% of total billed charges,246.77,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.21,97,,,percent of total billed charges,97% of total billed charges,277.61,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.21,97,,,percent of total billed charges,97% of total billed charges,286.87,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.21,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,3163.8,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,362.33,181.17,,326.1,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,289.86,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.1,90,,,Percent of total Billed charges,90% of total billed charges,148.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,351.46,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,333.34,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,326.1,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,253.63,70,,,percent of total billed charges,70% of total billed charges,326.1,90,,,percent of total billed charges,90% of total billed charges,344.21,95,,,percent of total billed charges,95% of total billed charges,344.21,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,311.6,86,,,percent of total billed charges,86% of total billed charges,289.86,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,351.46,97,,,percent of total billed charges,97% of total billed charges,326.1,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.46,97,,,percent of total billed charges,97% of total billed charges,336.97,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,135,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,351.46,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135,3163.8,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,454.1,227.05,,408.69,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,363.28,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.69,90,,,Percent of total Billed charges,90% of total billed charges,210.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,440.48,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,417.77,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,408.69,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,317.87,70,,,percent of total billed charges,70% of total billed charges,408.69,90,,,percent of total billed charges,90% of total billed charges,431.4,95,,,percent of total billed charges,95% of total billed charges,431.4,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,390.53,86,,,percent of total billed charges,86% of total billed charges,363.28,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,440.48,97,,,percent of total billed charges,97% of total billed charges,408.69,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.48,97,,,percent of total billed charges,97% of total billed charges,422.31,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.48,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,191.16,7310.49,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,565.09,282.55,,508.58,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,452.07,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,508.58,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,548.14,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,519.88,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,508.58,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,395.56,70,,,percent of total billed charges,70% of total billed charges,508.58,90,,,percent of total billed charges,90% of total billed charges,536.84,95,,,percent of total billed charges,95% of total billed charges,536.84,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,485.98,86,,,percent of total billed charges,86% of total billed charges,452.07,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,548.14,97,,,percent of total billed charges,97% of total billed charges,508.58,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.14,97,,,percent of total billed charges,97% of total billed charges,525.53,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,548.14,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,7310.49,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,787.05,393.53,,708.35,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,629.64,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.35,90,,,Percent of total Billed charges,90% of total billed charges,281.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,763.44,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,724.09,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,708.35,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,550.94,70,,,percent of total billed charges,70% of total billed charges,708.35,90,,,percent of total billed charges,90% of total billed charges,747.7,95,,,percent of total billed charges,95% of total billed charges,747.7,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,676.86,86,,,percent of total billed charges,86% of total billed charges,629.64,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,763.44,97,,,percent of total billed charges,97% of total billed charges,708.35,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,763.44,97,,,percent of total billed charges,97% of total billed charges,731.96,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,256,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,763.44,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,256,12593.67,
11719- Trim nondystrophic nails,3431549,CDM,510,RC,11719,HCPCS,Outpatient,,,34.92,17.46,,31.43,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,27.94,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,32.13,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,31.43,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24.44,70,,,percent of total billed charges,70% of total billed charges,31.43,90,,,percent of total billed charges,90% of total billed charges,33.17,95,,,percent of total billed charges,95% of total billed charges,33.17,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30.03,86,,,percent of total billed charges,86% of total billed charges,27.94,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33.87,97,,,percent of total billed charges,97% of total billed charges,31.43,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.87,97,,,percent of total billed charges,97% of total billed charges,32.48,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.44,280.22,
11719-PF TRIMMING NONDYSTROPHIC NAILS ANY NUMBER,4321327,CDM,981,RC,11719,HCPCS,Outpatient,,,14.72,7.36,,13.25,90,,,percent of total billed charges,90% of total Billed charges,20.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.39,155,,,Fee Schedule,155% of CMS OPPS Rate,7.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,8.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,11.39,155,,,Fee Schedule,155% of CMS OPPS Rate,7.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.73,155,,,Fee Schedule,155% of CMS OPPS Rate,31.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,7.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,44.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.85,44.2,
11720- Debride/nails/any method/1 to 5,3431550,CDM,510,RC,11720,HCPCS,Outpatient,,,81.24,40.62,,73.12,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,64.99,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.12,90,,,Percent of total Billed charges,90% of total billed charges,17.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.8,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,74.74,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.12,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,56.87,70,,,percent of total billed charges,70% of total billed charges,73.12,90,,,percent of total billed charges,90% of total billed charges,77.18,95,,,percent of total billed charges,95% of total billed charges,77.18,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.87,86,,,percent of total billed charges,86% of total billed charges,64.99,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.8,97,,,percent of total billed charges,97% of total billed charges,73.12,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.8,97,,,percent of total billed charges,97% of total billed charges,75.55,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.8,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.57,280.22,
11720-PF DEBRIDEMENT NAIL ANY METHOD 1-5,4321329,CDM,981,RC,11720,HCPCS,Outpatient,,,29.2,14.60,,26.28,90,,,percent of total billed charges,90% of total Billed charges,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.61,155,,,Fee Schedule,155% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,16.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,22.61,155,,,Fee Schedule,155% of CMS OPPS Rate,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.87,155,,,Fee Schedule,155% of CMS OPPS Rate,67.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.49,67.87,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,510,RC,11721,HCPCS,Outpatient,,,110.94,55.47,,99.85,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,88.75,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.85,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,107.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,102.06,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,99.85,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,77.66,70,,,percent of total billed charges,70% of total billed charges,99.85,90,,,percent of total billed charges,90% of total billed charges,105.39,95,,,percent of total billed charges,95% of total billed charges,105.39,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,95.41,86,,,percent of total billed charges,86% of total billed charges,88.75,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,107.61,97,,,percent of total billed charges,97% of total billed charges,99.85,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.61,97,,,percent of total billed charges,97% of total billed charges,103.17,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,280.22,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,43.52,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,38.69,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.52,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,46.91,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,44.49,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.52,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,33.85,70,,,percent of total billed charges,70% of total billed charges,43.52,90,,,percent of total billed charges,90% of total billed charges,45.94,95,,,percent of total billed charges,95% of total billed charges,45.94,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.59,86,,,percent of total billed charges,86% of total billed charges,38.69,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,46.91,97,,,percent of total billed charges,97% of total billed charges,43.52,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.91,97,,,percent of total billed charges,97% of total billed charges,44.97,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.91,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,280.22,
11721-PF DEBRIDEMENT NAIL ANY METHOD 6/>,4321330,CDM,981,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,43.52,90,,,percent of total billed charges,90% of total Billed charges,65.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.11,155,,,Fee Schedule,155% of CMS OPPS Rate,101.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,101.11,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,97.86,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,86.98,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,105.47,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,100.03,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,97.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,76.11,70,,,percent of total billed charges,70% of total billed charges,97.86,90,,,percent of total billed charges,90% of total billed charges,103.29,95,,,percent of total billed charges,95% of total billed charges,103.29,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,93.51,86,,,percent of total billed charges,86% of total billed charges,86.98,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,105.47,97,,,percent of total billed charges,97% of total billed charges,97.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.47,97,,,percent of total billed charges,97% of total billed charges,101.12,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.47,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.11,880.35,
11730-PF AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1,4321332,CDM,981,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,97.86,90,,,percent of total billed charges,90% of total Billed charges,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.95,90,,,Percent of total Billed charges,90% of total billed charges,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,249.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.75,249.16,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,31.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,27.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,31.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,31.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,22.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,27.16,78.65,,,percent of total billed charges,78.65% of total billed charges,30.85,89.33,,,percent of total billed charges,89.33% of total billed charges,31.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.17,70,,,percent of total billed charges,70% of total billed charges,31.08,90,,,percent of total billed charges,90% of total billed charges,32.8,95,,,percent of total billed charges,95% of total billed charges,32.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,86,,,percent of total billed charges,86% of total billed charges,27.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,33.49,97,,,percent of total billed charges,97% of total billed charges,31.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.49,97,,,percent of total billed charges,97% of total billed charges,32.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,33.49,
11732-PF AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL,4321333,CDM,981,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,31.08,90,,,percent of total billed charges,90% of total Billed charges,49.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,19.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.32,155,,,Fee Schedule,155% of CMS OPPS Rate,76.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,87.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.21,87.72,
11740- Evacuation of Subungual Hematoma,3431554,CDM,510,RC,11740,HCPCS,Outpatient,,,140.32,70.16,,126.29,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,112.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.29,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,136.11,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,129.09,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,126.29,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,98.22,70,,,percent of total billed charges,70% of total billed charges,126.29,90,,,percent of total billed charges,90% of total billed charges,133.3,95,,,percent of total billed charges,95% of total billed charges,133.3,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,120.68,86,,,percent of total billed charges,86% of total billed charges,112.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,136.11,97,,,percent of total billed charges,97% of total billed charges,126.29,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.11,97,,,percent of total billed charges,97% of total billed charges,130.5,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.11,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,566.05,
11740-PF EVACUATION SUBUNGUAL HEMATOM,4321334,CDM,981,RC,11740,HCPCS,Outpatient,,,59.98,29.99,,53.98,90,,,percent of total billed charges,90% of total Billed charges,82.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.48,155,,,Fee Schedule,155% of CMS OPPS Rate,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.48,155,,,Fee Schedule,155% of CMS OPPS Rate,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.26,155,,,Fee Schedule,155% of CMS OPPS Rate,128.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,95.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24,128.26,
EVAC SUBUNGUAL HEMATOMA,3428427,CDM,981,RC,11740,HCPCS,Outpatient,,,140.32,70.16,,126.29,90,,,percent of total billed charges,90% of total Billed charges,82.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.48,155,,,Fee Schedule,155% of CMS OPPS Rate,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.48,155,,,Fee Schedule,155% of CMS OPPS Rate,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.26,155,,,Fee Schedule,155% of CMS OPPS Rate,128.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,95.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24,128.26,
11750- Excise/nail/matrix/perm removal,3431555,CDM,761,RC,11750,HCPCS,Outpatient,,,400.26,200.13,,360.23,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,320.21,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388.25,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,368.24,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,360.23,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,280.18,70,,,percent of total billed charges,70% of total billed charges,360.23,90,,,percent of total billed charges,90% of total billed charges,380.25,95,,,percent of total billed charges,95% of total billed charges,380.25,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,344.22,86,,,percent of total billed charges,86% of total billed charges,320.21,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,388.25,97,,,percent of total billed charges,97% of total billed charges,360.23,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,388.25,97,,,percent of total billed charges,97% of total billed charges,372.24,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,388.25,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,280.18,1818.76,
11750-PF EXCISION NAIL MATRIX PERMANENT REMOVAL,4321336,CDM,981,RC,11750,HCPCS,Outpatient,,,192.56,96.28,,173.3,90,,,percent of total billed charges,90% of total Billed charges,246.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.23,155,,,Fee Schedule,155% of CMS OPPS Rate,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.23,155,,,Fee Schedule,155% of CMS OPPS Rate,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,382.52,155,,,Fee Schedule,155% of CMS OPPS Rate,382.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,194.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,438.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,96.28,438.6,
11755- Biopsy of nail unit,3431556,CDM,510,RC,11755,HCPCS,Outpatient,,,309.26,154.63,,278.33,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,247.41,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.33,90,,,Percent of total Billed charges,90% of total billed charges,82.79,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.98,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,284.52,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,278.33,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,216.48,70,,,percent of total billed charges,70% of total billed charges,278.33,90,,,percent of total billed charges,90% of total billed charges,293.8,95,,,percent of total billed charges,95% of total billed charges,293.8,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.96,86,,,percent of total billed charges,86% of total billed charges,247.41,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.98,97,,,percent of total billed charges,97% of total billed charges,278.33,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.98,97,,,percent of total billed charges,97% of total billed charges,287.61,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.98,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.26,3163.8,
11760- Repair of nail bed,3431557,CDM,510,RC,11760,HCPCS,Outpatient,,,472.11,236.06,,424.9,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,377.69,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.9,90,,,Percent of total Billed charges,90% of total billed charges,25.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,457.95,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,434.34,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,424.9,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,330.48,70,,,percent of total billed charges,70% of total billed charges,424.9,90,,,percent of total billed charges,90% of total billed charges,448.5,95,,,percent of total billed charges,95% of total billed charges,448.5,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,406.01,86,,,percent of total billed charges,86% of total billed charges,377.69,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.95,97,,,percent of total billed charges,97% of total billed charges,424.9,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.95,97,,,percent of total billed charges,97% of total billed charges,439.06,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,457.95,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23,2832.2,
11760-PF REPAIR NAIL BED,4321337,CDM,981,RC,11760,HCPCS,Outpatient,,,212.46,106.23,,191.21,90,,,percent of total billed charges,90% of total Billed charges,283.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.64,155,,,Fee Schedule,155% of CMS OPPS Rate,106.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,169.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,169.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,97.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,200.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,164.64,155,,,Fee Schedule,155% of CMS OPPS Rate,106.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.8,155,,,Fee Schedule,155% of CMS OPPS Rate,439.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,106.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,447.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,447.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23,447.44,
11762- Reconstruct/nail bed/graft,3431558,CDM,510,RC,11762,HCPCS,Outpatient,,,732.86,366.43,,659.57,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.57,90,,,Percent of total Billed charges,90% of total billed charges,50.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,710.87,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,674.23,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,659.57,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,513,70,,,percent of total billed charges,70% of total billed charges,659.57,90,,,percent of total billed charges,90% of total billed charges,696.22,95,,,percent of total billed charges,95% of total billed charges,696.22,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,630.26,86,,,percent of total billed charges,86% of total billed charges,586.29,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,710.87,97,,,percent of total billed charges,97% of total billed charges,659.57,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.87,97,,,percent of total billed charges,97% of total billed charges,681.56,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,710.87,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46,8413.78,
11762-PF RECONSTRUCTION NAIL BED W/GRAFT,4321338,CDM,981,RC,11762,HCPCS,Outpatient,,,359.92,179.96,,323.93,90,,,percent of total billed charges,90% of total Billed charges,455.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.92,155,,,Fee Schedule,155% of CMS OPPS Rate,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,283.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,283.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,211.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.92,155,,,Fee Schedule,155% of CMS OPPS Rate,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.07,155,,,Fee Schedule,155% of CMS OPPS Rate,706.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,551.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,551.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,706.07,
PHY-RECONSTRUCT NAIL BED WITH GRAFT,3428510,CDM,981,RC,11762,HCPCS,Outpatient,,,732.86,366.43,,659.57,90,,,percent of total billed charges,90% of total Billed charges,455.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.92,155,,,Fee Schedule,155% of CMS OPPS Rate,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,283.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,283.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,211.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.92,155,,,Fee Schedule,155% of CMS OPPS Rate,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.07,155,,,Fee Schedule,155% of CMS OPPS Rate,706.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,551.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,551.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,706.07,
11765- Wedge excision/skin of nail fold,3431559,CDM,510,RC,11765,HCPCS,Outpatient,,,409.94,204.97,,368.95,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,327.95,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.95,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,397.64,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,377.14,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,368.95,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,286.96,70,,,percent of total billed charges,70% of total billed charges,368.95,90,,,percent of total billed charges,90% of total billed charges,389.44,95,,,percent of total billed charges,95% of total billed charges,389.44,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,352.55,86,,,percent of total billed charges,86% of total billed charges,327.95,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,397.64,97,,,percent of total billed charges,97% of total billed charges,368.95,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,397.64,97,,,percent of total billed charges,97% of total billed charges,381.24,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,397.64,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1818.76,
11765-PF WEDGE EXCISION SKIN NAIL FOLD,4321343,CDM,981,RC,11765,HCPCS,Outpatient,,,174.04,87.02,,156.64,90,,,percent of total billed charges,90% of total Billed charges,241.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,134.87,155,,,Fee Schedule,155% of CMS OPPS Rate,87.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,95.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,134.87,155,,,Fee Schedule,155% of CMS OPPS Rate,87.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.78,155,,,Fee Schedule,155% of CMS OPPS Rate,373.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,87.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,87.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,282.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,373.78,
11770- Exc/pilonidal cyst/sinus/simple,3431560,CDM,510,RC,11770,HCPCS,Outpatient,,,915.8,457.90,,824.22,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,732.64,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,824.22,90,,,Percent of total Billed charges,90% of total billed charges,166.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,888.33,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,842.54,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,824.22,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,641.06,70,,,percent of total billed charges,70% of total billed charges,824.22,90,,,percent of total billed charges,90% of total billed charges,870.01,95,,,percent of total billed charges,95% of total billed charges,870.01,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,787.59,86,,,percent of total billed charges,86% of total billed charges,732.64,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,888.33,97,,,percent of total billed charges,97% of total billed charges,824.22,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.33,97,,,percent of total billed charges,97% of total billed charges,851.69,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,888.33,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,151.47,12593.67,
11771 - PF Excision Pilonidal Cyst/ Sinus Extensive,4311473,CDM,960,RC,11771,HCPCS,Outpatient,,,1046.47,523.24,,941.82,90,,,percent of total billed charges,90% of total Billed charges,1051.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,440.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,683.12,155,,,Fee Schedule,155% of CMS OPPS Rate,440.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,440.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,663.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,666.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,666.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,348.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,881.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,786.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,544.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,683.12,155,,,Fee Schedule,155% of CMS OPPS Rate,440.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1630.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1630.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,440.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,233,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,482.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,440.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1127.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1127.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,233,1630.38,
11771- Exc/pilonidal cyst/sinus/extensive,3431561,CDM,510,RC,11771,HCPCS,Outpatient,,,1625.21,812.61,,1462.69,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1462.69,90,,,Percent of total Billed charges,90% of total billed charges,256.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1576.45,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1495.19,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1462.69,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1137.65,70,,,percent of total billed charges,70% of total billed charges,1462.69,90,,,percent of total billed charges,90% of total billed charges,1543.95,95,,,percent of total billed charges,95% of total billed charges,1543.95,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1397.68,86,,,percent of total billed charges,86% of total billed charges,1300.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1576.45,97,,,percent of total billed charges,97% of total billed charges,1462.69,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1576.45,97,,,percent of total billed charges,97% of total billed charges,1511.45,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,233,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1576.45,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,233,12593.67,
11772 - PF Excision Pilonidal Cyst/ Sinus Complicated,4311474,CDM,960,RC,11772,HCPCS,Outpatient,,,1338.05,669.03,,1204.25,90,,,percent of total billed charges,90% of total Billed charges,1313.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,563.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,873.46,155,,,Fee Schedule,155% of CMS OPPS Rate,563.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,563.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,869.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,864.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,864.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,462.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1127.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1020.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,694.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,873.46,155,,,Fee Schedule,155% of CMS OPPS Rate,563.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,2036.45,155,,,Fee Schedule,155% of CMS OPPS Rate,2036.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,563.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,233,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,517.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,563.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1339.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,233,2036.45,
11772- Exc/pilonidal cyst/sinus/comp,3431562,CDM,510,RC,11772,HCPCS,Outpatient,,,1995.38,997.69,,1795.84,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1596.3,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1795.84,90,,,Percent of total Billed charges,90% of total billed charges,256.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1935.52,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1835.75,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1795.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.77,70,,,percent of total billed charges,70% of total billed charges,1795.84,90,,,percent of total billed charges,90% of total billed charges,1895.61,95,,,percent of total billed charges,95% of total billed charges,1895.61,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1716.03,86,,,percent of total billed charges,86% of total billed charges,1596.3,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1935.52,97,,,percent of total billed charges,97% of total billed charges,1795.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1935.52,97,,,percent of total billed charges,97% of total billed charges,1855.7,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,233,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1935.52,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,233,12593.67,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,60.21,30.11,,54.19,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,48.17,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.4,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,55.39,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,54.19,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,42.15,70,,,percent of total billed charges,70% of total billed charges,54.19,90,,,percent of total billed charges,90% of total billed charges,57.2,95,,,percent of total billed charges,95% of total billed charges,57.2,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,51.78,86,,,percent of total billed charges,86% of total billed charges,48.17,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,58.4,97,,,percent of total billed charges,97% of total billed charges,54.19,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.4,97,,,percent of total billed charges,97% of total billed charges,56,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.4,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.15,880.35,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,91.05,45.53,,81.95,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,72.84,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.32,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,83.77,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.95,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,63.74,70,,,percent of total billed charges,70% of total billed charges,81.95,90,,,percent of total billed charges,90% of total billed charges,86.5,95,,,percent of total billed charges,95% of total billed charges,86.5,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.3,86,,,percent of total billed charges,86% of total billed charges,72.84,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.32,97,,,percent of total billed charges,97% of total billed charges,81.95,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.32,97,,,percent of total billed charges,97% of total billed charges,84.68,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.32,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.74,880.35,
11921- Tattooing/intraderm 6.1-20.0 sq cm,3431565,CDM,510,RC,11921,HCPCS,Outpatient,,,557,278.50,,501.3,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,445.6,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,501.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,540.29,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,512.44,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,501.3,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,389.9,70,,,percent of total billed charges,70% of total billed charges,501.3,90,,,percent of total billed charges,90% of total billed charges,529.15,95,,,percent of total billed charges,95% of total billed charges,529.15,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,479.02,86,,,percent of total billed charges,86% of total billed charges,445.6,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,540.29,97,,,percent of total billed charges,97% of total billed charges,501.3,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,540.29,97,,,percent of total billed charges,97% of total billed charges,518.01,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,540.29,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,389.9,2832.2,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,127.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.28,155,,,Fee Schedule,155% of CMS OPPS Rate,198.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,198.28,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,106.02,53.01,,95.42,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,84.82,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,102.84,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,97.54,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.42,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.21,70,,,percent of total billed charges,70% of total billed charges,95.42,90,,,percent of total billed charges,90% of total billed charges,100.72,95,,,percent of total billed charges,95% of total billed charges,100.72,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.18,86,,,percent of total billed charges,86% of total billed charges,84.82,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,102.84,97,,,percent of total billed charges,97% of total billed charges,95.42,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.84,97,,,percent of total billed charges,97% of total billed charges,98.6,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.84,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,74.21,880.34,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,148.44,74.22,,133.6,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,118.75,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,143.99,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,136.56,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.6,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,70,,,percent of total billed charges,70% of total billed charges,133.6,90,,,percent of total billed charges,90% of total billed charges,141.02,95,,,percent of total billed charges,95% of total billed charges,141.02,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.66,86,,,percent of total billed charges,86% of total billed charges,118.75,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,143.99,97,,,percent of total billed charges,97% of total billed charges,133.6,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.99,97,,,percent of total billed charges,97% of total billed charges,138.05,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,143.99,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.91,2832.2,
11971- Rmv tissue expander w/o prosthesis,3431568,CDM,510,RC,11971,HCPCS,Outpatient,,,1414.12,707.06,,1272.71,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1131.3,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1272.71,90,,,Percent of total Billed charges,90% of total billed charges,276.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1371.7,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.99,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1272.71,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,989.88,70,,,percent of total billed charges,70% of total billed charges,1272.71,90,,,percent of total billed charges,90% of total billed charges,1343.41,95,,,percent of total billed charges,95% of total billed charges,1343.41,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1216.14,86,,,percent of total billed charges,86% of total billed charges,1131.3,80,,,percent of total billed charges,80% of total billed charges,2397.44,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1371.7,97,,,percent of total billed charges,97% of total billed charges,1272.71,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1371.7,97,,,percent of total billed charges,97% of total billed charges,1315.13,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1371.7,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.72,12593.67,
11976- Rmv implant contraceptive capsule,3431569,CDM,510,RC,11976,HCPCS,Outpatient,,,370.77,185.39,,333.69,90,,,percent of total billed charges,90% of total Billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,296.62,80,,,Percent of total Billed charges,80% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.69,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,359.65,97,,,Percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,341.11,92,,,Percent of total billed charges,92% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,333.69,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,259.54,70,,,percent of total billed charges,70% of total billed charges,333.69,90,,,percent of total billed charges,90% of total billed charges,352.23,95,,,percent of total billed charges,95% of total billed charges,352.23,95,,,percent of total billed charges,95% of total billed charges,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,318.86,86,,,percent of total billed charges,86% of total billed charges,296.62,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,359.65,97,,,percent of total billed charges,97% of total billed charges,333.69,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.65,97,,,percent of total billed charges,97% of total billed charges,344.82,93,,,percent of total billed charges,93% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,359.65,97,,,percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,3163.81,
11976-PF REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES,4321345,CDM,981,RC,11976,HCPCS,Outpatient,,,185.74,92.87,,167.17,90,,,percent of total billed charges,90% of total Billed charges,232.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,143.93,155,,,Fee Schedule,155% of CMS OPPS Rate,92.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,172.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,143.93,155,,,Fee Schedule,155% of CMS OPPS Rate,92.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.03,155,,,Fee Schedule,155% of CMS OPPS Rate,360.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,360.03,
11980PF Hormone pellet implant/subq,4267404,CDM,960,RC,11980,HCPCS,Outpatient,,,132.8,66.40,,119.52,90,,,percent of total billed charges,90% of total Billed charges,144.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.69,155,,,Fee Schedule,155% of CMS OPPS Rate,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,66.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.69,155,,,Fee Schedule,155% of CMS OPPS Rate,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.36,155,,,Fee Schedule,155% of CMS OPPS Rate,223.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,208.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.93,223.36,
11981- Insert/drug delivery implant,3431571,CDM,510,RC,11981,HCPCS,Outpatient,,,259.44,129.72,,233.5,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,207.55,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,90,,,Percent of total Billed charges,90% of total billed charges,83.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,251.66,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,238.68,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,233.5,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,181.61,70,,,percent of total billed charges,70% of total billed charges,233.5,90,,,percent of total billed charges,90% of total billed charges,246.47,95,,,percent of total billed charges,95% of total billed charges,246.47,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,223.12,86,,,percent of total billed charges,86% of total billed charges,207.55,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,251.66,97,,,percent of total billed charges,97% of total billed charges,233.5,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.66,97,,,percent of total billed charges,97% of total billed charges,241.28,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,251.66,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.73,566.05,
AMB IUD Implant Admin Charge:Insert Drug Implant Device 11981,3444230,CDM,960,RC,11981,HCPCS,Outpatient,,,259.44,129.72,,233.5,90,,,percent of total billed charges,90% of total Billed charges,159.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.88,155,,,Fee Schedule,155% of CMS OPPS Rate,247.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.36,264.52,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,156.69,78.35,,141.02,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,125.35,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,90,,,Percent of total Billed charges,90% of total billed charges,101.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,151.99,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,144.15,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,141.02,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,109.68,70,,,percent of total billed charges,70% of total billed charges,141.02,90,,,percent of total billed charges,90% of total billed charges,148.86,95,,,percent of total billed charges,95% of total billed charges,148.86,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,134.75,86,,,percent of total billed charges,86% of total billed charges,125.35,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,151.99,97,,,percent of total billed charges,97% of total billed charges,141.02,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.99,97,,,percent of total billed charges,97% of total billed charges,145.72,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,151.99,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92.33,1840.7,
11983- Remove/reinsert drug deliv implant,3431573,CDM,510,RC,11983,HCPCS,Outpatient,,,369.3,184.65,,332.37,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,295.44,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.37,90,,,Percent of total Billed charges,90% of total billed charges,182.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.22,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,339.76,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.37,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,258.51,70,,,percent of total billed charges,70% of total billed charges,332.37,90,,,percent of total billed charges,90% of total billed charges,350.84,95,,,percent of total billed charges,95% of total billed charges,350.84,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.6,86,,,percent of total billed charges,86% of total billed charges,295.44,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.22,97,,,percent of total billed charges,97% of total billed charges,332.37,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.22,97,,,percent of total billed charges,97% of total billed charges,343.45,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.22,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.98,1840.7,
12001 - PF Smpl Rpr Scalp/ Neck/ Ax/ Genit/ Trunk 2.5 cm/ <,4311475,CDM,960,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,84.12,90,,,percent of total billed charges,90% of total Billed charges,134.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.4,90,,,Percent of total Billed charges,90% of total billed charges,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.68,155,,,Fee Schedule,155% of CMS OPPS Rate,208.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,208.68,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,84.12,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.12,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.67,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,85.99,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.12,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,70,,,percent of total billed charges,70% of total billed charges,84.12,90,,,percent of total billed charges,90% of total billed charges,88.8,95,,,percent of total billed charges,95% of total billed charges,88.8,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.38,86,,,percent of total billed charges,86% of total billed charges,74.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.67,97,,,percent of total billed charges,97% of total billed charges,84.12,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.67,97,,,percent of total billed charges,97% of total billed charges,86.93,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.67,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,880.35,
12001- Rep Superfic Wound 2.5Cm Less,3431574,CDM,761,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,84.12,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.12,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.67,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,85.99,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.12,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,70,,,percent of total billed charges,70% of total billed charges,84.12,90,,,percent of total billed charges,90% of total billed charges,88.8,95,,,percent of total billed charges,95% of total billed charges,88.8,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.38,86,,,percent of total billed charges,86% of total billed charges,74.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.67,97,,,percent of total billed charges,97% of total billed charges,84.12,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.67,97,,,percent of total billed charges,97% of total billed charges,86.93,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.67,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,880.35,
12001-PF SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4321346,CDM,981,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,84.12,90,,,percent of total billed charges,90% of total Billed charges,134.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.4,90,,,Percent of total Billed charges,90% of total billed charges,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.68,155,,,Fee Schedule,155% of CMS OPPS Rate,208.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,208.68,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,111.09,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,98.74,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.09,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,119.73,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,113.56,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.09,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,86.4,70,,,percent of total billed charges,70% of total billed charges,111.09,90,,,percent of total billed charges,90% of total billed charges,117.26,95,,,percent of total billed charges,95% of total billed charges,117.26,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.15,86,,,percent of total billed charges,86% of total billed charges,98.74,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,119.73,97,,,percent of total billed charges,97% of total billed charges,111.09,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.73,97,,,percent of total billed charges,97% of total billed charges,114.79,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119.73,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,880.35,
12002-PF SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM,4321348,CDM,981,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,111.09,90,,,percent of total billed charges,90% of total Billed charges,167.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.35,90,,,Percent of total Billed charges,90% of total billed charges,35.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.12,155,,,Fee Schedule,155% of CMS OPPS Rate,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.12,155,,,Fee Schedule,155% of CMS OPPS Rate,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.9,155,,,Fee Schedule,155% of CMS OPPS Rate,259.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.5,259.9,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,139.44,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,123.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.44,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,150.28,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,142.54,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,139.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,108.45,70,,,percent of total billed charges,70% of total billed charges,139.44,90,,,percent of total billed charges,90% of total billed charges,147.18,95,,,percent of total billed charges,95% of total billed charges,147.18,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,133.24,86,,,percent of total billed charges,86% of total billed charges,123.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,150.28,97,,,percent of total billed charges,97% of total billed charges,139.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.28,97,,,percent of total billed charges,97% of total billed charges,144.08,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.28,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,880.35,
12004-PF SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM,4321349,CDM,981,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,139.44,90,,,percent of total billed charges,90% of total Billed charges,200.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,114.36,155,,,Fee Schedule,155% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,114.36,155,,,Fee Schedule,155% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.19,155,,,Fee Schedule,155% of CMS OPPS Rate,310.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,176.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,244.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,310.19,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,181.16,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,161.03,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.16,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,195.25,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,185.19,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,181.16,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,140.9,70,,,percent of total billed charges,70% of total billed charges,181.16,90,,,percent of total billed charges,90% of total billed charges,191.23,95,,,percent of total billed charges,95% of total billed charges,191.23,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,173.11,86,,,percent of total billed charges,86% of total billed charges,161.03,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,195.25,97,,,percent of total billed charges,97% of total billed charges,181.16,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.25,97,,,percent of total billed charges,97% of total billed charges,187.2,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.25,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12005-PF SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM,4321351,CDM,981,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,181.16,90,,,percent of total billed charges,90% of total Billed charges,267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.3,155,,,Fee Schedule,155% of CMS OPPS Rate,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.3,155,,,Fee Schedule,155% of CMS OPPS Rate,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.41,155,,,Fee Schedule,155% of CMS OPPS Rate,414.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,414.41,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,220.78,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,196.25,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.78,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,237.95,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,225.69,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,171.72,70,,,percent of total billed charges,70% of total billed charges,220.78,90,,,percent of total billed charges,90% of total billed charges,233.04,95,,,percent of total billed charges,95% of total billed charges,233.04,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,210.97,86,,,percent of total billed charges,86% of total billed charges,196.25,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,237.95,97,,,percent of total billed charges,97% of total billed charges,220.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.95,97,,,percent of total billed charges,97% of total billed charges,228.14,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.95,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12006-PF SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM,4321352,CDM,981,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,220.78,90,,,percent of total billed charges,90% of total Billed charges,318.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,183.68,155,,,Fee Schedule,155% of CMS OPPS Rate,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.68,155,,,Fee Schedule,155% of CMS OPPS Rate,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.4,155,,,Fee Schedule,155% of CMS OPPS Rate,494.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,494.4,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,273.65,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,243.24,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.65,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,294.93,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,279.73,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,273.65,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,212.84,70,,,percent of total billed charges,70% of total billed charges,273.65,90,,,percent of total billed charges,90% of total billed charges,288.85,95,,,percent of total billed charges,95% of total billed charges,288.85,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,261.48,86,,,percent of total billed charges,86% of total billed charges,243.24,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,294.93,97,,,percent of total billed charges,97% of total billed charges,273.65,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.93,97,,,percent of total billed charges,97% of total billed charges,282.77,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,294.93,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,880.34,
12007-PF SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0C,4321354,CDM,981,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,273.65,90,,,percent of total billed charges,90% of total Billed charges,373.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,227.49,155,,,Fee Schedule,155% of CMS OPPS Rate,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,227.49,155,,,Fee Schedule,155% of CMS OPPS Rate,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,579.19,155,,,Fee Schedule,155% of CMS OPPS Rate,579.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,448.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,579.19,
12011- PF Smpl Rpr F/ E/ E/ N/ L/ M 2.5 cm/ <,4311476,CDM,960,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,104.81,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,252.36,
12011- Rep Superfic Wounds 2.5Cm Less,3431579,CDM,761,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,104.81,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,93.16,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.81,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,112.96,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,104.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,81.52,70,,,percent of total billed charges,70% of total billed charges,104.81,90,,,percent of total billed charges,90% of total billed charges,110.63,95,,,percent of total billed charges,95% of total billed charges,110.63,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,100.15,86,,,percent of total billed charges,86% of total billed charges,93.16,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,112.96,97,,,percent of total billed charges,97% of total billed charges,104.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.96,97,,,percent of total billed charges,97% of total billed charges,108.3,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112.96,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,880.35,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,104.81,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,93.16,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.81,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,112.96,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,107.13,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,104.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,81.52,70,,,percent of total billed charges,70% of total billed charges,104.81,90,,,percent of total billed charges,90% of total billed charges,110.63,95,,,percent of total billed charges,95% of total billed charges,110.63,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,100.15,86,,,percent of total billed charges,86% of total billed charges,93.16,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,112.96,97,,,percent of total billed charges,97% of total billed charges,104.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.96,97,,,percent of total billed charges,97% of total billed charges,108.3,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112.96,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,880.35,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,119.35,59.68,,107.42,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,252.36,
12011-PF SIMPLE REPAIR F/E/E/N/L/M 2.5CM/<,4321355,CDM,981,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,104.81,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,252.36,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,110.74,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,98.43,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.74,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,119.35,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,113.2,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,110.74,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,86.13,70,,,percent of total billed charges,70% of total billed charges,110.74,90,,,percent of total billed charges,90% of total billed charges,116.89,95,,,percent of total billed charges,95% of total billed charges,116.89,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,105.81,86,,,percent of total billed charges,86% of total billed charges,98.43,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,119.35,97,,,percent of total billed charges,97% of total billed charges,110.74,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.35,97,,,percent of total billed charges,97% of total billed charges,114.43,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119.35,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,880.35,
12013-PF SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM,4321357,CDM,981,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,110.74,90,,,percent of total billed charges,90% of total Billed charges,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.89,155,,,Fee Schedule,155% of CMS OPPS Rate,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,94.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,94.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.89,155,,,Fee Schedule,155% of CMS OPPS Rate,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,267.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,176.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,267.17,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,368.19,184.10,,331.37,90,,,percent of total billed charges,90% of total Billed charges,214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.8,155,,,Fee Schedule,155% of CMS OPPS Rate,332.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,332.8,
12014-PF SIMPLE REPAIR F/E/E/N/L/M 5.1CM-7.5 CM,4321358,CDM,981,RC,12014,HCPCS,Outpatient,,,159.53,79.77,,143.58,90,,,percent of total billed charges,90% of total Billed charges,214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.8,155,,,Fee Schedule,155% of CMS OPPS Rate,332.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,332.8,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,200.19,100.10,,180.17,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,160.15,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.17,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,194.18,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,184.17,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,180.17,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,140.13,70,,,percent of total billed charges,70% of total billed charges,180.17,90,,,percent of total billed charges,90% of total billed charges,190.18,95,,,percent of total billed charges,95% of total billed charges,190.18,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,172.16,86,,,percent of total billed charges,86% of total billed charges,160.15,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,194.18,97,,,percent of total billed charges,97% of total billed charges,180.17,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.18,97,,,percent of total billed charges,97% of total billed charges,186.18,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.18,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,880.35,
12015-PF SIMPLE REPAIR F/E/E/N/L/M 7.6CM-12.5 CM,4321360,CDM,981,RC,12015,HCPCS,Outpatient,,,200.19,100.10,,180.17,90,,,percent of total billed charges,90% of total Billed charges,262.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.14,155,,,Fee Schedule,155% of CMS OPPS Rate,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.14,155,,,Fee Schedule,155% of CMS OPPS Rate,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,407.42,155,,,Fee Schedule,155% of CMS OPPS Rate,407.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,252.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,323.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.5,407.42,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,244.19,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,217.06,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.19,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,263.18,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,249.61,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,244.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,189.92,70,,,percent of total billed charges,70% of total billed charges,244.19,90,,,percent of total billed charges,90% of total billed charges,257.75,95,,,percent of total billed charges,95% of total billed charges,257.75,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,233.34,86,,,percent of total billed charges,86% of total billed charges,217.06,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,263.18,97,,,percent of total billed charges,97% of total billed charges,244.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.18,97,,,percent of total billed charges,97% of total billed charges,252.33,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,263.18,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12016-PF SIMPLE REPAIR F/E/E/N/L/M 12.6CM-20.0 CM,4321361,CDM,981,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,244.19,90,,,percent of total billed charges,90% of total Billed charges,344.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202.23,155,,,Fee Schedule,155% of CMS OPPS Rate,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,206.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,206.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,175.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202.23,155,,,Fee Schedule,155% of CMS OPPS Rate,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.02,155,,,Fee Schedule,155% of CMS OPPS Rate,534.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,288.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,534.02,
12017-PF SIMPLE REPAIR F/E/E/N/L/M 20.1CM-30.0 CM,4321363,CDM,981,RC,12017,HCPCS,Outpatient,,,328.28,164.14,,295.45,90,,,percent of total billed charges,90% of total Billed charges,314.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,243.89,155,,,Fee Schedule,155% of CMS OPPS Rate,157.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,245.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,245.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,289.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,209.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,243.89,155,,,Fee Schedule,155% of CMS OPPS Rate,157.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,487.71,155,,,Fee Schedule,155% of CMS OPPS Rate,487.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,157.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,301.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,306,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,306,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,487.71,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,332.76,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,295.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.76,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.64,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,340.15,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.76,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,258.81,70,,,percent of total billed charges,70% of total billed charges,332.76,90,,,percent of total billed charges,90% of total billed charges,351.24,95,,,percent of total billed charges,95% of total billed charges,351.24,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.97,86,,,percent of total billed charges,86% of total billed charges,295.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.64,97,,,percent of total billed charges,97% of total billed charges,332.76,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.64,97,,,percent of total billed charges,97% of total billed charges,343.85,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.64,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,880.35,
12018-PF SIMPLE REPAIR F/E/E/N/L/M >30.0 CM,4321364,CDM,981,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,332.76,90,,,percent of total billed charges,90% of total Billed charges,356.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.62,155,,,Fee Schedule,155% of CMS OPPS Rate,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,264.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,279.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,279.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,329.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,239.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.62,155,,,Fee Schedule,155% of CMS OPPS Rate,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.79,155,,,Fee Schedule,155% of CMS OPPS Rate,552.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,552.79,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,756.73,378.37,,681.06,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,605.38,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.06,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,734.03,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,696.19,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,681.06,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,529.71,70,,,percent of total billed charges,70% of total billed charges,681.06,90,,,percent of total billed charges,90% of total billed charges,718.89,95,,,percent of total billed charges,95% of total billed charges,718.89,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,650.79,86,,,percent of total billed charges,86% of total billed charges,605.38,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,734.03,97,,,percent of total billed charges,97% of total billed charges,681.06,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.03,97,,,percent of total billed charges,97% of total billed charges,703.76,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,734.03,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,2832.2,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,756.8,378.40,,681.12,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,723.74,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,378,189.00,,340.2,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,302.4,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,340.2,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,366.66,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,347.76,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,340.2,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,264.6,70,,,percent of total billed charges,70% of total billed charges,340.2,90,,,percent of total billed charges,90% of total billed charges,359.1,95,,,percent of total billed charges,95% of total billed charges,359.1,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,325.08,86,,,percent of total billed charges,86% of total billed charges,302.4,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,366.66,97,,,percent of total billed charges,97% of total billed charges,340.2,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.66,97,,,percent of total billed charges,97% of total billed charges,351.54,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.66,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,2832.2,
12020-PF TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE,4321366,CDM,981,RC,12020,HCPCS,Outpatient,,,378,189.00,,340.2,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,723.74,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,254.3,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,226.04,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.3,90,,,Percent of total Billed charges,90% of total billed charges,129.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,274.07,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,259.95,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,254.3,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,197.79,70,,,percent of total billed charges,70% of total billed charges,254.3,90,,,percent of total billed charges,90% of total billed charges,268.42,95,,,percent of total billed charges,95% of total billed charges,268.42,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,242.99,86,,,percent of total billed charges,86% of total billed charges,226.04,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,274.07,97,,,percent of total billed charges,97% of total billed charges,254.3,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.07,97,,,percent of total billed charges,97% of total billed charges,262.77,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,274.07,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118,1818.76,
12021-PF TX SUPERFICIAL WOUND DEHISCENCE W/PACKING,4321367,CDM,981,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,254.3,90,,,percent of total billed charges,90% of total Billed charges,305.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,210.46,155,,,Fee Schedule,155% of CMS OPPS Rate,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,207.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,207.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,210.46,155,,,Fee Schedule,155% of CMS OPPS Rate,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.49,155,,,Fee Schedule,155% of CMS OPPS Rate,473.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,327.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.81,473.49,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,299,149.50,,269.1,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,239.2,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.1,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,290.03,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,275.08,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,269.1,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,209.3,70,,,percent of total billed charges,70% of total billed charges,269.1,90,,,percent of total billed charges,90% of total billed charges,284.05,95,,,percent of total billed charges,95% of total billed charges,284.05,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,257.14,86,,,percent of total billed charges,86% of total billed charges,239.2,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,290.03,97,,,percent of total billed charges,97% of total billed charges,269.1,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.03,97,,,percent of total billed charges,97% of total billed charges,278.07,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,290.03,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,1818.76,
12031-PF REPAIR INTERMEDIATE S/A/T/E 2.5 CM/<,4321369,CDM,981,RC,12031,HCPCS,Outpatient,,,299,149.50,,269.1,90,,,percent of total billed charges,90% of total Billed charges,391.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,223.76,155,,,Fee Schedule,155% of CMS OPPS Rate,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,223.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,223.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,263.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,223.76,155,,,Fee Schedule,155% of CMS OPPS Rate,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.12,155,,,Fee Schedule,155% of CMS OPPS Rate,607.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,495.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,607.12,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,337.24,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,299.77,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.24,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,363.47,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,344.73,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,337.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,262.3,70,,,percent of total billed charges,70% of total billed charges,337.24,90,,,percent of total billed charges,90% of total billed charges,355.97,95,,,percent of total billed charges,95% of total billed charges,355.97,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,322.25,86,,,percent of total billed charges,86% of total billed charges,299.77,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,363.47,97,,,percent of total billed charges,97% of total billed charges,337.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.47,97,,,percent of total billed charges,97% of total billed charges,348.48,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,363.47,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1818.76,
12032-PF REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM,4321378,CDM,981,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,337.24,90,,,percent of total billed charges,90% of total Billed charges,463.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,279.48,155,,,Fee Schedule,155% of CMS OPPS Rate,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,278.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,278.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,328.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,279.48,155,,,Fee Schedule,155% of CMS OPPS Rate,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.18,155,,,Fee Schedule,155% of CMS OPPS Rate,719.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,719.18,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,368.59,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,327.63,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.59,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,397.25,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,376.78,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,368.59,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,286.68,70,,,percent of total billed charges,70% of total billed charges,368.59,90,,,percent of total billed charges,90% of total billed charges,389.06,95,,,percent of total billed charges,95% of total billed charges,389.06,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,352.2,86,,,percent of total billed charges,86% of total billed charges,327.63,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,397.25,97,,,percent of total billed charges,97% of total billed charges,368.59,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,397.25,97,,,percent of total billed charges,97% of total billed charges,380.87,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,397.25,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1818.76,
12034-PF REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM,4321386,CDM,981,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,368.59,90,,,percent of total billed charges,90% of total Billed charges,513.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.91,155,,,Fee Schedule,155% of CMS OPPS Rate,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,305.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,305.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,360.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.91,155,,,Fee Schedule,155% of CMS OPPS Rate,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,796.05,155,,,Fee Schedule,155% of CMS OPPS Rate,796.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,618.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.5,796.05,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,438.62,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,389.88,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.62,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,472.73,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,448.36,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,438.62,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,341.15,70,,,percent of total billed charges,70% of total billed charges,438.62,90,,,percent of total billed charges,90% of total billed charges,462.98,95,,,percent of total billed charges,95% of total billed charges,462.98,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,419.12,86,,,percent of total billed charges,86% of total billed charges,389.88,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,472.73,97,,,percent of total billed charges,97% of total billed charges,438.62,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.73,97,,,percent of total billed charges,97% of total billed charges,453.24,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,472.73,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12035-PF REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM,4321387,CDM,981,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,438.62,90,,,percent of total billed charges,90% of total Billed charges,605.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,361.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,362.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,362.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,427.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,286.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.2,155,,,Fee Schedule,155% of CMS OPPS Rate,938.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,938.2,
12036-PF REPAIR INTERMEDIATE S/A/T/E 20.1-30.0 CM,4321388,CDM,981,RC,12036,HCPCS,Outpatient,,,576.13,288.07,,518.52,90,,,percent of total billed charges,90% of total Billed charges,692.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,427.55,155,,,Fee Schedule,155% of CMS OPPS Rate,275.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,275.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,428.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,428.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,551.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,505.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,346.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,427.55,155,,,Fee Schedule,155% of CMS OPPS Rate,275.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1073.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1073.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,275.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,414.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,275.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,821.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,821.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1073.82,
"12037 - PF Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands",3715363,CDM,960,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,604.22,90,,,percent of total billed charges,90% of total Billed charges,788.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,263.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,409.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1222.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1222.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,916.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1222.64,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,604.22,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,537.09,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,604.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,651.22,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,617.65,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,604.22,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,469.95,70,,,percent of total billed charges,70% of total billed charges,604.22,90,,,percent of total billed charges,90% of total billed charges,637.79,95,,,percent of total billed charges,95% of total billed charges,637.79,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,577.37,86,,,percent of total billed charges,86% of total billed charges,537.09,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,651.22,97,,,percent of total billed charges,97% of total billed charges,604.22,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,651.22,97,,,percent of total billed charges,97% of total billed charges,624.36,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,651.22,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,8413.78,
12037-PF REPAIR INTERMEDIATE S/A/T/E >30.0 CM,4321389,CDM,981,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,604.22,90,,,percent of total billed charges,90% of total Billed charges,788.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,263.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,409.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1222.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1222.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,916.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1222.64,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,260.02,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,231.13,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.02,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,280.24,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,265.8,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,260.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,202.24,70,,,percent of total billed charges,70% of total billed charges,260.02,90,,,percent of total billed charges,90% of total billed charges,274.46,95,,,percent of total billed charges,95% of total billed charges,274.46,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,248.46,86,,,percent of total billed charges,86% of total billed charges,231.13,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,280.24,97,,,percent of total billed charges,97% of total billed charges,260.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.24,97,,,percent of total billed charges,97% of total billed charges,268.69,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.24,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,1818.76,
12041-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/<,4321390,CDM,981,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,260.02,90,,,percent of total billed charges,90% of total Billed charges,387.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,215.67,155,,,Fee Schedule,155% of CMS OPPS Rate,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,217.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,217.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,215.67,155,,,Fee Schedule,155% of CMS OPPS Rate,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.17,155,,,Fee Schedule,155% of CMS OPPS Rate,601.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,221.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,518.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,601.17,
12042 - PF Rpr Intrmdt N/ H/ F/ Xtrnl Gent 2.6-7.5 cm,4311477,CDM,960,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,349.35,90,,,percent of total billed charges,90% of total Billed charges,479.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,214.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.84,155,,,Fee Schedule,155% of CMS OPPS Rate,742.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.5,742.84,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,349.35,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,310.54,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.35,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,376.52,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,357.12,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,349.35,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,271.72,70,,,percent of total billed charges,70% of total billed charges,349.35,90,,,percent of total billed charges,90% of total billed charges,368.76,95,,,percent of total billed charges,95% of total billed charges,368.76,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,333.83,86,,,percent of total billed charges,86% of total billed charges,310.54,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,376.52,97,,,percent of total billed charges,97% of total billed charges,349.35,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.52,97,,,percent of total billed charges,97% of total billed charges,361,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,376.52,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,1818.76,
12042-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM,4321391,CDM,981,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,349.35,90,,,percent of total billed charges,90% of total Billed charges,479.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,214.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.84,155,,,Fee Schedule,155% of CMS OPPS Rate,742.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.5,742.84,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,386.49,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,343.54,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.49,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,416.55,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,395.08,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,386.49,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,300.6,70,,,percent of total billed charges,70% of total billed charges,386.49,90,,,percent of total billed charges,90% of total billed charges,407.96,95,,,percent of total billed charges,95% of total billed charges,407.96,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,369.31,86,,,percent of total billed charges,86% of total billed charges,343.54,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,416.55,97,,,percent of total billed charges,97% of total billed charges,386.49,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.55,97,,,percent of total billed charges,97% of total billed charges,399.37,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.55,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,2832.2,
12044-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM,4321392,CDM,981,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,386.49,90,,,percent of total billed charges,90% of total Billed charges,565.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,319.67,155,,,Fee Schedule,155% of CMS OPPS Rate,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,320.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,320.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,320.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,172.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,377.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,246.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.67,155,,,Fee Schedule,155% of CMS OPPS Rate,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,876,155,,,Fee Schedule,155% of CMS OPPS Rate,876,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,707.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,876,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,495.32,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,440.28,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.32,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,533.84,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,506.32,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,495.32,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,385.25,70,,,percent of total billed charges,70% of total billed charges,495.32,90,,,percent of total billed charges,90% of total billed charges,522.83,95,,,percent of total billed charges,95% of total billed charges,522.83,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,473.3,86,,,percent of total billed charges,86% of total billed charges,440.28,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,533.84,97,,,percent of total billed charges,97% of total billed charges,495.32,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,533.84,97,,,percent of total billed charges,97% of total billed charges,511.83,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,533.84,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2832.2,
12045-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM,4321393,CDM,981,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,495.32,90,,,percent of total billed charges,90% of total Billed charges,653.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,411.8,155,,,Fee Schedule,155% of CMS OPPS Rate,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,265.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,402.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,402.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,475.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,314.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,411.8,155,,,Fee Schedule,155% of CMS OPPS Rate,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1013.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1013.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,741.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1013.68,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,585.95,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,520.84,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.95,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,631.52,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,598.97,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,585.95,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,455.74,70,,,percent of total billed charges,70% of total billed charges,585.95,90,,,percent of total billed charges,90% of total billed charges,618.5,95,,,percent of total billed charges,95% of total billed charges,618.5,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,559.9,86,,,percent of total billed charges,86% of total billed charges,520.84,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,631.52,97,,,percent of total billed charges,97% of total billed charges,585.95,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.52,97,,,percent of total billed charges,97% of total billed charges,605.48,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,631.52,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2832.2,
12046-PF RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM,4321394,CDM,981,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,585.95,90,,,percent of total billed charges,90% of total Billed charges,794.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,483.32,155,,,Fee Schedule,155% of CMS OPPS Rate,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,476.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,476.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,249.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,562.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,394.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,483.32,155,,,Fee Schedule,155% of CMS OPPS Rate,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1231.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1231.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,460.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,876.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1231.35,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,651.99,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,579.54,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,651.99,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,702.7,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,666.48,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,651.99,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,507.1,70,,,percent of total billed charges,70% of total billed charges,651.99,90,,,percent of total billed charges,90% of total billed charges,688.21,95,,,percent of total billed charges,95% of total billed charges,688.21,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,623.01,86,,,percent of total billed charges,86% of total billed charges,579.54,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,702.7,97,,,percent of total billed charges,97% of total billed charges,651.99,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,702.7,97,,,percent of total billed charges,97% of total billed charges,673.72,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,702.7,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,8413.78,
12047-PF REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM,4321395,CDM,981,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,651.99,90,,,percent of total billed charges,90% of total Billed charges,877.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,539.62,155,,,Fee Schedule,155% of CMS OPPS Rate,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,527.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,533.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,533.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,296.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,629.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,444.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,539.62,155,,,Fee Schedule,155% of CMS OPPS Rate,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1360.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,481.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,962.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1360.4,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,302.8,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,269.15,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.8,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,326.35,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,309.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,302.8,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,235.51,70,,,percent of total billed charges,70% of total billed charges,302.8,90,,,percent of total billed charges,90% of total billed charges,319.62,95,,,percent of total billed charges,95% of total billed charges,319.62,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,289.34,86,,,percent of total billed charges,86% of total billed charges,269.15,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,326.35,97,,,percent of total billed charges,97% of total billed charges,302.8,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.35,97,,,percent of total billed charges,97% of total billed charges,312.89,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,326.35,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,1818.76,
12051-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/<,4321396,CDM,981,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,302.8,90,,,percent of total billed charges,90% of total Billed charges,429.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,251.19,155,,,Fee Schedule,155% of CMS OPPS Rate,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,251.19,155,,,Fee Schedule,155% of CMS OPPS Rate,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.42,155,,,Fee Schedule,155% of CMS OPPS Rate,665.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,539.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,665.42,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,356.54,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,316.93,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.54,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,384.28,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,364.47,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,356.54,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,277.31,70,,,percent of total billed charges,70% of total billed charges,356.54,90,,,percent of total billed charges,90% of total billed charges,376.35,95,,,percent of total billed charges,95% of total billed charges,376.35,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,340.7,86,,,percent of total billed charges,86% of total billed charges,316.93,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,384.28,97,,,percent of total billed charges,97% of total billed charges,356.54,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.28,97,,,percent of total billed charges,97% of total billed charges,368.43,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.28,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1818.76,
12052-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM,4321397,CDM,981,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,356.54,90,,,percent of total billed charges,90% of total Billed charges,489.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.42,155,,,Fee Schedule,155% of CMS OPPS Rate,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,299.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,295.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,295.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,164.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,219.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.42,155,,,Fee Schedule,155% of CMS OPPS Rate,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,758.48,155,,,Fee Schedule,155% of CMS OPPS Rate,758.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,616.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,758.48,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,385.93,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,343.05,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.93,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,415.95,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,394.51,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,385.93,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,300.17,70,,,percent of total billed charges,70% of total billed charges,385.93,90,,,percent of total billed charges,90% of total billed charges,407.37,95,,,percent of total billed charges,95% of total billed charges,407.37,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,368.78,86,,,percent of total billed charges,86% of total billed charges,343.05,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,415.95,97,,,percent of total billed charges,97% of total billed charges,385.93,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.95,97,,,percent of total billed charges,97% of total billed charges,398.79,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,415.95,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1818.76,
12053-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 5.1-7.5 CM,4321400,CDM,981,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,385.93,90,,,percent of total billed charges,90% of total Billed charges,551.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,321.14,155,,,Fee Schedule,155% of CMS OPPS Rate,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,320.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,320.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,242.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,321.14,155,,,Fee Schedule,155% of CMS OPPS Rate,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.22,155,,,Fee Schedule,155% of CMS OPPS Rate,854.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,686.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,854.22,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,400.37,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,355.89,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.37,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,431.51,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,409.27,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,400.37,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,311.4,70,,,percent of total billed charges,70% of total billed charges,400.37,90,,,percent of total billed charges,90% of total billed charges,422.62,95,,,percent of total billed charges,95% of total billed charges,422.62,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,382.58,86,,,percent of total billed charges,86% of total billed charges,355.89,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,431.51,97,,,percent of total billed charges,97% of total billed charges,400.37,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,431.51,97,,,percent of total billed charges,97% of total billed charges,413.72,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.51,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,1818.76,
12054-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 7.6-12.5 CM,4321401,CDM,981,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,400.37,90,,,percent of total billed charges,90% of total Billed charges,581.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,332.66,155,,,Fee Schedule,155% of CMS OPPS Rate,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,214.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,333.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,333.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,178.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,393.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,260.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,332.66,155,,,Fee Schedule,155% of CMS OPPS Rate,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,901.54,155,,,Fee Schedule,155% of CMS OPPS Rate,901.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,307.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,731.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,731.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.5,901.54,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,550.02,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,488.9,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.02,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.8,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,562.24,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,550.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,427.79,70,,,percent of total billed charges,70% of total billed charges,550.02,90,,,percent of total billed charges,90% of total billed charges,580.57,95,,,percent of total billed charges,95% of total billed charges,580.57,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,525.57,86,,,percent of total billed charges,86% of total billed charges,488.9,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,592.8,97,,,percent of total billed charges,97% of total billed charges,550.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.8,97,,,percent of total billed charges,97% of total billed charges,568.35,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.8,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12055-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM,4321404,CDM,981,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,550.02,90,,,percent of total billed charges,90% of total Billed charges,773.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,454.4,155,,,Fee Schedule,155% of CMS OPPS Rate,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,453.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,453.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,244.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,359.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,454.4,155,,,Fee Schedule,155% of CMS OPPS Rate,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1198.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1198.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,884,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1198.48,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,694.94,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,617.72,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.94,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,748.99,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,710.38,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,694.94,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,540.51,70,,,percent of total billed charges,70% of total billed charges,694.94,90,,,percent of total billed charges,90% of total billed charges,733.54,95,,,percent of total billed charges,95% of total billed charges,733.54,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,664.05,86,,,percent of total billed charges,86% of total billed charges,617.72,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,748.99,97,,,percent of total billed charges,97% of total billed charges,694.94,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,748.99,97,,,percent of total billed charges,97% of total billed charges,718.1,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,748.99,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12056-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM,4321406,CDM,981,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,694.94,90,,,percent of total billed charges,90% of total Billed charges,925.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,577.34,155,,,Fee Schedule,155% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,578.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,575.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,575.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,273.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,678.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,450.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,577.34,155,,,Fee Schedule,155% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1434.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1434.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,514.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1080.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1434.63,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,761.63,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,677.01,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.63,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,820.87,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,778.56,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,761.63,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,592.38,70,,,percent of total billed charges,70% of total billed charges,761.63,90,,,percent of total billed charges,90% of total billed charges,803.95,95,,,percent of total billed charges,95% of total billed charges,803.95,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,727.78,86,,,percent of total billed charges,86% of total billed charges,677.01,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,820.87,97,,,percent of total billed charges,97% of total billed charges,761.63,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,820.87,97,,,percent of total billed charges,97% of total billed charges,787.02,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,820.87,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1818.76,
12057-PF REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM,4321407,CDM,981,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,761.63,90,,,percent of total billed charges,90% of total Billed charges,994.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,631.8,155,,,Fee Schedule,155% of CMS OPPS Rate,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,407.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,639.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,638.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,638.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,314.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,501.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,631.8,155,,,Fee Schedule,155% of CMS OPPS Rate,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1541.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1249.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1249.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1541.43,
13100-PF REPAIR COMPLEX TRUNK 1.1-2.5 CM,4321409,CDM,981,RC,13100,HCPCS,Outpatient,,,399.01,199.51,,359.11,90,,,percent of total billed charges,90% of total Billed charges,514.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.72,155,,,Fee Schedule,155% of CMS OPPS Rate,192.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,302.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,300.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,300.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,165.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,354.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,224.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,298.72,155,,,Fee Schedule,155% of CMS OPPS Rate,192.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.37,155,,,Fee Schedule,155% of CMS OPPS Rate,797.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,623.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60,797.37,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,438.89,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,390.13,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,473.03,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,448.65,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,438.89,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,341.36,70,,,percent of total billed charges,70% of total billed charges,438.89,90,,,percent of total billed charges,90% of total billed charges,463.28,95,,,percent of total billed charges,95% of total billed charges,463.28,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,419.39,86,,,percent of total billed charges,86% of total billed charges,390.13,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.03,97,,,percent of total billed charges,97% of total billed charges,438.89,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.03,97,,,percent of total billed charges,97% of total billed charges,453.52,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473.03,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,341.36,2832.2,
13101-PF REPAIR COMPLEX TRUNK 2.6-7.5 CM,4321410,CDM,981,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,438.89,90,,,percent of total billed charges,90% of total Billed charges,611.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,366.03,155,,,Fee Schedule,155% of CMS OPPS Rate,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,366.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,366.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,432.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,271.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,366.03,155,,,Fee Schedule,155% of CMS OPPS Rate,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,947.65,155,,,Fee Schedule,155% of CMS OPPS Rate,947.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,357.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,794.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,794.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,947.65,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,131.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,116.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,131.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,134.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,93.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,114.74,78.65,,,percent of total billed charges,78.65% of total billed charges,130.32,89.33,,,percent of total billed charges,89.33% of total billed charges,131.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,102.12,70,,,percent of total billed charges,70% of total billed charges,131.29,90,,,percent of total billed charges,90% of total billed charges,138.59,95,,,percent of total billed charges,95% of total billed charges,138.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.46,86,,,percent of total billed charges,86% of total billed charges,116.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,141.5,97,,,percent of total billed charges,97% of total billed charges,131.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.5,97,,,percent of total billed charges,97% of total billed charges,135.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.16,141.5,
13102-PF REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/<,4321414,CDM,981,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,131.29,90,,,percent of total billed charges,90% of total Billed charges,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,108.93,155,,,Fee Schedule,155% of CMS OPPS Rate,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,108.93,155,,,Fee Schedule,155% of CMS OPPS Rate,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.64,155,,,Fee Schedule,155% of CMS OPPS Rate,282.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,219.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.7,282.64,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,411.75,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,366,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.75,90,,,Percent of total Billed charges,90% of total billed charges,66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,443.78,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,420.9,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,411.75,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,320.25,70,,,percent of total billed charges,70% of total billed charges,411.75,90,,,percent of total billed charges,90% of total billed charges,434.63,95,,,percent of total billed charges,95% of total billed charges,434.63,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,393.45,86,,,percent of total billed charges,86% of total billed charges,366,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,443.78,97,,,percent of total billed charges,97% of total billed charges,411.75,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,443.78,97,,,percent of total billed charges,97% of total billed charges,425.48,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,443.78,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60,2832.2,
13120-PF REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM,4321415,CDM,981,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,411.75,90,,,percent of total billed charges,90% of total Billed charges,558,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,343.51,155,,,Fee Schedule,155% of CMS OPPS Rate,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,221.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,342.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,342.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,404.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,255.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,343.51,155,,,Fee Schedule,155% of CMS OPPS Rate,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,864.9,155,,,Fee Schedule,155% of CMS OPPS Rate,864.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,294.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,649.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60,864.9,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,461.93,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,410.6,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,497.85,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,472.19,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,461.93,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,359.28,70,,,percent of total billed charges,70% of total billed charges,461.93,90,,,percent of total billed charges,90% of total billed charges,487.59,95,,,percent of total billed charges,95% of total billed charges,487.59,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,441.4,86,,,percent of total billed charges,86% of total billed charges,410.6,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,497.85,97,,,percent of total billed charges,97% of total billed charges,461.93,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.85,97,,,percent of total billed charges,97% of total billed charges,477.32,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,497.85,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,359.28,2832.2,
13121-PF REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM,4321417,CDM,981,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,461.93,90,,,percent of total billed charges,90% of total Billed charges,649.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,259.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,383.01,155,,,Fee Schedule,155% of CMS OPPS Rate,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,390.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,387.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,387.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,288.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,383.01,155,,,Fee Schedule,155% of CMS OPPS Rate,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.07,155,,,Fee Schedule,155% of CMS OPPS Rate,1006.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,394.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,888.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,219.93,1006.07,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,167.59,83.80,,150.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,134.07,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,150.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,162.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,154.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,107.03,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,131.81,78.65,,,percent of total billed charges,78.65% of total billed charges,149.71,89.33,,,percent of total billed charges,89.33% of total billed charges,150.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.31,70,,,percent of total billed charges,70% of total billed charges,150.83,90,,,percent of total billed charges,90% of total billed charges,159.21,95,,,percent of total billed charges,95% of total billed charges,159.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.13,86,,,percent of total billed charges,86% of total billed charges,134.07,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,162.56,97,,,percent of total billed charges,97% of total billed charges,150.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,162.56,97,,,percent of total billed charges,97% of total billed charges,155.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.03,162.56,
13122-PF REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<,4321418,CDM,981,RC,13122,HCPCS,Outpatient,,,167.59,83.80,,150.83,90,,,percent of total billed charges,90% of total Billed charges,202.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.94,155,,,Fee Schedule,155% of CMS OPPS Rate,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,125.94,155,,,Fee Schedule,155% of CMS OPPS Rate,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.51,155,,,Fee Schedule,155% of CMS OPPS Rate,314.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.84,314.51,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,482.19,241.10,,433.97,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,385.75,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,433.97,90,,,Percent of total Billed charges,90% of total billed charges,78.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,467.72,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,443.61,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,433.97,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,337.53,70,,,percent of total billed charges,70% of total billed charges,433.97,90,,,percent of total billed charges,90% of total billed charges,458.08,95,,,percent of total billed charges,95% of total billed charges,458.08,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,414.68,86,,,percent of total billed charges,86% of total billed charges,385.75,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,467.72,97,,,percent of total billed charges,97% of total billed charges,433.97,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,467.72,97,,,percent of total billed charges,97% of total billed charges,448.44,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.72,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,71,1818.76,
13131-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM,4321420,CDM,981,RC,13131,HCPCS,Outpatient,,,482.19,241.10,,433.97,90,,,percent of total billed charges,90% of total Billed charges,599.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,360.24,155,,,Fee Schedule,155% of CMS OPPS Rate,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,366.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,364.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,364.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,201.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,273.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,360.24,155,,,Fee Schedule,155% of CMS OPPS Rate,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.71,155,,,Fee Schedule,155% of CMS OPPS Rate,929.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,325.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,718.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,718.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71,929.71,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,542.08,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,481.85,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,584.24,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,554.13,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.08,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,421.62,70,,,percent of total billed charges,70% of total billed charges,542.08,90,,,percent of total billed charges,90% of total billed charges,572.19,95,,,percent of total billed charges,95% of total billed charges,572.19,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.99,86,,,percent of total billed charges,86% of total billed charges,481.85,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.24,97,,,percent of total billed charges,97% of total billed charges,542.08,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.24,97,,,percent of total billed charges,97% of total billed charges,560.15,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,584.24,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,421.62,2832.2,
13132-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM,4321423,CDM,981,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,542.08,90,,,percent of total billed charges,90% of total Billed charges,739.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,452.06,155,,,Fee Schedule,155% of CMS OPPS Rate,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,291.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,459.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,456.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,456.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,318.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,538.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,339.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,452.06,155,,,Fee Schedule,155% of CMS OPPS Rate,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1145.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,519.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1171.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1171.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,177,1171.64,
13133-PF REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<,4321425,CDM,981,RC,13133,HCPCS,Outpatient,,,253.06,126.53,,227.75,90,,,percent of total billed charges,90% of total Billed charges,283.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,107.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,188.54,155,,,Fee Schedule,155% of CMS OPPS Rate,121.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,188.54,155,,,Fee Schedule,155% of CMS OPPS Rate,121.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.98,155,,,Fee Schedule,155% of CMS OPPS Rate,438.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,121.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,105.69,438.98,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,499.23,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,443.76,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.23,90,,,Percent of total Billed charges,90% of total billed charges,194.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.06,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,510.32,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.23,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,388.29,70,,,percent of total billed charges,70% of total billed charges,499.23,90,,,percent of total billed charges,90% of total billed charges,526.97,95,,,percent of total billed charges,95% of total billed charges,526.97,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.04,86,,,percent of total billed charges,86% of total billed charges,443.76,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.06,97,,,percent of total billed charges,97% of total billed charges,499.23,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.06,97,,,percent of total billed charges,97% of total billed charges,515.87,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.06,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177,2832.2,
13151-PF REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM,4321427,CDM,981,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,499.23,90,,,percent of total billed charges,90% of total Billed charges,670.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,416.08,155,,,Fee Schedule,155% of CMS OPPS Rate,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,268.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,421.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,419.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,419.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,231.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,495.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,315.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,416.08,155,,,Fee Schedule,155% of CMS OPPS Rate,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1039.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,402.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,814.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,814.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,177,1039.88,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,602.93,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,535.94,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,602.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,649.82,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,616.33,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,602.93,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,468.94,70,,,percent of total billed charges,70% of total billed charges,602.93,90,,,percent of total billed charges,90% of total billed charges,636.42,95,,,percent of total billed charges,95% of total billed charges,636.42,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,576.13,86,,,percent of total billed charges,86% of total billed charges,535.94,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,649.82,97,,,percent of total billed charges,97% of total billed charges,602.93,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.82,97,,,percent of total billed charges,97% of total billed charges,623.03,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,649.82,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,2832.2,
13152-PF REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM,4321430,CDM,981,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,602.93,90,,,percent of total billed charges,90% of total Billed charges,797.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,351,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,502.12,155,,,Fee Schedule,155% of CMS OPPS Rate,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,507.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,505.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,505.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,502.12,155,,,Fee Schedule,155% of CMS OPPS Rate,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1235.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,351,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,517.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1130.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298.96,1235.97,
13153-PF REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<,4322014,CDM,981,RC,13153,HCPCS,Outpatient,,,277.23,138.62,,249.51,90,,,percent of total billed charges,90% of total Billed charges,312.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,208.12,155,,,Fee Schedule,155% of CMS OPPS Rate,134.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,212.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,212.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,250.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,165.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,208.12,155,,,Fee Schedule,155% of CMS OPPS Rate,134.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.1,155,,,Fee Schedule,155% of CMS OPPS Rate,485.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.74,485.1,
13160 - PF 2ndry Clsr Surg Wound/ Dehsn Extsv/ Complic,4311478,CDM,960,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,1451.3,90,,,percent of total billed charges,90% of total Billed charges,1560.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1197.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,642.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1554.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1419.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,950.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2419.19,155,,,Fee Schedule,155% of CMS OPPS Rate,2419.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,770.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1650.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,244,2419.19,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,1451.3,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.05,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.3,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1564.18,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.56,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1451.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.79,70,,,percent of total billed charges,70% of total billed charges,1451.3,90,,,percent of total billed charges,90% of total billed charges,1531.93,95,,,percent of total billed charges,95% of total billed charges,1531.93,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1386.8,86,,,percent of total billed charges,86% of total billed charges,1290.05,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1564.18,97,,,percent of total billed charges,97% of total billed charges,1451.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1564.18,97,,,percent of total billed charges,97% of total billed charges,1499.68,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1564.18,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,8413.78,
13160-PF SECONDARY CLOSURE SURG WOUND/DEHSN EXTSV/COMPLIC,4322013,CDM,981,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,1451.3,90,,,percent of total billed charges,90% of total Billed charges,1560.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1197.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,642.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1554.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1419.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,950.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2419.19,155,,,Fee Schedule,155% of CMS OPPS Rate,2419.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,770.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1650.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,244,2419.19,
"14000 - (PF) Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less",3634893,CDM,960,RC,14000,HCPCS,Outpatient,,,1007.83,503.92,,907.05,90,,,percent of total billed charges,90% of total Billed charges,1086.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,483.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,748.77,155,,,Fee Schedule,155% of CMS OPPS Rate,483.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,483.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,745.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,734.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,734.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,403.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,966.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,866.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,563.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,748.77,155,,,Fee Schedule,155% of CMS OPPS Rate,483.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1683.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1683.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,483.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,117,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,571.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,483.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1255.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1255.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117,1683.32,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,1314.46,657.23,,1183.01,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.57,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.01,90,,,Percent of total Billed charges,90% of total billed charges,290.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1275.03,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.3,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1183.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,920.12,70,,,percent of total billed charges,70% of total billed charges,1183.01,90,,,percent of total billed charges,90% of total billed charges,1248.74,95,,,percent of total billed charges,95% of total billed charges,1248.74,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.44,86,,,percent of total billed charges,86% of total billed charges,1051.57,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1275.03,97,,,percent of total billed charges,97% of total billed charges,1183.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275.03,97,,,percent of total billed charges,97% of total billed charges,1222.45,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,264,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1275.03,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,264,8413.78,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,1124.34,562.17,,1011.91,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,899.47,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.91,90,,,Percent of total Billed charges,90% of total billed charges,165,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1090.61,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1034.39,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1011.91,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,787.04,70,,,percent of total billed charges,70% of total billed charges,1011.91,90,,,percent of total billed charges,90% of total billed charges,1068.12,95,,,percent of total billed charges,95% of total billed charges,1068.12,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,966.93,86,,,percent of total billed charges,86% of total billed charges,899.47,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1090.61,97,,,percent of total billed charges,97% of total billed charges,1011.91,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1090.61,97,,,percent of total billed charges,97% of total billed charges,1045.64,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,150,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1090.61,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,150,8413.78,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,1410.33,705.17,,1269.3,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.26,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.3,90,,,Percent of total Billed charges,90% of total billed charges,249.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1368.02,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1297.5,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1269.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,987.23,70,,,percent of total billed charges,70% of total billed charges,1269.3,90,,,percent of total billed charges,90% of total billed charges,1339.81,95,,,percent of total billed charges,95% of total billed charges,1339.81,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1212.88,86,,,percent of total billed charges,86% of total billed charges,1128.26,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1368.02,97,,,percent of total billed charges,97% of total billed charges,1269.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368.02,97,,,percent of total billed charges,97% of total billed charges,1311.61,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1368.02,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,226.5,8413.78,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,1239.78,619.89,,1115.8,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,991.82,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1115.8,90,,,Percent of total Billed charges,90% of total billed charges,195.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1202.59,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.6,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1115.8,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,867.85,70,,,percent of total billed charges,70% of total billed charges,1115.8,90,,,percent of total billed charges,90% of total billed charges,1177.79,95,,,percent of total billed charges,95% of total billed charges,1177.79,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1066.21,86,,,percent of total billed charges,86% of total billed charges,991.82,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1202.59,97,,,percent of total billed charges,97% of total billed charges,1115.8,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.59,97,,,percent of total billed charges,97% of total billed charges,1153,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1202.59,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.5,8413.78,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,1514.25,757.13,,1362.83,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1211.4,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1362.83,90,,,Percent of total Billed charges,90% of total billed charges,305.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1468.82,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1393.11,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1362.83,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.98,70,,,percent of total billed charges,70% of total billed charges,1362.83,90,,,percent of total billed charges,90% of total billed charges,1438.54,95,,,percent of total billed charges,95% of total billed charges,1438.54,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1302.26,86,,,percent of total billed charges,86% of total billed charges,1211.4,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1468.82,97,,,percent of total billed charges,97% of total billed charges,1362.83,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1468.82,97,,,percent of total billed charges,97% of total billed charges,1408.25,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1468.82,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,277.5,8413.78,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,1514.25,757.13,,1362.83,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1211.4,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1362.83,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1468.82,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1393.11,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1362.83,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.98,70,,,percent of total billed charges,70% of total billed charges,1362.83,90,,,percent of total billed charges,90% of total billed charges,1438.54,95,,,percent of total billed charges,95% of total billed charges,1438.54,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1302.26,86,,,percent of total billed charges,86% of total billed charges,1211.4,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1468.82,97,,,percent of total billed charges,97% of total billed charges,1362.83,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1468.82,97,,,percent of total billed charges,97% of total billed charges,1408.25,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1468.82,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,8413.78,
14350- Filleted/fng/toe/recip site prep,3431610,CDM,510,RC,14350,HCPCS,Outpatient,,,1760.71,880.36,,1584.64,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1408.57,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1584.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1707.89,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1619.85,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1584.64,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.5,70,,,percent of total billed charges,70% of total billed charges,1584.64,90,,,percent of total billed charges,90% of total billed charges,1672.67,95,,,percent of total billed charges,95% of total billed charges,1672.67,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1514.21,86,,,percent of total billed charges,86% of total billed charges,1408.57,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1707.89,97,,,percent of total billed charges,97% of total billed charges,1584.64,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1707.89,97,,,percent of total billed charges,97% of total billed charges,1637.46,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1707.89,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1232.5,8413.78,
"15002- Wnd Prep,Ch/Inf,Trk/Arm/Lg",3431611,CDM,510,RC,15002,HCPCS,Outpatient,,,889.22,444.61,,800.3,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,711.38,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,800.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,862.54,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,818.08,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,800.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,622.45,70,,,percent of total billed charges,70% of total billed charges,800.3,90,,,percent of total billed charges,90% of total billed charges,844.76,95,,,percent of total billed charges,95% of total billed charges,844.76,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,764.73,86,,,percent of total billed charges,86% of total billed charges,711.38,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,862.54,97,,,percent of total billed charges,97% of total billed charges,800.3,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.54,97,,,percent of total billed charges,97% of total billed charges,826.97,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,862.54,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,622.45,8413.78,
"15003- Wnd Prep,Ch/Inf Addl 100 Cm",3431612,CDM,510,RC,15003,HCPCS,Outpatient,,,181.13,90.57,,163.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,144.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,163.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,166.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,115.67,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,142.46,78.65,,,percent of total billed charges,78.65% of total billed charges,161.81,89.33,,,percent of total billed charges,89.33% of total billed charges,163.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,126.79,70,,,percent of total billed charges,70% of total billed charges,163.02,90,,,percent of total billed charges,90% of total billed charges,172.07,95,,,percent of total billed charges,95% of total billed charges,172.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.77,86,,,percent of total billed charges,86% of total billed charges,144.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,175.7,97,,,percent of total billed charges,97% of total billed charges,163.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.7,97,,,percent of total billed charges,97% of total billed charges,168.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.67,175.7,
"15004- Wnd Prep Ch/Inf,F/N/Hf/G",3431613,CDM,960,RC,15004,HCPCS,Outpatient,,,525.51,262.76,,472.96,90,,,percent of total billed charges,90% of total Billed charges,636.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,193.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,395.59,155,,,Fee Schedule,155% of CMS OPPS Rate,255.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,398.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,403.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,403.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,215.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,313.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,395.59,155,,,Fee Schedule,155% of CMS OPPS Rate,255.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,985.85,155,,,Fee Schedule,155% of CMS OPPS Rate,985.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,255.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,382.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,255.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,798.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193.81,985.85,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,255.71,127.86,,230.14,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,204.57,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.04,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,235.25,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.14,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,179,70,,,percent of total billed charges,70% of total billed charges,230.14,90,,,percent of total billed charges,90% of total billed charges,242.92,95,,,percent of total billed charges,95% of total billed charges,242.92,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,219.91,86,,,percent of total billed charges,86% of total billed charges,204.57,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.04,97,,,percent of total billed charges,97% of total billed charges,230.14,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.04,97,,,percent of total billed charges,97% of total billed charges,237.81,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.04,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,179,8413.78,
15100PF Split-Thickness Autograft Trunk/Arms/Legs First 100s,4281204,CDM,960,RC,15100,HCPCS,Outpatient,,,1445.06,722.53,,1300.55,90,,,percent of total billed charges,90% of total Billed charges,1536.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,696.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,298,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1079.08,155,,,Fee Schedule,155% of CMS OPPS Rate,696.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,696.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1072.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1072.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1071.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1071.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1392.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1264.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,851,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1079.08,155,,,Fee Schedule,155% of CMS OPPS Rate,696.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2382.13,155,,,Fee Schedule,155% of CMS OPPS Rate,2382.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,696.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,298,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,834.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,696.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1730.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1730.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298,2382.13,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,226.37,113.19,,203.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,181.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,219.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,208.26,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,144.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,178.04,78.65,,,percent of total billed charges,78.65% of total billed charges,202.22,89.33,,,percent of total billed charges,89.33% of total billed charges,203.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,158.46,70,,,percent of total billed charges,70% of total billed charges,203.73,90,,,percent of total billed charges,90% of total billed charges,215.05,95,,,percent of total billed charges,95% of total billed charges,215.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.68,86,,,percent of total billed charges,86% of total billed charges,181.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,219.58,97,,,percent of total billed charges,97% of total billed charges,203.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,219.58,97,,,percent of total billed charges,97% of total billed charges,210.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.56,219.58,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,1459.07,729.54,,1313.16,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.26,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1415.3,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1342.34,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1313.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.35,70,,,percent of total billed charges,70% of total billed charges,1313.16,90,,,percent of total billed charges,90% of total billed charges,1386.12,95,,,percent of total billed charges,95% of total billed charges,1386.12,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1254.8,86,,,percent of total billed charges,86% of total billed charges,1167.26,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1415.3,97,,,percent of total billed charges,97% of total billed charges,1313.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.3,97,,,percent of total billed charges,97% of total billed charges,1356.94,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1415.3,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1021.35,8413.78,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,212.17,106.09,,190.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,169.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,190.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,205.8,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,195.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,135.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,166.88,78.65,,,percent of total billed charges,78.65% of total billed charges,189.53,89.33,,,percent of total billed charges,89.33% of total billed charges,190.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,148.52,70,,,percent of total billed charges,70% of total billed charges,190.95,90,,,percent of total billed charges,90% of total billed charges,201.56,95,,,percent of total billed charges,95% of total billed charges,201.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.47,86,,,percent of total billed charges,86% of total billed charges,169.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,205.8,97,,,percent of total billed charges,97% of total billed charges,190.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,205.8,97,,,percent of total billed charges,97% of total billed charges,197.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.8,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.5,205.8,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,1415.57,707.79,,1274.01,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.46,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1373.1,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.32,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1274.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,990.9,70,,,percent of total billed charges,70% of total billed charges,1274.01,90,,,percent of total billed charges,90% of total billed charges,1344.79,95,,,percent of total billed charges,95% of total billed charges,1344.79,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1217.39,86,,,percent of total billed charges,86% of total billed charges,1132.46,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1373.1,97,,,percent of total billed charges,97% of total billed charges,1274.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1373.1,97,,,percent of total billed charges,97% of total billed charges,1316.48,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1373.1,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,990.9,8413.78,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,1392.29,696.15,,1253.06,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.83,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1253.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1350.52,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1280.91,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1253.06,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,974.6,70,,,percent of total billed charges,70% of total billed charges,1253.06,90,,,percent of total billed charges,90% of total billed charges,1322.68,95,,,percent of total billed charges,95% of total billed charges,1322.68,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1197.37,86,,,percent of total billed charges,86% of total billed charges,1113.83,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1350.52,97,,,percent of total billed charges,97% of total billed charges,1253.06,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1350.52,97,,,percent of total billed charges,97% of total billed charges,1294.83,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1350.52,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,974.6,15858.98,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,1353.32,676.66,,1217.99,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.66,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1312.72,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.05,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1217.99,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,947.32,70,,,percent of total billed charges,70% of total billed charges,1217.99,90,,,percent of total billed charges,90% of total billed charges,1285.65,95,,,percent of total billed charges,95% of total billed charges,1285.65,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1163.86,86,,,percent of total billed charges,86% of total billed charges,1082.66,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1312.72,97,,,percent of total billed charges,97% of total billed charges,1217.99,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1312.72,97,,,percent of total billed charges,97% of total billed charges,1258.59,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1312.72,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,947.32,8413.78,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,1213.83,606.92,,1092.45,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,971.06,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1092.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1177.42,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.72,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1092.45,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,849.68,70,,,percent of total billed charges,70% of total billed charges,1092.45,90,,,percent of total billed charges,90% of total billed charges,1153.14,95,,,percent of total billed charges,95% of total billed charges,1153.14,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1043.89,86,,,percent of total billed charges,86% of total billed charges,971.06,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1177.42,97,,,percent of total billed charges,97% of total billed charges,1092.45,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1177.42,97,,,percent of total billed charges,97% of total billed charges,1128.86,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1177.42,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,849.68,8413.78,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,140.94,70.47,,126.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,112.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,126.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,136.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,129.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,110.85,78.65,,,percent of total billed charges,78.65% of total billed charges,125.9,89.33,,,percent of total billed charges,89.33% of total billed charges,126.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.66,70,,,percent of total billed charges,70% of total billed charges,126.85,90,,,percent of total billed charges,90% of total billed charges,133.89,95,,,percent of total billed charges,95% of total billed charges,133.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.21,86,,,percent of total billed charges,86% of total billed charges,112.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,136.71,97,,,percent of total billed charges,97% of total billed charges,126.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,136.71,97,,,percent of total billed charges,97% of total billed charges,131.07,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.01,136.71,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,1578.13,789.07,,1420.32,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1262.5,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1420.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1530.79,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.88,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1420.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.69,70,,,percent of total billed charges,70% of total billed charges,1420.32,90,,,percent of total billed charges,90% of total billed charges,1499.22,95,,,percent of total billed charges,95% of total billed charges,1499.22,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1357.19,86,,,percent of total billed charges,86% of total billed charges,1262.5,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1530.79,97,,,percent of total billed charges,97% of total billed charges,1420.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1530.79,97,,,percent of total billed charges,97% of total billed charges,1467.66,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1530.79,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1104.69,8413.78,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,218.23,109.12,,196.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,174.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,211.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,200.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,139.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,171.64,78.65,,,percent of total billed charges,78.65% of total billed charges,194.95,89.33,,,percent of total billed charges,89.33% of total billed charges,196.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,152.76,70,,,percent of total billed charges,70% of total billed charges,196.41,90,,,percent of total billed charges,90% of total billed charges,207.32,95,,,percent of total billed charges,95% of total billed charges,207.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.68,86,,,percent of total billed charges,86% of total billed charges,174.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,211.68,97,,,percent of total billed charges,97% of total billed charges,196.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,211.68,97,,,percent of total billed charges,97% of total billed charges,202.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.37,211.68,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,1673.85,836.93,,1506.47,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1339.08,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1506.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1623.63,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1539.94,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1506.47,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.7,70,,,percent of total billed charges,70% of total billed charges,1506.47,90,,,percent of total billed charges,90% of total billed charges,1590.16,95,,,percent of total billed charges,95% of total billed charges,1590.16,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1439.51,86,,,percent of total billed charges,86% of total billed charges,1339.08,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1623.63,97,,,percent of total billed charges,97% of total billed charges,1506.47,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1623.63,97,,,percent of total billed charges,97% of total billed charges,1556.68,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1623.63,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1171.7,8413.78,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,272.7,136.35,,245.43,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,218.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,264.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,250.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,174.15,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,214.48,78.65,,,percent of total billed charges,78.65% of total billed charges,243.61,89.33,,,percent of total billed charges,89.33% of total billed charges,245.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,190.89,70,,,percent of total billed charges,70% of total billed charges,245.43,90,,,percent of total billed charges,90% of total billed charges,259.07,95,,,percent of total billed charges,95% of total billed charges,259.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.52,86,,,percent of total billed charges,86% of total billed charges,218.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,264.52,97,,,percent of total billed charges,97% of total billed charges,245.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,264.52,97,,,percent of total billed charges,97% of total billed charges,253.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.15,264.52,
15271 - PF AppSkn Sub Grft T/A/L Area/100sq cm/<1st 25,4309233,CDM,960,RC,15271,HCPCS,Outpatient,,,171.15,85.58,,154.04,90,,,percent of total billed charges,90% of total Billed charges,229.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.29,155,,,Fee Schedule,155% of CMS OPPS Rate,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.29,155,,,Fee Schedule,155% of CMS OPPS Rate,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.34,155,,,Fee Schedule,155% of CMS OPPS Rate,355.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,128.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.13,355.34,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,361.36,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,321.21,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,389.46,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,369.39,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,361.36,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,281.06,70,,,percent of total billed charges,70% of total billed charges,361.36,90,,,percent of total billed charges,90% of total billed charges,381.43,95,,,percent of total billed charges,95% of total billed charges,381.43,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,345.3,86,,,percent of total billed charges,86% of total billed charges,321.21,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,389.46,97,,,percent of total billed charges,97% of total billed charges,361.36,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.46,97,,,percent of total billed charges,97% of total billed charges,373.4,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,389.46,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281.06,15858.98,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,170.54,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,151.59,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,183.81,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,174.33,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.54,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,132.64,70,,,percent of total billed charges,70% of total billed charges,170.54,90,,,percent of total billed charges,90% of total billed charges,180.02,95,,,percent of total billed charges,95% of total billed charges,180.02,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,162.96,86,,,percent of total billed charges,86% of total billed charges,151.59,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.81,97,,,percent of total billed charges,97% of total billed charges,170.54,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.81,97,,,percent of total billed charges,97% of total billed charges,176.23,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,183.81,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.64,8413.78,
15275-OCC Skin sub graft face/nk/hf/g,3536971,CDM,983,RC,15275,HCPCS,Outpatient,,,246.52,123.26,,221.87,90,,,percent of total billed charges,90% of total Billed charges,243.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.91,155,,,Fee Schedule,155% of CMS OPPS Rate,377.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.44,377.91,
15576 - FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL,3997179,CDM,960,RC,15576,HCPCS,Outpatient,,,1289.43,644.72,,1160.49,90,,,percent of total billed charges,90% of total Billed charges,1370.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,622.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,574.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,964.6,155,,,Fee Schedule,155% of CMS OPPS Rate,622.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,622.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,986.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,975.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,975.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,537.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1244.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1150.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,731.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,964.6,155,,,Fee Schedule,155% of CMS OPPS Rate,622.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,2123.93,155,,,Fee Schedule,155% of CMS OPPS Rate,2123.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,622.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,649.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,622.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1643.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1643.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,537.6,2123.93,
15730 - PF Midface Flap w/ Preservation of Vascular Pedicle(s),4333233,CDM,960,RC,15730,HCPCS,Outpatient,,,1716.32,858.16,,1544.69,90,,,percent of total billed charges,90% of total Billed charges,2225.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,877.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,742.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1360.14,155,,,Fee Schedule,155% of CMS OPPS Rate,877.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1222.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,877.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1374.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1374.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1365.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1365.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,807.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,877.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1755.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1611.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1035.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1360.14,155,,,Fee Schedule,155% of CMS OPPS Rate,877.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3449.42,155,,,Fee Schedule,155% of CMS OPPS Rate,3449.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,877.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1675.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,877.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,742.16,3449.42,
"15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk",3572796,CDM,960,RC,15734,HCPCS,Outpatient,,,3076.46,1538.23,,2768.81,90,,,percent of total billed charges,90% of total Billed charges,2973.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1480.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2295.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1480.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2020.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1480.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2272.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2272.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2300.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2300.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1058.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1480.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2961.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2714.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1877.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2295.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1480.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,4608.35,155,,,Fee Schedule,155% of CMS OPPS Rate,4608.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1480.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1565.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1480.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,3091.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3091.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4608.35,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,1394.05,697.03,,1254.65,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1115.24,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1254.65,90,,,Percent of total Billed charges,90% of total billed charges,328.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1352.23,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1282.53,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1254.65,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,975.84,70,,,percent of total billed charges,70% of total billed charges,1254.65,90,,,percent of total billed charges,90% of total billed charges,1324.35,95,,,percent of total billed charges,95% of total billed charges,1324.35,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1198.88,86,,,percent of total billed charges,86% of total billed charges,1115.24,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1352.23,97,,,percent of total billed charges,97% of total billed charges,1254.65,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1352.23,97,,,percent of total billed charges,97% of total billed charges,1296.47,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1352.23,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,298.5,8413.78,
"15769 - PF Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis,",3712907,CDM,960,RC,15769,HCPCS,Outpatient,,,971.64,485.82,,874.48,90,,,percent of total billed charges,90% of total Billed charges,935.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,468.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726,155,,,Fee Schedule,155% of CMS OPPS Rate,468.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,468.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,722.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,718.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,718.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,429.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,936.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,848.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,561.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,726,155,,,Fee Schedule,155% of CMS OPPS Rate,468.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1450.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1450.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,468.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,533.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,468.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.05,1450.71,
15770 - PF Graft; derma-fat-fascia,3712908,CDM,960,RC,15770,HCPCS,Outpatient,,,1348.55,674.28,,1213.7,90,,,percent of total billed charges,90% of total Billed charges,1294.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,646.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,480,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1002.83,155,,,Fee Schedule,155% of CMS OPPS Rate,646.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,646.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,992.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,980.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,980.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,535.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1293.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1156.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,745.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1002.83,155,,,Fee Schedule,155% of CMS OPPS Rate,646.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2006.66,155,,,Fee Schedule,155% of CMS OPPS Rate,2006.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,646.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,480,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,612.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,646.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1385.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1385.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,480,2006.66,
15777 - Acellular Derm Matrix Implt Bio for Soft Tiss Reinfo,3898973,CDM,983,RC,15777,HCPCS,Outpatient,,,570.85,285.43,,513.77,90,,,percent of total billed charges,90% of total Billed charges,427.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,212.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,169.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,329.3,155,,,Fee Schedule,155% of CMS OPPS Rate,212.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,331.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,331.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,182.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,391.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,267.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,329.3,155,,,Fee Schedule,155% of CMS OPPS Rate,212.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,662.01,155,,,Fee Schedule,155% of CMS OPPS Rate,662.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,212.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,196.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,212.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.42,662.01,
15778- IMPL ABSRB MESH/PRSTH DLYD CLSR DFCT INFCTJ/TRMA,4199248,CDM,960,RC,15778,HCPCS,Outpatient,,,899.49,449.75,,809.54,90,,,percent of total billed charges,90% of total Billed charges,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.87,155,,,Fee Schedule,155% of CMS OPPS Rate,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,776.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.87,155,,,Fee Schedule,155% of CMS OPPS Rate,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.87,155,,,Fee Schedule,155% of CMS OPPS Rate,601.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.85,809.54,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,419.21,209.61,,377.29,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,335.37,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,406.63,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,385.67,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,377.29,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,293.45,70,,,percent of total billed charges,70% of total billed charges,377.29,90,,,percent of total billed charges,90% of total billed charges,398.25,95,,,percent of total billed charges,95% of total billed charges,398.25,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,360.52,86,,,percent of total billed charges,86% of total billed charges,335.37,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,406.63,97,,,percent of total billed charges,97% of total billed charges,377.29,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.63,97,,,percent of total billed charges,97% of total billed charges,389.87,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,406.63,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.64,1818.76,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,805.26,402.63,,724.73,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,644.21,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,781.1,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,740.84,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,724.73,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,563.68,70,,,percent of total billed charges,70% of total billed charges,724.73,90,,,percent of total billed charges,90% of total billed charges,765,95,,,percent of total billed charges,95% of total billed charges,765,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,692.52,86,,,percent of total billed charges,86% of total billed charges,644.21,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,781.1,97,,,percent of total billed charges,97% of total billed charges,724.73,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,781.1,97,,,percent of total billed charges,97% of total billed charges,748.89,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,781.1,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,2832.2,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,406.23,203.12,,365.61,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,324.98,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,365.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,394.04,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,373.73,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,365.61,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,284.36,70,,,percent of total billed charges,70% of total billed charges,365.61,90,,,percent of total billed charges,90% of total billed charges,385.92,95,,,percent of total billed charges,95% of total billed charges,385.92,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,349.36,86,,,percent of total billed charges,86% of total billed charges,324.98,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,394.04,97,,,percent of total billed charges,97% of total billed charges,365.61,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.04,97,,,percent of total billed charges,97% of total billed charges,377.79,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,394.04,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,284.36,2832.2,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,699.07,349.54,,629.16,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,559.26,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,629.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,678.1,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,643.14,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,629.16,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,489.35,70,,,percent of total billed charges,70% of total billed charges,629.16,90,,,percent of total billed charges,90% of total billed charges,664.12,95,,,percent of total billed charges,95% of total billed charges,664.12,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,601.2,86,,,percent of total billed charges,86% of total billed charges,559.26,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,678.1,97,,,percent of total billed charges,97% of total billed charges,629.16,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,678.1,97,,,percent of total billed charges,97% of total billed charges,650.14,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,678.1,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,1818.76,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,902.14,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,801.9,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,902.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,972.31,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,922.19,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,902.14,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,701.67,70,,,percent of total billed charges,70% of total billed charges,902.14,90,,,percent of total billed charges,90% of total billed charges,952.26,95,,,percent of total billed charges,95% of total billed charges,952.26,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,862.05,86,,,percent of total billed charges,86% of total billed charges,801.9,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,972.31,97,,,percent of total billed charges,97% of total billed charges,902.14,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,972.31,97,,,percent of total billed charges,97% of total billed charges,932.21,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,972.31,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,701.67,8413.78,
"15820 - PF Blepharoplasty, lower eyelid;",3712911,CDM,960,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,902.14,90,,,percent of total billed charges,90% of total Billed charges,1022.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.79,155,,,Fee Schedule,155% of CMS OPPS Rate,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,481.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,731.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,731.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,418.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,863.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,519.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,746.79,155,,,Fee Schedule,155% of CMS OPPS Rate,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1585.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1585.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,556.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1151.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,418.38,1585.05,
"15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad",3622066,CDM,960,RC,15821,HCPCS,Outpatient,,,1074.37,537.19,,966.93,90,,,percent of total billed charges,90% of total Billed charges,1102.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,802.47,155,,,Fee Schedule,155% of CMS OPPS Rate,517.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,517.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,786.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,786.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,430.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,928.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,566.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,802.47,155,,,Fee Schedule,155% of CMS OPPS Rate,517.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1708.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1708.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,517.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,631.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,517.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1236.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1236.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,430.42,1708.26,
"15822 - Blepharoplasty, upper eyelid",3572797,CDM,960,RC,15822,HCPCS,Outpatient,,,778.72,389.36,,700.85,90,,,percent of total billed charges,90% of total Billed charges,810.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,375.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.93,155,,,Fee Schedule,155% of CMS OPPS Rate,375.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,375.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,584.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,567.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,567.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,309.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,669.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,413.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,581.93,155,,,Fee Schedule,155% of CMS OPPS Rate,375.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1256.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,375.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,536.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,375.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,894.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,894.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,309.7,1256.09,
"15823 -Blepharoplasty, upper eyelid; with excessive skin weighting down lid",3566780,CDM,960,RC,15823,HCPCS,Outpatient,,,1073.06,536.53,,965.75,90,,,percent of total billed charges,90% of total Billed charges,1100.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.44,155,,,Fee Schedule,155% of CMS OPPS Rate,517.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,517.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,785.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,785.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,429.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1034.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,927.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,562.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,801.44,155,,,Fee Schedule,155% of CMS OPPS Rate,517.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1705.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1705.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,517.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,664.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,517.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1236.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1236.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,429.48,1705.08,
15830-MA EXC SKIN ABD,3428767,CDM,510,RC,15830,HCPCS,Outpatient,,,3066.16,1533.08,,2759.54,90,,,percent of total billed charges,90% of total Billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2452.93,80,,,Percent of total Billed charges,80% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2759.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2974.18,97,,,Percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2820.87,92,,,Percent of total billed charges,92% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14348.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22874.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28973.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2759.54,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2146.31,70,,,percent of total billed charges,70% of total billed charges,2759.54,90,,,percent of total billed charges,90% of total billed charges,2912.85,95,,,percent of total billed charges,95% of total billed charges,2912.85,95,,,percent of total billed charges,95% of total billed charges,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10795.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2636.9,86,,,percent of total billed charges,86% of total billed charges,2452.93,80,,,percent of total billed charges,80% of total billed charges,5414.7,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2974.18,97,,,percent of total billed charges,97% of total billed charges,2759.54,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2974.18,97,,,percent of total billed charges,97% of total billed charges,2851.53,93,,,percent of total billed charges,93% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2974.18,97,,,percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,5397.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4588.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2146.31,28973.61,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,118.03,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,104.91,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,127.21,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,120.65,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,118.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,91.8,70,,,percent of total billed charges,70% of total billed charges,118.03,90,,,percent of total billed charges,90% of total billed charges,124.58,95,,,percent of total billed charges,95% of total billed charges,124.58,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.78,86,,,percent of total billed charges,86% of total billed charges,104.91,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,127.21,97,,,percent of total billed charges,97% of total billed charges,118.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.21,97,,,percent of total billed charges,97% of total billed charges,121.96,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.21,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.8,8413.78,
15851-PF REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON,4322012,CDM,981,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,118.03,90,,,percent of total billed charges,90% of total Billed charges,163.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.82,155,,,Fee Schedule,155% of CMS OPPS Rate,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.82,155,,,Fee Schedule,155% of CMS OPPS Rate,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,253.27,155,,,Fee Schedule,155% of CMS OPPS Rate,253.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.03,253.27,
15852-PF DRESSING CHANGE UNDER ANESTHESIA,4322011,CDM,981,RC,15852,HCPCS,Outpatient,,,92.41,46.21,,83.17,90,,,percent of total billed charges,90% of total Billed charges,93.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.83,155,,,Fee Schedule,155% of CMS OPPS Rate,46.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,71.83,155,,,Fee Schedule,155% of CMS OPPS Rate,46.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.99,155,,,Fee Schedule,155% of CMS OPPS Rate,144.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,46.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,95.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.36,144.99,
"15999PF Unlisted procedure, excision pressure ulcer",4281203,CDM,960,RC,15999,HCPCS,Outpatient,,,131.14,65.57,,118.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.34,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.34,118.03,
16000-PF INITIAL TX 1ST DEGREE BURN LOCAL TX,4322010,CDM,981,RC,16000,HCPCS,Outpatient,,,94.49,47.25,,85.04,90,,,percent of total billed charges,90% of total Billed charges,118.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.96,155,,,Fee Schedule,155% of CMS OPPS Rate,45.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.96,155,,,Fee Schedule,155% of CMS OPPS Rate,45.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.47,155,,,Fee Schedule,155% of CMS OPPS Rate,183.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,138.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18,183.47,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,100.13,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,89.01,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.13,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,107.92,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,102.36,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,100.13,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,77.88,70,,,percent of total billed charges,70% of total billed charges,100.13,90,,,percent of total billed charges,90% of total billed charges,105.7,95,,,percent of total billed charges,95% of total billed charges,105.7,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,95.68,86,,,percent of total billed charges,86% of total billed charges,89.01,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,107.92,97,,,percent of total billed charges,97% of total billed charges,100.13,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.92,97,,,percent of total billed charges,97% of total billed charges,103.47,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.92,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,880.35,
16020-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL,4322009,CDM,981,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,100.13,90,,,percent of total billed charges,90% of total Billed charges,132.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.24,155,,,Fee Schedule,155% of CMS OPPS Rate,205.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,205.24,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,203.41,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,180.81,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.41,90,,,Percent of total Billed charges,90% of total billed charges,110.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,219.23,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,207.93,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,203.41,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,158.21,70,,,percent of total billed charges,70% of total billed charges,203.41,90,,,percent of total billed charges,90% of total billed charges,214.71,95,,,percent of total billed charges,95% of total billed charges,214.71,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,194.37,86,,,percent of total billed charges,86% of total billed charges,180.81,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,219.23,97,,,percent of total billed charges,97% of total billed charges,203.41,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.23,97,,,percent of total billed charges,97% of total billed charges,210.19,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,219.23,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,100.55,880.34,
16025-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM,4322008,CDM,981,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,203.41,90,,,percent of total billed charges,90% of total Billed charges,258.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,166.7,155,,,Fee Schedule,155% of CMS OPPS Rate,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.7,155,,,Fee Schedule,155% of CMS OPPS Rate,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.26,155,,,Fee Schedule,155% of CMS OPPS Rate,400.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,300.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.82,400.26,
16030 - PF Dress/ Debrid Prtl-Thkns Burns 1st/ Subq Lg,4311479,CDM,960,RC,16030,HCPCS,Outpatient,,,270.02,135.01,,243.02,90,,,percent of total billed charges,90% of total Billed charges,318.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.45,155,,,Fee Schedule,155% of CMS OPPS Rate,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.45,155,,,Fee Schedule,155% of CMS OPPS Rate,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.55,155,,,Fee Schedule,155% of CMS OPPS Rate,493.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,361.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.07,493.55,
16030-PF DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE,4322007,CDM,981,RC,16030,HCPCS,Outpatient,,,270.02,135.01,,243.02,90,,,percent of total billed charges,90% of total Billed charges,318.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.45,155,,,Fee Schedule,155% of CMS OPPS Rate,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.45,155,,,Fee Schedule,155% of CMS OPPS Rate,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.55,155,,,Fee Schedule,155% of CMS OPPS Rate,493.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,361.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.07,493.55,
16035-PF ESCHAROTOMY FIRST INCISION,4321310,CDM,981,RC,16035,HCPCS,Outpatient,,,386.08,193.04,,347.47,90,,,percent of total billed charges,90% of total Billed charges,385.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,190.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,299.2,155,,,Fee Schedule,155% of CMS OPPS Rate,193.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,193.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,305.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,305.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,360.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,243.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,299.2,155,,,Fee Schedule,155% of CMS OPPS Rate,193.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,597.91,155,,,Fee Schedule,155% of CMS OPPS Rate,597.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,193.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,193.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,403.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,154.32,597.91,
16036-PF ESCHAROTOMY EACH ADDITIONAL INCISION,4321312,CDM,981,RC,16036,HCPCS,Outpatient,,,165.56,82.78,,149,90,,,percent of total billed charges,90% of total Billed charges,161.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.31,155,,,Fee Schedule,155% of CMS OPPS Rate,82.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,128.31,155,,,Fee Schedule,155% of CMS OPPS Rate,82.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.6,155,,,Fee Schedule,155% of CMS OPPS Rate,250.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,165.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.13,250.6,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,85.71,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.43,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.93,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,98.57,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,96.43,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,75,70,,,percent of total billed charges,70% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.14,86,,,percent of total billed charges,86% of total billed charges,85.71,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,103.93,97,,,percent of total billed charges,97% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.93,97,,,percent of total billed charges,97% of total billed charges,99.64,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.93,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,880.35,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,3.96,1.98,,3.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.17,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3.56,90,,,Percent of total Billed charges,90% of total billed charges,4.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3.11,78.65,,,percent of total billed charges,78.65% of total billed charges,3.54,89.33,,,percent of total billed charges,89.33% of total billed charges,3.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2.77,70,,,percent of total billed charges,70% of total billed charges,3.56,90,,,percent of total billed charges,90% of total billed charges,3.76,95,,,percent of total billed charges,95% of total billed charges,3.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.41,86,,,percent of total billed charges,86% of total billed charges,3.17,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3.84,97,,,percent of total billed charges,97% of total billed charges,3.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.84,97,,,percent of total billed charges,97% of total billed charges,3.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.53,4.68,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,194.55,97.28,,175.1,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,155.64,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.1,90,,,Percent of total Billed charges,90% of total billed charges,128.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,188.71,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,178.99,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,175.1,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,136.19,70,,,percent of total billed charges,70% of total billed charges,175.1,90,,,percent of total billed charges,90% of total billed charges,184.82,95,,,percent of total billed charges,95% of total billed charges,184.82,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,167.31,86,,,percent of total billed charges,86% of total billed charges,155.64,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,188.71,97,,,percent of total billed charges,97% of total billed charges,175.1,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.71,97,,,percent of total billed charges,97% of total billed charges,180.93,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,188.71,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116.39,1818.76,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,119.57,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,106.29,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.57,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,128.87,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,122.23,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,119.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,93,70,,,percent of total billed charges,70% of total billed charges,119.57,90,,,percent of total billed charges,90% of total billed charges,126.22,95,,,percent of total billed charges,95% of total billed charges,126.22,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,114.26,86,,,percent of total billed charges,86% of total billed charges,106.29,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,128.87,97,,,percent of total billed charges,97% of total billed charges,119.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.87,97,,,percent of total billed charges,97% of total billed charges,123.56,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,128.87,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,880.35,
17110-PF DESTRUCTION BENIGN LESIONS UP TO 14,4321314,CDM,981,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,119.57,90,,,percent of total billed charges,90% of total Billed charges,167.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.41,90,,,Percent of total Billed charges,90% of total billed charges,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.98,155,,,Fee Schedule,155% of CMS OPPS Rate,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.98,155,,,Fee Schedule,155% of CMS OPPS Rate,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.87,155,,,Fee Schedule,155% of CMS OPPS Rate,258.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,216.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,258.87,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,146.48,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.2,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.48,90,,,Percent of total Billed charges,90% of total billed charges,56.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,157.87,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,149.73,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,146.48,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,113.93,70,,,percent of total billed charges,70% of total billed charges,146.48,90,,,percent of total billed charges,90% of total billed charges,154.61,95,,,percent of total billed charges,95% of total billed charges,154.61,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,139.97,86,,,percent of total billed charges,86% of total billed charges,130.2,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,157.87,97,,,percent of total billed charges,97% of total billed charges,146.48,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.87,97,,,percent of total billed charges,97% of total billed charges,151.36,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,157.87,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.37,880.35,
17111-PF DESTRUCTION BENIGN LESIONS 15/>,4321316,CDM,981,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,146.48,90,,,percent of total billed charges,90% of total Billed charges,200.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.92,155,,,Fee Schedule,155% of CMS OPPS Rate,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.92,155,,,Fee Schedule,155% of CMS OPPS Rate,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.47,155,,,Fee Schedule,155% of CMS OPPS Rate,310.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.37,310.47,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,67.53,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,60.02,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.53,90,,,Percent of total Billed charges,90% of total billed charges,28.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,72.78,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,69.03,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,67.53,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,52.52,70,,,percent of total billed charges,70% of total billed charges,67.53,90,,,percent of total billed charges,90% of total billed charges,71.28,95,,,percent of total billed charges,95% of total billed charges,71.28,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,64.53,86,,,percent of total billed charges,86% of total billed charges,60.02,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,72.78,97,,,percent of total billed charges,97% of total billed charges,67.53,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.78,97,,,percent of total billed charges,97% of total billed charges,69.78,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72.78,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.82,880.35,
17250-PF CHEMICAL CAUTERIZATION OF GRANULATION TISSUE,4322006,CDM,981,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,67.53,90,,,percent of total billed charges,90% of total Billed charges,110.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.82,155,,,Fee Schedule,155% of CMS OPPS Rate,171.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,153,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.82,171.82,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,139.33,69.67,,125.4,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,111.46,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.4,90,,,Percent of total Billed charges,90% of total billed charges,56.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.15,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,128.18,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.4,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,97.53,70,,,percent of total billed charges,70% of total billed charges,125.4,90,,,percent of total billed charges,90% of total billed charges,132.36,95,,,percent of total billed charges,95% of total billed charges,132.36,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.82,86,,,percent of total billed charges,86% of total billed charges,111.46,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.15,97,,,percent of total billed charges,97% of total billed charges,125.4,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.15,97,,,percent of total billed charges,97% of total billed charges,129.58,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.15,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.44,880.35,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,172.72,86.36,,155.45,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,138.18,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.45,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.54,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,158.9,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,155.45,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,120.9,70,,,percent of total billed charges,70% of total billed charges,155.45,90,,,percent of total billed charges,90% of total billed charges,164.08,95,,,percent of total billed charges,95% of total billed charges,164.08,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.54,86,,,percent of total billed charges,86% of total billed charges,138.18,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.54,97,,,percent of total billed charges,97% of total billed charges,155.45,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.54,97,,,percent of total billed charges,97% of total billed charges,160.63,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.54,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,880.35,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,219.23,109.62,,197.31,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,175.38,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,197.31,90,,,Percent of total Billed charges,90% of total billed charges,93.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,212.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,201.69,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,197.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,153.46,70,,,percent of total billed charges,70% of total billed charges,197.31,90,,,percent of total billed charges,90% of total billed charges,208.27,95,,,percent of total billed charges,95% of total billed charges,208.27,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,188.54,86,,,percent of total billed charges,86% of total billed charges,175.38,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,212.65,97,,,percent of total billed charges,97% of total billed charges,197.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.65,97,,,percent of total billed charges,97% of total billed charges,203.88,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85,880.35,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,242.85,121.43,,218.57,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,194.28,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.57,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,235.56,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,223.42,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,218.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,170,70,,,percent of total billed charges,70% of total billed charges,218.57,90,,,percent of total billed charges,90% of total billed charges,230.71,95,,,percent of total billed charges,95% of total billed charges,230.71,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208.85,86,,,percent of total billed charges,86% of total billed charges,194.28,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,235.56,97,,,percent of total billed charges,97% of total billed charges,218.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.56,97,,,percent of total billed charges,97% of total billed charges,225.85,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,235.56,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,880.35,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,259.89,129.95,,233.9,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,207.91,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.9,90,,,Percent of total Billed charges,90% of total billed charges,121.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,252.09,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,239.1,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,233.9,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,181.92,70,,,percent of total billed charges,70% of total billed charges,233.9,90,,,percent of total billed charges,90% of total billed charges,246.9,95,,,percent of total billed charges,95% of total billed charges,246.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,223.51,86,,,percent of total billed charges,86% of total billed charges,207.91,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,252.09,97,,,percent of total billed charges,97% of total billed charges,233.9,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.09,97,,,percent of total billed charges,97% of total billed charges,241.7,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,252.09,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.56,1818.76,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,305.13,152.57,,274.62,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,244.1,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.62,90,,,Percent of total Billed charges,90% of total billed charges,141.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,295.98,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,280.72,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,274.62,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,213.59,70,,,percent of total billed charges,70% of total billed charges,274.62,90,,,percent of total billed charges,90% of total billed charges,289.87,95,,,percent of total billed charges,95% of total billed charges,289.87,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,262.41,86,,,percent of total billed charges,86% of total billed charges,244.1,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,295.98,97,,,percent of total billed charges,97% of total billed charges,274.62,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.98,97,,,percent of total billed charges,97% of total billed charges,283.77,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,295.98,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.61,1818.76,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,189.76,94.88,,170.78,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,151.81,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.78,90,,,Percent of total Billed charges,90% of total billed charges,62.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.07,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,174.58,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.78,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,132.83,70,,,percent of total billed charges,70% of total billed charges,170.78,90,,,percent of total billed charges,90% of total billed charges,180.27,95,,,percent of total billed charges,95% of total billed charges,180.27,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.19,86,,,percent of total billed charges,86% of total billed charges,151.81,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.07,97,,,percent of total billed charges,97% of total billed charges,170.78,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.07,97,,,percent of total billed charges,97% of total billed charges,176.48,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.07,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.1,880.34,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,208.48,104.24,,187.63,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,166.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.63,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.23,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,191.8,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,145.94,70,,,percent of total billed charges,70% of total billed charges,187.63,90,,,percent of total billed charges,90% of total billed charges,198.06,95,,,percent of total billed charges,95% of total billed charges,198.06,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.29,86,,,percent of total billed charges,86% of total billed charges,166.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.23,97,,,percent of total billed charges,97% of total billed charges,187.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.23,97,,,percent of total billed charges,97% of total billed charges,193.89,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.23,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,880.34,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,240.85,120.43,,216.77,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,192.68,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.77,90,,,Percent of total Billed charges,90% of total billed charges,112.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.62,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,221.58,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.77,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,168.6,70,,,percent of total billed charges,70% of total billed charges,216.77,90,,,percent of total billed charges,90% of total billed charges,228.81,95,,,percent of total billed charges,95% of total billed charges,228.81,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,207.13,86,,,percent of total billed charges,86% of total billed charges,192.68,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.62,97,,,percent of total billed charges,97% of total billed charges,216.77,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.62,97,,,percent of total billed charges,97% of total billed charges,223.99,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.62,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.26,880.35,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,272.65,136.33,,245.39,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,218.12,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.39,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,264.47,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,250.84,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,245.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,190.86,70,,,percent of total billed charges,70% of total billed charges,245.39,90,,,percent of total billed charges,90% of total billed charges,259.02,95,,,percent of total billed charges,95% of total billed charges,259.02,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,234.48,86,,,percent of total billed charges,86% of total billed charges,218.12,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,264.47,97,,,percent of total billed charges,97% of total billed charges,245.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.47,97,,,percent of total billed charges,97% of total billed charges,253.56,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,264.47,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,1818.76,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,333.31,166.66,,299.98,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,266.65,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.98,90,,,Percent of total Billed charges,90% of total billed charges,158.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,323.31,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,306.65,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,299.98,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,233.32,70,,,percent of total billed charges,70% of total billed charges,299.98,90,,,percent of total billed charges,90% of total billed charges,316.64,95,,,percent of total billed charges,95% of total billed charges,316.64,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,286.65,86,,,percent of total billed charges,86% of total billed charges,266.65,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,323.31,97,,,percent of total billed charges,97% of total billed charges,299.98,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.31,97,,,percent of total billed charges,97% of total billed charges,309.98,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,323.31,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,144.48,1818.76,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,403.39,201.70,,363.05,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,322.71,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.05,90,,,Percent of total Billed charges,90% of total billed charges,192.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,391.29,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,371.12,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,363.05,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,282.37,70,,,percent of total billed charges,70% of total billed charges,363.05,90,,,percent of total billed charges,90% of total billed charges,383.22,95,,,percent of total billed charges,95% of total billed charges,383.22,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,346.92,86,,,percent of total billed charges,86% of total billed charges,322.71,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,391.29,97,,,percent of total billed charges,97% of total billed charges,363.05,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.29,97,,,percent of total billed charges,97% of total billed charges,375.15,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,391.29,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,175.35,1818.76,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,172.12,86.06,,154.91,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,137.7,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.91,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,166.96,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,158.35,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.91,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,120.48,70,,,percent of total billed charges,70% of total billed charges,154.91,90,,,percent of total billed charges,90% of total billed charges,163.51,95,,,percent of total billed charges,95% of total billed charges,163.51,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.02,86,,,percent of total billed charges,86% of total billed charges,137.7,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,166.96,97,,,percent of total billed charges,97% of total billed charges,154.91,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.96,97,,,percent of total billed charges,97% of total billed charges,160.07,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,166.96,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,880.35,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,235,117.50,,211.5,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,188,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.5,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,227.95,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,216.2,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,211.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,164.5,70,,,percent of total billed charges,70% of total billed charges,211.5,90,,,percent of total billed charges,90% of total billed charges,223.25,95,,,percent of total billed charges,95% of total billed charges,223.25,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.1,86,,,percent of total billed charges,86% of total billed charges,188,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,227.95,97,,,percent of total billed charges,97% of total billed charges,211.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.95,97,,,percent of total billed charges,97% of total billed charges,218.55,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.95,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,1818.76,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,271.36,135.68,,244.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,217.09,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.22,90,,,Percent of total Billed charges,90% of total billed charges,129.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,263.22,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,249.65,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,244.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,189.95,70,,,percent of total billed charges,70% of total billed charges,244.22,90,,,percent of total billed charges,90% of total billed charges,257.79,95,,,percent of total billed charges,95% of total billed charges,257.79,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,233.37,86,,,percent of total billed charges,86% of total billed charges,217.09,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,263.22,97,,,percent of total billed charges,97% of total billed charges,244.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.22,97,,,percent of total billed charges,97% of total billed charges,252.36,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,263.22,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.39,1818.76,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,340.43,170.22,,306.39,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,272.34,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.39,90,,,Percent of total Billed charges,90% of total billed charges,162.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,330.22,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,313.2,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,306.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,238.3,70,,,percent of total billed charges,70% of total billed charges,306.39,90,,,percent of total billed charges,90% of total billed charges,323.41,95,,,percent of total billed charges,95% of total billed charges,323.41,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,292.77,86,,,percent of total billed charges,86% of total billed charges,272.34,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,330.22,97,,,percent of total billed charges,97% of total billed charges,306.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.22,97,,,percent of total billed charges,97% of total billed charges,316.6,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,330.22,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,147.67,1818.76,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,396.61,198.31,,356.95,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,317.29,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.95,90,,,Percent of total Billed charges,90% of total billed charges,194.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,384.71,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,364.88,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,356.95,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,277.63,70,,,percent of total billed charges,70% of total billed charges,356.95,90,,,percent of total billed charges,90% of total billed charges,376.78,95,,,percent of total billed charges,95% of total billed charges,376.78,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,341.08,86,,,percent of total billed charges,86% of total billed charges,317.29,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,384.71,97,,,percent of total billed charges,97% of total billed charges,356.95,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.71,97,,,percent of total billed charges,97% of total billed charges,368.85,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.71,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.23,2832.2,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,539.99,270.00,,485.99,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,431.99,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.99,90,,,Percent of total Billed charges,90% of total billed charges,267.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,523.79,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,496.79,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,485.99,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,377.99,70,,,percent of total billed charges,70% of total billed charges,485.99,90,,,percent of total billed charges,90% of total billed charges,512.99,95,,,percent of total billed charges,95% of total billed charges,512.99,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,464.39,86,,,percent of total billed charges,86% of total billed charges,431.99,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,523.79,97,,,percent of total billed charges,97% of total billed charges,485.99,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.79,97,,,percent of total billed charges,97% of total billed charges,502.19,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.79,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,242.78,2832.2,
17340 Cryotherapy of skin,3428315,CDM,983,RC,17340,HCPCS,Outpatient,,,98.28,49.14,,88.45,90,,,percent of total billed charges,90% of total Billed charges,98.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.18,155,,,Fee Schedule,155% of CMS OPPS Rate,47.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.18,155,,,Fee Schedule,155% of CMS OPPS Rate,47.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.55,155,,,Fee Schedule,155% of CMS OPPS Rate,152.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.77,152.55,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,340,170.00,,306,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,272,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,306,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,329.8,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,312.8,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,306,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,238,70,,,percent of total billed charges,70% of total billed charges,306,90,,,percent of total billed charges,90% of total billed charges,323,95,,,percent of total billed charges,95% of total billed charges,323,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,292.4,86,,,percent of total billed charges,86% of total billed charges,272,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,329.8,97,,,percent of total billed charges,97% of total billed charges,306,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.8,97,,,percent of total billed charges,97% of total billed charges,316.2,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,329.8,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,880.35,
19000- Drainage Of Breast Lesion,3431635,CDM,360,RC,19000,HCPCS,Outpatient,,,257.32,128.66,,231.59,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,205.86,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.59,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,249.6,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,236.73,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,231.59,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,180.12,70,,,percent of total billed charges,70% of total billed charges,231.59,90,,,percent of total billed charges,90% of total billed charges,244.45,95,,,percent of total billed charges,95% of total billed charges,244.45,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,221.3,86,,,percent of total billed charges,86% of total billed charges,205.86,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,249.6,97,,,percent of total billed charges,97% of total billed charges,231.59,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.6,97,,,percent of total billed charges,97% of total billed charges,239.31,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,249.6,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,3163.8,
US add Aspiration Breast Cyst,645158,CDM,320,RC,19000,HCPCS,Outpatient,,,250.9,125.45,,225.81,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,200.72,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.81,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.37,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,230.83,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225.81,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,175.63,70,,,percent of total billed charges,70% of total billed charges,225.81,90,,,percent of total billed charges,90% of total billed charges,238.36,95,,,percent of total billed charges,95% of total billed charges,238.36,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215.77,86,,,percent of total billed charges,86% of total billed charges,200.72,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,243.37,97,,,percent of total billed charges,97% of total billed charges,225.81,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.37,97,,,percent of total billed charges,97% of total billed charges,233.34,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.37,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,3163.8,
19001- Punc asp breast cyst ea additional,3428771,CDM,360,RC,19001,HCPCS,Outpatient,,,69.44,34.72,,62.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,55.55,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,62.5,90,,,Percent of total Billed charges,90% of total billed charges,22.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,67.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,63.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,44.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,54.62,78.65,,,percent of total billed charges,78.65% of total billed charges,62.03,89.33,,,percent of total billed charges,89.33% of total billed charges,62.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.61,70,,,percent of total billed charges,70% of total billed charges,62.5,90,,,percent of total billed charges,90% of total billed charges,65.97,95,,,percent of total billed charges,95% of total billed charges,65.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.72,86,,,percent of total billed charges,86% of total billed charges,55.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,67.36,97,,,percent of total billed charges,97% of total billed charges,62.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.36,97,,,percent of total billed charges,97% of total billed charges,64.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,67.36,
19020-,3428772,CDM,361,RC,19020,HCPCS,Outpatient,,,1196.78,598.39,,1077.1,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,957.42,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1077.1,90,,,Percent of total Billed charges,90% of total billed charges,80.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1160.88,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1101.04,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1077.1,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,837.75,70,,,percent of total billed charges,70% of total billed charges,1077.1,90,,,percent of total billed charges,90% of total billed charges,1136.94,95,,,percent of total billed charges,95% of total billed charges,1136.94,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1029.23,86,,,percent of total billed charges,86% of total billed charges,957.42,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1160.88,97,,,percent of total billed charges,97% of total billed charges,1077.1,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.88,97,,,percent of total billed charges,97% of total billed charges,1113.01,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1160.88,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73,7310.49,
19020-PF MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP,4322005,CDM,981,RC,19020,HCPCS,Outpatient,,,609.88,304.94,,548.89,90,,,percent of total billed charges,90% of total Billed charges,754.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,472.66,155,,,Fee Schedule,155% of CMS OPPS Rate,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,246.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,545.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,371.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,472.66,155,,,Fee Schedule,155% of CMS OPPS Rate,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1170.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1170.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,388.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,915.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73,1170.2,
MA rad inj Ductogram/Galactogram,3922894,CDM,320,RC,19030,HCPCS,Outpatient,,,408.5,204.25,,367.65,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,326.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,367.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,396.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,375.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,260.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,321.29,78.65,,,percent of total billed charges,78.65% of total billed charges,364.92,89.33,,,percent of total billed charges,89.33% of total billed charges,367.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,285.95,70,,,percent of total billed charges,70% of total billed charges,367.65,90,,,percent of total billed charges,90% of total billed charges,388.08,95,,,percent of total billed charges,95% of total billed charges,388.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.31,86,,,percent of total billed charges,86% of total billed charges,326.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,396.25,97,,,percent of total billed charges,97% of total billed charges,367.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,396.25,97,,,percent of total billed charges,97% of total billed charges,379.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.88,396.25,
19081- Bx breast 1st lesion w/o US,3428775,CDM,320,RC,19081,HCPCS,Outpatient,,,1264.59,632.30,,1138.13,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.67,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.13,90,,,Percent of total Billed charges,90% of total billed charges,163.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1226.65,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.42,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,885.21,70,,,percent of total billed charges,70% of total billed charges,1138.13,90,,,percent of total billed charges,90% of total billed charges,1201.36,95,,,percent of total billed charges,95% of total billed charges,1201.36,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.55,86,,,percent of total billed charges,86% of total billed charges,1011.67,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.65,97,,,percent of total billed charges,97% of total billed charges,1138.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.65,97,,,percent of total billed charges,97% of total billed charges,1176.07,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1226.65,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.3,7310.49,
MA Stereostatic Bilat Breast Biopsy,3310457,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,1103.49,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,980.88,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1103.49,90,,,Percent of total Billed charges,90% of total billed charges,163.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1189.32,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.01,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,858.27,70,,,percent of total billed charges,70% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1054.45,86,,,percent of total billed charges,86% of total billed charges,980.88,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1189.32,97,,,percent of total billed charges,97% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1189.32,97,,,percent of total billed charges,97% of total billed charges,1140.27,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1189.32,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.3,7310.49,
MA Stereostatic Lt Breast Biopsy,3310459,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,1103.49,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,980.88,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1103.49,90,,,Percent of total Billed charges,90% of total billed charges,163.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1189.32,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.01,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,858.27,70,,,percent of total billed charges,70% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1054.45,86,,,percent of total billed charges,86% of total billed charges,980.88,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1189.32,97,,,percent of total billed charges,97% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1189.32,97,,,percent of total billed charges,97% of total billed charges,1140.27,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1189.32,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.3,7310.49,
MA Stereostatic Rt Breast Biopsy,3310461,CDM,320,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,1103.49,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,980.88,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1103.49,90,,,Percent of total Billed charges,90% of total billed charges,163.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1189.32,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.01,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,858.27,70,,,percent of total billed charges,70% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1164.8,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1054.45,86,,,percent of total billed charges,86% of total billed charges,980.88,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1189.32,97,,,percent of total billed charges,97% of total billed charges,1103.49,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1189.32,97,,,percent of total billed charges,97% of total billed charges,1140.27,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1189.32,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.3,7310.49,
MA Stereotactic Lt Breast Biopsy:Read,603846,CDM,972,RC,19081,HCPCS,Outpatient,,,1226.1,613.05,,1103.49,90,,,percent of total billed charges,90% of total Billed charges,636.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,986.22,155,,,Fee Schedule,155% of CMS OPPS Rate,986.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,705.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,1103.49,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,510,RC,19082,HCPCS,Outpatient,,,976,488.00,,878.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,780.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,878.4,90,,,Percent of total Billed charges,90% of total billed charges,77.42,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,897.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,623.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,767.65,78.65,,,percent of total billed charges,78.65% of total billed charges,871.88,89.33,,,percent of total billed charges,89.33% of total billed charges,878.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,683.2,70,,,percent of total billed charges,70% of total billed charges,878.4,90,,,percent of total billed charges,90% of total billed charges,927.2,95,,,percent of total billed charges,95% of total billed charges,927.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.36,86,,,percent of total billed charges,86% of total billed charges,780.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,946.72,97,,,percent of total billed charges,97% of total billed charges,878.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.72,97,,,percent of total billed charges,97% of total billed charges,907.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,946.72,
MA Stereo Each Additional Placement,3310463,CDM,320,RC,19082,HCPCS,Outpatient,,,936.3,468.15,,842.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,749.04,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,842.67,90,,,Percent of total Billed charges,90% of total billed charges,77.42,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,908.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,861.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,597.94,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,736.42,78.65,,,percent of total billed charges,78.65% of total billed charges,836.41,89.33,,,percent of total billed charges,89.33% of total billed charges,842.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,655.41,70,,,percent of total billed charges,70% of total billed charges,842.67,90,,,percent of total billed charges,90% of total billed charges,889.49,95,,,percent of total billed charges,95% of total billed charges,889.49,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.22,86,,,percent of total billed charges,86% of total billed charges,749.04,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,908.21,97,,,percent of total billed charges,97% of total billed charges,842.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,908.21,97,,,percent of total billed charges,97% of total billed charges,870.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,908.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,908.21,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,401,RC,19083,HCPCS,Outpatient,,,1276.8,638.40,,1149.12,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.44,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.12,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1238.5,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1174.66,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1149.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,893.76,70,,,percent of total billed charges,70% of total billed charges,1149.12,90,,,percent of total billed charges,90% of total billed charges,1212.96,95,,,percent of total billed charges,95% of total billed charges,1212.96,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1098.05,86,,,percent of total billed charges,86% of total billed charges,1021.44,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1238.5,97,,,percent of total billed charges,97% of total billed charges,1149.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1238.5,97,,,percent of total billed charges,97% of total billed charges,1187.42,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1238.5,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
Read,3317779,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,440.14,90,,,percent of total billed charges,90% of total Billed charges,631.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,285.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.19,155,,,Fee Schedule,155% of CMS OPPS Rate,978.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.89,978.19,
Read,3317786,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,440.14,90,,,percent of total billed charges,90% of total Billed charges,631.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,285.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.19,155,,,Fee Schedule,155% of CMS OPPS Rate,978.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.89,978.19,
Read,3317793,CDM,972,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,440.14,90,,,percent of total billed charges,90% of total Billed charges,631.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,285.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.19,155,,,Fee Schedule,155% of CMS OPPS Rate,978.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.89,978.19,
Read,3370945,CDM,402,RC,19083,HCPCS,Outpatient,,,489.04,244.52,,440.14,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,391.23,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.14,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,474.37,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,449.92,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,440.14,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,342.33,70,,,percent of total billed charges,70% of total billed charges,440.14,90,,,percent of total billed charges,90% of total billed charges,464.59,95,,,percent of total billed charges,95% of total billed charges,464.59,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,420.57,86,,,percent of total billed charges,86% of total billed charges,391.23,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,474.37,97,,,percent of total billed charges,97% of total billed charges,440.14,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,474.37,97,,,percent of total billed charges,97% of total billed charges,454.81,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,474.37,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
US Breast Biopsy Bilateral,645152,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.30,,1100.34,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,978.08,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.34,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1185.92,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,855.82,70,,,percent of total billed charges,70% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.44,86,,,percent of total billed charges,86% of total billed charges,978.08,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1185.92,97,,,percent of total billed charges,97% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1185.92,97,,,percent of total billed charges,97% of total billed charges,1137.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1185.92,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
US Breast Biopsy Lt,3310496,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.30,,1100.34,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,978.08,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.34,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1185.92,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,855.82,70,,,percent of total billed charges,70% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.44,86,,,percent of total billed charges,86% of total billed charges,978.08,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1185.92,97,,,percent of total billed charges,97% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1185.92,97,,,percent of total billed charges,97% of total billed charges,1137.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1185.92,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
US Breast Biopsy Rt,3310542,CDM,320,RC,19083,HCPCS,Outpatient,,,1222.6,611.30,,1100.34,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,978.08,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.34,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1185.92,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,855.82,70,,,percent of total billed charges,70% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.44,86,,,percent of total billed charges,86% of total billed charges,978.08,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1185.92,97,,,percent of total billed charges,97% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1185.92,97,,,percent of total billed charges,97% of total billed charges,1137.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1185.92,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
US Vacuum Assist biopsy,652800,CDM,401,RC,19083,HCPCS,Outpatient,,,1222.6,611.30,,1100.34,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,978.08,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.34,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1185.92,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,855.82,70,,,percent of total billed charges,70% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1161.47,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.44,86,,,percent of total billed charges,86% of total billed charges,978.08,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1185.92,97,,,percent of total billed charges,97% of total billed charges,1100.34,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1185.92,97,,,percent of total billed charges,97% of total billed charges,1137.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1185.92,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,510,RC,19084,HCPCS,Outpatient,,,963.48,481.74,,867.13,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,770.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,867.13,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,934.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,886.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,615.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,757.8,78.65,,,percent of total billed charges,78.65% of total billed charges,860.69,89.33,,,percent of total billed charges,89.33% of total billed charges,867.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,674.44,70,,,percent of total billed charges,70% of total billed charges,867.13,90,,,percent of total billed charges,90% of total billed charges,915.31,95,,,percent of total billed charges,95% of total billed charges,915.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,828.59,86,,,percent of total billed charges,86% of total billed charges,770.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,934.58,97,,,percent of total billed charges,97% of total billed charges,867.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,934.58,97,,,percent of total billed charges,97% of total billed charges,896.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,934.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,934.58,
"19084 Biopsy, breast, with placement of breast localization device(s) ProFee",3621150,CDM,510,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,182.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,182.07,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,196.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,186.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,129.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,159.11,78.65,,,percent of total billed charges,78.65% of total billed charges,180.72,89.33,,,percent of total billed charges,89.33% of total billed charges,182.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.61,70,,,percent of total billed charges,70% of total billed charges,182.07,90,,,percent of total billed charges,90% of total billed charges,192.19,95,,,percent of total billed charges,95% of total billed charges,192.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.98,86,,,percent of total billed charges,86% of total billed charges,161.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.23,97,,,percent of total billed charges,97% of total billed charges,182.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.23,97,,,percent of total billed charges,97% of total billed charges,188.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,196.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,196.23,
US Breast Biopsy Each Additional,3310548,CDM,401,RC,19084,HCPCS,Outpatient,,,921.54,460.77,,829.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,737.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,829.39,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,893.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,847.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,588.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,724.81,78.65,,,percent of total billed charges,78.65% of total billed charges,823.23,89.33,,,percent of total billed charges,89.33% of total billed charges,829.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,645.08,70,,,percent of total billed charges,70% of total billed charges,829.39,90,,,percent of total billed charges,90% of total billed charges,875.46,95,,,percent of total billed charges,95% of total billed charges,875.46,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,792.52,86,,,percent of total billed charges,86% of total billed charges,737.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,893.89,97,,,percent of total billed charges,97% of total billed charges,829.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,893.89,97,,,percent of total billed charges,97% of total billed charges,857.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,893.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,893.89,
19100- Bx breast percut w/o image,3428778,CDM,401,RC,19100,HCPCS,Outpatient,,,393.47,196.74,,354.12,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,314.78,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.12,90,,,Percent of total Billed charges,90% of total billed charges,67.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,381.67,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,361.99,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,354.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,275.43,70,,,percent of total billed charges,70% of total billed charges,354.12,90,,,percent of total billed charges,90% of total billed charges,373.8,95,,,percent of total billed charges,95% of total billed charges,373.8,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,338.38,86,,,percent of total billed charges,86% of total billed charges,314.78,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,381.67,97,,,percent of total billed charges,97% of total billed charges,354.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.67,97,,,percent of total billed charges,97% of total billed charges,365.93,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.67,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.25,7310.49,
19101-MSA BIOPSY OF BREAST OPEN,3428779,CDM,360,RC,19101,HCPCS,Outpatient,,,855.9,427.95,,770.31,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,684.72,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,770.31,90,,,Percent of total Billed charges,90% of total billed charges,160.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,830.22,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,787.43,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,770.31,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,599.13,70,,,percent of total billed charges,70% of total billed charges,770.31,90,,,percent of total billed charges,90% of total billed charges,813.11,95,,,percent of total billed charges,95% of total billed charges,813.11,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,736.07,86,,,percent of total billed charges,86% of total billed charges,684.72,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,830.22,97,,,percent of total billed charges,97% of total billed charges,770.31,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.22,97,,,percent of total billed charges,97% of total billed charges,795.99,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,146,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,830.22,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,146,16759.7,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,510,RC,19110,HCPCS,Outpatient,,,1254.75,627.38,,1129.28,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1003.8,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1129.28,90,,,Percent of total Billed charges,90% of total billed charges,217.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1217.11,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1154.37,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1129.28,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,878.33,70,,,percent of total billed charges,70% of total billed charges,1129.28,90,,,percent of total billed charges,90% of total billed charges,1192.01,95,,,percent of total billed charges,95% of total billed charges,1192.01,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1079.09,86,,,percent of total billed charges,86% of total billed charges,1003.8,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1217.11,97,,,percent of total billed charges,97% of total billed charges,1129.28,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.11,97,,,percent of total billed charges,97% of total billed charges,1166.92,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,198,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1217.11,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,198,16759.7,
19120- Removal of breast lesion,3428780,CDM,360,RC,19120,HCPCS,Outpatient,,,1349.16,674.58,,1214.24,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1079.33,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1214.24,90,,,Percent of total Billed charges,90% of total billed charges,190.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1308.69,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1241.23,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1214.24,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,944.41,70,,,percent of total billed charges,70% of total billed charges,1214.24,90,,,percent of total billed charges,90% of total billed charges,1281.7,95,,,percent of total billed charges,95% of total billed charges,1281.7,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1160.28,86,,,percent of total billed charges,86% of total billed charges,1079.33,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1308.69,97,,,percent of total billed charges,97% of total billed charges,1214.24,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1308.69,97,,,percent of total billed charges,97% of total billed charges,1254.72,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1308.69,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173,16759.7,
19125 - PF Exc Breast Les Preop Plmt Rad Marker Open 1 Les PF,4305374,CDM,960,RC,19125,HCPCS,Outpatient,,,1228.24,614.12,,1105.42,90,,,percent of total billed charges,90% of total Billed charges,1020.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,711.12,155,,,Fee Schedule,155% of CMS OPPS Rate,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,458.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,694.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,704.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,704.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,917.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,830.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,587.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,711.12,155,,,Fee Schedule,155% of CMS OPPS Rate,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1581.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,487.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1081.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1081.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.97,1581.17,
19125- Excision breast lesion,3428781,CDM,960,RC,19125,HCPCS,Outpatient,,,1228.24,614.12,,1105.42,90,,,percent of total billed charges,90% of total Billed charges,1020.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,711.12,155,,,Fee Schedule,155% of CMS OPPS Rate,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,458.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,694.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,704.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,704.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,917.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,830.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,587.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,711.12,155,,,Fee Schedule,155% of CMS OPPS Rate,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1581.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,487.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,458.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1081.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1081.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.97,1581.17,
19126 - PF Exc Brst Les Preop Plmt Rad Marker Opn Ea Addl PF,4305371,CDM,960,RC,19126,HCPCS,Outpatient,,,343.95,171.98,,309.56,90,,,percent of total billed charges,90% of total Billed charges,326.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,251.46,155,,,Fee Schedule,155% of CMS OPPS Rate,162.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,254.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,254.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,299.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,219.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,251.46,155,,,Fee Schedule,155% of CMS OPPS Rate,162.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,506.6,155,,,Fee Schedule,155% of CMS OPPS Rate,506.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,328.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,130.37,506.6,
Read,603866,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,213.26,90,,,percent of total billed charges,90% of total Billed charges,321.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.48,155,,,Fee Schedule,155% of CMS OPPS Rate,498.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.59,498.48,
Read,603868,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,213.26,90,,,percent of total billed charges,90% of total Billed charges,321.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.48,155,,,Fee Schedule,155% of CMS OPPS Rate,498.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.59,498.48,
Read,603870,CDM,972,RC,19281,HCPCS,Outpatient,,,236.95,118.48,,213.26,90,,,percent of total billed charges,90% of total Billed charges,321.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.99,155,,,Fee Schedule,155% of CMS OPPS Rate,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.48,155,,,Fee Schedule,155% of CMS OPPS Rate,498.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.59,498.48,
MA Mammo Each Additional Loc,603408,CDM,320,RC,19282,HCPCS,Outpatient,,,414.73,207.37,,373.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,331.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,373.26,90,,,Percent of total Billed charges,90% of total billed charges,43.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,402.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,381.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,264.86,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,326.19,78.65,,,percent of total billed charges,78.65% of total billed charges,370.48,89.33,,,percent of total billed charges,89.33% of total billed charges,373.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,290.31,70,,,percent of total billed charges,70% of total billed charges,373.26,90,,,percent of total billed charges,90% of total billed charges,393.99,95,,,percent of total billed charges,95% of total billed charges,393.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.67,86,,,percent of total billed charges,86% of total billed charges,331.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,402.29,97,,,percent of total billed charges,97% of total billed charges,373.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,402.29,97,,,percent of total billed charges,97% of total billed charges,385.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,402.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,402.29,
US add Needle Localization,652878,CDM,320,RC,19285,HCPCS,Outpatient,,,895.22,447.61,,805.7,90,,,percent of total billed charges,90% of total Billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,716.18,80,,,Percent of total Billed charges,80% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,805.7,90,,,Percent of total Billed charges,90% of total billed charges,77.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,868.36,97,,,Percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,823.6,92,,,Percent of total billed charges,92% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,805.7,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,626.65,70,,,percent of total billed charges,70% of total billed charges,805.7,90,,,percent of total billed charges,90% of total billed charges,850.46,95,,,percent of total billed charges,95% of total billed charges,850.46,95,,,percent of total billed charges,95% of total billed charges,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,769.89,86,,,percent of total billed charges,86% of total billed charges,716.18,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,868.36,97,,,percent of total billed charges,97% of total billed charges,805.7,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,868.36,97,,,percent of total billed charges,97% of total billed charges,832.55,93,,,percent of total billed charges,93% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,868.36,97,,,percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.71,3163.81,
19300 - Mastectomy for gynecomastia,3898978,CDM,983,RC,19300,HCPCS,Outpatient,,,1495.53,747.77,,1345.98,90,,,percent of total billed charges,90% of total Billed charges,984.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.52,155,,,Fee Schedule,155% of CMS OPPS Rate,422.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,743.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,506.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,654.52,155,,,Fee Schedule,155% of CMS OPPS Rate,422.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1526.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1526.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,492.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1017.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1017.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,332.11,1526.19,
19301 Partial Mastectomy,3550405,CDM,510,RC,19301,HCPCS,Outpatient,,,1769.31,884.66,,1592.38,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1415.45,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1592.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1716.23,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1627.77,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1592.38,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1238.52,70,,,percent of total billed charges,70% of total billed charges,1592.38,90,,,percent of total billed charges,90% of total billed charges,1680.84,95,,,percent of total billed charges,95% of total billed charges,1680.84,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1521.61,86,,,percent of total billed charges,86% of total billed charges,1415.45,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1716.23,97,,,percent of total billed charges,97% of total billed charges,1592.38,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1716.23,97,,,percent of total billed charges,97% of total billed charges,1645.46,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1716.23,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1238.52,16759.7,
"19303- Mastectomy, simple, complete",3569390,CDM,510,RC,19303,HCPCS,Outpatient,,,2571.8,1285.90,,2314.62,90,,,percent of total billed charges,90% of total Billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.44,80,,,Percent of total Billed charges,80% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2314.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2494.65,97,,,Percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2366.06,92,,,Percent of total billed charges,92% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14348.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22874.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28973.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2314.62,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1800.26,70,,,percent of total billed charges,70% of total billed charges,2314.62,90,,,percent of total billed charges,90% of total billed charges,2443.21,95,,,percent of total billed charges,95% of total billed charges,2443.21,95,,,percent of total billed charges,95% of total billed charges,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10795.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2211.75,86,,,percent of total billed charges,86% of total billed charges,2057.44,80,,,percent of total billed charges,80% of total billed charges,5414.7,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2494.65,97,,,percent of total billed charges,97% of total billed charges,2314.62,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2494.65,97,,,percent of total billed charges,97% of total billed charges,2391.77,93,,,percent of total billed charges,93% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2494.65,97,,,percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,5397.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4588.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1800.26,28973.61,
"19307 - Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis min",3572798,CDM,960,RC,19307,HCPCS,Outpatient,,,3161.49,1580.75,,2845.34,90,,,percent of total billed charges,90% of total Billed charges,2365.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1176.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2806.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1823.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1176.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1176.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1822.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1822.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1856.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1856.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,962.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2353,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2190.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1558.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1823.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1176.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,3666.26,155,,,Fee Schedule,155% of CMS OPPS Rate,3666.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1176.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1196.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1176.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2401.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2401.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,962.94,3666.26,
19316- Mastopexy,3431639,CDM,510,RC,19316,HCPCS,Outpatient,,,2063.18,1031.59,,1856.86,90,,,percent of total billed charges,90% of total Billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1650.54,80,,,Percent of total Billed charges,80% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1856.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2001.28,97,,,Percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1898.13,92,,,Percent of total billed charges,92% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14348.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22874.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28973.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1856.86,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1444.23,70,,,percent of total billed charges,70% of total billed charges,1856.86,90,,,percent of total billed charges,90% of total billed charges,1960.02,95,,,percent of total billed charges,95% of total billed charges,1960.02,95,,,percent of total billed charges,95% of total billed charges,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10795.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1774.33,86,,,percent of total billed charges,86% of total billed charges,1650.54,80,,,percent of total billed charges,80% of total billed charges,5414.7,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2001.28,97,,,percent of total billed charges,97% of total billed charges,1856.86,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2001.28,97,,,percent of total billed charges,97% of total billed charges,1918.76,93,,,percent of total billed charges,93% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2001.28,97,,,percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,5397.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4588.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1444.23,28973.61,
20101- Explore penetrating wound/chest,3434642,CDM,510,RC,20101,HCPCS,Outpatient,,,1494.22,747.11,,1344.8,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1195.38,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1449.39,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1374.68,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1344.8,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.95,70,,,percent of total billed charges,70% of total billed charges,1344.8,90,,,percent of total billed charges,90% of total billed charges,1419.51,95,,,percent of total billed charges,95% of total billed charges,1419.51,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1285.03,86,,,percent of total billed charges,86% of total billed charges,1195.38,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1449.39,97,,,percent of total billed charges,97% of total billed charges,1344.8,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.39,97,,,percent of total billed charges,97% of total billed charges,1389.62,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1449.39,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1045.95,8413.78,
20103 - PF Exploration Penetrating Wound Spx Extremity,4311480,CDM,960,RC,20103,HCPCS,Outpatient,,,804.9,402.45,,724.41,90,,,percent of total billed charges,90% of total Billed charges,880.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.42,155,,,Fee Schedule,155% of CMS OPPS Rate,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,338.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,521.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,526.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,526.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,335.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,620.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,420.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,525.42,155,,,Fee Schedule,155% of CMS OPPS Rate,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1364.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1364.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,438.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1149.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,335.05,1364.23,
20103- Explore penetrating wnd/extremity,3434643,CDM,510,RC,20103,HCPCS,Outpatient,,,1439.15,719.58,,1295.24,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.32,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1295.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1395.98,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1324.02,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1295.24,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1007.41,70,,,percent of total billed charges,70% of total billed charges,1295.24,90,,,percent of total billed charges,90% of total billed charges,1367.19,95,,,percent of total billed charges,95% of total billed charges,1367.19,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1237.67,86,,,percent of total billed charges,86% of total billed charges,1151.32,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1395.98,97,,,percent of total billed charges,97% of total billed charges,1295.24,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.98,97,,,percent of total billed charges,97% of total billed charges,1338.41,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1395.98,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,630.67,7310.49,
20103-PF EXPLORATION PENETRATING WOUND SPX EXTREMITY,4322004,CDM,981,RC,20103,HCPCS,Outpatient,,,677.98,338.99,,610.18,90,,,percent of total billed charges,90% of total Billed charges,880.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.42,155,,,Fee Schedule,155% of CMS OPPS Rate,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,338.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,521.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,526.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,526.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,335.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,620.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,420.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,525.42,155,,,Fee Schedule,155% of CMS OPPS Rate,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1364.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1364.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,438.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,338.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1149.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,335.05,1364.23,
20200- Biopsy/muscle/superficial,3434644,CDM,510,RC,20200,HCPCS,Outpatient,,,554.34,277.17,,498.91,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,443.47,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.91,90,,,Percent of total Billed charges,90% of total billed charges,89.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,537.71,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,509.99,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,498.91,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,388.04,70,,,percent of total billed charges,70% of total billed charges,498.91,90,,,percent of total billed charges,90% of total billed charges,526.62,95,,,percent of total billed charges,95% of total billed charges,526.62,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,476.73,86,,,percent of total billed charges,86% of total billed charges,443.47,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,537.71,97,,,percent of total billed charges,97% of total billed charges,498.91,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.71,97,,,percent of total billed charges,97% of total billed charges,515.54,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.71,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81,7310.49,
20205 - PF Biopsy Muscle Deep,4311481,CDM,960,RC,20205,HCPCS,Outpatient,,,366.71,183.36,,330.04,90,,,percent of total billed charges,90% of total Billed charges,446.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,239.38,155,,,Fee Schedule,155% of CMS OPPS Rate,154.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,236.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,236.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,239.38,155,,,Fee Schedule,155% of CMS OPPS Rate,154.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,692,155,,,Fee Schedule,155% of CMS OPPS Rate,692,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,154.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,278.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,154.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,555.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,555.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99.5,692,
20205- Biopsy/muscle/deep,3434645,CDM,510,RC,20205,HCPCS,Outpatient,,,776.55,388.28,,698.9,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,621.24,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.9,90,,,Percent of total Billed charges,90% of total billed charges,109.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,753.25,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,714.43,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,698.9,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,543.59,70,,,percent of total billed charges,70% of total billed charges,698.9,90,,,percent of total billed charges,90% of total billed charges,737.72,95,,,percent of total billed charges,95% of total billed charges,737.72,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,667.83,86,,,percent of total billed charges,86% of total billed charges,621.24,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,753.25,97,,,percent of total billed charges,97% of total billed charges,698.9,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.25,97,,,percent of total billed charges,97% of total billed charges,722.19,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,753.25,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99.5,12593.67,
CT add Needle Bx Bone Superficial,645132,CDM,350,RC,20220,HCPCS,Outpatient,,,574.5,287.25,,517.05,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,459.6,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.05,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,557.27,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,528.54,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,517.05,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,402.15,70,,,percent of total billed charges,70% of total billed charges,517.05,90,,,percent of total billed charges,90% of total billed charges,545.78,95,,,percent of total billed charges,95% of total billed charges,545.78,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,494.07,86,,,percent of total billed charges,86% of total billed charges,459.6,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,557.27,97,,,percent of total billed charges,97% of total billed charges,517.05,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.27,97,,,percent of total billed charges,97% of total billed charges,534.29,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,557.27,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,7310.49,
Read,4181194,CDM,972,RC,20220,HCPCS,Outpatient,,,229.8,114.90,,206.82,90,,,percent of total billed charges,90% of total Billed charges,308.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,75.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,478.3,155,,,Fee Schedule,155% of CMS OPPS Rate,478.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,293.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63,478.3,
20225- Biopsy/bone/trocar/needle,3434646,CDM,360,RC,20225,HCPCS,Outpatient,,,974.9,487.45,,877.41,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,779.92,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,877.41,90,,,Percent of total Billed charges,90% of total billed charges,107.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,945.65,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,896.91,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,877.41,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,682.43,70,,,percent of total billed charges,70% of total billed charges,877.41,90,,,percent of total billed charges,90% of total billed charges,926.16,95,,,percent of total billed charges,95% of total billed charges,926.16,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,838.41,86,,,percent of total billed charges,86% of total billed charges,779.92,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,945.65,97,,,percent of total billed charges,97% of total billed charges,877.41,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.65,97,,,percent of total billed charges,97% of total billed charges,906.66,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,945.65,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98,7310.49,
CT add Needle Bx Bone Deep,645134,CDM,360,RC,20225,HCPCS,Outpatient,,,936.54,468.27,,842.89,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,749.23,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,842.89,90,,,Percent of total Billed charges,90% of total billed charges,107.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,908.44,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,861.62,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,842.89,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,655.58,70,,,percent of total billed charges,70% of total billed charges,842.89,90,,,percent of total billed charges,90% of total billed charges,889.71,95,,,percent of total billed charges,95% of total billed charges,889.71,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,805.42,86,,,percent of total billed charges,86% of total billed charges,749.23,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,908.44,97,,,percent of total billed charges,97% of total billed charges,842.89,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,908.44,97,,,percent of total billed charges,97% of total billed charges,870.98,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,908.44,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98,7310.49,
Read,4181192,CDM,972,RC,20225,HCPCS,Outpatient,,,374.61,187.31,,337.15,90,,,percent of total billed charges,90% of total Billed charges,492.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,195.44,155,,,Fee Schedule,155% of CMS OPPS Rate,126.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,116.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.44,155,,,Fee Schedule,155% of CMS OPPS Rate,126.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,763.65,155,,,Fee Schedule,155% of CMS OPPS Rate,763.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,126.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,634.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,126.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1045.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,98,1045.16,
20245- Biopsy/bone/open/deep,3434647,CDM,510,RC,20245,HCPCS,Outpatient,,,918.24,459.12,,826.42,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,734.59,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,826.42,90,,,Percent of total Billed charges,90% of total billed charges,248.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,890.69,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,844.78,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,826.42,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,642.77,70,,,percent of total billed charges,70% of total billed charges,826.42,90,,,percent of total billed charges,90% of total billed charges,872.33,95,,,percent of total billed charges,95% of total billed charges,872.33,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,789.69,86,,,percent of total billed charges,86% of total billed charges,734.59,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,890.69,97,,,percent of total billed charges,97% of total billed charges,826.42,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,890.69,97,,,percent of total billed charges,97% of total billed charges,853.96,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,890.69,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.5,12593.67,
20520- Rmv/FB/muscle/tendon sheath/simple,3434648,CDM,510,RC,20520,HCPCS,Outpatient,,,546.51,273.26,,491.86,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,437.21,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.86,90,,,Percent of total Billed charges,90% of total billed charges,68.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,530.11,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,502.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,491.86,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,382.56,70,,,percent of total billed charges,70% of total billed charges,491.86,90,,,percent of total billed charges,90% of total billed charges,519.18,95,,,percent of total billed charges,95% of total billed charges,519.18,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,470,86,,,percent of total billed charges,86% of total billed charges,437.21,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,530.11,97,,,percent of total billed charges,97% of total billed charges,491.86,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,530.11,97,,,percent of total billed charges,97% of total billed charges,508.25,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,530.11,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.5,7310.49,
20520-PF REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPL,4322003,CDM,981,RC,20520,HCPCS,Outpatient,,,281.92,140.96,,253.73,90,,,percent of total billed charges,90% of total Billed charges,346.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,218.47,155,,,Fee Schedule,155% of CMS OPPS Rate,140.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,218.47,155,,,Fee Schedule,155% of CMS OPPS Rate,140.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.01,155,,,Fee Schedule,155% of CMS OPPS Rate,537.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,140.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,140.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,395.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.5,537.01,
20525- Rmv FB/musc/tend/sheath/deep/comp,3434649,CDM,510,RC,20525,HCPCS,Outpatient,,,1172.53,586.27,,1055.28,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,938.02,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1055.28,90,,,Percent of total Billed charges,90% of total billed charges,132,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1137.35,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1078.73,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1055.28,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,820.77,70,,,percent of total billed charges,70% of total billed charges,1055.28,90,,,percent of total billed charges,90% of total billed charges,1113.9,95,,,percent of total billed charges,95% of total billed charges,1113.9,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1008.38,86,,,percent of total billed charges,86% of total billed charges,938.02,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1137.35,97,,,percent of total billed charges,97% of total billed charges,1055.28,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1137.35,97,,,percent of total billed charges,97% of total billed charges,1090.45,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,120,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1137.35,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,120,12593.67,
20525-PF RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP,4322002,CDM,981,RC,20525,HCPCS,Outpatient,,,482.2,241.10,,433.98,90,,,percent of total billed charges,90% of total Billed charges,682.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.71,155,,,Fee Schedule,155% of CMS OPPS Rate,241.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,370.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,370.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,237.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,291.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,373.71,155,,,Fee Schedule,155% of CMS OPPS Rate,241.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1057.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1057.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,241.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,120,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,392.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,241.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,939.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,939.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120,1057.12,
20526- Inj/therapeutic/carpal tunnel,3434650,CDM,510,RC,20526,HCPCS,Outpatient,,,210.6,105.30,,189.54,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,168.48,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.54,90,,,Percent of total Billed charges,90% of total billed charges,54.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.28,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,193.75,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.54,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,147.42,70,,,percent of total billed charges,70% of total billed charges,189.54,90,,,percent of total billed charges,90% of total billed charges,200.07,95,,,percent of total billed charges,95% of total billed charges,200.07,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.12,86,,,percent of total billed charges,86% of total billed charges,168.48,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.28,97,,,percent of total billed charges,97% of total billed charges,189.54,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.28,97,,,percent of total billed charges,97% of total billed charges,195.86,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.28,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.78,1325.49,
20527- Inj/enzyme/palmar fascial cord,3434651,CDM,510,RC,20527,HCPCS,Outpatient,,,222.74,111.37,,200.47,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,178.19,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,216.06,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,204.92,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,200.47,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,155.92,70,,,percent of total billed charges,70% of total billed charges,200.47,90,,,percent of total billed charges,90% of total billed charges,211.6,95,,,percent of total billed charges,95% of total billed charges,211.6,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,191.56,86,,,percent of total billed charges,86% of total billed charges,178.19,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,216.06,97,,,percent of total billed charges,97% of total billed charges,200.47,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.06,97,,,percent of total billed charges,97% of total billed charges,207.15,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,216.06,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,155.92,1325.49,
20550- Inj/sng ten sheath/lig/aponeurosis,3434652,CDM,360,RC,20550,HCPCS,Outpatient,,,147.17,73.59,,132.45,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,117.74,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.45,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,142.75,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,135.4,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,132.45,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,103.02,70,,,percent of total billed charges,70% of total billed charges,132.45,90,,,percent of total billed charges,90% of total billed charges,139.81,95,,,percent of total billed charges,95% of total billed charges,139.81,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,126.57,86,,,percent of total billed charges,86% of total billed charges,117.74,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,142.75,97,,,percent of total billed charges,97% of total billed charges,132.45,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.75,97,,,percent of total billed charges,97% of total billed charges,136.87,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.75,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,1325.49,
20550-PF INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS,4321318,CDM,981,RC,20550,HCPCS,Outpatient,,,77.48,38.74,,69.73,90,,,percent of total billed charges,90% of total Billed charges,94.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.33,90,,,Percent of total Billed charges,90% of total billed charges,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.03,155,,,Fee Schedule,155% of CMS OPPS Rate,38.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,60.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,60.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.03,155,,,Fee Schedule,155% of CMS OPPS Rate,38.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.79,155,,,Fee Schedule,155% of CMS OPPS Rate,145.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,145.79,
20551- Inj/single tendon origin/insertio,3434653,CDM,510,RC,20551,HCPCS,Outpatient,,,148.44,74.22,,133.6,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,118.75,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.6,90,,,Percent of total Billed charges,90% of total billed charges,42.64,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,143.99,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,136.56,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.6,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,103.91,70,,,percent of total billed charges,70% of total billed charges,133.6,90,,,percent of total billed charges,90% of total billed charges,141.02,95,,,percent of total billed charges,95% of total billed charges,141.02,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.66,86,,,percent of total billed charges,86% of total billed charges,118.75,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,143.99,97,,,percent of total billed charges,97% of total billed charges,133.6,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.99,97,,,percent of total billed charges,97% of total billed charges,138.05,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.99,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.76,1325.49,
20552- Inj/sng/mult trigger pnts/1/2 musc,3434654,CDM,360,RC,20552,HCPCS,Outpatient,,,136.98,68.49,,123.28,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,109.58,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.28,90,,,Percent of total Billed charges,90% of total billed charges,34.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.87,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,126.02,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,123.28,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,95.89,70,,,percent of total billed charges,70% of total billed charges,123.28,90,,,percent of total billed charges,90% of total billed charges,130.13,95,,,percent of total billed charges,95% of total billed charges,130.13,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.8,86,,,percent of total billed charges,86% of total billed charges,109.58,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.87,97,,,percent of total billed charges,97% of total billed charges,123.28,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.87,97,,,percent of total billed charges,97% of total billed charges,127.39,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.87,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.06,1325.49,
20552-PF INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLE,4322001,CDM,981,RC,20552,HCPCS,Outpatient,,,72.58,36.29,,65.32,90,,,percent of total billed charges,90% of total Billed charges,87.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,56.23,155,,,Fee Schedule,155% of CMS OPPS Rate,36.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,45.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.23,155,,,Fee Schedule,155% of CMS OPPS Rate,36.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.07,155,,,Fee Schedule,155% of CMS OPPS Rate,136.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.06,136.07,
20553- Inj/sng/mult trigger pnts/3/> musc,3434655,CDM,510,RC,20553,HCPCS,Outpatient,,,157.43,78.72,,141.69,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,125.94,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.69,90,,,Percent of total Billed charges,90% of total billed charges,37.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,152.71,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,144.84,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,141.69,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,110.2,70,,,percent of total billed charges,70% of total billed charges,141.69,90,,,percent of total billed charges,90% of total billed charges,149.56,95,,,percent of total billed charges,95% of total billed charges,149.56,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,135.39,86,,,percent of total billed charges,86% of total billed charges,125.94,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,152.71,97,,,percent of total billed charges,97% of total billed charges,141.69,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,97,,,percent of total billed charges,97% of total billed charges,146.41,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.71,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.47,1325.49,
20553-PF INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES,4321321,CDM,981,RC,20553,HCPCS,Outpatient,,,83.3,41.65,,74.97,90,,,percent of total billed charges,90% of total Billed charges,100.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.56,155,,,Fee Schedule,155% of CMS OPPS Rate,41.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,64.56,155,,,Fee Schedule,155% of CMS OPPS Rate,41.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.3,155,,,Fee Schedule,155% of CMS OPPS Rate,156.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,41.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,123.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.47,156.3,
20600- Arthrocentesis/sm jnt/bursa/w/o US,3434656,CDM,360,RC,20600,HCPCS,Outpatient,,,135.42,67.71,,121.88,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,108.34,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.88,90,,,Percent of total Billed charges,90% of total billed charges,19.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,131.36,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,124.59,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,121.88,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,94.79,70,,,percent of total billed charges,70% of total billed charges,121.88,90,,,percent of total billed charges,90% of total billed charges,128.65,95,,,percent of total billed charges,95% of total billed charges,128.65,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,116.46,86,,,percent of total billed charges,86% of total billed charges,108.34,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,131.36,97,,,percent of total billed charges,97% of total billed charges,121.88,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.36,97,,,percent of total billed charges,97% of total billed charges,125.94,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.36,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18,1325.49,
20600-PF ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US,4322000,CDM,981,RC,20600,HCPCS,Outpatient,,,69.66,34.83,,62.69,90,,,percent of total billed charges,90% of total Billed charges,85.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.68,90,,,Percent of total Billed charges,90% of total billed charges,18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.99,155,,,Fee Schedule,155% of CMS OPPS Rate,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.99,155,,,Fee Schedule,155% of CMS OPPS Rate,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.9,155,,,Fee Schedule,155% of CMS OPPS Rate,132.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18,132.9,
20605- Arthrocentes/intm jnt/bursa/w/o US,3434658,CDM,360,RC,20605,HCPCS,Outpatient,,,139.61,69.81,,125.65,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,111.69,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.65,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.42,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,128.44,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.65,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,97.73,70,,,percent of total billed charges,70% of total billed charges,125.65,90,,,percent of total billed charges,90% of total billed charges,132.63,95,,,percent of total billed charges,95% of total billed charges,132.63,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,120.06,86,,,percent of total billed charges,86% of total billed charges,111.69,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.42,97,,,percent of total billed charges,97% of total billed charges,125.65,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.42,97,,,percent of total billed charges,97% of total billed charges,129.84,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.42,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1325.49,
20605-PF ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O U,4321999,CDM,981,RC,20605,HCPCS,Outpatient,,,73.32,36.66,,65.99,90,,,percent of total billed charges,90% of total Billed charges,89.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.49,90,,,Percent of total Billed charges,90% of total billed charges,21.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,56.81,155,,,Fee Schedule,155% of CMS OPPS Rate,36.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,44.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.81,155,,,Fee Schedule,155% of CMS OPPS Rate,36.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.18,155,,,Fee Schedule,155% of CMS OPPS Rate,138.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,118.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.5,138.18,
20606-PF ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,4321323,CDM,981,RC,20606,HCPCS,Outpatient,,,102.56,51.28,,92.3,90,,,percent of total billed charges,90% of total Billed charges,135.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,79.47,155,,,Fee Schedule,155% of CMS OPPS Rate,51.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,79.47,155,,,Fee Schedule,155% of CMS OPPS Rate,51.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.58,155,,,Fee Schedule,155% of CMS OPPS Rate,210.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.35,210.58,
20610- Arthrocentes/maj jnt/bursa/w/o US,3434660,CDM,360,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,149.11,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,132.54,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.11,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.71,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,152.43,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,149.11,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,115.98,70,,,percent of total billed charges,70% of total billed charges,149.11,90,,,percent of total billed charges,90% of total billed charges,157.4,95,,,percent of total billed charges,95% of total billed charges,157.4,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.48,86,,,percent of total billed charges,86% of total billed charges,132.54,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.71,97,,,percent of total billed charges,97% of total billed charges,149.11,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.71,97,,,percent of total billed charges,97% of total billed charges,154.08,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.71,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,1325.49,
20610- Arthrocentesis/inject/major joint,3434636,CDM,320,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,149.11,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,132.54,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.11,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.71,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,152.43,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,149.11,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,115.98,70,,,percent of total billed charges,70% of total billed charges,149.11,90,,,percent of total billed charges,90% of total billed charges,157.4,95,,,percent of total billed charges,95% of total billed charges,157.4,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.48,86,,,percent of total billed charges,86% of total billed charges,132.54,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.71,97,,,percent of total billed charges,97% of total billed charges,149.11,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.71,97,,,percent of total billed charges,97% of total billed charges,154.08,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.71,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,1325.49,
20610-PF ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US,4321998,CDM,981,RC,20610,HCPCS,Outpatient,,,88.9,44.45,,80.01,90,,,percent of total billed charges,90% of total Billed charges,106.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.78,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.46,155,,,Fee Schedule,155% of CMS OPPS Rate,165.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,165.46,
Read,602055,CDM,972,RC,20610,HCPCS,Outpatient,,,111.57,55.79,,100.41,90,,,percent of total billed charges,90% of total Billed charges,106.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.78,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.46,155,,,Fee Schedule,155% of CMS OPPS Rate,165.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,165.46,
20611- Arthrocentesis Aspir+/Injection Major Jt/Bursa with US,3434661,CDM,510,RC,20611,HCPCS,Outpatient,,,251.68,125.84,,226.51,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,201.34,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.51,90,,,Percent of total Billed charges,90% of total billed charges,54.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,244.13,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,231.55,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,226.51,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,176.18,70,,,percent of total billed charges,70% of total billed charges,226.51,90,,,percent of total billed charges,90% of total billed charges,239.1,95,,,percent of total billed charges,95% of total billed charges,239.1,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,216.44,86,,,percent of total billed charges,86% of total billed charges,201.34,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,244.13,97,,,percent of total billed charges,97% of total billed charges,226.51,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.13,97,,,percent of total billed charges,97% of total billed charges,234.06,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.13,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.82,1325.49,
20670- Remove implant/superficial,3434664,CDM,510,RC,20670,HCPCS,Outpatient,,,885.43,442.72,,796.89,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,708.34,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,796.89,90,,,Percent of total Billed charges,90% of total billed charges,102.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,858.87,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,814.6,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,796.89,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,619.8,70,,,percent of total billed charges,70% of total billed charges,796.89,90,,,percent of total billed charges,90% of total billed charges,841.16,95,,,percent of total billed charges,95% of total billed charges,841.16,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,761.47,86,,,percent of total billed charges,86% of total billed charges,708.34,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,858.87,97,,,percent of total billed charges,97% of total billed charges,796.89,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,858.87,97,,,percent of total billed charges,97% of total billed charges,823.45,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,858.87,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.5,7310.49,
20680- Remove implant/deep,3434665,CDM,510,RC,20680,HCPCS,Outpatient,,,1530.14,765.07,,1377.13,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.11,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1377.13,90,,,Percent of total Billed charges,90% of total billed charges,188.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1484.24,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.73,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1377.13,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.1,70,,,percent of total billed charges,70% of total billed charges,1377.13,90,,,percent of total billed charges,90% of total billed charges,1453.63,95,,,percent of total billed charges,95% of total billed charges,1453.63,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1315.92,86,,,percent of total billed charges,86% of total billed charges,1224.11,80,,,percent of total billed charges,80% of total billed charges,2397.44,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1484.24,97,,,percent of total billed charges,97% of total billed charges,1377.13,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1484.24,97,,,percent of total billed charges,97% of total billed charges,1423.03,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1484.24,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,171.5,12593.67,
20950-PF MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME,4321326,CDM,981,RC,20950,HCPCS,Outpatient,,,170.14,85.07,,153.13,90,,,percent of total billed charges,90% of total Billed charges,255.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.84,155,,,Fee Schedule,155% of CMS OPPS Rate,85.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.84,155,,,Fee Schedule,155% of CMS OPPS Rate,85.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.56,155,,,Fee Schedule,155% of CMS OPPS Rate,395.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,219.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,480.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75,480.76,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,518.64,259.32,,466.78,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,466.78,90,,,Percent of total Billed charges,90% of total billed charges,208.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,503.08,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,477.15,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,466.78,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,363.05,70,,,percent of total billed charges,70% of total billed charges,466.78,90,,,percent of total billed charges,90% of total billed charges,492.71,95,,,percent of total billed charges,95% of total billed charges,492.71,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,446.03,86,,,percent of total billed charges,86% of total billed charges,414.91,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,503.08,97,,,percent of total billed charges,97% of total billed charges,466.78,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.08,97,,,percent of total billed charges,97% of total billed charges,482.34,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.08,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.16,7310.49,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,688.11,344.06,,619.3,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,550.49,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.3,90,,,Percent of total Billed charges,90% of total billed charges,285.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,667.47,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,633.06,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,619.3,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,481.68,70,,,percent of total billed charges,70% of total billed charges,619.3,90,,,percent of total billed charges,90% of total billed charges,653.7,95,,,percent of total billed charges,95% of total billed charges,653.7,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,591.77,86,,,percent of total billed charges,86% of total billed charges,550.49,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,667.47,97,,,percent of total billed charges,97% of total billed charges,619.3,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,667.47,97,,,percent of total billed charges,97% of total billed charges,639.94,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,667.47,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,259.78,7310.49,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,811.54,405.77,,730.39,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,649.23,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.39,90,,,Percent of total Billed charges,90% of total billed charges,336.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,787.19,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,746.62,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,730.39,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,568.08,70,,,percent of total billed charges,70% of total billed charges,730.39,90,,,percent of total billed charges,90% of total billed charges,770.96,95,,,percent of total billed charges,95% of total billed charges,770.96,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,697.92,86,,,percent of total billed charges,86% of total billed charges,649.23,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,787.19,97,,,percent of total billed charges,97% of total billed charges,730.39,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.19,97,,,percent of total billed charges,97% of total billed charges,754.73,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,787.19,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,305.52,7310.49,
21015- Rad res sft tis tum/face/scalp/<2c,3434685,CDM,960,RC,21015,HCPCS,Outpatient,,,1407.68,703.84,,1266.91,90,,,percent of total billed charges,90% of total Billed charges,1363.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,680.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,252,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1054.23,155,,,Fee Schedule,155% of CMS OPPS Rate,680.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,680.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1129.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1129.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1052.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1052.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,567.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1360.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1242.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,823.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1054.23,155,,,Fee Schedule,155% of CMS OPPS Rate,680.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2113.22,155,,,Fee Schedule,155% of CMS OPPS Rate,2113.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,680.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,252,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,680.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1442.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1442.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,252,2113.22,
21016- Rad resect/tumor/face/scalp/2cm/>,3434686,CDM,960,RC,21016,HCPCS,Outpatient,,,2053.77,1026.89,,1848.39,90,,,percent of total billed charges,90% of total Billed charges,1985.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,990.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,810.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1535.83,155,,,Fee Schedule,155% of CMS OPPS Rate,990.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,990.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1620.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1620.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1525.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1525.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,818.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,990.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1981.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1799.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1213.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1535.83,155,,,Fee Schedule,155% of CMS OPPS Rate,990.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,3077.62,155,,,Fee Schedule,155% of CMS OPPS Rate,3077.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,990.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1038.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,990.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,2120.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2120.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,810.47,3077.62,
21315-PF CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION,4321328,CDM,981,RC,21315,HCPCS,Outpatient,,,118.7,59.35,,106.83,90,,,percent of total billed charges,90% of total Billed charges,178.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,119.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.99,155,,,Fee Schedule,155% of CMS OPPS Rate,59.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,224.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,224.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,220.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,220.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,166.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,91.99,155,,,Fee Schedule,155% of CMS OPPS Rate,59.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.98,155,,,Fee Schedule,155% of CMS OPPS Rate,275.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,552.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.35,552.84,
21320-PF CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION,4321997,CDM,981,RC,21320,HCPCS,Outpatient,,,186.36,93.18,,167.72,90,,,percent of total billed charges,90% of total Billed charges,279.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,144.43,155,,,Fee Schedule,155% of CMS OPPS Rate,93.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,186.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,150.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,144.43,155,,,Fee Schedule,155% of CMS OPPS Rate,93.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,433.29,155,,,Fee Schedule,155% of CMS OPPS Rate,433.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,93.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,519.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.18,519.52,
21440-PF CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX,4321331,CDM,981,RC,21440,HCPCS,Outpatient,,,1012.12,506.06,,910.91,90,,,percent of total billed charges,90% of total Billed charges,1144.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,506.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.38,155,,,Fee Schedule,155% of CMS OPPS Rate,506.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,752.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,752.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,704.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,704.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,403.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1012.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,494.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,784.38,155,,,Fee Schedule,155% of CMS OPPS Rate,506.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1773.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1773.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,506.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,294.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,506.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1130.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,294.34,1773.57,
21480-PF CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ,4321996,CDM,981,RC,21480,HCPCS,Outpatient,,,63.3,31.65,,56.97,90,,,percent of total billed charges,90% of total Billed charges,94.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,49.04,155,,,Fee Schedule,155% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.04,155,,,Fee Schedule,155% of CMS OPPS Rate,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.16,155,,,Fee Schedule,155% of CMS OPPS Rate,147.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.98,184.96,
21485-PF CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ,4321335,CDM,981,RC,21485,HCPCS,Outpatient,,,1448.9,724.45,,1304.01,90,,,percent of total billed charges,90% of total Billed charges,1628.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,724.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1122.88,155,,,Fee Schedule,155% of CMS OPPS Rate,724.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,954.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,724.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1073.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1073.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1002.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1002.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,516.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1182.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,698.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1122.88,155,,,Fee Schedule,155% of CMS OPPS Rate,724.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2523.52,155,,,Fee Schedule,155% of CMS OPPS Rate,2523.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,724.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,452.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,724.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1400.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1400.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.5,2523.52,
21501- I&D deep abscess/hema/neck/thorax,3434703,CDM,510,RC,21501,HCPCS,Outpatient,,,1227.97,613.99,,1105.17,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,982.38,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1105.17,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1191.13,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.73,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1105.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,859.58,70,,,percent of total billed charges,70% of total billed charges,1105.17,90,,,percent of total billed charges,90% of total billed charges,1166.57,95,,,percent of total billed charges,95% of total billed charges,1166.57,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1056.05,86,,,percent of total billed charges,86% of total billed charges,982.38,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1191.13,97,,,percent of total billed charges,97% of total billed charges,1105.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.13,97,,,percent of total billed charges,97% of total billed charges,1142.01,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1191.13,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,12593.67,
21552 - PF Exc Tumor Soft Tis Neck/Ant Thorax Subq 3cm/>,4301617,CDM,960,RC,21552,HCPCS,Outpatient,,,938.8,469.40,,844.92,90,,,percent of total billed charges,90% of total Billed charges,887.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,686.39,155,,,Fee Schedule,155% of CMS OPPS Rate,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,678.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,678.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,359.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,800.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,556.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,686.39,155,,,Fee Schedule,155% of CMS OPPS Rate,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1376.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1376.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,445.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,909.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,348.4,1376.29,
21554- Exc IM tum/neck/ant thorax 5cm/>,3434706,CDM,510,RC,21554,HCPCS,Outpatient,,,1937.32,968.66,,1743.59,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.86,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1743.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1879.2,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1782.33,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1743.59,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.12,70,,,percent of total billed charges,70% of total billed charges,1743.59,90,,,percent of total billed charges,90% of total billed charges,1840.45,95,,,percent of total billed charges,95% of total billed charges,1840.45,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1666.1,86,,,percent of total billed charges,86% of total billed charges,1549.86,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1879.2,97,,,percent of total billed charges,97% of total billed charges,1743.59,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1879.2,97,,,percent of total billed charges,97% of total billed charges,1801.71,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1879.2,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1356.12,12593.67,
21555- Exc SQ tum/neck or ant thorax <3cm,3434707,CDM,510,RC,21555,HCPCS,Outpatient,,,623.3,311.65,,560.97,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,498.64,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,560.97,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,604.6,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,573.44,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,560.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,436.31,70,,,percent of total billed charges,70% of total billed charges,560.97,90,,,percent of total billed charges,90% of total billed charges,592.14,95,,,percent of total billed charges,95% of total billed charges,592.14,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,536.04,86,,,percent of total billed charges,86% of total billed charges,498.64,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,604.6,97,,,percent of total billed charges,97% of total billed charges,560.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,604.6,97,,,percent of total billed charges,97% of total billed charges,579.67,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,604.6,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,7310.49,
21555- PF Exc Tumor Sft Tiss Neck/ Ant Thorax Subq <3 cm,4311482,CDM,960,RC,21555,HCPCS,Outpatient,,,623.3,311.65,,560.97,90,,,percent of total billed charges,90% of total Billed charges,716.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,298.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,463.34,155,,,Fee Schedule,155% of CMS OPPS Rate,298.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,298.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,505.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,455.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,455.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,537.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,360.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,463.34,155,,,Fee Schedule,155% of CMS OPPS Rate,298.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1109.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1109.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,298.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,298.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,826.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,826.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,1109.88,
21556- Exc IM tum/neck or ant thorax <5cm,3434708,CDM,510,RC,21556,HCPCS,Outpatient,,,1394,697.00,,1254.6,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1115.2,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1254.6,90,,,Percent of total Billed charges,90% of total billed charges,132,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1352.18,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1282.48,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1254.6,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,975.8,70,,,percent of total billed charges,70% of total billed charges,1254.6,90,,,percent of total billed charges,90% of total billed charges,1324.3,95,,,percent of total billed charges,95% of total billed charges,1324.3,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1198.84,86,,,percent of total billed charges,86% of total billed charges,1115.2,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1352.18,97,,,percent of total billed charges,97% of total billed charges,1254.6,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1352.18,97,,,percent of total billed charges,97% of total billed charges,1296.42,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,120,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1352.18,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,120,12593.67,
21601-EXCISION OF CHEST WALL TUMOR,3430804,CDM,510,RC,21601,HCPCS,Outpatient,,,2698.29,1349.15,,2428.46,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2158.63,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2428.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2617.34,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2482.43,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2428.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1888.8,70,,,percent of total billed charges,70% of total billed charges,2428.46,90,,,percent of total billed charges,90% of total billed charges,2563.38,95,,,percent of total billed charges,95% of total billed charges,2563.38,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2320.53,86,,,percent of total billed charges,86% of total billed charges,2158.63,80,,,percent of total billed charges,80% of total billed charges,2397.42,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2617.34,97,,,percent of total billed charges,97% of total billed charges,2428.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2617.34,97,,,percent of total billed charges,97% of total billed charges,2509.41,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2617.34,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1888.8,12593.67,
21620- Ostectomy of sternum/ partial,3434713,CDM,510,RC,21620,HCPCS,Outpatient,,,1336.08,668.04,,1202.47,90,,,percent of total billed charges,90% of total Billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1068.86,80,,,Percent of total Billed charges,80% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1202.47,90,,,Percent of total Billed charges,90% of total billed charges,288.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1296,97,,,Percent of total billed charges,97% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1229.19,92,,,Percent of total billed charges,92% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1202.47,90,,,percent of total billed charges,90% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,935.26,70,,,percent of total billed charges,70% of total billed charges,1202.47,90,,,percent of total billed charges,90% of total billed charges,1269.28,95,,,percent of total billed charges,95% of total billed charges,1269.28,95,,,percent of total billed charges,95% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1149.03,86,,,percent of total billed charges,86% of total billed charges,1068.86,80,,,percent of total billed charges,80% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1296,97,,,percent of total billed charges,97% of total billed charges,1202.47,90,,,percent of total billed charges,90% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1296,97,,,percent of total billed charges,97% of total billed charges,1242.55,93,,,percent of total billed charges,93% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1296,97,,,percent of total billed charges,97% of total billed charges,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1336.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,262.5,1336.08,
21750- Close median sternotomy separation,3434714,CDM,510,RC,21750,HCPCS,Outpatient,,,1816.48,908.24,,1634.83,90,,,percent of total billed charges,90% of total Billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1453.18,80,,,Percent of total Billed charges,80% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1634.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1761.99,97,,,Percent of total billed charges,97% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1671.16,92,,,Percent of total billed charges,92% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1634.83,90,,,percent of total billed charges,90% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1271.54,70,,,percent of total billed charges,70% of total billed charges,1634.83,90,,,percent of total billed charges,90% of total billed charges,1725.66,95,,,percent of total billed charges,95% of total billed charges,1725.66,95,,,percent of total billed charges,95% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1562.17,86,,,percent of total billed charges,86% of total billed charges,1453.18,80,,,percent of total billed charges,80% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1761.99,97,,,percent of total billed charges,97% of total billed charges,1634.83,90,,,percent of total billed charges,90% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1761.99,97,,,percent of total billed charges,97% of total billed charges,1689.33,93,,,percent of total billed charges,93% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1761.99,97,,,percent of total billed charges,97% of total billed charges,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1816.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1271.54,1816.48,
21825- Open tx/sternum fracture,3434716,CDM,510,RC,21825,HCPCS,Outpatient,,,1449.85,724.93,,1304.87,90,,,percent of total billed charges,90% of total Billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1159.88,80,,,Percent of total Billed charges,80% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1304.87,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1406.35,97,,,Percent of total billed charges,97% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1333.86,92,,,Percent of total billed charges,92% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1304.87,90,,,percent of total billed charges,90% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.9,70,,,percent of total billed charges,70% of total billed charges,1304.87,90,,,percent of total billed charges,90% of total billed charges,1377.36,95,,,percent of total billed charges,95% of total billed charges,1377.36,95,,,percent of total billed charges,95% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1246.87,86,,,percent of total billed charges,86% of total billed charges,1159.88,80,,,percent of total billed charges,80% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1406.35,97,,,percent of total billed charges,97% of total billed charges,1304.87,90,,,percent of total billed charges,90% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1406.35,97,,,percent of total billed charges,97% of total billed charges,1348.36,93,,,percent of total billed charges,93% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1406.35,97,,,percent of total billed charges,97% of total billed charges,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1449.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,112,1449.85,
21930- Exc/tumor/back/flank/SQ/<3cm,3434718,CDM,510,RC,21930,HCPCS,Outpatient,,,1291,645.50,,1161.9,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1032.8,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1161.9,90,,,Percent of total Billed charges,90% of total billed charges,138.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1252.27,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1187.72,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1161.9,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,903.7,70,,,percent of total billed charges,70% of total billed charges,1161.9,90,,,percent of total billed charges,90% of total billed charges,1226.45,95,,,percent of total billed charges,95% of total billed charges,1226.45,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1110.26,86,,,percent of total billed charges,86% of total billed charges,1032.8,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1252.27,97,,,percent of total billed charges,97% of total billed charges,1161.9,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1252.27,97,,,percent of total billed charges,97% of total billed charges,1200.63,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,126,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1252.27,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,126,7310.49,
21931 - PF Exc Tumor Sft Tiss Back/ Flank Subq 3 cm/ >,4311483,CDM,960,RC,21931,HCPCS,Outpatient,,,1106.14,553.07,,995.53,90,,,percent of total billed charges,90% of total Billed charges,934.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,465.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,365,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,722.08,155,,,Fee Schedule,155% of CMS OPPS Rate,465.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,758.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,718.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,718.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,474.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,931.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,847.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,594.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,722.08,155,,,Fee Schedule,155% of CMS OPPS Rate,465.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1449.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,465.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,365,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,509.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,465.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,950.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365,1449.08,
21931- Exc subq tumor/back/flank 3cm/>,3434719,CDM,510,RC,21931,HCPCS,Outpatient,,,1247.33,623.67,,1122.6,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,997.86,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1209.91,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1147.54,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1122.6,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,873.13,70,,,percent of total billed charges,70% of total billed charges,1122.6,90,,,percent of total billed charges,90% of total billed charges,1184.96,95,,,percent of total billed charges,95% of total billed charges,1184.96,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1072.7,86,,,percent of total billed charges,86% of total billed charges,997.86,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1209.91,97,,,percent of total billed charges,97% of total billed charges,1122.6,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1209.91,97,,,percent of total billed charges,97% of total billed charges,1160.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1209.91,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,873.13,7310.49,
21932- Exc IM tumor/back/flank/ < 5 cm,3434720,CDM,510,RC,21932,HCPCS,Outpatient,,,1759.17,879.59,,1583.25,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.34,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1583.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1706.39,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.44,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1583.25,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.42,70,,,percent of total billed charges,70% of total billed charges,1583.25,90,,,percent of total billed charges,90% of total billed charges,1671.21,95,,,percent of total billed charges,95% of total billed charges,1671.21,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1512.89,86,,,percent of total billed charges,86% of total billed charges,1407.34,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1706.39,97,,,percent of total billed charges,97% of total billed charges,1583.25,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1706.39,97,,,percent of total billed charges,97% of total billed charges,1636.03,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1706.39,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1231.42,12593.67,
21933- Exc IM tumor/back/flank/5 cm/>,3434721,CDM,510,RC,21933,HCPCS,Outpatient,,,1966.31,983.16,,1769.68,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1573.05,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1769.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1907.32,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.01,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1769.68,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1376.42,70,,,percent of total billed charges,70% of total billed charges,1769.68,90,,,percent of total billed charges,90% of total billed charges,1867.99,95,,,percent of total billed charges,95% of total billed charges,1867.99,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1691.03,86,,,percent of total billed charges,86% of total billed charges,1573.05,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1907.32,97,,,percent of total billed charges,97% of total billed charges,1769.68,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1907.32,97,,,percent of total billed charges,97% of total billed charges,1828.67,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1907.32,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1376.42,12593.67,
22900 - PF Exc Tumor Sft Tiss Abdl Wall Subfascial <5 cm,4311484,CDM,960,RC,22900,HCPCS,Outpatient,,,1331.77,665.89,,1198.59,90,,,percent of total billed charges,90% of total Billed charges,1124.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,869.36,155,,,Fee Schedule,155% of CMS OPPS Rate,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,907.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,859.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,859.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,454.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1014.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,709.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,869.36,155,,,Fee Schedule,155% of CMS OPPS Rate,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1743.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1743.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,412.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1129.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1129.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1743.32,
22900- Ex IM tumor/abdominal wall < 5 cm,3434786,CDM,510,RC,22900,HCPCS,Outpatient,,,1499.45,749.73,,1349.51,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.56,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1349.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1454.47,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1379.49,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1349.51,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.62,70,,,percent of total billed charges,70% of total billed charges,1349.51,90,,,percent of total billed charges,90% of total billed charges,1424.48,95,,,percent of total billed charges,95% of total billed charges,1424.48,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1289.53,86,,,percent of total billed charges,86% of total billed charges,1199.56,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1454.47,97,,,percent of total billed charges,97% of total billed charges,1349.51,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1454.47,97,,,percent of total billed charges,97% of total billed charges,1394.49,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1454.47,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1049.62,12593.67,
22901-PF EXC TUMOR ABDOM WALL 5CM OR >,3428955,CDM,960,RC,22901,HCPCS,Outpatient,,,1781.38,890.69,,1603.24,90,,,percent of total billed charges,90% of total Billed charges,1332.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,662.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,516.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1027.62,155,,,Fee Schedule,155% of CMS OPPS Rate,662.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,662.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1077.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1025.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1025.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,670.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1325.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1209.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1027.62,155,,,Fee Schedule,155% of CMS OPPS Rate,662.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,2065.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2065.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,662.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,516.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,661.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,662.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1330.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1330.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,516.63,2065.9,
22902 - PF Exc Tumor Sft Tiss Abdl Wall Subq <3 cm,4311485,CDM,960,RC,22902,HCPCS,Outpatient,,,777.16,388.58,,699.44,90,,,percent of total billed charges,90% of total Billed charges,784.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,258.87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,507.32,155,,,Fee Schedule,155% of CMS OPPS Rate,327.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,533.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,499.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,499.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,338.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,589.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,407.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,507.32,155,,,Fee Schedule,155% of CMS OPPS Rate,327.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1216.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1216.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,327.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,411.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,327.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,873.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,873.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,258.87,1216.69,
22902- Excise subq tumor/abd wall <3 cm,3434787,CDM,510,RC,22902,HCPCS,Outpatient,,,1217.07,608.54,,1095.36,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,973.66,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1095.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1180.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1119.7,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1095.36,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,851.95,70,,,percent of total billed charges,70% of total billed charges,1095.36,90,,,percent of total billed charges,90% of total billed charges,1156.22,95,,,percent of total billed charges,95% of total billed charges,1156.22,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1046.68,86,,,percent of total billed charges,86% of total billed charges,973.66,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1180.56,97,,,percent of total billed charges,97% of total billed charges,1095.36,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1180.56,97,,,percent of total billed charges,97% of total billed charges,1131.88,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1180.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,851.95,7310.49,
22903 - PF Exc Tumor Sft Tiss Abdl Wall Subq 3 cm/ >,4311486,CDM,960,RC,22903,HCPCS,Outpatient,,,1038.13,519.07,,934.32,90,,,percent of total billed charges,90% of total Billed charges,876.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,340.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,677.68,155,,,Fee Schedule,155% of CMS OPPS Rate,437.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,437.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,708.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,670.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,670.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,443.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,791.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,555.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,677.68,155,,,Fee Schedule,155% of CMS OPPS Rate,437.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,1359.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1359.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,437.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,340.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,435.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,437.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,893.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,893.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,340.9,1359.26,
22903- Exc/abd soft tissue tumor/3cm or >,3434788,CDM,510,RC,22903,HCPCS,Outpatient,,,1169.41,584.71,,1052.47,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,935.53,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1052.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1134.33,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.86,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1052.47,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,818.59,70,,,percent of total billed charges,70% of total billed charges,1052.47,90,,,percent of total billed charges,90% of total billed charges,1110.94,95,,,percent of total billed charges,95% of total billed charges,1110.94,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1005.69,86,,,percent of total billed charges,86% of total billed charges,935.53,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1134.33,97,,,percent of total billed charges,97% of total billed charges,1052.47,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1134.33,97,,,percent of total billed charges,97% of total billed charges,1087.55,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1134.33,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,818.59,12593.67,
22904 - PF Rad Resection Tumor Soft Tissue Abdl Wall <5cm,4301627,CDM,960,RC,22904,HCPCS,Outpatient,,,2217.5,1108.75,,1995.75,90,,,percent of total billed charges,90% of total Billed charges,2104.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1045.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,811.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1621.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1045.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1511.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1045.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1700.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1700.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1622.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1622.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1048.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2091.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1914.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1349.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1621.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1045.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,3262.33,155,,,Fee Schedule,155% of CMS OPPS Rate,3262.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1045.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1041.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1045.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,2080.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2080.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,811.1,3262.33,
22905-PF RESECT ABD TUM > 5 CM,3428961,CDM,510,RC,22905,HCPCS,Outpatient,,,3553.16,1776.58,,3197.84,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.53,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3446.57,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.91,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.21,70,,,percent of total billed charges,70% of total billed charges,3197.84,90,,,percent of total billed charges,90% of total billed charges,3375.5,95,,,percent of total billed charges,95% of total billed charges,3375.5,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.72,86,,,percent of total billed charges,86% of total billed charges,2842.53,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.57,97,,,percent of total billed charges,97% of total billed charges,3197.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.57,97,,,percent of total billed charges,97% of total billed charges,3304.44,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3446.57,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
23071- Exc SQ tumor/shoulder area 3cm/>,3434794,CDM,510,RC,23071,HCPCS,Outpatient,,,1109.95,554.98,,998.96,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,887.96,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1076.65,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.15,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,998.96,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,776.97,70,,,percent of total billed charges,70% of total billed charges,998.96,90,,,percent of total billed charges,90% of total billed charges,1054.45,95,,,percent of total billed charges,95% of total billed charges,1054.45,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,954.56,86,,,percent of total billed charges,86% of total billed charges,887.96,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1076.65,97,,,percent of total billed charges,97% of total billed charges,998.96,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.65,97,,,percent of total billed charges,97% of total billed charges,1032.25,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1076.65,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,776.97,7310.49,
23073- Exc IM tumor/shoulder area 5cm/>,3434795,CDM,510,RC,23073,HCPCS,Outpatient,,,1841.54,920.77,,1657.39,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1473.23,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1657.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1786.29,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1694.22,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1657.39,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.08,70,,,percent of total billed charges,70% of total billed charges,1657.39,90,,,percent of total billed charges,90% of total billed charges,1749.46,95,,,percent of total billed charges,95% of total billed charges,1749.46,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1583.72,86,,,percent of total billed charges,86% of total billed charges,1473.23,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1786.29,97,,,percent of total billed charges,97% of total billed charges,1657.39,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1786.29,97,,,percent of total billed charges,97% of total billed charges,1712.63,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1786.29,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1289.08,12593.67,
23410-PF OPEN REPAIR OF ROTATOR CUFF ACUTE,4321995,CDM,981,RC,23410,HCPCS,Outpatient,,,1609.06,804.53,,1448.15,90,,,percent of total billed charges,90% of total Billed charges,1611.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,804.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1247.02,155,,,Fee Schedule,155% of CMS OPPS Rate,804.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,804.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1318.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1318.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1233.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1233.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,806.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1455.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,983.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1247.02,155,,,Fee Schedule,155% of CMS OPPS Rate,804.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2497.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2497.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,804.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1036.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,804.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1661.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1661.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2497.56,
23412-PF OPEN REPAIR OF ROTATOR CUFF CHRONIC,4321994,CDM,981,RC,23412,HCPCS,Outpatient,,,1672.58,836.29,,1505.32,90,,,percent of total billed charges,90% of total Billed charges,1675.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,836.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,579,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1296.25,155,,,Fee Schedule,155% of CMS OPPS Rate,836.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,836.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1371.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1371.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1283.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1283.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,843.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,836.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1672.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1515.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1026.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1296.25,155,,,Fee Schedule,155% of CMS OPPS Rate,836.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,2596.64,155,,,Fee Schedule,155% of CMS OPPS Rate,2596.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,836.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,579,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1131.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,836.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1725.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,579,2596.64,
23500-PF CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION,4321993,CDM,981,RC,23500,HCPCS,Outpatient,,,444,222.00,,399.6,90,,,percent of total billed charges,90% of total Billed charges,436.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,344.08,155,,,Fee Schedule,155% of CMS OPPS Rate,221.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,221.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,359.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,325.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,325.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,248.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,344.08,155,,,Fee Schedule,155% of CMS OPPS Rate,221.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,676.47,155,,,Fee Schedule,155% of CMS OPPS Rate,676.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,221.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,221.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,427.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.5,676.47,
23505-PF CLSD TX CLAVICULAR FRACTURE W/MANIPULATION,4321992,CDM,981,RC,23505,HCPCS,Outpatient,,,653.24,326.62,,587.92,90,,,percent of total billed charges,90% of total Billed charges,676.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,506.26,155,,,Fee Schedule,155% of CMS OPPS Rate,326.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,475.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,535.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,535.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,491.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,491.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,301.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,653.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,580,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,382.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,506.26,155,,,Fee Schedule,155% of CMS OPPS Rate,326.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1047.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1047.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,362.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,693.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,693.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94.5,1047.89,
23515-PF OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION,4321991,CDM,981,RC,23515,HCPCS,Outpatient,,,1412.22,706.11,,1271,90,,,percent of total billed charges,90% of total Billed charges,1412.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,706.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1094.46,155,,,Fee Schedule,155% of CMS OPPS Rate,706.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1028.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,706.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1156.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1156.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1078.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1078.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,648.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1412.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1272.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,855.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1094.46,155,,,Fee Schedule,155% of CMS OPPS Rate,706.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,2189.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2189.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,706.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,660.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,706.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1470.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1470.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,648.67,2189.9,
23520-PF CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION,4321990,CDM,981,RC,23520,HCPCS,Outpatient,,,461.66,230.83,,415.49,90,,,percent of total billed charges,90% of total Billed charges,462.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,357.77,155,,,Fee Schedule,155% of CMS OPPS Rate,230.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,377.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,341.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,341.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,199.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,402.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,261.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,357.77,155,,,Fee Schedule,155% of CMS OPPS Rate,230.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,717.08,155,,,Fee Schedule,155% of CMS OPPS Rate,717.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,455.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,455.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67,717.08,
23525-PF CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION,4321989,CDM,981,RC,23525,HCPCS,Outpatient,,,705.9,352.95,,635.31,90,,,percent of total billed charges,90% of total Billed charges,734.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,352.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,547.07,155,,,Fee Schedule,155% of CMS OPPS Rate,352.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,574.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,289.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,705.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,618.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,404.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,547.07,155,,,Fee Schedule,155% of CMS OPPS Rate,352.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1138.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,352.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,393.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,352.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,775.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,1138.1,
23530-PF OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC,4321988,CDM,981,RC,23530,HCPCS,Outpatient,,,1129.88,564.94,,1016.89,90,,,percent of total billed charges,90% of total Billed charges,1130.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.66,155,,,Fee Schedule,155% of CMS OPPS Rate,564.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,564.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,921.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,856.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,856.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,513.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1129.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1010.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,678.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,875.66,155,,,Fee Schedule,155% of CMS OPPS Rate,564.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1752.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1752.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,564.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,613.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,564.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1152.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1152.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,513.86,1752.31,
23532-PF OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF,4321987,CDM,981,RC,23532,HCPCS,Outpatient,,,1228.58,614.29,,1105.72,90,,,percent of total billed charges,90% of total Billed charges,1229.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,614.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.15,155,,,Fee Schedule,155% of CMS OPPS Rate,614.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,614.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1004.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,934.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,934.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,592.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1228.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1102.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,741.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,952.15,155,,,Fee Schedule,155% of CMS OPPS Rate,614.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1905.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1905.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,614.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,674.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,614.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1256.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,592.17,1905.4,
23540-PF CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION,4321986,CDM,981,RC,23540,HCPCS,Outpatient,,,460.54,230.27,,414.49,90,,,percent of total billed charges,90% of total Billed charges,460.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.9,155,,,Fee Schedule,155% of CMS OPPS Rate,230.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,369.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,336.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,336.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,396.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,257.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,356.9,155,,,Fee Schedule,155% of CMS OPPS Rate,230.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,714.35,155,,,Fee Schedule,155% of CMS OPPS Rate,714.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,434.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,434.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63,714.35,
23545-PF CLSD TX ACROMIOCLAVICULAR DISLC W/ MANIPULATION,4321985,CDM,981,RC,23545,HCPCS,Outpatient,,,631.14,315.57,,568.03,90,,,percent of total billed charges,90% of total Billed charges,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,489.12,155,,,Fee Schedule,155% of CMS OPPS Rate,315.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,315.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,454.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,454.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,260.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,631.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,536.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,352.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,489.12,155,,,Fee Schedule,155% of CMS OPPS Rate,315.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1015.47,155,,,Fee Schedule,155% of CMS OPPS Rate,1015.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,315.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,641.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118,1015.47,
23550-PF OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC,4321984,CDM,981,RC,23550,HCPCS,Outpatient,,,1121.42,560.71,,1009.28,90,,,percent of total billed charges,90% of total Billed charges,1122.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.1,155,,,Fee Schedule,155% of CMS OPPS Rate,560.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,920.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,920.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,855.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,855.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,544.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1009.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,673.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,869.1,155,,,Fee Schedule,155% of CMS OPPS Rate,560.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1739.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1739.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,560.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,674.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,560.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1149.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544.75,1739.32,
23552-PF OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF,4321983,CDM,981,RC,23552,HCPCS,Outpatient,,,1270.3,635.15,,1143.27,90,,,percent of total billed charges,90% of total Billed charges,1277.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,635.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,394.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.47,155,,,Fee Schedule,155% of CMS OPPS Rate,635.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1049.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,977.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,977.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,627.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1153.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,773.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.47,155,,,Fee Schedule,155% of CMS OPPS Rate,635.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1980.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1980.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,635.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,689.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,635.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1327.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1327.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,394.5,1980.64,
23570-PF CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION,4321982,CDM,981,RC,23570,HCPCS,Outpatient,,,469.32,234.66,,422.39,90,,,percent of total billed charges,90% of total Billed charges,461.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,383.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,347.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,347.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,410.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,265.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,715.26,155,,,Fee Schedule,155% of CMS OPPS Rate,715.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,454.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73,715.26,
23575-PF CLTX SCAPULAR FX W/MANJ W/WO SKELETAL TRACTION,4321981,CDM,981,RC,23575,HCPCS,Outpatient,,,740.54,370.27,,666.49,90,,,percent of total billed charges,90% of total Billed charges,768.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,573.9,155,,,Fee Schedule,155% of CMS OPPS Rate,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,603.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,553.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,553.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,331.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,652.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,430.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,573.9,155,,,Fee Schedule,155% of CMS OPPS Rate,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1191.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,380.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,794.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,794.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,1191.19,
23585-PF OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD,4321980,CDM,981,RC,23585,HCPCS,Outpatient,,,1919.92,959.96,,1727.93,90,,,percent of total billed charges,90% of total Billed charges,1926.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,959.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1487.92,155,,,Fee Schedule,155% of CMS OPPS Rate,959.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,959.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1575.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1480.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1480.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,865.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,959.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1919.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1746.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1185.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1487.92,155,,,Fee Schedule,155% of CMS OPPS Rate,959.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,2986.17,155,,,Fee Schedule,155% of CMS OPPS Rate,2986.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,959.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,695.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,959.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1995.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1995.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,695.15,2986.17,
23600-PF CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION,4321979,CDM,981,RC,23600,HCPCS,Outpatient,,,611.54,305.77,,550.39,90,,,percent of total billed charges,90% of total Billed charges,625.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,305.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,116.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,473.94,155,,,Fee Schedule,155% of CMS OPPS Rate,305.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,305.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,449.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,449.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,529.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,340.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,473.94,155,,,Fee Schedule,155% of CMS OPPS Rate,305.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.8,155,,,Fee Schedule,155% of CMS OPPS Rate,969.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,305.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,305.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,636.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,116.5,969.8,
23605-PF CLTX PROX HUMRL FX W/MANJ W/WO SKELETAL TRAC,4321978,CDM,981,RC,23605,HCPCS,Outpatient,,,837.6,418.80,,753.84,90,,,percent of total billed charges,90% of total Billed charges,874.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,649.14,155,,,Fee Schedule,155% of CMS OPPS Rate,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,607.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,418.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,682.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,394.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,492.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,649.14,155,,,Fee Schedule,155% of CMS OPPS Rate,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1356.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1356.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,185,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,500.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,923.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,185,1356.11,
23615-PF OPEN TREATMENT PROXIMAL HUMERAL FRACTURE,4321977,CDM,981,RC,23615,HCPCS,Outpatient,,,1731.96,865.98,,1558.76,90,,,percent of total billed charges,90% of total Billed charges,1735.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,865.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1342.25,155,,,Fee Schedule,155% of CMS OPPS Rate,865.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1262.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,865.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1420.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1420.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1328.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1328.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,817.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1567.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1058.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1342.25,155,,,Fee Schedule,155% of CMS OPPS Rate,865.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2689.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2689.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,865.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,473,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,847.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,865.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1793.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1793.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,473,2689.9,
23616-PF OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT,4321976,CDM,981,RC,23616,HCPCS,Outpatient,,,2432.48,1216.24,,2189.23,90,,,percent of total billed charges,90% of total Billed charges,2436.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1216.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1885.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1216.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1770.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1216.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1991.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1991.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1876.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1876.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1255.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1216.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2432.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2214.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1510.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1885.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1216.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3776.99,155,,,Fee Schedule,155% of CMS OPPS Rate,3776.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1216.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1433.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1216.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2529.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2529.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,3776.99,
23620-PF CLTX GREATER HUMERAL TUBEROSITY FX W/O MANJ,4321975,CDM,981,RC,23620,HCPCS,Outpatient,,,505.4,252.70,,454.86,90,,,percent of total billed charges,90% of total Billed charges,513.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,391.69,155,,,Fee Schedule,155% of CMS OPPS Rate,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,412.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,373.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,373.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,505.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,440.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,284.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,391.69,155,,,Fee Schedule,155% of CMS OPPS Rate,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,795.94,155,,,Fee Schedule,155% of CMS OPPS Rate,795.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,252.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,795.94,
23625-PF CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION,4321974,CDM,981,RC,23625,HCPCS,Outpatient,,,697.36,348.68,,627.62,90,,,percent of total billed charges,90% of total Billed charges,722.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,540.45,155,,,Fee Schedule,155% of CMS OPPS Rate,348.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,563.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,517.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,517.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,697.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,610.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,402.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,540.45,155,,,Fee Schedule,155% of CMS OPPS Rate,348.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1119.47,155,,,Fee Schedule,155% of CMS OPPS Rate,1119.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,348.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,414.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,348.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,752.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,752.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,1119.47,
23630-PF OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE,4321973,CDM,981,RC,23630,HCPCS,Outpatient,,,1528.72,764.36,,1375.85,90,,,percent of total billed charges,90% of total Billed charges,1528.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,764.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,400,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1184.76,155,,,Fee Schedule,155% of CMS OPPS Rate,764.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,764.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1252.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1252.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1167.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1167.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,686.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1528.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1378.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,925.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1184.76,155,,,Fee Schedule,155% of CMS OPPS Rate,764.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2369.27,155,,,Fee Schedule,155% of CMS OPPS Rate,2369.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,764.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,703.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,764.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1582.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1582.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,400,2369.27,
23650-PF CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANE,4321972,CDM,981,RC,23650,HCPCS,Outpatient,,,590.12,295.06,,531.11,90,,,percent of total billed charges,90% of total Billed charges,613.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,295.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,457.33,155,,,Fee Schedule,155% of CMS OPPS Rate,295.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,295.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,429.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,429.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,241.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,506.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,334.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,457.33,155,,,Fee Schedule,155% of CMS OPPS Rate,295.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.38,155,,,Fee Schedule,155% of CMS OPPS Rate,950.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,295.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,295.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,591.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99,950.38,
23655-PF CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES,4321971,CDM,981,RC,23655,HCPCS,Outpatient,,,794.98,397.49,,715.48,90,,,percent of total billed charges,90% of total Billed charges,796.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,397.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,616.09,155,,,Fee Schedule,155% of CMS OPPS Rate,397.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,397.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,648.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,648.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,596.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,596.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,353.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,463.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,616.09,155,,,Fee Schedule,155% of CMS OPPS Rate,397.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1234.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,397.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,139,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,335.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,397.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,790.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139,1234.37,
23660-PF OPEN TX ACUTE SHOULDER DISLOCATION,4321970,CDM,981,RC,23660,HCPCS,Outpatient,,,1149.4,574.70,,1034.46,90,,,percent of total billed charges,90% of total Billed charges,1147.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.77,155,,,Fee Schedule,155% of CMS OPPS Rate,574.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,834.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,574.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,938.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,938.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,872.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,872.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,551.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1149.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1029.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,689.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,890.77,155,,,Fee Schedule,155% of CMS OPPS Rate,574.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1779,155,,,Fee Schedule,155% of CMS OPPS Rate,1779,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,574.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,707.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,574.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1175.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1175.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,551.86,1779,
23665-PF  CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ,4321969,CDM,981,RC,23665,HCPCS,Outpatient,,,781.52,390.76,,703.37,90,,,percent of total billed charges,90% of total Billed charges,812.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,390.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,605.66,155,,,Fee Schedule,155% of CMS OPPS Rate,390.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,584.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,584.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,362,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,689.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,455.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,605.66,155,,,Fee Schedule,155% of CMS OPPS Rate,390.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1258.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,390.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,390.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,839.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,839.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,1258.62,
23670-PF OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX,4321968,CDM,981,RC,23670,HCPCS,Outpatient,,,1708.52,854.26,,1537.67,90,,,percent of total billed charges,90% of total Billed charges,1709.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,854.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,400,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1324.09,155,,,Fee Schedule,155% of CMS OPPS Rate,854.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1248.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1404.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1314.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1314.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,764.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1708.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1551.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1047.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1324.09,155,,,Fee Schedule,155% of CMS OPPS Rate,854.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2649.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2649.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,854.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,764.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,854.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1773.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1773.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,400,2649.32,
23675-PF CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MANJ,4321967,CDM,981,RC,23675,HCPCS,Outpatient,,,980.48,490.24,,882.43,90,,,percent of total billed charges,90% of total Billed charges,1027.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,490.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,759.87,155,,,Fee Schedule,155% of CMS OPPS Rate,490.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,490.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,805.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,745.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,745.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,466.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,490.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,980.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,879.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,587.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,759.87,155,,,Fee Schedule,155% of CMS OPPS Rate,490.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1592.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1592.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,490.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,531.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,490.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1094.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,150.5,1592.1,
23680-PF OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE,4321966,CDM,981,RC,23680,HCPCS,Outpatient,,,1826.24,913.12,,1643.62,90,,,percent of total billed charges,90% of total Billed charges,1827.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,913.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1415.32,155,,,Fee Schedule,155% of CMS OPPS Rate,913.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,913.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1495.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1401.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1401.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,841.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,913.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1826.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1653.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1120.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1415.32,155,,,Fee Schedule,155% of CMS OPPS Rate,913.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2831.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2831.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,913.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,958.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,913.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1882.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2831.91,
23930- I&D/upper arm/elbow/deep absc/hema,3434837,CDM,510,RC,23930,HCPCS,Outpatient,,,919.94,459.97,,827.95,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,735.95,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,827.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,892.34,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,846.34,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,827.95,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,643.96,70,,,percent of total billed charges,70% of total billed charges,827.95,90,,,percent of total billed charges,90% of total billed charges,873.94,95,,,percent of total billed charges,95% of total billed charges,873.94,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,791.15,86,,,percent of total billed charges,86% of total billed charges,735.95,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,892.34,97,,,percent of total billed charges,97% of total billed charges,827.95,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,892.34,97,,,percent of total billed charges,97% of total billed charges,855.54,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,892.34,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,643.96,12593.67,
23931- I&D/upper arm/elbow/bursa,3434838,CDM,360,RC,23931,HCPCS,Outpatient,,,757.95,378.98,,682.16,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,606.36,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,682.16,90,,,Percent of total Billed charges,90% of total billed charges,43.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,735.21,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,697.31,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,682.16,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,530.57,70,,,percent of total billed charges,70% of total billed charges,682.16,90,,,percent of total billed charges,90% of total billed charges,720.05,95,,,percent of total billed charges,95% of total billed charges,720.05,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,651.84,86,,,percent of total billed charges,86% of total billed charges,606.36,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,735.21,97,,,percent of total billed charges,97% of total billed charges,682.16,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,735.21,97,,,percent of total billed charges,97% of total billed charges,704.89,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,735.21,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.5,7310.49,
23931-PF INCISION&DRAINAGE UPPER ARM/ELBOW BURSA,4321965,CDM,981,RC,23931,HCPCS,Outpatient,,,310.36,155.18,,279.32,90,,,percent of total billed charges,90% of total Billed charges,440.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,240.51,155,,,Fee Schedule,155% of CMS OPPS Rate,155.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,248.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,248.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,175.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,240.51,155,,,Fee Schedule,155% of CMS OPPS Rate,155.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,682.29,155,,,Fee Schedule,155% of CMS OPPS Rate,682.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,155.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,556.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.5,682.29,
23935- Inc/deep/open bone cortex/hum/elbo,3434839,CDM,510,RC,23935,HCPCS,Outpatient,,,1323.49,661.75,,1191.14,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.79,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.14,90,,,Percent of total Billed charges,90% of total billed charges,238.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1283.79,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.61,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1191.14,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,926.44,70,,,percent of total billed charges,70% of total billed charges,1191.14,90,,,percent of total billed charges,90% of total billed charges,1257.32,95,,,percent of total billed charges,95% of total billed charges,1257.32,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1138.2,86,,,percent of total billed charges,86% of total billed charges,1058.79,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1283.79,97,,,percent of total billed charges,97% of total billed charges,1191.14,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1283.79,97,,,percent of total billed charges,97% of total billed charges,1230.85,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,217,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1283.79,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,217,14511.58,
24000- Arthrotomy/elbow/exp/drain/rmv FB,3434840,CDM,510,RC,24000,HCPCS,Outpatient,,,1233.02,616.51,,1109.72,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,986.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1109.72,90,,,Percent of total Billed charges,90% of total billed charges,308.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1196.03,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.38,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1109.72,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,863.11,70,,,percent of total billed charges,70% of total billed charges,1109.72,90,,,percent of total billed charges,90% of total billed charges,1171.37,95,,,percent of total billed charges,95% of total billed charges,1171.37,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1060.4,86,,,percent of total billed charges,86% of total billed charges,986.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1196.03,97,,,percent of total billed charges,97% of total billed charges,1109.72,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.03,97,,,percent of total billed charges,97% of total billed charges,1146.71,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1196.03,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,280.5,14511.58,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,360,RC,24065,HCPCS,Outpatient,,,325.87,162.94,,293.28,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,260.7,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.28,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,316.09,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,299.8,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,293.28,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,228.11,70,,,percent of total billed charges,70% of total billed charges,293.28,90,,,percent of total billed charges,90% of total billed charges,309.58,95,,,percent of total billed charges,95% of total billed charges,309.58,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,280.25,86,,,percent of total billed charges,86% of total billed charges,260.7,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,316.09,97,,,percent of total billed charges,97% of total billed charges,293.28,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.09,97,,,percent of total billed charges,97% of total billed charges,303.06,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,316.09,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
24071- Exc/tumor/up arm/elbow SQ/>/=3cm,3434843,CDM,510,RC,24071,HCPCS,Outpatient,,,1071.07,535.54,,963.96,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,856.86,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,963.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1038.94,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,985.38,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,963.96,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,749.75,70,,,percent of total billed charges,70% of total billed charges,963.96,90,,,percent of total billed charges,90% of total billed charges,1017.52,95,,,percent of total billed charges,95% of total billed charges,1017.52,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,921.12,86,,,percent of total billed charges,86% of total billed charges,856.86,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1038.94,97,,,percent of total billed charges,97% of total billed charges,963.96,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1038.94,97,,,percent of total billed charges,97% of total billed charges,996.1,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1038.94,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,749.75,12593.67,
24073 - PF Exc Tumor Sft Tiss Upper Arm/ Elbw Subfasc 5 cm/ >,4311490,CDM,960,RC,24073,HCPCS,Outpatient,,,1626.35,813.18,,1463.72,90,,,percent of total billed charges,90% of total Billed charges,1373.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,684.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1061.66,155,,,Fee Schedule,155% of CMS OPPS Rate,684.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,684.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1120.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1120.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1057.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1057.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,702.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1369.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1247.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,862.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1061.66,155,,,Fee Schedule,155% of CMS OPPS Rate,684.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,2128.38,155,,,Fee Schedule,155% of CMS OPPS Rate,2128.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,684.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,692.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,684.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1408.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1408.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,684.94,2128.38,
24073- Exc IM tumor/upper arm/elbow 5cm/>,3434844,CDM,510,RC,24073,HCPCS,Outpatient,,,1830.17,915.09,,1647.15,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1464.14,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1647.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1775.26,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1683.76,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1647.15,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.12,70,,,percent of total billed charges,70% of total billed charges,1647.15,90,,,percent of total billed charges,90% of total billed charges,1738.66,95,,,percent of total billed charges,95% of total billed charges,1738.66,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1573.95,86,,,percent of total billed charges,86% of total billed charges,1464.14,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1775.26,97,,,percent of total billed charges,97% of total billed charges,1647.15,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1775.26,97,,,percent of total billed charges,97% of total billed charges,1702.06,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1775.26,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1281.12,12593.67,
24075- Exc/tumor/upper arm/elbow/SQ/<3cm,3434845,CDM,510,RC,24075,HCPCS,Outpatient,,,671.43,335.72,,604.29,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,537.14,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,604.29,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,651.29,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,617.72,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,604.29,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,470,70,,,percent of total billed charges,70% of total billed charges,604.29,90,,,percent of total billed charges,90% of total billed charges,637.86,95,,,percent of total billed charges,95% of total billed charges,637.86,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,577.43,86,,,percent of total billed charges,86% of total billed charges,537.14,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,651.29,97,,,percent of total billed charges,97% of total billed charges,604.29,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,651.29,97,,,percent of total billed charges,97% of total billed charges,624.43,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,651.29,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,7310.49,
24076- Exc IM tumor/upper arm/elbow < 5 m,3434846,CDM,510,RC,24076,HCPCS,Outpatient,,,1428.47,714.24,,1285.62,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.78,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1285.62,90,,,Percent of total Billed charges,90% of total billed charges,129.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1385.62,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1314.19,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1285.62,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,999.93,70,,,percent of total billed charges,70% of total billed charges,1285.62,90,,,percent of total billed charges,90% of total billed charges,1357.05,95,,,percent of total billed charges,95% of total billed charges,1357.05,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1228.48,86,,,percent of total billed charges,86% of total billed charges,1142.78,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1385.62,97,,,percent of total billed charges,97% of total billed charges,1285.62,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1385.62,97,,,percent of total billed charges,97% of total billed charges,1328.48,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1385.62,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.5,12593.67,
24105- Excision/olecranon bursa,3434848,CDM,510,RC,24105,HCPCS,Outpatient,,,921.69,460.85,,829.52,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,737.35,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,829.52,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,894.04,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,847.95,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,829.52,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,645.18,70,,,percent of total billed charges,70% of total billed charges,829.52,90,,,percent of total billed charges,90% of total billed charges,875.61,95,,,percent of total billed charges,95% of total billed charges,875.61,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,792.65,86,,,percent of total billed charges,86% of total billed charges,737.35,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,894.04,97,,,percent of total billed charges,97% of total billed charges,829.52,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,894.04,97,,,percent of total billed charges,97% of total billed charges,857.17,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,894.04,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,14511.58,
24110- Exc/curet/bone cyst/bgn tum/humeru,3434849,CDM,510,RC,24110,HCPCS,Outpatient,,,1538.84,769.42,,1384.96,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.07,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1384.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1492.67,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1415.73,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1384.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.19,70,,,percent of total billed charges,70% of total billed charges,1384.96,90,,,percent of total billed charges,90% of total billed charges,1461.9,95,,,percent of total billed charges,95% of total billed charges,1461.9,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1323.4,86,,,percent of total billed charges,86% of total billed charges,1231.07,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1492.67,97,,,percent of total billed charges,97% of total billed charges,1384.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1492.67,97,,,percent of total billed charges,97% of total billed charges,1431.12,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1492.67,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1077.19,14511.58,
24120- Exc/curet/bone cyst/bgn tum head/neck/radius/olecranon proc,3434850,CDM,510,RC,24120,HCPCS,Outpatient,,,1387.03,693.52,,1248.33,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.33,90,,,Percent of total Billed charges,90% of total billed charges,432.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1345.42,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1276.07,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1248.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,970.92,70,,,percent of total billed charges,70% of total billed charges,1248.33,90,,,percent of total billed charges,90% of total billed charges,1317.68,95,,,percent of total billed charges,95% of total billed charges,1317.68,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.85,86,,,percent of total billed charges,86% of total billed charges,1109.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1345.42,97,,,percent of total billed charges,97% of total billed charges,1248.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1345.42,97,,,percent of total billed charges,97% of total billed charges,1289.94,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,393.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1345.42,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,393.5,14511.58,
24147- Part exc/bone/olecranon process,3434851,CDM,510,RC,24147,HCPCS,Outpatient,,,1631.94,815.97,,1468.75,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1305.55,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1468.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1582.98,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1501.38,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1468.75,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.36,70,,,percent of total billed charges,70% of total billed charges,1468.75,90,,,percent of total billed charges,90% of total billed charges,1550.34,95,,,percent of total billed charges,95% of total billed charges,1550.34,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1403.47,86,,,percent of total billed charges,86% of total billed charges,1305.55,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1582.98,97,,,percent of total billed charges,97% of total billed charges,1468.75,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1582.98,97,,,percent of total billed charges,97% of total billed charges,1517.7,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1582.98,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1142.36,14511.58,
24200- Rmv foreign body/up arm/elbow/SQ,3434852,CDM,510,RC,24200,HCPCS,Outpatient,,,554.02,277.01,,498.62,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,443.22,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.62,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,537.4,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,509.7,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,498.62,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,387.81,70,,,percent of total billed charges,70% of total billed charges,498.62,90,,,percent of total billed charges,90% of total billed charges,526.32,95,,,percent of total billed charges,95% of total billed charges,526.32,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,476.46,86,,,percent of total billed charges,86% of total billed charges,443.22,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,537.4,97,,,percent of total billed charges,97% of total billed charges,498.62,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.4,97,,,percent of total billed charges,97% of total billed charges,515.24,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.4,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,7310.49,
24200-PF RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS,4321339,CDM,981,RC,24200,HCPCS,Outpatient,,,269.92,134.96,,242.93,90,,,percent of total billed charges,90% of total Billed charges,343.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.19,155,,,Fee Schedule,155% of CMS OPPS Rate,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,225.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,209.19,155,,,Fee Schedule,155% of CMS OPPS Rate,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.1,155,,,Fee Schedule,155% of CMS OPPS Rate,532.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,405.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,532.1,
24201- Rmv foreign body/up arm/elbow/deep,3434853,CDM,510,RC,24201,HCPCS,Outpatient,,,1394.6,697.30,,1255.14,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1115.68,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1255.14,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1352.76,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.03,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1255.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,976.22,70,,,percent of total billed charges,70% of total billed charges,1255.14,90,,,percent of total billed charges,90% of total billed charges,1324.87,95,,,percent of total billed charges,95% of total billed charges,1324.87,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1199.36,86,,,percent of total billed charges,86% of total billed charges,1115.68,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1352.76,97,,,percent of total billed charges,97% of total billed charges,1255.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1352.76,97,,,percent of total billed charges,97% of total billed charges,1296.98,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1352.76,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,12593.67,
24201-PF REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP,4321340,CDM,981,RC,24201,HCPCS,Outpatient,,,717.68,358.84,,645.91,90,,,percent of total billed charges,90% of total Billed charges,883.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,358.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,556.19,155,,,Fee Schedule,155% of CMS OPPS Rate,358.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,582.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,582.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,542.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,542.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,343.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,717.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,639.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,434.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,556.19,155,,,Fee Schedule,155% of CMS OPPS Rate,358.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1369.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1369.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,358.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,536.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,358.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1096.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,1369.04,
24341-PF REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA TDN/MUSC,4321341,CDM,981,RC,24341,HCPCS,Outpatient,,,1455.36,727.68,,1309.82,90,,,percent of total billed charges,90% of total Billed charges,1453.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1127.9,155,,,Fee Schedule,155% of CMS OPPS Rate,727.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1063.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,727.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1195.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1107.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1107.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,680.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1306.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,869.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1127.9,155,,,Fee Schedule,155% of CMS OPPS Rate,727.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,2253.14,155,,,Fee Schedule,155% of CMS OPPS Rate,2253.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,727.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,600,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,676.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,727.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1504.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,600,2253.14,
24342-PF RINSJ RPTD BICEPS/TRICEPS TDN DSTL W/WO TDN GRF,4321964,CDM,981,RC,24342,HCPCS,Outpatient,,,1520.1,760.05,,1368.09,90,,,percent of total billed charges,90% of total Billed charges,1523.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,760.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,520,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1178.06,155,,,Fee Schedule,155% of CMS OPPS Rate,760.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,760.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1247.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1247.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1165.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1165.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,753.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1520.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1375.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,924.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1178.06,155,,,Fee Schedule,155% of CMS OPPS Rate,760.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,2361.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2361.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,760.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,520,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,780.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,760.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,1575.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1575.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,520,2361.36,
24500-PF CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION,4321963,CDM,981,RC,24500,HCPCS,Outpatient,,,649.7,324.85,,584.73,90,,,percent of total billed charges,90% of total Billed charges,672.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,324.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,503.5,155,,,Fee Schedule,155% of CMS OPPS Rate,324.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,324.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,526.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,478.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,478.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,283.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,365.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,503.5,155,,,Fee Schedule,155% of CMS OPPS Rate,324.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1042.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1042.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,324.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,324.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,697,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,697,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,1042.87,
24505-PF CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ,4321962,CDM,981,RC,24505,HCPCS,Outpatient,,,886.4,443.20,,797.76,90,,,percent of total billed charges,90% of total Billed charges,932.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,443.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,686.96,155,,,Fee Schedule,155% of CMS OPPS Rate,443.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,443.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,720.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,664.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,664.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,418.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,886.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,783.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,519.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,686.96,155,,,Fee Schedule,155% of CMS OPPS Rate,443.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1444.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,443.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,163,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,519.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,443.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,991.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,163,1444.85,
24515-PF OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE,4321961,CDM,981,RC,24515,HCPCS,Outpatient,,,1726.78,863.39,,1554.1,90,,,percent of total billed charges,90% of total Billed charges,1730,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,863.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1338.25,155,,,Fee Schedule,155% of CMS OPPS Rate,863.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1256.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,863.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1413.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1320.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1320.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,839.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1726.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1558.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1051.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1338.25,155,,,Fee Schedule,155% of CMS OPPS Rate,863.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,2681.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2681.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,863.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,392,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,887.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,863.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1773.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1773.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,392,2681.5,
24516-PF TX HUMRAL SHAFT FX W/INSJ IMED IMPLT W/W CERCLGE,4321960,CDM,981,RC,24516,HCPCS,Outpatient,,,1688.94,844.47,,1520.05,90,,,percent of total billed charges,90% of total Billed charges,1692.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,844.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,761.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1308.93,155,,,Fee Schedule,155% of CMS OPPS Rate,844.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,844.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1381.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1294.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1294.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,829,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1688.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1528.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1035.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1308.93,155,,,Fee Schedule,155% of CMS OPPS Rate,844.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2622.88,155,,,Fee Schedule,155% of CMS OPPS Rate,2622.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,844.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,887.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,844.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1744.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1744.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,761.57,2622.88,
24530-PF CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ,4321959,CDM,981,RC,24530,HCPCS,Outpatient,,,684.9,342.45,,616.41,90,,,percent of total billed charges,90% of total Billed charges,710.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,123.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,530.78,155,,,Fee Schedule,155% of CMS OPPS Rate,342.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,554.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,505.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,505.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,306.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,387.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.78,155,,,Fee Schedule,155% of CMS OPPS Rate,342.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1101.46,155,,,Fee Schedule,155% of CMS OPPS Rate,1101.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,357.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,123.5,1101.46,
24535-PF CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ,4321958,CDM,981,RC,24535,HCPCS,Outpatient,,,1118.14,559.07,,1006.33,90,,,percent of total billed charges,90% of total Billed charges,1161.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,866.54,155,,,Fee Schedule,155% of CMS OPPS Rate,559.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,910.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,910.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,842.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,842.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,533.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1118.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,993.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,661.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,866.54,155,,,Fee Schedule,155% of CMS OPPS Rate,559.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1800.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1800.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,559.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,206,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,598.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,559.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,206,1800.03,
24538-PF PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX,4321957,CDM,981,RC,24538,HCPCS,Outpatient,,,1539.36,769.68,,1385.42,90,,,percent of total billed charges,90% of total Billed charges,1543.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,206,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1193,155,,,Fee Schedule,155% of CMS OPPS Rate,769.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,769.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1225.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1137.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1137.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,710.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1342.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,899.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1193,155,,,Fee Schedule,155% of CMS OPPS Rate,769.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,2392.05,155,,,Fee Schedule,155% of CMS OPPS Rate,2392.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,769.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,206,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,751.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,769.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1498.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1498.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,206,2392.05,
24545-PF OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN,4321956,CDM,981,RC,24545,HCPCS,Outpatient,,,1819.06,909.53,,1637.15,90,,,percent of total billed charges,90% of total Billed charges,1824.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,909.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,423.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1409.77,155,,,Fee Schedule,155% of CMS OPPS Rate,909.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,909.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1494.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1401.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1401.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,852.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,909.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1819.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1653.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1120.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1409.77,155,,,Fee Schedule,155% of CMS OPPS Rate,909.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2827.74,155,,,Fee Schedule,155% of CMS OPPS Rate,2827.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,909.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,866.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,909.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1887,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1887,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,423.5,2827.74,
24546-PF OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XT,4321955,CDM,981,RC,24546,HCPCS,Outpatient,,,2035.68,1017.84,,1832.11,90,,,percent of total billed charges,90% of total Billed charges,2040.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1017.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,469,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1577.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1017.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1484.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1017.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1669.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1669.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1567.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1567.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1021.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1017.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2035.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1849.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1254.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1577.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1017.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,3162.05,155,,,Fee Schedule,155% of CMS OPPS Rate,3162.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1017.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,469,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1115.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1017.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2113.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2113.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,469,3162.05,
24560-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ,4321950,CDM,981,RC,24560,HCPCS,Outpatient,,,574.64,287.32,,517.18,90,,,percent of total billed charges,90% of total Billed charges,606.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,287.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,445.33,155,,,Fee Schedule,155% of CMS OPPS Rate,287.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,468.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,468.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,425.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,425.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,249.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,501.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,324.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,445.33,155,,,Fee Schedule,155% of CMS OPPS Rate,287.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,940.57,155,,,Fee Schedule,155% of CMS OPPS Rate,940.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,287.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,287.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,625.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111,940.57,
24565-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ,4321949,CDM,981,RC,24565,HCPCS,Outpatient,,,968.32,484.16,,871.49,90,,,percent of total billed charges,90% of total Billed charges,1008.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,484.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,173.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,750.45,155,,,Fee Schedule,155% of CMS OPPS Rate,484.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,484.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,725.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,725.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,435.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,856.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,567.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,750.45,155,,,Fee Schedule,155% of CMS OPPS Rate,484.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1563.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1563.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,484.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,510.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,484.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1058.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1058.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,173.5,1563.86,
24566-PF PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MANJ,4321948,CDM,981,RC,24566,HCPCS,Outpatient,,,1405.82,702.91,,1265.24,90,,,percent of total billed charges,90% of total Billed charges,1406.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,702.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.51,155,,,Fee Schedule,155% of CMS OPPS Rate,702.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1025.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,702.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1153.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1153.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1068.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1068.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,655.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1261.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,843.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1089.51,155,,,Fee Schedule,155% of CMS OPPS Rate,702.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2180.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2180.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,702.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,664,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,702.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1442.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1442.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,655.2,2180.82,
24575-PF OPEN TX HUMERAL EPICONDYLAR FRACTURE,4321947,CDM,981,RC,24575,HCPCS,Outpatient,,,1431.98,715.99,,1288.78,90,,,percent of total billed charges,90% of total Billed charges,1433.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,715.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,396,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1109.78,155,,,Fee Schedule,155% of CMS OPPS Rate,715.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,715.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1176.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1176.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1094.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1094.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,708.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1431.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1291.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,865.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1109.78,155,,,Fee Schedule,155% of CMS OPPS Rate,715.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2222.42,155,,,Fee Schedule,155% of CMS OPPS Rate,2222.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,715.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,396,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,715.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1478.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1478.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,396,2222.42,
24576-PF CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ,4321946,CDM,981,RC,24576,HCPCS,Outpatient,,,607.72,303.86,,546.95,90,,,percent of total billed charges,90% of total Billed charges,640.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,470.98,155,,,Fee Schedule,155% of CMS OPPS Rate,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,494.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,447.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,447.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,528.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,340.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,470.98,155,,,Fee Schedule,155% of CMS OPPS Rate,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.14,155,,,Fee Schedule,155% of CMS OPPS Rate,992.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,666.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111,992.14,
24577-PF CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ,4321945,CDM,981,RC,24577,HCPCS,Outpatient,,,993.48,496.74,,894.13,90,,,percent of total billed charges,90% of total Billed charges,1037,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,496.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,173.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,769.93,155,,,Fee Schedule,155% of CMS OPPS Rate,496.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,746.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,746.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,451.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,993.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,880.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,584.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,769.93,155,,,Fee Schedule,155% of CMS OPPS Rate,496.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1607.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1607.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,496.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,496.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1090.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1090.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,173.5,1607.35,
24579-PF OPEN TREATMENT HUMERAL CONDYLAR FRACTURE,4321944,CDM,981,RC,24579,HCPCS,Outpatient,,,1635.8,817.90,,1472.22,90,,,percent of total billed charges,90% of total Billed charges,1636.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,817.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,396,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1267.75,155,,,Fee Schedule,155% of CMS OPPS Rate,817.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1188.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,817.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1336.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1336.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1247.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1247.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,797.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1635.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1472.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,989.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1267.75,155,,,Fee Schedule,155% of CMS OPPS Rate,817.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,2536.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2536.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,817.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,396,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,866.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,817.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1689.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1689.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,396,2536.53,
24582-PF PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MANJ,4321943,CDM,981,RC,24582,HCPCS,Outpatient,,,1590.26,795.13,,1431.23,90,,,percent of total billed charges,90% of total Billed charges,1591.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,795.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1232.45,155,,,Fee Schedule,155% of CMS OPPS Rate,795.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,795.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1301.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1301.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1204.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1204.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,739.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1590.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1421.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,947.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1232.45,155,,,Fee Schedule,155% of CMS OPPS Rate,795.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2467.07,155,,,Fee Schedule,155% of CMS OPPS Rate,2467.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,795.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,712.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,795.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1623.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1623.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,712.22,2467.07,
24586-PF OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO,4321942,CDM,981,RC,24586,HCPCS,Outpatient,,,2134.88,1067.44,,1921.39,90,,,percent of total billed charges,90% of total Billed charges,2139.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1067.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,650,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1654.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1067.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1555.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1067.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1749.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1643.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1643.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1051.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1067.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2134.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1939.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1316.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1654.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1067.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,3316.02,155,,,Fee Schedule,155% of CMS OPPS Rate,3316.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1067.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,650,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1205.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1067.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2207.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2207.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,650,3316.02,
24587-PF OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHR,4321941,CDM,981,RC,24587,HCPCS,Outpatient,,,2140.94,1070.47,,1926.85,90,,,percent of total billed charges,90% of total Billed charges,2146.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1070.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,780,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1659.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1070.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1556.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1070.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1750.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1750.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1646.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1646.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1042.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1070.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2140.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1942.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1323.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1659.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1070.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,3326.86,155,,,Fee Schedule,155% of CMS OPPS Rate,3326.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1070.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,780,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1208.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1070.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2210,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2210,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,780,3326.86,
24600-PF TREATMENT CLOSED ELBOW DISLOCATION W/O ANES,4321940,CDM,981,RC,24600,HCPCS,Outpatient,,,678.54,339.27,,610.69,90,,,percent of total billed charges,90% of total Billed charges,705.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,525.85,155,,,Fee Schedule,155% of CMS OPPS Rate,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,339.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,540.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,502.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,502.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,299.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,396.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,525.85,155,,,Fee Schedule,155% of CMS OPPS Rate,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1094.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,406.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,705.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.5,1094.22,
24605-PF TREATMENT CLOSED ELBOW DISLOCATION REQ ANES,4321939,CDM,981,RC,24605,HCPCS,Outpatient,,,932.98,466.49,,839.68,90,,,percent of total billed charges,90% of total Billed charges,932.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,466.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,723.04,155,,,Fee Schedule,155% of CMS OPPS Rate,466.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,466.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,759.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,759.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,699.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,699.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,429.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,932.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,825.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,545.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,723.04,155,,,Fee Schedule,155% of CMS OPPS Rate,466.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1445.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1445.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,466.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,411.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,466.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,935,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,935,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157.5,1445.93,
24615-PF CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ,4321938,CDM,981,RC,24615,HCPCS,Outpatient,,,1402.16,701.08,,1261.94,90,,,percent of total billed charges,90% of total Billed charges,1403.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,701.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1086.67,155,,,Fee Schedule,155% of CMS OPPS Rate,701.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,701.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1147.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1071.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1071.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1402.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1264.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,851,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1086.67,155,,,Fee Schedule,155% of CMS OPPS Rate,701.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2174.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2174.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,701.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,701.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1439.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1439.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2174.9,
24620-PF CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ,4321937,CDM,981,RC,24620,HCPCS,Outpatient,,,1148.8,574.40,,1033.92,90,,,percent of total billed charges,90% of total Billed charges,1128.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,890.32,155,,,Fee Schedule,155% of CMS OPPS Rate,574.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,791.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,574.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,890.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,890.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,827.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,827.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,518.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,975.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,652.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,890.32,155,,,Fee Schedule,155% of CMS OPPS Rate,574.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1748.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1748.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,574.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,513.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,574.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1111.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1111.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,140.5,1748.52,
24635-PF OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW,4321936,CDM,981,RC,24635,HCPCS,Outpatient,,,1322.2,661.10,,1189.98,90,,,percent of total billed charges,90% of total Billed charges,1321.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,661.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1024.69,155,,,Fee Schedule,155% of CMS OPPS Rate,661.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,962.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,661.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1082.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1082.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1005.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1005.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,732.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1322.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1186.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,793.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1024.69,155,,,Fee Schedule,155% of CMS OPPS Rate,661.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2048.33,155,,,Fee Schedule,155% of CMS OPPS Rate,2048.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,661.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1112.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,661.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1355.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1355.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2048.33,
24640-PF CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MAN,4321935,CDM,981,RC,24640,HCPCS,Outpatient,,,153.92,76.96,,138.53,90,,,percent of total billed charges,90% of total Billed charges,176.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.27,155,,,Fee Schedule,155% of CMS OPPS Rate,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.27,155,,,Fee Schedule,155% of CMS OPPS Rate,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.56,155,,,Fee Schedule,155% of CMS OPPS Rate,273.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,163.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,260.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53,273.56,
24650-PF CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION,4321934,CDM,981,RC,24650,HCPCS,Outpatient,,,475.84,237.92,,428.26,90,,,percent of total billed charges,90% of total Billed charges,489.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,103,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,368.76,155,,,Fee Schedule,155% of CMS OPPS Rate,237.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,387.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,350.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,350.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,265.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,368.76,155,,,Fee Schedule,155% of CMS OPPS Rate,237.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,759.14,155,,,Fee Schedule,155% of CMS OPPS Rate,759.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,237.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,103,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,252.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,237.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,509.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,509.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,103,759.14,
24655-PF CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION,4321933,CDM,981,RC,24655,HCPCS,Outpatient,,,791.04,395.52,,711.94,90,,,percent of total billed charges,90% of total Billed charges,828.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,613.04,155,,,Fee Schedule,155% of CMS OPPS Rate,395.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,395.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,639.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,587.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,587.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,362.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,791.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,692.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,613.04,155,,,Fee Schedule,155% of CMS OPPS Rate,395.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1284.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1284.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,395.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,395.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,854.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1284.19,
24665-PF OPEN TX RADIAL HEAD/NECK FRACTURE,4321932,CDM,981,RC,24665,HCPCS,Outpatient,,,1281.5,640.75,,1153.35,90,,,percent of total billed charges,90% of total Billed charges,1283.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,640.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,314.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,993.15,155,,,Fee Schedule,155% of CMS OPPS Rate,640.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,640.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1051.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,973.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,973.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,617.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,640.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1281.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1148.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,764.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,993.15,155,,,Fee Schedule,155% of CMS OPPS Rate,640.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1989.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1989.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,640.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,640.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1313.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,314.5,1989.24,
24666-PF OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC,4321931,CDM,981,RC,24666,HCPCS,Outpatient,,,1435.1,717.55,,1291.59,90,,,percent of total billed charges,90% of total Billed charges,1435.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,717.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,488,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1112.19,155,,,Fee Schedule,155% of CMS OPPS Rate,717.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,717.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1178,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1097.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1097.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,698.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1294.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,868.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1112.19,155,,,Fee Schedule,155% of CMS OPPS Rate,717.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2225.51,155,,,Fee Schedule,155% of CMS OPPS Rate,2225.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,717.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,488,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,750.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,717.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1479.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1479.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,488,2225.51,
24670-PF CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ,4321930,CDM,981,RC,24670,HCPCS,Outpatient,,,521.54,260.77,,469.39,90,,,percent of total billed charges,90% of total Billed charges,542.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,404.19,155,,,Fee Schedule,155% of CMS OPPS Rate,260.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,385.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,385.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,230.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,454.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,404.19,155,,,Fee Schedule,155% of CMS OPPS Rate,260.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,840.44,155,,,Fee Schedule,155% of CMS OPPS Rate,840.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,260.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,100,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,260.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,568.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,568.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,100,840.44,
24675-PF CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ,4321929,CDM,981,RC,24675,HCPCS,Outpatient,,,817.34,408.67,,735.61,90,,,percent of total billed charges,90% of total Billed charges,859.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,408.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,633.44,155,,,Fee Schedule,155% of CMS OPPS Rate,408.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,593.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,408.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,667.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,614.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,614.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,386.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,725.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,479.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,633.44,155,,,Fee Schedule,155% of CMS OPPS Rate,408.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1332.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1332.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,408.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,456.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,408.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,903.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,903.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,182.5,1332.01,
24685-PF OPEN TREATMENT ULNAR FRACTURE PROXIMAL END,4321928,CDM,981,RC,24685,HCPCS,Outpatient,,,1276,638.00,,1148.4,90,,,percent of total billed charges,90% of total Billed charges,1277.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,638,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,419,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,988.9,155,,,Fee Schedule,155% of CMS OPPS Rate,638,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,932.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,638,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1049.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,972.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,972.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,621.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1276,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1147.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,765.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,988.9,155,,,Fee Schedule,155% of CMS OPPS Rate,638,100,,,Fee Schedule,100% of CMS OPPS Rate ,1979.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1979.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,638,100,,,Fee Schedule,100% of CMS OPPS Rate ,419,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,729.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,638,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1315.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,419,1979.44,
25028- I&D/forearm/wrist/deep absc/hemato,3434886,CDM,510,RC,25028,HCPCS,Outpatient,,,1773.96,886.98,,1596.56,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.17,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1596.56,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1720.74,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.04,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1596.56,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1241.77,70,,,percent of total billed charges,70% of total billed charges,1596.56,90,,,percent of total billed charges,90% of total billed charges,1685.26,95,,,percent of total billed charges,95% of total billed charges,1685.26,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1525.61,86,,,percent of total billed charges,86% of total billed charges,1419.17,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1720.74,97,,,percent of total billed charges,97% of total billed charges,1596.56,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1720.74,97,,,percent of total billed charges,97% of total billed charges,1649.78,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1720.74,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,14511.58,
25031- I&D/bursa/forearm/wrist,3434887,CDM,510,RC,25031,HCPCS,Outpatient,,,954.47,477.24,,859.02,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,763.58,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.02,90,,,Percent of total Billed charges,90% of total billed charges,43.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,925.84,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,878.11,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,859.02,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,668.13,70,,,percent of total billed charges,70% of total billed charges,859.02,90,,,percent of total billed charges,90% of total billed charges,906.75,95,,,percent of total billed charges,95% of total billed charges,906.75,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,820.84,86,,,percent of total billed charges,86% of total billed charges,763.58,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,925.84,97,,,percent of total billed charges,97% of total billed charges,859.02,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,925.84,97,,,percent of total billed charges,97% of total billed charges,887.66,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,925.84,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.5,6993.46,
25065- Bx/soft tis/forearm/wrist/superfic,3434888,CDM,510,RC,25065,HCPCS,Outpatient,,,671.43,335.72,,604.29,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,537.14,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,604.29,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,651.29,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,617.72,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,604.29,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,470,70,,,percent of total billed charges,70% of total billed charges,604.29,90,,,percent of total billed charges,90% of total billed charges,637.86,95,,,percent of total billed charges,95% of total billed charges,637.86,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,577.43,86,,,percent of total billed charges,86% of total billed charges,537.14,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,651.29,97,,,percent of total billed charges,97% of total billed charges,604.29,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,651.29,97,,,percent of total billed charges,97% of total billed charges,624.43,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,651.29,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
25073-MSA EXC FOREARM TUM DEEP 3CM/>,3429072,CDM,360,RC,25073,HCPCS,Outpatient,,,1395.46,697.73,,1255.91,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.37,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1255.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1353.6,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.82,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1255.91,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,976.82,70,,,percent of total billed charges,70% of total billed charges,1255.91,90,,,percent of total billed charges,90% of total billed charges,1325.69,95,,,percent of total billed charges,95% of total billed charges,1325.69,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1200.1,86,,,percent of total billed charges,86% of total billed charges,1116.37,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1353.6,97,,,percent of total billed charges,97% of total billed charges,1255.91,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1353.6,97,,,percent of total billed charges,97% of total billed charges,1297.78,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1353.6,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,976.82,12593.67,
25075 - PF Exc Tumor Sft Tiss Forewarm &/ Wrist Subq <3 cm,4305456,CDM,960,RC,25075,HCPCS,Outpatient,,,641.19,320.60,,577.07,90,,,percent of total billed charges,90% of total Billed charges,804.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,311.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1247.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,943.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1247.05,
25076 - PF Exc Tumor Soft Tiss Forearm&/Wrist Subfasc <3cm,4301626,CDM,960,RC,25076,HCPCS,Outpatient,,,1075.12,537.56,,967.61,90,,,percent of total billed charges,90% of total Billed charges,1012.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,507.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,786.05,155,,,Fee Schedule,155% of CMS OPPS Rate,507.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,507.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,830.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,770.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,770.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,420.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,908.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,604.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,786.05,155,,,Fee Schedule,155% of CMS OPPS Rate,507.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1569.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1569.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,507.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,637.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,507.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1038.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1038.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1569.65,
25248-PF EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST,4321927,CDM,981,RC,25248,HCPCS,Outpatient,,,813.96,406.98,,732.56,90,,,percent of total billed charges,90% of total Billed charges,818.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,406.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,630.8,155,,,Fee Schedule,155% of CMS OPPS Rate,406.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,406.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,666.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,618.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,618.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,415.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,729.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,489.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,630.8,155,,,Fee Schedule,155% of CMS OPPS Rate,406.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1268.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1268.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,406.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,574.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,406.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,826.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,826.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1268.71,
25260-PF RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MU,4321342,CDM,981,RC,25260,HCPCS,Outpatient,,,1239.8,619.90,,1115.82,90,,,percent of total billed charges,90% of total Billed charges,1238.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,960.85,155,,,Fee Schedule,155% of CMS OPPS Rate,619.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,619.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1012.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1012.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,936.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,936.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,646.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1104.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,728.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,960.85,155,,,Fee Schedule,155% of CMS OPPS Rate,619.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1919.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1919.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,619.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,363,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,908.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,619.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1273.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1273.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,363,1919.91,
25270 - PF Rpr Tdn/ Musc Xtnsr F/ Arm&/ Wrist Prim 1 Ea Tdn,4311492,CDM,960,RC,25270,HCPCS,Outpatient,,,1144.69,572.35,,1030.22,90,,,percent of total billed charges,90% of total Billed charges,963.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,439,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,747.26,155,,,Fee Schedule,155% of CMS OPPS Rate,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,482.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,790.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,729.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,729.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,519.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,861.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,568.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,747.26,155,,,Fee Schedule,155% of CMS OPPS Rate,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1493.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1493.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,439,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,798.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,992.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,439,1493.78,
25270-PF RPR TDN/MUSC XTNSR F/ARM&/WRIST PRIM 1 EA TDN,4321344,CDM,981,RC,25270,HCPCS,Outpatient,,,964.2,482.10,,867.78,90,,,percent of total billed charges,90% of total Billed charges,963.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,439,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,747.26,155,,,Fee Schedule,155% of CMS OPPS Rate,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,482.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,790.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,729.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,729.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,519.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,861.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,568.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,747.26,155,,,Fee Schedule,155% of CMS OPPS Rate,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1493.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1493.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,439,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,798.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,482.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,992.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,439,1493.78,
25500-PF CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION,4321926,CDM,981,RC,25500,HCPCS,Outpatient,,,500.94,250.47,,450.85,90,,,percent of total billed charges,90% of total Billed charges,523.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,250.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,78.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,388.23,155,,,Fee Schedule,155% of CMS OPPS Rate,250.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,403.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,366.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,366.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,432.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,279.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,388.23,155,,,Fee Schedule,155% of CMS OPPS Rate,250.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.56,155,,,Fee Schedule,155% of CMS OPPS Rate,811.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,250.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,250.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.5,811.56,
25505-PF CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION,4321925,CDM,981,RC,25505,HCPCS,Outpatient,,,903.3,451.65,,812.97,90,,,percent of total billed charges,90% of total Billed charges,941.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,451.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,700.04,155,,,Fee Schedule,155% of CMS OPPS Rate,451.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,735.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,677.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,677.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,424.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,903.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,799.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,528,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,700.04,155,,,Fee Schedule,155% of CMS OPPS Rate,451.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1460.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1460.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,451.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,145,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,484.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,451.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,991.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,145,1460.05,
25515-PF OPEN TREATMENT RADIAL SHAFT FRACTURE,4321924,CDM,981,RC,25515,HCPCS,Outpatient,,,1310.3,655.15,,1179.27,90,,,percent of total billed charges,90% of total Billed charges,1310.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,360,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1015.47,155,,,Fee Schedule,155% of CMS OPPS Rate,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,655.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1074.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1074.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,998.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,998.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,638.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1310.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1178.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,788.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1015.47,155,,,Fee Schedule,155% of CMS OPPS Rate,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,2032,155,,,Fee Schedule,155% of CMS OPPS Rate,2032,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,360,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,720.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,655.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1346.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1346.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360,2032,
25520-PF CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT,4321923,CDM,981,RC,25520,HCPCS,Outpatient,,,1065.58,532.79,,959.02,90,,,percent of total billed charges,90% of total Billed charges,1094.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,532.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.81,155,,,Fee Schedule,155% of CMS OPPS Rate,532.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,532.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,867.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,799.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,799.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,483.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1065.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,626.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,825.81,155,,,Fee Schedule,155% of CMS OPPS Rate,532.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1697.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1697.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,532.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,534.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,532.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1130.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,483.37,1697.14,
25525-PF OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE,4321922,CDM,981,RC,25525,HCPCS,Outpatient,,,1547.52,773.76,,1392.77,90,,,percent of total billed charges,90% of total Billed charges,1546.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,410,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1199.33,155,,,Fee Schedule,155% of CMS OPPS Rate,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,773.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1266.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1266.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1179.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1179.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,776.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1547.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1391.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,933.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1199.33,155,,,Fee Schedule,155% of CMS OPPS Rate,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,2396.66,155,,,Fee Schedule,155% of CMS OPPS Rate,2396.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,410,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,903.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1583.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1583.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,410,2396.66,
25526-PF OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE,4321921,CDM,981,RC,25526,HCPCS,Outpatient,,,1875.74,937.87,,1688.17,90,,,percent of total billed charges,90% of total Billed charges,1878.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,937.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,517,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1453.7,155,,,Fee Schedule,155% of CMS OPPS Rate,937.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1364.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,937.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1535.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1535.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1435.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1435.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,946.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1693.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1146.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1453.7,155,,,Fee Schedule,155% of CMS OPPS Rate,937.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2912.17,155,,,Fee Schedule,155% of CMS OPPS Rate,2912.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,937.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,517,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1050.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,937.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1931.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1931.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,517,2912.17,
25530-PF CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION,4321920,CDM,981,RC,25530,HCPCS,Outpatient,,,469.64,234.82,,422.68,90,,,percent of total billed charges,90% of total Billed charges,486.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,363.97,155,,,Fee Schedule,155% of CMS OPPS Rate,234.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,383.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,345.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,345.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,204.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,407.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,261.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,363.97,155,,,Fee Schedule,155% of CMS OPPS Rate,234.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.64,155,,,Fee Schedule,155% of CMS OPPS Rate,753.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,234.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,234.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,509.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,509.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,108,753.64,
25535-PF CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION,4321919,CDM,981,RC,25535,HCPCS,Outpatient,,,894.34,447.17,,804.91,90,,,percent of total billed charges,90% of total Billed charges,928.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,447.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,160.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,693.11,155,,,Fee Schedule,155% of CMS OPPS Rate,447.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,447.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,726.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,667.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,667.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,417.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,894.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,787.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,518.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,693.11,155,,,Fee Schedule,155% of CMS OPPS Rate,447.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1438.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1438.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,447.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,477.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,447.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,969.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,160.5,1438.63,
25545-PF OPEN TREATMENT OF ULNAR SHAFT FRACTURE,4321918,CDM,981,RC,25545,HCPCS,Outpatient,,,1221.06,610.53,,1098.95,90,,,percent of total billed charges,90% of total Billed charges,1220.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,610.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,340,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,946.32,155,,,Fee Schedule,155% of CMS OPPS Rate,610.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,999.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,925.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,925.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,599.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1221.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1092,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,726.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,946.32,155,,,Fee Schedule,155% of CMS OPPS Rate,610.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1892.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1892.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,610.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,340,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,705.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,610.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1251.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1251.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,340,1892.01,
25560-PF CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN,4321917,CDM,981,RC,25560,HCPCS,Outpatient,,,504.04,252.02,,453.64,90,,,percent of total billed charges,90% of total Billed charges,530.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,390.62,155,,,Fee Schedule,155% of CMS OPPS Rate,252.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,407.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,209.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,435.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,281.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,390.62,155,,,Fee Schedule,155% of CMS OPPS Rate,252.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,821.87,155,,,Fee Schedule,155% of CMS OPPS Rate,821.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,252.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,252.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.5,821.87,
25565-PF CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ,4321916,CDM,981,RC,25565,HCPCS,Outpatient,,,919.72,459.86,,827.75,90,,,percent of total billed charges,90% of total Billed charges,966.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,200.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,712.77,155,,,Fee Schedule,155% of CMS OPPS Rate,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,459.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,745.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,689.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,689.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,440.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,919.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,814.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,542.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,712.77,155,,,Fee Schedule,155% of CMS OPPS Rate,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1498.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1498.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1034.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1034.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,200.5,1498.08,
25574-PF OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA,4321915,CDM,981,RC,25574,HCPCS,Outpatient,,,1321.92,660.96,,1189.73,90,,,percent of total billed charges,90% of total Billed charges,1321.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,660.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,532.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1024.47,155,,,Fee Schedule,155% of CMS OPPS Rate,660.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,660.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1081.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1081.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1004.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1004.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,619.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1185.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,792.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1024.47,155,,,Fee Schedule,155% of CMS OPPS Rate,660.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,2048.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2048.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,660.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,631.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,660.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1353.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1353.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,532.91,2048.46,
25575-PF OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS&ULNA,4321914,CDM,981,RC,25575,HCPCS,Outpatient,,,1770.92,885.46,,1593.83,90,,,percent of total billed charges,90% of total Billed charges,1773.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,885.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,431,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1372.45,155,,,Fee Schedule,155% of CMS OPPS Rate,885.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1448.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1350.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1350.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,844.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,885.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1770.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1594.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1071.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1372.45,155,,,Fee Schedule,155% of CMS OPPS Rate,885.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2748.2,155,,,Fee Schedule,155% of CMS OPPS Rate,2748.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,885.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,431,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,883.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,885.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1816.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1816.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,431,2748.2,
25600-PF CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MAN,4321913,CDM,981,RC,25600,HCPCS,Outpatient,,,623.52,311.76,,561.17,90,,,percent of total billed charges,90% of total Billed charges,634.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,729.5,90,,,Percent of total Billed charges,90% of total billed charges,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,483.21,155,,,Fee Schedule,155% of CMS OPPS Rate,311.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,504.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,504.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,452.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,452.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,247.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,339.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,483.21,155,,,Fee Schedule,155% of CMS OPPS Rate,311.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.38,155,,,Fee Schedule,155% of CMS OPPS Rate,983.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,311.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,311.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,572.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,572.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.5,983.38,
25605-PF CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF,4321912,CDM,981,RC,25605,HCPCS,Outpatient,,,1004.7,502.35,,904.23,90,,,percent of total billed charges,90% of total Billed charges,1029.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,502.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1227.94,90,,,Percent of total Billed charges,90% of total billed charges,166,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,778.64,155,,,Fee Schedule,155% of CMS OPPS Rate,502.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,502.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,820.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,820.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,757.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,757.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,528.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,894.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,595.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,778.64,155,,,Fee Schedule,155% of CMS OPPS Rate,502.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1596.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1596.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,502.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,166,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,502.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1241.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1241.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,166,1596.35,
25606-PF PRQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP,4321911,CDM,981,RC,25606,HCPCS,Outpatient,,,1302.82,651.41,,1172.54,90,,,percent of total billed charges,90% of total Billed charges,1303.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,651.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1009.69,155,,,Fee Schedule,155% of CMS OPPS Rate,651.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,946.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,651.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1064.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,984.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,984.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,626.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1302.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1162.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,773.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1009.69,155,,,Fee Schedule,155% of CMS OPPS Rate,651.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2019.93,155,,,Fee Schedule,155% of CMS OPPS Rate,2019.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,651.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,616.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,651.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1331.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1331.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,616.84,2019.93,
25607-PF OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP,4321910,CDM,981,RC,25607,HCPCS,Outpatient,,,1445.48,722.74,,1300.93,90,,,percent of total billed charges,90% of total Billed charges,1444.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,722.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.23,155,,,Fee Schedule,155% of CMS OPPS Rate,722.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1049.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,722.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1180.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1180.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1095.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1095.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,662.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1445.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1292.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,861.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1120.23,155,,,Fee Schedule,155% of CMS OPPS Rate,722.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2238.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,722.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,667.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,722.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1481.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1481.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,662.68,2238.36,
25608-PF OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG,4321909,CDM,981,RC,25608,HCPCS,Outpatient,,,1619.04,809.52,,1457.14,90,,,percent of total billed charges,90% of total Billed charges,1619.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,809.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1254.76,155,,,Fee Schedule,155% of CMS OPPS Rate,809.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1177.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1324.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1324.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1232.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1232.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,756.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1619.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1454.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,972.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1254.76,155,,,Fee Schedule,155% of CMS OPPS Rate,809.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,2510.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2510.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,809.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,767.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,809.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1663.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1663.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,756.84,2510.8,
25609-PF OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG,4321908,CDM,981,RC,25609,HCPCS,Outpatient,,,2056.9,1028.45,,1851.21,90,,,percent of total billed charges,90% of total Billed charges,2058.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1028.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1594.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1028.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1498.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1028.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1685.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1685.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1571.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1571.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,963.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1028.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2056.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1854.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1243.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1594.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1028.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,3191.14,155,,,Fee Schedule,155% of CMS OPPS Rate,3191.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1028.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,981.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1028.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2122.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2122.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,963.96,3191.14,
25622-PF CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ,4321907,CDM,981,RC,25622,HCPCS,Outpatient,,,552.22,276.11,,497,90,,,percent of total billed charges,90% of total Billed charges,571.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,122,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,427.97,155,,,Fee Schedule,155% of CMS OPPS Rate,276.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,449.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,449.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,406.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,406.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,238.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,480.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,427.97,155,,,Fee Schedule,155% of CMS OPPS Rate,276.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,885.24,155,,,Fee Schedule,155% of CMS OPPS Rate,885.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,122,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,595,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,595,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,122,885.24,
25624-PF CLOSED TX CARPAL SCAPHOID FRACTURE W/MANJ,4321906,CDM,981,RC,25624,HCPCS,Outpatient,,,866.7,433.35,,780.03,90,,,percent of total billed charges,90% of total Billed charges,906.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,433.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,155,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,671.68,155,,,Fee Schedule,155% of CMS OPPS Rate,433.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,433.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,703.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,642.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,642.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,384.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,758.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,495.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,671.68,155,,,Fee Schedule,155% of CMS OPPS Rate,433.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1405.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1405.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,433.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,155,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,433.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,907.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,907.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,155,1405.82,
25628-PF OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE,4321905,CDM,981,RC,25628,HCPCS,Outpatient,,,1406.7,703.35,,1266.03,90,,,percent of total billed charges,90% of total Billed charges,1408.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.19,155,,,Fee Schedule,155% of CMS OPPS Rate,703.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1026.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,703.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1154.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1154.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1073.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1073.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,674.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1406.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1266.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,840.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1090.19,155,,,Fee Schedule,155% of CMS OPPS Rate,703.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2183.11,155,,,Fee Schedule,155% of CMS OPPS Rate,2183.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,703.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,679.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,703.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1454.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1454.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,674.16,2183.11,
25630-PF CLTX CARPAL BONE FX W/O MANJ EACH BONE,4321904,CDM,981,RC,25630,HCPCS,Outpatient,,,555.88,277.94,,500.29,90,,,percent of total billed charges,90% of total Billed charges,572.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.79,155,,,Fee Schedule,155% of CMS OPPS Rate,277.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,452.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,412.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,412.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,243.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,486.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,315.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,430.79,155,,,Fee Schedule,155% of CMS OPPS Rate,277.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,887.67,155,,,Fee Schedule,155% of CMS OPPS Rate,887.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,277.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,277.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,599.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,243.34,887.67,
25635-PF CLTX CARPAL BONE FX W/MANJ EACH BONE,4321903,CDM,981,RC,25635,HCPCS,Outpatient,,,823.58,411.79,,741.22,90,,,percent of total billed charges,90% of total Billed charges,861.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,411.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,638.27,155,,,Fee Schedule,155% of CMS OPPS Rate,411.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,411.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,670.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,612.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,612.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,348.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,823.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,723.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,474.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,638.27,155,,,Fee Schedule,155% of CMS OPPS Rate,411.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1335.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1335.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,411.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,145,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,411.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,899.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,145,1335.95,
25645-PF OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA,4321902,CDM,981,RC,25645,HCPCS,Outpatient,,,1121.78,560.89,,1009.6,90,,,percent of total billed charges,90% of total Billed charges,1122.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.36,155,,,Fee Schedule,155% of CMS OPPS Rate,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,814.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,915.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,915.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,850.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,850.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,537.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1121.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1004.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,673.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,869.36,155,,,Fee Schedule,155% of CMS OPPS Rate,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1739.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1739.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,625.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,560.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1145.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,537.21,1739.66,
25650-PF CLOSED TREATMENT ULNAR STYLOID FRACTURE,4321901,CDM,981,RC,25650,HCPCS,Outpatient,,,599.64,299.82,,539.68,90,,,percent of total billed charges,90% of total Billed charges,618.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,464.72,155,,,Fee Schedule,155% of CMS OPPS Rate,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,299.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,484.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,441.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,441.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,258.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,599.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,520.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,464.72,155,,,Fee Schedule,155% of CMS OPPS Rate,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,958.37,155,,,Fee Schedule,155% of CMS OPPS Rate,958.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,146,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,287.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,630.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146,958.37,
25660-PF CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MANJ,4321900,CDM,981,RC,25660,HCPCS,Outpatient,,,874.46,437.23,,787.01,90,,,percent of total billed charges,90% of total Billed charges,873.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,677.69,155,,,Fee Schedule,155% of CMS OPPS Rate,437.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,437.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,612.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,612.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,368.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,722.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,477.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,677.69,155,,,Fee Schedule,155% of CMS OPPS Rate,437.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1353.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1353.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,437.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,104,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,437.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,801.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,801.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,104,1353.68,
25670-PF OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1/> BONES,4321899,CDM,981,RC,25670,HCPCS,Outpatient,,,1193,596.50,,1073.7,90,,,percent of total billed charges,90% of total Billed charges,1194.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,924.58,155,,,Fee Schedule,155% of CMS OPPS Rate,596.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,868.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,596.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,976.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,908.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,908.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,579.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1072.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,719.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,924.58,155,,,Fee Schedule,155% of CMS OPPS Rate,596.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1851.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1851.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,596.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,653.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,596.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1216.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1216.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,1851.97,
25675-PF CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ,4321898,CDM,981,RC,25675,HCPCS,Outpatient,,,809.52,404.76,,728.57,90,,,percent of total billed charges,90% of total Billed charges,841.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,404.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,627.36,155,,,Fee Schedule,155% of CMS OPPS Rate,404.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,642.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,593.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,593.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,359.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,700.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,464.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,627.36,155,,,Fee Schedule,155% of CMS OPPS Rate,404.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1304.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1304.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,404.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,104,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,450.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,404.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,855.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,855.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,104,1304.88,
25676-PF OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC,4321897,CDM,981,RC,25676,HCPCS,Outpatient,,,1233.68,616.84,,1110.31,90,,,percent of total billed charges,90% of total Billed charges,1235.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,616.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,956.1,155,,,Fee Schedule,155% of CMS OPPS Rate,616.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,901.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,616.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1014.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1014.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,942.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,942.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,600.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,616.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1233.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1111.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,743.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,956.1,155,,,Fee Schedule,155% of CMS OPPS Rate,616.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1914.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1914.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,616.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,674.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,616.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1273.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1273.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,1914.28,
25680-PF CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MANJ,4321896,CDM,981,RC,25680,HCPCS,Outpatient,,,1035.68,517.84,,932.11,90,,,percent of total billed charges,90% of total Billed charges,1035.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,802.65,155,,,Fee Schedule,155% of CMS OPPS Rate,517.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,517.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,841.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,841.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,775.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,775.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,421.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1035.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,915.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,608.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,802.65,155,,,Fee Schedule,155% of CMS OPPS Rate,517.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1604.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1604.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,517.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,461.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,517.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,928.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,928.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,224,1604.93,
25685-PF OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC,4321895,CDM,981,RC,25685,HCPCS,Outpatient,,,1444.96,722.48,,1300.46,90,,,percent of total billed charges,90% of total Billed charges,1446.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,722.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1119.84,155,,,Fee Schedule,155% of CMS OPPS Rate,722.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,722.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1181.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1104.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1104.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,693.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1444.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1303.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,880.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1119.84,155,,,Fee Schedule,155% of CMS OPPS Rate,722.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,2242.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2242.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,722.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,776.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,722.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1485.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2242.8,
25690-PF CLOSED TX LUNATE DISLOCATION W/MANIPULATION,4321894,CDM,981,RC,25690,HCPCS,Outpatient,,,959.34,479.67,,863.41,90,,,percent of total billed charges,90% of total Billed charges,959.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,228,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,743.49,155,,,Fee Schedule,155% of CMS OPPS Rate,479.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,479.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,779.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,717.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,717.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,432.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,959.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,847.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,561.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,743.49,155,,,Fee Schedule,155% of CMS OPPS Rate,479.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1486.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1486.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,479.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,228,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,479.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,960.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,960.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,228,1486.95,
25695-PF OPEN TREATMENT LUNATE DISLOCATION,4321893,CDM,981,RC,25695,HCPCS,Outpatient,,,1246.3,623.15,,1121.67,90,,,percent of total billed charges,90% of total Billed charges,1248.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,623.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,455,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,965.88,155,,,Fee Schedule,155% of CMS OPPS Rate,623.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,906.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,623.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1019.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1019.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,950.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,950.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,601.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1246.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1121.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,756.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,965.88,155,,,Fee Schedule,155% of CMS OPPS Rate,623.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1934.74,155,,,Fee Schedule,155% of CMS OPPS Rate,1934.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,623.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,455,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,673.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,623.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1276.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1276.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,455,1934.74,
26010- Drainage/finger abscess/simple,3434901,CDM,510,RC,26010,HCPCS,Outpatient,,,862.27,431.14,,776.04,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,689.82,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,776.04,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,836.4,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,793.29,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,776.04,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,603.59,70,,,percent of total billed charges,70% of total billed charges,776.04,90,,,percent of total billed charges,90% of total billed charges,819.16,95,,,percent of total billed charges,95% of total billed charges,819.16,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,741.55,86,,,percent of total billed charges,86% of total billed charges,689.82,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,836.4,97,,,percent of total billed charges,97% of total billed charges,776.04,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,836.4,97,,,percent of total billed charges,97% of total billed charges,801.91,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,836.4,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,880.34,
26010-PF DRAINAGE FINGER ABSCESS SIMPLE,4321892,CDM,981,RC,26010,HCPCS,Outpatient,,,270.24,135.12,,243.22,90,,,percent of total billed charges,90% of total Billed charges,405.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.42,155,,,Fee Schedule,155% of CMS OPPS Rate,135.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,154.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,209.42,155,,,Fee Schedule,155% of CMS OPPS Rate,135.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,628.29,155,,,Fee Schedule,155% of CMS OPPS Rate,628.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,500.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,500.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.5,628.29,
26011-PF DRAINAGE FINGER ABSCESS COMPLICATED,4321891,CDM,981,RC,26011,HCPCS,Outpatient,,,358.94,179.47,,323.05,90,,,percent of total billed charges,90% of total Billed charges,538.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.16,155,,,Fee Schedule,155% of CMS OPPS Rate,179.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,172.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,211.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.16,155,,,Fee Schedule,155% of CMS OPPS Rate,179.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,834.52,155,,,Fee Schedule,155% of CMS OPPS Rate,834.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,401.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,754.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,80,834.52,
26020-PF DRAINAGE TENDON SHEATH DIGIT&/PALM EACH,4321347,CDM,981,RC,26020,HCPCS,Outpatient,,,1082.24,541.12,,974.02,90,,,percent of total billed charges,90% of total Billed charges,1082.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,541.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,126.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,838.74,155,,,Fee Schedule,155% of CMS OPPS Rate,541.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,888.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,819.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,819.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,398.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1082.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,967.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,637.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,838.74,155,,,Fee Schedule,155% of CMS OPPS Rate,541.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,1678.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1678.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,541.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,642.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,541.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,872.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,872.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,126.5,1678.06,
26030-PF DRAINAGE OF PALMAR BURSA MULTIPLE BURSA,4321889,CDM,981,RC,26030,HCPCS,Outpatient,,,958.8,479.40,,862.92,90,,,percent of total billed charges,90% of total Billed charges,958.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,425.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,743.05,155,,,Fee Schedule,155% of CMS OPPS Rate,479.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,479.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,729.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,729.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,460.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,860.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,571.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,743.05,155,,,Fee Schedule,155% of CMS OPPS Rate,479.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1485.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,479.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,725.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,479.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,994.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,994.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,425.89,1485.49,
26070-PF ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT,4321888,CDM,981,RC,26070,HCPCS,Outpatient,,,626.68,313.34,,564.01,90,,,percent of total billed charges,90% of total Billed charges,624.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,313.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,485.68,155,,,Fee Schedule,155% of CMS OPPS Rate,313.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,514.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,471.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,471.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,275.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,626.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,360.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,485.68,155,,,Fee Schedule,155% of CMS OPPS Rate,313.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,967.62,155,,,Fee Schedule,155% of CMS OPPS Rate,967.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,313.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,551.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,313.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,620.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,189,967.62,
26075-PF ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA,4321887,CDM,981,RC,26075,HCPCS,Outpatient,,,657.84,328.92,,592.06,90,,,percent of total billed charges,90% of total Billed charges,656.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,328.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,509.83,155,,,Fee Schedule,155% of CMS OPPS Rate,328.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,328.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,536.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,491.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,491.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,294.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,580.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,509.83,155,,,Fee Schedule,155% of CMS OPPS Rate,328.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1017.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1017.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,328.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,583.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,328.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,646.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,646.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,189,1017.28,
26080-PF ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA,4321886,CDM,981,RC,26080,HCPCS,Outpatient,,,771.4,385.70,,694.26,90,,,percent of total billed charges,90% of total Billed charges,771.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,385.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,597.84,155,,,Fee Schedule,155% of CMS OPPS Rate,385.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,385.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,629.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,575.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,575.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,356.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,679.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,597.84,155,,,Fee Schedule,155% of CMS OPPS Rate,385.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1195.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1195.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,385.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,624.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,385.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,779.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,779.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,1195.33,
26115-PF EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM,4321350,CDM,981,RC,26115,HCPCS,Outpatient,,,672.8,336.40,,605.52,90,,,percent of total billed charges,90% of total Billed charges,842.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,333.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,374.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,1305.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1305.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,989.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,989.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,1305.16,
26350-PF RPR/ADVMNT FLXR TDN N/Z/2 W/O FR GRAFT EA TENDON,4321885,CDM,981,RC,26350,HCPCS,Outpatient,,,1416,708.00,,1274.4,90,,,percent of total billed charges,90% of total Billed charges,1425.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,707.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,367.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1097.38,155,,,Fee Schedule,155% of CMS OPPS Rate,707.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,707.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1159.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1159.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1037.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1037.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,668.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1415.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1224.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,774.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1097.38,155,,,Fee Schedule,155% of CMS OPPS Rate,707.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2209.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2209.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,707.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,943.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,707.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1387.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1387.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,367.5,2209.35,
26410-PF REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH,4321884,CDM,981,RC,26410,HCPCS,Outpatient,,,1139.88,569.94,,1025.89,90,,,percent of total billed charges,90% of total Billed charges,1147.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,569.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,221.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,883.41,155,,,Fee Schedule,155% of CMS OPPS Rate,569.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,569.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,823.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,823.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,531.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,971.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,611.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,883.41,155,,,Fee Schedule,155% of CMS OPPS Rate,569.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1778.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1778.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,569.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,750.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,569.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1099.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1099.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221.5,1778.36,
26418-PF REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH,4321883,CDM,981,RC,26418,HCPCS,Outpatient,,,1175.32,587.66,,1057.79,90,,,percent of total billed charges,90% of total Billed charges,1182.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,587.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,910.87,155,,,Fee Schedule,155% of CMS OPPS Rate,587.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,587.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,948.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,841.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,841.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,533.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,993.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,620.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.87,155,,,Fee Schedule,155% of CMS OPPS Rate,587.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1833.46,155,,,Fee Schedule,155% of CMS OPPS Rate,1833.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,587.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,737.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,587.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1119.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1119.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,231.5,1833.46,
26420-PF REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH,4321353,CDM,981,RC,26420,HCPCS,Outpatient,,,1419.5,709.75,,1277.55,90,,,percent of total billed charges,90% of total Billed charges,1430.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,361.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1100.1,155,,,Fee Schedule,155% of CMS OPPS Rate,709.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,709.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1151.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1151.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1039.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1039.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,670.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1419.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1226.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,783.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1100.1,155,,,Fee Schedule,155% of CMS OPPS Rate,709.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.59,155,,,Fee Schedule,155% of CMS OPPS Rate,2216.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,709.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,894.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,709.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1383.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1383.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,361.5,2216.59,
26600-PF CLTX METACARPAL FX W/O MANIPULATION EACH BONE,4321882,CDM,981,RC,26600,HCPCS,Outpatient,,,553.4,276.70,,498.06,90,,,percent of total billed charges,90% of total Billed charges,564.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,653.88,90,,,Percent of total Billed charges,90% of total billed charges,69.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,428.89,155,,,Fee Schedule,155% of CMS OPPS Rate,276.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,448.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,404.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,404.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,220.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,553.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,304.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,428.89,155,,,Fee Schedule,155% of CMS OPPS Rate,276.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,874.77,155,,,Fee Schedule,155% of CMS OPPS Rate,874.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,573.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.5,874.77,
26605-PF CLTX METACARPAL FX W/MANIPULATION EACH BONE,4321881,CDM,981,RC,26605,HCPCS,Outpatient,,,579.2,289.60,,521.28,90,,,percent of total billed charges,90% of total Billed charges,607.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,289.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,448.86,155,,,Fee Schedule,155% of CMS OPPS Rate,289.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,289.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,470.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,427.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,427.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,261.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,579.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,504.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,325.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,448.86,155,,,Fee Schedule,155% of CMS OPPS Rate,289.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,942.18,155,,,Fee Schedule,155% of CMS OPPS Rate,942.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,289.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,106,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,289.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,631.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106,942.18,
26607-PF CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE,4321880,CDM,981,RC,26607,HCPCS,Outpatient,,,985.98,492.99,,887.38,90,,,percent of total billed charges,90% of total Billed charges,988.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,492.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,764.12,155,,,Fee Schedule,155% of CMS OPPS Rate,492.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,492.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,778.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,778.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,713.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,713.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,410.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,841.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,554.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,764.12,155,,,Fee Schedule,155% of CMS OPPS Rate,492.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1532.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,492.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,160,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,506.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,492.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,915.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,160,1532.55,
26608-PF PRQ SKELETAL FIXJ METACARPAL FX EACH BONE,4321879,CDM,981,RC,26608,HCPCS,Outpatient,,,936.88,468.44,,843.19,90,,,percent of total billed charges,90% of total Billed charges,936.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,468.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,173,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,726.08,155,,,Fee Schedule,155% of CMS OPPS Rate,468.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,468.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,768.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,768.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,704.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,704.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,444.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,468.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,936.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,543.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,726.08,155,,,Fee Schedule,155% of CMS OPPS Rate,468.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1451.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,468.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,468.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,955.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,173,1451.14,
26615-PF OPEN TX METACARPAL FRACTURE SINGLE EA BONE,4321878,CDM,981,RC,26615,HCPCS,Outpatient,,,1119.32,559.66,,1007.39,90,,,percent of total billed charges,90% of total Billed charges,1119.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,232,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,867.47,155,,,Fee Schedule,155% of CMS OPPS Rate,559.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,921.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,849.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,849.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,497.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1002.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,660.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,867.47,155,,,Fee Schedule,155% of CMS OPPS Rate,559.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1734.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1734.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,559.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,232,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,508.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,559.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1160.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,232,1734.87,
26641-PF CLTX CARPO/METACARPAL DISLOCATION THUMB W/MAN,4321877,CDM,981,RC,26641,HCPCS,Outpatient,,,744.28,372.14,,669.85,90,,,percent of total billed charges,90% of total Billed charges,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,576.8,155,,,Fee Schedule,155% of CMS OPPS Rate,372.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,555.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,555.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,511.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,511.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,292.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,603.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,398.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,576.8,155,,,Fee Schedule,155% of CMS OPPS Rate,372.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,372.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,372.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,698.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.5,1205.2,
26645-PF CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ,4321876,CDM,981,RC,26645,HCPCS,Outpatient,,,773.76,386.88,,696.38,90,,,percent of total billed charges,90% of total Billed charges,808.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,386.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,599.65,155,,,Fee Schedule,155% of CMS OPPS Rate,386.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,386.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,630.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,630.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,579.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,579.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,342.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,683.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,451.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,599.65,155,,,Fee Schedule,155% of CMS OPPS Rate,386.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1252.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1252.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,386.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,432.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,386.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,845.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,845.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89,1252.91,
26650-PF PRQ SKELETAL FIX CARPO/METACARPAL FX DISLC THUMB,4321860,CDM,981,RC,26650,HCPCS,Outpatient,,,933.36,466.68,,840.02,90,,,percent of total billed charges,90% of total Billed charges,932.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,466.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,723.35,155,,,Fee Schedule,155% of CMS OPPS Rate,466.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,466.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,766.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,701.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,701.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,445.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,933.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,827.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,539.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,723.35,155,,,Fee Schedule,155% of CMS OPPS Rate,466.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1445.7,155,,,Fee Schedule,155% of CMS OPPS Rate,1445.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,466.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,545.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,466.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,955.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,224,1445.7,
26665-PF OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB,4321859,CDM,981,RC,26665,HCPCS,Outpatient,,,1216.76,608.38,,1095.08,90,,,percent of total billed charges,90% of total Billed charges,1214.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,608.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,942.99,155,,,Fee Schedule,155% of CMS OPPS Rate,608.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,891.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,608.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1003.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,927.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,927.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,562.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1216.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1094.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,722.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,942.99,155,,,Fee Schedule,155% of CMS OPPS Rate,608.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1882.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,608.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,628.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,608.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1262.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1262.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,562.07,1882.09,
26670-PF CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES,4321858,CDM,981,RC,26670,HCPCS,Outpatient,,,615.36,307.68,,553.82,90,,,percent of total billed charges,90% of total Billed charges,648.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,476.89,155,,,Fee Schedule,155% of CMS OPPS Rate,307.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,494.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,455.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,455.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,263.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,538,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,354.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,476.89,155,,,Fee Schedule,155% of CMS OPPS Rate,307.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,648.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,1004.71,
26675-PF CLTX CARPO/MTCRPL DISLC THUMB MANJ EA JT W/ANES,4321857,CDM,981,RC,26675,HCPCS,Outpatient,,,826.16,413.08,,743.54,90,,,percent of total billed charges,90% of total Billed charges,861.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,640.26,155,,,Fee Schedule,155% of CMS OPPS Rate,413.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,672.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,618.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,618.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,370.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,729.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,482.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,640.26,155,,,Fee Schedule,155% of CMS OPPS Rate,413.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1335.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1335.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,413.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,423.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,413.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,900.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,900.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,1335.45,
26685-PF OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB,4321856,CDM,981,RC,26685,HCPCS,Outpatient,,,1119.06,559.53,,1007.15,90,,,percent of total billed charges,90% of total Billed charges,1120.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.26,155,,,Fee Schedule,155% of CMS OPPS Rate,559.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,921.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,849.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,849.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,523.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1119.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1002.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,659.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,867.26,155,,,Fee Schedule,155% of CMS OPPS Rate,559.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1736.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1736.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,559.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,592.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,559.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1161.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1161.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,523.01,1736.2,
26686-PF OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ,4321855,CDM,981,RC,26686,HCPCS,Outpatient,,,1221.62,610.81,,1099.46,90,,,percent of total billed charges,90% of total Billed charges,1223.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,610.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,488,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,946.74,155,,,Fee Schedule,155% of CMS OPPS Rate,610.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,891.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,610.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1002.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1002.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,932.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,932.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,585.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1221.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1100.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,740.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,946.74,155,,,Fee Schedule,155% of CMS OPPS Rate,610.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1896.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1896.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,610.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,488,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,663.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,610.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1254.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1254.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,488,1896.55,
26700-PF CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES,4321854,CDM,981,RC,26700,HCPCS,Outpatient,,,618.86,309.43,,556.97,90,,,percent of total billed charges,90% of total Billed charges,639.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,479.6,155,,,Fee Schedule,155% of CMS OPPS Rate,309.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,309.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,493.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,456.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,456.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,258.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,538.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,357.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,479.6,155,,,Fee Schedule,155% of CMS OPPS Rate,309.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.6,155,,,Fee Schedule,155% of CMS OPPS Rate,991.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,309.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,309.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,621.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,621.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39,991.6,
26705-PF CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES,4321853,CDM,981,RC,26705,HCPCS,Outpatient,,,774.8,387.40,,697.32,90,,,percent of total billed charges,90% of total Billed charges,796.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,387.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,600.47,155,,,Fee Schedule,155% of CMS OPPS Rate,387.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,387.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,613.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,561.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,561.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,337.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,774.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,662.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,432,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,600.47,155,,,Fee Schedule,155% of CMS OPPS Rate,387.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1235.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,387.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,386.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,387.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,830.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,1235.02,
26720-PF CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA,4321852,CDM,981,RC,26720,HCPCS,Outpatient,,,365.86,182.93,,329.27,90,,,percent of total billed charges,90% of total Billed charges,374.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,435.76,90,,,Percent of total Billed charges,90% of total billed charges,56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,283.54,155,,,Fee Schedule,155% of CMS OPPS Rate,182.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,283.54,155,,,Fee Schedule,155% of CMS OPPS Rate,182.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.2,155,,,Fee Schedule,155% of CMS OPPS Rate,580.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56,580.2,
26725-PF CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA,4321851,CDM,981,RC,26725,HCPCS,Outpatient,,,597.6,298.80,,537.84,90,,,percent of total billed charges,90% of total Billed charges,629.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,298.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,463.12,155,,,Fee Schedule,155% of CMS OPPS Rate,298.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,298.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,486.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,445.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,445.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,275.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,597.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,525.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,343.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,463.12,155,,,Fee Schedule,155% of CMS OPPS Rate,298.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,975.88,155,,,Fee Schedule,155% of CMS OPPS Rate,975.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,298.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,298.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,665.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,975.88,
26727-PF PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T,4321850,CDM,981,RC,26727,HCPCS,Outpatient,,,921.46,460.73,,829.31,90,,,percent of total billed charges,90% of total Billed charges,920.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,460.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,714.12,155,,,Fee Schedule,155% of CMS OPPS Rate,460.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,671.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,460.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,755.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,691.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,691.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,436.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,816,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,531.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,714.12,155,,,Fee Schedule,155% of CMS OPPS Rate,460.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1426.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,460.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,520.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,460.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,941.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,941.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,224,1426.87,
26735-PF OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA,4321849,CDM,981,RC,26735,HCPCS,Outpatient,,,1158.1,579.05,,1042.29,90,,,percent of total billed charges,90% of total Billed charges,1158.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,897.53,155,,,Fee Schedule,155% of CMS OPPS Rate,579.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,952.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,879.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,879.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,520.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1037.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,683.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,897.53,155,,,Fee Schedule,155% of CMS OPPS Rate,579.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1795.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1795.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,579.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,579.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1202.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,224,1795.09,
26740-PF CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ,4321848,CDM,981,RC,26740,HCPCS,Outpatient,,,426.16,213.08,,383.54,90,,,percent of total billed charges,90% of total Billed charges,435.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,330.27,155,,,Fee Schedule,155% of CMS OPPS Rate,213.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,236.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,330.27,155,,,Fee Schedule,155% of CMS OPPS Rate,213.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,675.3,155,,,Fee Schedule,155% of CMS OPPS Rate,675.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,213.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,214.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,213.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,449.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39,675.3,
26742-PF CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ,4321847,CDM,981,RC,26742,HCPCS,Outpatient,,,661.14,330.57,,595.03,90,,,percent of total billed charges,90% of total Billed charges,693.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,330.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,512.38,155,,,Fee Schedule,155% of CMS OPPS Rate,330.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,536.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,493.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,493.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,661.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,582.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,381.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,512.38,155,,,Fee Schedule,155% of CMS OPPS Rate,330.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1075.3,155,,,Fee Schedule,155% of CMS OPPS Rate,1075.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,330.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,405.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,330.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,721.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,721.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,1075.3,
26746-PF OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA,4321846,CDM,981,RC,26746,HCPCS,Outpatient,,,1448.98,724.49,,1304.08,90,,,percent of total billed charges,90% of total Billed charges,1449.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,724.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1122.96,155,,,Fee Schedule,155% of CMS OPPS Rate,724.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,724.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1190.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1190.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1104.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1104.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,620.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1303.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,864.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1122.96,155,,,Fee Schedule,155% of CMS OPPS Rate,724.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,2247.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2247.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,724.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,643.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,724.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1501.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1501.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,224,2247.44,
26750-PF CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA,4321845,CDM,981,RC,26750,HCPCS,Outpatient,,,368.26,184.13,,331.43,90,,,percent of total billed charges,90% of total Billed charges,364.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,285.4,155,,,Fee Schedule,155% of CMS OPPS Rate,184.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,317.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,285.4,155,,,Fee Schedule,155% of CMS OPPS Rate,184.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.42,155,,,Fee Schedule,155% of CMS OPPS Rate,564.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,184.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,356.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48,564.42,
26755-PF CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA,4321844,CDM,981,RC,26755,HCPCS,Outpatient,,,541.94,270.97,,487.75,90,,,percent of total billed charges,90% of total Billed charges,580.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,420,155,,,Fee Schedule,155% of CMS OPPS Rate,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,270.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,438.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,402.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,402.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,243.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,475.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,312.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,420,155,,,Fee Schedule,155% of CMS OPPS Rate,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.93,155,,,Fee Schedule,155% of CMS OPPS Rate,899.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,301.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,612,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,612,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73,899.93,
26765-PF OPEN TX DISTAL PHALANGEAL FRACTURE EACH,4321843,CDM,981,RC,26765,HCPCS,Outpatient,,,976.48,488.24,,878.83,90,,,percent of total billed charges,90% of total Billed charges,974.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,178,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,756.77,155,,,Fee Schedule,155% of CMS OPPS Rate,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,803.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,736.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,736.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,419.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,869.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,566.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,756.77,155,,,Fee Schedule,155% of CMS OPPS Rate,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1510.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1510.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,178,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1008.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1008.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,178,1510.69,
26770-PF CLTX IPHAL JT DISLC W/MANJ W/O ANES,4321839,CDM,981,RC,26770,HCPCS,Outpatient,,,516.76,258.38,,465.08,90,,,percent of total billed charges,90% of total Billed charges,536.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,400.49,155,,,Fee Schedule,155% of CMS OPPS Rate,258.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,412.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,380.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,380.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,215.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,449.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,297.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,400.49,155,,,Fee Schedule,155% of CMS OPPS Rate,258.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,831.39,155,,,Fee Schedule,155% of CMS OPPS Rate,831.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,258.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,289.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,258.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,831.39,
26775-PF CLTX IPHAL JT DISLC W/MANJ REQ ANES,4321835,CDM,981,RC,26775,HCPCS,Outpatient,,,693,346.50,,623.7,90,,,percent of total billed charges,90% of total Billed charges,725.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,346.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,537.06,155,,,Fee Schedule,155% of CMS OPPS Rate,346.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,554.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,506.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,506.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,692.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,597.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,386.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,537.06,155,,,Fee Schedule,155% of CMS OPPS Rate,346.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1124.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,346.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,346.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,751.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,751.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67,1124.06,
26785-PF OPEN TX INTERPHALANGEAL JOINT DISLOCATION,4321834,CDM,981,RC,26785,HCPCS,Outpatient,,,1066.04,533.02,,959.44,90,,,percent of total billed charges,90% of total Billed charges,1063.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,533.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,826.17,155,,,Fee Schedule,155% of CMS OPPS Rate,533.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,533.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,875.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,875.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,805.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,805.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,454.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,533.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,950.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,624.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,826.17,155,,,Fee Schedule,155% of CMS OPPS Rate,533.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1648.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,533.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,533.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1100.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1648.75,
26951-PF AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR,4321833,CDM,981,RC,26951,HCPCS,Outpatient,,,1331.92,665.96,,1198.73,90,,,percent of total billed charges,90% of total Billed charges,1337.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,665.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1032.22,155,,,Fee Schedule,155% of CMS OPPS Rate,665.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1066.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,959.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,959.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,577.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1331.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1131.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,722.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1032.22,155,,,Fee Schedule,155% of CMS OPPS Rate,665.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,2073.85,155,,,Fee Schedule,155% of CMS OPPS Rate,2073.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,665.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,637.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,665.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1278.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1278.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,182.5,2073.85,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,855.9,427.95,,770.31,90,,,percent of total billed charges,90% of total Billed charges,514.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,229.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.82,155,,,Fee Schedule,155% of CMS OPPS Rate,797.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,663,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,663,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,797.82,
27041- Biopsy/soft tissue/pelvis/hip/deep,3434958,CDM,510,RC,27041,HCPCS,Outpatient,,,1861.37,930.69,,1675.23,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1489.1,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1675.23,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1805.53,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.46,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1675.23,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.96,70,,,percent of total billed charges,70% of total billed charges,1675.23,90,,,percent of total billed charges,90% of total billed charges,1768.3,95,,,percent of total billed charges,95% of total billed charges,1768.3,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1600.78,86,,,percent of total billed charges,86% of total billed charges,1489.1,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1805.53,97,,,percent of total billed charges,97% of total billed charges,1675.23,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1805.53,97,,,percent of total billed charges,97% of total billed charges,1731.07,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1805.53,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
27043- Exc subq tum/sft tis/pel/hip 3cm/>,3434959,CDM,510,RC,27043,HCPCS,Outpatient,,,1245.26,622.63,,1120.73,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,996.21,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1120.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1207.9,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1145.64,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1120.73,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,871.68,70,,,percent of total billed charges,70% of total billed charges,1120.73,90,,,percent of total billed charges,90% of total billed charges,1183,95,,,percent of total billed charges,95% of total billed charges,1183,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1070.92,86,,,percent of total billed charges,86% of total billed charges,996.21,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1207.9,97,,,percent of total billed charges,97% of total billed charges,1120.73,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1207.9,97,,,percent of total billed charges,97% of total billed charges,1158.09,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1207.9,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,871.68,12593.67,
27045 - PF Exc Tumor Soft Tissue Pelvis & Hip Subfasc 5cm/>,4309234,CDM,960,RC,27045,HCPCS,Outpatient,,,1544.95,772.48,,1390.46,90,,,percent of total billed charges,90% of total Billed charges,1460.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,728.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1129.55,155,,,Fee Schedule,155% of CMS OPPS Rate,728.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,728.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1190.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1190.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1126.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1126.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,752.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1457.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1328.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,918.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1129.55,155,,,Fee Schedule,155% of CMS OPPS Rate,728.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2263.31,155,,,Fee Schedule,155% of CMS OPPS Rate,2263.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,728.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,741.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,728.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1508.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1508.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,728.74,2263.31,
27047- Exc tumor/pelvis/hip/SQ/<3 cm,3434960,CDM,510,RC,27047,HCPCS,Outpatient,,,1277.72,638.86,,1149.95,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1022.18,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.95,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1239.39,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1175.5,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1149.95,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,894.4,70,,,percent of total billed charges,70% of total billed charges,1149.95,90,,,percent of total billed charges,90% of total billed charges,1213.83,95,,,percent of total billed charges,95% of total billed charges,1213.83,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1098.84,86,,,percent of total billed charges,86% of total billed charges,1022.18,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1239.39,97,,,percent of total billed charges,97% of total billed charges,1149.95,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1239.39,97,,,percent of total billed charges,97% of total billed charges,1188.28,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1239.39,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,12593.67,
27048 - EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM,4037479,CDM,983,RC,27048,HCPCS,Outpatient,,,1610.12,805.06,,1449.11,90,,,percent of total billed charges,90% of total Billed charges,1210.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,605.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.25,155,,,Fee Schedule,155% of CMS OPPS Rate,605.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,605.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,981.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,981.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,925.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,925.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,491.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1092.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,755.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,938.25,155,,,Fee Schedule,155% of CMS OPPS Rate,605.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1876.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1876.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,605.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,580.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,605.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1234.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,491.95,1876.71,
27049 PF - Resect hip/pelv tum <5CM - Assistant,4135109,CDM,960,RC,27049,HCPCS,Outpatient,,,3211.59,1605.80,,2890.43,90,,,percent of total billed charges,90% of total Billed charges,2688.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1335.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,252.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2070.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1335.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1915.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1335.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2154.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2154.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2059.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2059.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1069.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1335.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2671.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2430.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1714.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2070.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1335.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,4166.6,155,,,Fee Schedule,155% of CMS OPPS Rate,4166.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1335.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1026.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1335.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2771.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2771.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,252.5,4166.6,
27059-PF RESECT HIP/PELV TUM 5 CM/>,3429129,CDM,510,RC,27059,HCPCS,Outpatient,,,4810.51,2405.26,,4329.46,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3848.41,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4329.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4666.19,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,4425.67,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4329.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3367.36,70,,,percent of total billed charges,70% of total billed charges,4329.46,90,,,percent of total billed charges,90% of total billed charges,4569.98,95,,,percent of total billed charges,95% of total billed charges,4569.98,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4137.04,86,,,percent of total billed charges,86% of total billed charges,3848.41,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4666.19,97,,,percent of total billed charges,97% of total billed charges,4329.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4666.19,97,,,percent of total billed charges,97% of total billed charges,4473.77,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4666.19,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
27200-PF CLOSED TREATMENT COCCYGEAL FRACTURE,4321356,CDM,981,RC,27200,HCPCS,Outpatient,,,364.7,182.35,,328.23,90,,,percent of total billed charges,90% of total Billed charges,363.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.64,155,,,Fee Schedule,155% of CMS OPPS Rate,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,300.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,273.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,273.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,159.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,208.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.64,155,,,Fee Schedule,155% of CMS OPPS Rate,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.58,155,,,Fee Schedule,155% of CMS OPPS Rate,563.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,355.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.5,563.58,
27222-PF CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ,4321359,CDM,981,RC,27222,HCPCS,Outpatient,,,1938.42,969.21,,1744.58,90,,,percent of total billed charges,90% of total Billed charges,1941.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,969.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1502.28,155,,,Fee Schedule,155% of CMS OPPS Rate,969.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1393.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,969.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1566.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1472.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1472.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,935.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,969.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1938.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1737.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1180.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1502.28,155,,,Fee Schedule,155% of CMS OPPS Rate,969.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3008.98,155,,,Fee Schedule,155% of CMS OPPS Rate,3008.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,969.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,878.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,969.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,1978.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1978.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,3008.98,
27227-PF OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT,4321832,CDM,981,RC,27227,HCPCS,Outpatient,,,3252.3,1626.15,,2927.07,90,,,percent of total billed charges,90% of total Billed charges,3262.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1626.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,819,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2520.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1626.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2369.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1626.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2665.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2665.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2522.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2522.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1597.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3252.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2976.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2045.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2520.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1626.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,5056.18,155,,,Fee Schedule,155% of CMS OPPS Rate,5056.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1626.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,819,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1615.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1626.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3404.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3404.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,819,5056.18,
27228-PF OPTX ACTBLR FX INVG ANT&POST 2 COLUMNS FX W/INT,4321830,CDM,981,RC,27228,HCPCS,Outpatient,,,3705.8,1852.90,,3335.22,90,,,percent of total billed charges,90% of total Billed charges,3715.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1852.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2871.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1852.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2778.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1852.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3125.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3125.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2870.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2870.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1829.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1852.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3705.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3386.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2331.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2871.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1852.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,5759.78,155,,,Fee Schedule,155% of CMS OPPS Rate,5759.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1852.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,889,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1791.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1852.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,3878.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3878.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,889,5759.78,
27250-PF CLTX HIP DISLOCATION TRAUMATIC W/O ANESTHESIA,4321829,CDM,981,RC,27250,HCPCS,Outpatient,,,370.7,185.35,,333.63,90,,,percent of total billed charges,90% of total Billed charges,371.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,204.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,287.29,155,,,Fee Schedule,155% of CMS OPPS Rate,185.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,293.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,293.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,251.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.29,155,,,Fee Schedule,155% of CMS OPPS Rate,185.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.9,155,,,Fee Schedule,155% of CMS OPPS Rate,575.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,502.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,371.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,185.35,575.9,
27252-PF CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA,4321828,CDM,981,RC,27252,HCPCS,Outpatient,,,1487.36,743.68,,1338.62,90,,,percent of total billed charges,90% of total Billed charges,1491.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,743.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,281.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1152.7,155,,,Fee Schedule,155% of CMS OPPS Rate,743.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1215.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1143.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1143.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,718.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1349.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,920.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1152.7,155,,,Fee Schedule,155% of CMS OPPS Rate,743.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,2311.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2311.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,743.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,772.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,743.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1530,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1530,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,281.5,2311.96,
27253-PF OPTX HIP DISLOCATION TRAUMATIC W/O INTERNAL FIX,4321827,CDM,981,RC,27253,HCPCS,Outpatient,,,1848.26,924.13,,1663.43,90,,,percent of total billed charges,90% of total Billed charges,1853.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,924.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,924.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,924.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1516.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1516.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1425.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1425.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,908.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1681.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1147.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,924.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,2873.03,155,,,Fee Schedule,155% of CMS OPPS Rate,2873.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,924.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1096.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,924.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,1912.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1912.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,637,2873.03,
27254-PF OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD,4321826,CDM,981,RC,27254,HCPCS,Outpatient,,,2501.78,1250.89,,2251.6,90,,,percent of total billed charges,90% of total Billed charges,2509.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1250.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1938.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1250.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1881.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1250.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2116.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1933.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1933.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1219.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1250.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2501.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2281.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1563.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1938.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1250.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,3889.77,155,,,Fee Schedule,155% of CMS OPPS Rate,3889.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1250.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1324.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1250.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,2579.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2579.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,637,3889.77,
27256-PF TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES,4321825,CDM,981,RC,27256,HCPCS,Outpatient,,,486.2,243.10,,437.58,90,,,percent of total billed charges,90% of total Billed charges,546.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,219.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,376.79,155,,,Fee Schedule,155% of CMS OPPS Rate,243.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,384.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,371.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,371.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,233.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,438.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,311.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,376.79,155,,,Fee Schedule,155% of CMS OPPS Rate,243.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,846.9,155,,,Fee Schedule,155% of CMS OPPS Rate,846.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,243.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,315.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,243.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,581.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,219.8,846.9,
27257-PF TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MANJ ANES,4321824,CDM,981,RC,27257,HCPCS,Outpatient,,,711.42,355.71,,640.28,90,,,percent of total billed charges,90% of total Billed charges,712.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,355.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,551.34,155,,,Fee Schedule,155% of CMS OPPS Rate,355.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,581.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,548.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,548.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,317.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,711.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,646.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,551.34,155,,,Fee Schedule,155% of CMS OPPS Rate,355.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1104.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1104.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,355.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,409.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,355.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,675.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,675.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,237,1104.34,
27258-PF OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM,4321823,CDM,981,RC,27258,HCPCS,Outpatient,,,2185.04,1092.52,,1966.54,90,,,percent of total billed charges,90% of total Billed charges,2191.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1092.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1693.39,155,,,Fee Schedule,155% of CMS OPPS Rate,1092.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1640.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1092.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1845.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1682.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1682.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1060.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2185.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1984.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1354.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1693.39,155,,,Fee Schedule,155% of CMS OPPS Rate,1092.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3396.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3396.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1092.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1214.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1092.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2260.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2260.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,637,3396.28,
27259-PF OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT,4321822,CDM,981,RC,27259,HCPCS,Outpatient,,,3036.18,1518.09,,2732.56,90,,,percent of total billed charges,90% of total Billed charges,3044.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1518.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2353.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1518.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2287.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1518.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2572.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2572.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2353.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2353.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1473.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1518.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3036.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2776.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1905.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2353.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1518.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,4719.42,155,,,Fee Schedule,155% of CMS OPPS Rate,4719.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1518.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1609.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1518.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,3169.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3169.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1473.54,4719.42,
27265-PF CLTX POST HIP ARTHRP DISLC W/O ANES,4321821,CDM,981,RC,27265,HCPCS,Outpatient,,,817.38,408.69,,735.64,90,,,percent of total billed charges,90% of total Billed charges,811.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,408.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,633.45,155,,,Fee Schedule,155% of CMS OPPS Rate,408.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,408.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,649.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,649.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,603.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,603.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,367.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,712.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,478.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,633.45,155,,,Fee Schedule,155% of CMS OPPS Rate,408.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1258.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,408.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,415.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,408.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,778.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,778.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,237,1258.03,
27266-PF CLTX POST HIP ARTHRP DISLC REQ ANES,4321820,CDM,981,RC,27266,HCPCS,Outpatient,,,1146.38,573.19,,1031.74,90,,,percent of total billed charges,90% of total Billed charges,1148.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,573.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,888.44,155,,,Fee Schedule,155% of CMS OPPS Rate,573.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,831.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,573.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,935.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,935.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,871.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,871.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,551.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1146.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1028.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,690.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,888.44,155,,,Fee Schedule,155% of CMS OPPS Rate,573.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1780.25,155,,,Fee Schedule,155% of CMS OPPS Rate,1780.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,573.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,566,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,573.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1173,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,237,1780.25,
27267-PF CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ,4321362,CDM,981,RC,27267,HCPCS,Outpatient,,,861.22,430.61,,775.1,90,,,percent of total billed charges,90% of total Billed charges,861.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.45,155,,,Fee Schedule,155% of CMS OPPS Rate,430.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,430.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,701.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,648.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,648.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,394.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,861.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,765.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,508.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,667.45,155,,,Fee Schedule,155% of CMS OPPS Rate,430.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1335.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1335.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,430.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,430.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,871.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,348.66,1335.79,
27268-PF CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ,4321365,CDM,981,RC,27268,HCPCS,Outpatient,,,1068.32,534.16,,961.49,90,,,percent of total billed charges,90% of total Billed charges,1068.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.93,155,,,Fee Schedule,155% of CMS OPPS Rate,534.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,534.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,870,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,809.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,809.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,486.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,955.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,643.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,827.93,155,,,Fee Schedule,155% of CMS OPPS Rate,534.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1656.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1656.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,534.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,429.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,534.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1085.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1085.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,429.91,1656.84,
27275-PF MANIPULATION HIP JOINT GENERAL ANESTHESIA,4321819,CDM,981,RC,27275,HCPCS,Outpatient,,,357.02,178.51,,321.32,90,,,percent of total billed charges,90% of total Billed charges,356.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.69,155,,,Fee Schedule,155% of CMS OPPS Rate,178.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,270.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,270.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,171.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,319.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,211.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,276.69,155,,,Fee Schedule,155% of CMS OPPS Rate,178.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.56,155,,,Fee Schedule,155% of CMS OPPS Rate,552.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,178.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,356.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.5,552.56,
27301- I&D deep absc/bursa/hema/thigh/kne,3434997,CDM,510,RC,27301,HCPCS,Outpatient,,,1727.58,863.79,,1554.82,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.06,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.82,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1675.75,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1589.37,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1554.82,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.31,70,,,percent of total billed charges,70% of total billed charges,1554.82,90,,,percent of total billed charges,90% of total billed charges,1641.2,95,,,percent of total billed charges,95% of total billed charges,1641.2,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1485.72,86,,,percent of total billed charges,86% of total billed charges,1382.06,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1675.75,97,,,percent of total billed charges,97% of total billed charges,1554.82,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1675.75,97,,,percent of total billed charges,97% of total billed charges,1606.65,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1675.75,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,12593.67,
27328 - PF Exc Tumor Soft Tissue Thigh/Knee Subfasc <5cm,4309232,CDM,960,RC,27328,HCPCS,Outpatient,,,1304.97,652.49,,1174.47,90,,,percent of total billed charges,90% of total Billed charges,1232.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,615.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,954.1,155,,,Fee Schedule,155% of CMS OPPS Rate,615.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,892.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,615.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1003.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1003.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,943.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,943.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,499.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1231.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1113.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,764.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,954.1,155,,,Fee Schedule,155% of CMS OPPS Rate,615.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1910.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,615.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,120,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,615.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1251.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1251.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120,1910.14,
27337- Exc SQ tumor/thigh/knee area 3cm/>,3435004,CDM,360,RC,27337,HCPCS,Outpatient,,,1108.71,554.36,,997.84,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,886.97,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,997.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1075.45,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.01,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,997.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,776.1,70,,,percent of total billed charges,70% of total billed charges,997.84,90,,,percent of total billed charges,90% of total billed charges,1053.27,95,,,percent of total billed charges,95% of total billed charges,1053.27,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,953.49,86,,,percent of total billed charges,86% of total billed charges,886.97,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1075.45,97,,,percent of total billed charges,97% of total billed charges,997.84,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1075.45,97,,,percent of total billed charges,97% of total billed charges,1031.1,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1075.45,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,776.1,12593.67,
27339- Exc IM tumor/thigh/knee area 5cm/>,3435005,CDM,510,RC,27339,HCPCS,Outpatient,,,1998.73,999.37,,1798.86,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1598.98,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1798.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1938.77,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.83,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1798.86,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1399.11,70,,,percent of total billed charges,70% of total billed charges,1798.86,90,,,percent of total billed charges,90% of total billed charges,1898.79,95,,,percent of total billed charges,95% of total billed charges,1898.79,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1718.91,86,,,percent of total billed charges,86% of total billed charges,1598.98,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1938.77,97,,,percent of total billed charges,97% of total billed charges,1798.86,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.77,97,,,percent of total billed charges,97% of total billed charges,1858.82,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1938.77,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1399.11,12593.67,
27372-PF REMOVAL FOREIGN BODY DEEP THIGH/KNEE,4321818,CDM,981,RC,27372,HCPCS,Outpatient,,,783.28,391.64,,704.95,90,,,percent of total billed charges,90% of total Billed charges,959.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,391.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,607.03,155,,,Fee Schedule,155% of CMS OPPS Rate,391.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,391.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,645.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,645.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,599.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,599.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,382.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,783.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,707.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,474.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,607.03,155,,,Fee Schedule,155% of CMS OPPS Rate,391.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1487.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1487.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,391.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,637.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,391.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1197.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1197.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1487.72,
27385-PF SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY,4321817,CDM,981,RC,27385,HCPCS,Outpatient,,,1174.5,587.25,,1057.05,90,,,percent of total billed charges,90% of total Billed charges,1178.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,587.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,486.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,910.24,155,,,Fee Schedule,155% of CMS OPPS Rate,587.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,587.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,945.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,869.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,869.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,602.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1174.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1025.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,675.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.24,155,,,Fee Schedule,155% of CMS OPPS Rate,587.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1826.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1826.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,587.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,703.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,587.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1271.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1271.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,486.5,1826.44,
27412 - PF Autologous Chondrocyte Implantation Knee,4313686,CDM,960,RC,27412,HCPCS,Outpatient,,,3436.29,1718.15,,3092.66,90,,,percent of total billed charges,90% of total Billed charges,3250.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1620.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2512.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1620.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2468.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1620.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2776.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2776.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2507.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2507.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1579.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1620.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3241.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2958.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2027.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2512.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1620.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,5038.8,155,,,Fee Schedule,155% of CMS OPPS Rate,5038.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1620.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1565.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1620.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,3366,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3366,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1565.8,5038.8,
27470-PF RPR NON/MAL FEMUR DSTL H/N W/O GRF,4321368,CDM,981,RC,27470,HCPCS,Outpatient,,,2319.44,1159.72,,2087.5,90,,,percent of total billed charges,90% of total Billed charges,2323.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1159.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,749,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1797.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1159.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1159.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1895.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1895.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1783.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1783.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1130.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2319.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2104.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1434.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1797.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1159.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,3602.18,155,,,Fee Schedule,155% of CMS OPPS Rate,3602.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1159.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,749,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1374.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1159.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,2399.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2399.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,749,3602.18,
27500-PF CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION,4321816,CDM,981,RC,27500,HCPCS,Outpatient,,,946.58,473.29,,851.92,90,,,percent of total billed charges,90% of total Billed charges,982.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,733.6,155,,,Fee Schedule,155% of CMS OPPS Rate,473.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,771.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,771.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,717.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,717.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,445.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,946.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,846.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,568.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,733.6,155,,,Fee Schedule,155% of CMS OPPS Rate,473.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1523.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1523.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,473.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,582.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,473.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1037,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,233.5,1523.15,
27502-PF CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ,4321371,CDM,981,RC,27502,HCPCS,Outpatient,,,1496.8,748.40,,1347.12,90,,,percent of total billed charges,90% of total Billed charges,1502.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,748.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,395,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1160.02,155,,,Fee Schedule,155% of CMS OPPS Rate,748.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1086.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,748.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1222.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1222.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1152.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1152.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,755.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1496.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1360.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,931.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1160.02,155,,,Fee Schedule,155% of CMS OPPS Rate,748.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,2329.15,155,,,Fee Schedule,155% of CMS OPPS Rate,2329.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,748.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,395,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,823.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,748.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1577.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1577.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,395,2329.15,
27510-PF CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ,4321372,CDM,981,RC,27510,HCPCS,Outpatient,,,1346.72,673.36,,1212.05,90,,,percent of total billed charges,90% of total Billed charges,1345.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,673.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,317,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1043.69,155,,,Fee Schedule,155% of CMS OPPS Rate,673.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,972.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,673.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1093.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1093.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1027.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1027.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,664.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1212.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,823.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1043.69,155,,,Fee Schedule,155% of CMS OPPS Rate,673.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2085.2,155,,,Fee Schedule,155% of CMS OPPS Rate,2085.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,673.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,317,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,643.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,673.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1392.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1392.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,317,2085.2,
27520-PF CLOSED TX PATELLAR FRACTURE W/O MANIPULATION,4321815,CDM,981,RC,27520,HCPCS,Outpatient,,,585.4,292.70,,526.86,90,,,percent of total billed charges,90% of total Billed charges,605.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,292.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,453.67,155,,,Fee Schedule,155% of CMS OPPS Rate,292.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,475.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,431.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,431.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,259.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,509.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,453.67,155,,,Fee Schedule,155% of CMS OPPS Rate,292.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.79,155,,,Fee Schedule,155% of CMS OPPS Rate,938.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,292.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,292.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,634.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131,938.79,
27524-PF OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR,4321814,CDM,981,RC,27524,HCPCS,Outpatient,,,1477.9,738.95,,1330.11,90,,,percent of total billed charges,90% of total Billed charges,1480.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,738.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,406,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1145.36,155,,,Fee Schedule,155% of CMS OPPS Rate,738.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1076.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,738.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1210.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1210.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1131.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1131.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,724.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1477.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1334.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,901.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1145.36,155,,,Fee Schedule,155% of CMS OPPS Rate,738.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,2295.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2295.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,738.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,406,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,857.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,738.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1523.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1523.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,406,2295.1,
27530-PF CLTX TIBIAL FX PROXIMAL W/O MANIPULATION,4321813,CDM,981,RC,27530,HCPCS,Outpatient,,,557.92,278.96,,502.13,90,,,percent of total billed charges,90% of total Billed charges,573.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,278.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,453.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,409.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,409.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,309.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,483.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,889.5,155,,,Fee Schedule,155% of CMS OPPS Rate,889.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,361.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,788.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.5,889.5,
27532-PF CLTX TIBIAL FX PROXIMAL W/WO MANJ W/SKEL TRACJ,4321812,CDM,981,RC,27532,HCPCS,Outpatient,,,1136.1,568.05,,1022.49,90,,,percent of total billed charges,90% of total Billed charges,1174.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,227.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,880.48,155,,,Fee Schedule,155% of CMS OPPS Rate,568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,926.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,861,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,861,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,546.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1015.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,681.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,880.48,155,,,Fee Schedule,155% of CMS OPPS Rate,568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1820.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1820.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,567.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1237.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1237.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,227.5,1820.24,
27535-PF OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR,4321811,CDM,981,RC,27535,HCPCS,Outpatient,,,1766.86,883.43,,1590.17,90,,,percent of total billed charges,90% of total Billed charges,1772.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,883.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,656,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1369.3,155,,,Fee Schedule,155% of CMS OPPS Rate,883.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,883.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1445.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1445.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1363.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1363.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,881.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,883.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1766.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1608.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1099.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1369.3,155,,,Fee Schedule,155% of CMS OPPS Rate,883.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2746.63,155,,,Fee Schedule,155% of CMS OPPS Rate,2746.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,883.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,656,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,906.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,883.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1831.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1831.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,656,2746.63,
27536-PF OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIX,4321810,CDM,981,RC,27536,HCPCS,Outpatient,,,2332.82,1166.41,,2099.54,90,,,percent of total billed charges,90% of total Billed charges,2338.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1166.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1807.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1166.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1700.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1912.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1912.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1800.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1800.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1133.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1166.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2332.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2124.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1450.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1807.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1166.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3624.4,155,,,Fee Schedule,155% of CMS OPPS Rate,3624.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1166.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1143.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1166.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2427.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2427.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544,3624.4,
27538-PF CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN,4321809,CDM,981,RC,27538,HCPCS,Outpatient,,,877.24,438.62,,789.52,90,,,percent of total billed charges,90% of total Billed charges,909.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,438.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,679.86,155,,,Fee Schedule,155% of CMS OPPS Rate,438.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,438.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,712.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,712.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,653.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,653.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,404.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,770.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,505.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,679.86,155,,,Fee Schedule,155% of CMS OPPS Rate,438.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1410.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1410.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,438.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,463.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,438.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,939.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,939.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,1410.44,
27540-PF OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE,4321808,CDM,981,RC,27540,HCPCS,Outpatient,,,1600.02,800.01,,1440.02,90,,,percent of total billed charges,90% of total Billed charges,1601.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,800,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1240,155,,,Fee Schedule,155% of CMS OPPS Rate,800,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1302.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1302.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1219.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1219.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,807.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1438.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,972.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1240,155,,,Fee Schedule,155% of CMS OPPS Rate,800,100,,,Fee Schedule,100% of CMS OPPS Rate ,2482.4,155,,,Fee Schedule,155% of CMS OPPS Rate,2482.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,800,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1001.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,800,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1648.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2482.4,
27550-PF CLTX TIBIAL SHAFT FX W/O MANIPULATION,4321800,CDM,981,RC,27550,HCPCS,Outpatient,,,929.96,464.98,,836.96,90,,,percent of total billed charges,90% of total Billed charges,967.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,464.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,720.72,155,,,Fee Schedule,155% of CMS OPPS Rate,464.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,464.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,777.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,777.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,718.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,718.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,419.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,848.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,565.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,720.72,155,,,Fee Schedule,155% of CMS OPPS Rate,464.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1500.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1500.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,464.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,495.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,464.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,987.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,987.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,1500.38,
27552-PF CLOSED TX KNEE DISLOCATION W/ANESTHESIA,4321807,CDM,981,RC,27552,HCPCS,Outpatient,,,1238.96,619.48,,1115.06,90,,,percent of total billed charges,90% of total Billed charges,1241.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,960.18,155,,,Fee Schedule,155% of CMS OPPS Rate,619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,619.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1010.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1010.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,938.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,938.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,590.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1107.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,743.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,960.18,155,,,Fee Schedule,155% of CMS OPPS Rate,619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1923.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1923.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,601.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1263.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1263.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,1923.97,
27556-PF OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR,4321806,CDM,981,RC,27556,HCPCS,Outpatient,,,1727.48,863.74,,1554.73,90,,,percent of total billed charges,90% of total Billed charges,1732.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,863.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1338.78,155,,,Fee Schedule,155% of CMS OPPS Rate,863.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1256.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,863.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1413.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1413.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1332.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1332.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,895.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1727.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1572.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1076.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1338.78,155,,,Fee Schedule,155% of CMS OPPS Rate,863.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2685.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2685.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,863.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,560,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1089.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,863.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1787.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1787.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,560,2685.1,
27557-PF OPEN TX KNEE DISLOCATION W/LIGAMENTOUS REPAIR,4321805,CDM,981,RC,27557,HCPCS,Outpatient,,,2060.08,1030.04,,1854.07,90,,,percent of total billed charges,90% of total Billed charges,2068.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1030.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,876,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1596.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1499.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1030.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1687.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1687.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1594.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1594.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1070.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2060.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1881.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1290.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1596.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,3205.76,155,,,Fee Schedule,155% of CMS OPPS Rate,3205.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1030.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,876,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1316.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1030.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,2141.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2141.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,876,3205.76,
27558-PF OPEN TX KNEE DISLOCATION W/REPAIR/RECONSTRUCTION,4321804,CDM,981,RC,27558,HCPCS,Outpatient,,,2347.78,1173.89,,2113,90,,,percent of total billed charges,90% of total Billed charges,2356.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1173.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1819.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1173.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1173.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1923.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1923.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1821.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1821.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1193.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1173.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2347.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2148.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1479.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1819.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1173.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,3651.94,155,,,Fee Schedule,155% of CMS OPPS Rate,3651.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1173.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1404.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1173.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,2443.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2443.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,3651.94,
27560-PF CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA,4321803,CDM,981,RC,27560,HCPCS,Outpatient,,,672.18,336.09,,604.96,90,,,percent of total billed charges,90% of total Billed charges,694.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,336.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,520.94,155,,,Fee Schedule,155% of CMS OPPS Rate,336.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,489.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,336.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,550.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,505.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,505.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,287.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,394.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,520.94,155,,,Fee Schedule,155% of CMS OPPS Rate,336.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1076.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,336.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,102,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,356.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,336.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,754.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102,1076.58,
27562-PF CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA,4321802,CDM,981,RC,27562,HCPCS,Outpatient,,,958.8,479.40,,862.92,90,,,percent of total billed charges,90% of total Billed charges,958.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,743.07,155,,,Fee Schedule,155% of CMS OPPS Rate,479.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,479.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,780.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,721.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,721.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,426,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,850.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,566.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,743.07,155,,,Fee Schedule,155% of CMS OPPS Rate,479.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1486.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1486.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,479.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,459.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,479.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,969.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,134.5,1486.37,
27566-PF OPTX PATELLAR DISLC W/WO PRTL/TOT PATELLECTOMY,4321801,CDM,981,RC,27566,HCPCS,Outpatient,,,1754,877.00,,1578.6,90,,,percent of total billed charges,90% of total Billed charges,1758.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,876.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1359.33,155,,,Fee Schedule,155% of CMS OPPS Rate,876.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1278.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1438.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1349.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1349.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,859.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1753.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1592.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1085.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1359.33,155,,,Fee Schedule,155% of CMS OPPS Rate,876.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2725.37,155,,,Fee Schedule,155% of CMS OPPS Rate,2725.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,876.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1003.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,876.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1806.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1806.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2725.37,
27590- Amputate thigh/through femur,3435060,CDM,510,RC,27590,HCPCS,Outpatient,,,2124.13,1062.07,,1911.72,90,,,percent of total billed charges,90% of total Billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1699.3,80,,,Percent of total Billed charges,80% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1911.72,90,,,Percent of total Billed charges,90% of total billed charges,529.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2060.41,97,,,Percent of total billed charges,97% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1954.2,92,,,Percent of total billed charges,92% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1911.72,90,,,percent of total billed charges,90% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1486.89,70,,,percent of total billed charges,70% of total billed charges,1911.72,90,,,percent of total billed charges,90% of total billed charges,2017.92,95,,,percent of total billed charges,95% of total billed charges,2017.92,95,,,percent of total billed charges,95% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1826.75,86,,,percent of total billed charges,86% of total billed charges,1699.3,80,,,percent of total billed charges,80% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.41,97,,,percent of total billed charges,97% of total billed charges,1911.72,90,,,percent of total billed charges,90% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.41,97,,,percent of total billed charges,97% of total billed charges,1975.44,93,,,percent of total billed charges,93% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,481.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2060.41,97,,,percent of total billed charges,97% of total billed charges,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,481.5,2124.13,
27592 - Amputate Leg at Thigh thru Femur Open Circular,3898995,CDM,983,RC,27592,HCPCS,Outpatient,,,1797.58,898.79,,1617.82,90,,,percent of total billed charges,90% of total Billed charges,1345.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,669.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,440.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1037.4,155,,,Fee Schedule,155% of CMS OPPS Rate,669.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,669.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1125.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,660.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1338.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1234.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,879.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1037.4,155,,,Fee Schedule,155% of CMS OPPS Rate,669.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,2085.12,155,,,Fee Schedule,155% of CMS OPPS Rate,2085.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,669.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,837.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,669.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1435.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1435.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,440.5,2085.12,
"27596 - (PF) Amputation, thigh, through femur, any level; re-amputation",3634896,CDM,510,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,1716.4,90,,,percent of total billed charges,90% of total Billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1525.69,80,,,Percent of total Billed charges,80% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1716.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1849.9,97,,,Percent of total billed charges,97% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1754.54,92,,,Percent of total billed charges,92% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1716.4,90,,,percent of total billed charges,90% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1334.98,70,,,percent of total billed charges,70% of total billed charges,1716.4,90,,,percent of total billed charges,90% of total billed charges,1811.75,95,,,percent of total billed charges,95% of total billed charges,1811.75,95,,,percent of total billed charges,95% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1640.11,86,,,percent of total billed charges,86% of total billed charges,1525.69,80,,,percent of total billed charges,80% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.9,97,,,percent of total billed charges,97% of total billed charges,1716.4,90,,,percent of total billed charges,90% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.9,97,,,percent of total billed charges,97% of total billed charges,1773.61,93,,,percent of total billed charges,93% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1849.9,97,,,percent of total billed charges,97% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1334.98,1907.11,
27600- Decompress fasciotomy/leg/ant/lat,3435063,CDM,510,RC,27600,HCPCS,Outpatient,,,1067.03,533.52,,960.33,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,853.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,960.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1035.02,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,981.67,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,960.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,746.92,70,,,percent of total billed charges,70% of total billed charges,960.33,90,,,percent of total billed charges,90% of total billed charges,1013.68,95,,,percent of total billed charges,95% of total billed charges,1013.68,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,917.65,86,,,percent of total billed charges,86% of total billed charges,853.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1035.02,97,,,percent of total billed charges,97% of total billed charges,960.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1035.02,97,,,percent of total billed charges,97% of total billed charges,992.34,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1035.02,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,746.92,14511.58,
"27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)",3621977,CDM,510,RC,27602,HCPCS,Outpatient,,,1285.76,642.88,,1157.18,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1028.61,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1157.18,90,,,Percent of total Billed charges,90% of total billed charges,302.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1247.19,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1182.9,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1157.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,900.03,70,,,percent of total billed charges,70% of total billed charges,1157.18,90,,,percent of total billed charges,90% of total billed charges,1221.47,95,,,percent of total billed charges,95% of total billed charges,1221.47,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1105.75,86,,,percent of total billed charges,86% of total billed charges,1028.61,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1247.19,97,,,percent of total billed charges,97% of total billed charges,1157.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.19,97,,,percent of total billed charges,97% of total billed charges,1195.76,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,275,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1247.19,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,275,14511.58,
27632- Exc SQ tumor/leg/ankle 3cm/>,3435075,CDM,510,RC,27632,HCPCS,Outpatient,,,1087.24,543.62,,978.52,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,869.79,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1054.62,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1000.26,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,978.52,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,761.07,70,,,percent of total billed charges,70% of total billed charges,978.52,90,,,percent of total billed charges,90% of total billed charges,1032.88,95,,,percent of total billed charges,95% of total billed charges,1032.88,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,935.03,86,,,percent of total billed charges,86% of total billed charges,869.79,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054.62,97,,,percent of total billed charges,97% of total billed charges,978.52,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.62,97,,,percent of total billed charges,97% of total billed charges,1011.13,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1054.62,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,761.07,12593.67,
27687- Gastrocnemius recession,3435090,CDM,510,RC,27687,HCPCS,Outpatient,,,1175.53,587.77,,1057.98,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,940.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1057.98,90,,,Percent of total Billed charges,90% of total billed charges,358.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1140.26,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1081.49,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1057.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,822.87,70,,,percent of total billed charges,70% of total billed charges,1057.98,90,,,percent of total billed charges,90% of total billed charges,1116.75,95,,,percent of total billed charges,95% of total billed charges,1116.75,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1010.96,86,,,percent of total billed charges,86% of total billed charges,940.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1140.26,97,,,percent of total billed charges,97% of total billed charges,1057.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1140.26,97,,,percent of total billed charges,97% of total billed charges,1093.24,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1140.26,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,325.5,14511.58,
27752-PF CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ,4321799,CDM,981,RC,27752,HCPCS,Outpatient,,,965.54,482.77,,868.99,90,,,percent of total billed charges,90% of total Billed charges,1005.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,748.28,155,,,Fee Schedule,155% of CMS OPPS Rate,482.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,482.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,790.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,733.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,733.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,466.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,578.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,748.28,155,,,Fee Schedule,155% of CMS OPPS Rate,482.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1558.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1558.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,482.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,524.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,482.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1075.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1075.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,233.5,1558.49,
27756-PF PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE,4321798,CDM,981,RC,27756,HCPCS,Outpatient,,,1128.26,564.13,,1015.43,90,,,percent of total billed charges,90% of total Billed charges,1131.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,500.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,874.4,155,,,Fee Schedule,155% of CMS OPPS Rate,564.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,564.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,856.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,856.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,541.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1128.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1010.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,674.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,874.4,155,,,Fee Schedule,155% of CMS OPPS Rate,564.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1753.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1753.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,564.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,500.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,652.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,564.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1158.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,500.16,1753.87,
27758-PF OPTX TIBIAL SHFT FX W/PLATE/SCREWS W/WO CERCLAG,4321797,CDM,981,RC,27758,HCPCS,Outpatient,,,1757.44,878.72,,1581.7,90,,,percent of total billed charges,90% of total Billed charges,1761.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,878.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,505.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1362.02,155,,,Fee Schedule,155% of CMS OPPS Rate,878.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,878.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1438.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1438.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1347.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1347.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,849.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,878.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1757.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1589.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1077.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1362.02,155,,,Fee Schedule,155% of CMS OPPS Rate,878.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,2730.54,155,,,Fee Schedule,155% of CMS OPPS Rate,2730.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,878.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,916.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,878.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1808.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1808.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,505.5,2730.54,
27759-PF TX TIBL SHFT FX IMED IMPLT W/WO SCREWS&/CERCLA,4321796,CDM,981,RC,27759,HCPCS,Outpatient,,,1959.42,979.71,,1763.48,90,,,percent of total billed charges,90% of total Billed charges,1964.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,979.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1518.54,155,,,Fee Schedule,155% of CMS OPPS Rate,979.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,979.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1606.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1606.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1510.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1510.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,964.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1959.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1782.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1213.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1518.54,155,,,Fee Schedule,155% of CMS OPPS Rate,979.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,3045.3,155,,,Fee Schedule,155% of CMS OPPS Rate,3045.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,979.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,562,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1029.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,979.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,2032.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2032.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,562,3045.3,
27760-PF CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION,4321795,CDM,981,RC,27760,HCPCS,Outpatient,,,594.06,297.03,,534.65,90,,,percent of total billed charges,90% of total Billed charges,616.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.4,155,,,Fee Schedule,155% of CMS OPPS Rate,297.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,490.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,445.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,445.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,270.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,525.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.4,155,,,Fee Schedule,155% of CMS OPPS Rate,297.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.47,155,,,Fee Schedule,155% of CMS OPPS Rate,955.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,313.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,657.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,270.35,955.47,
27762-PF CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ,4321794,CDM,981,RC,27762,HCPCS,Outpatient,,,859.18,429.59,,773.26,90,,,percent of total billed charges,90% of total Billed charges,899.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,429.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.86,155,,,Fee Schedule,155% of CMS OPPS Rate,429.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,618.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,429.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,695.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,643.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,643.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,413.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,859.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,759.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,504.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,665.86,155,,,Fee Schedule,155% of CMS OPPS Rate,429.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1394.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1394.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,429.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,478.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,429.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,955.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,413.12,1394.27,
27766-PF OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE,4321793,CDM,981,RC,27766,HCPCS,Outpatient,,,1183.38,591.69,,1065.04,90,,,percent of total billed charges,90% of total Billed charges,1182.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,591.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917.12,155,,,Fee Schedule,155% of CMS OPPS Rate,591.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,862.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,591.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,969.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,969.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,899.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,899.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,585.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1061.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,704.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,917.12,155,,,Fee Schedule,155% of CMS OPPS Rate,591.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1833.25,155,,,Fee Schedule,155% of CMS OPPS Rate,1833.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,591.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,628.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,591.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1233.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1233.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,585.96,1833.25,
27780-PF CLTX PROX FIBULA/SHFT FX W/O MANJ,4321792,CDM,981,RC,27780,HCPCS,Outpatient,,,552.88,276.44,,497.59,90,,,percent of total billed charges,90% of total Billed charges,573.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.47,155,,,Fee Schedule,155% of CMS OPPS Rate,276.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,407.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,407.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,241,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,428.47,155,,,Fee Schedule,155% of CMS OPPS Rate,276.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,889.62,155,,,Fee Schedule,155% of CMS OPPS Rate,889.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,294.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,599.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,241,889.62,
27781-PF CLTX PROX FIBULA/SHFT FX W/MANJ,4321791,CDM,981,RC,27781,HCPCS,Outpatient,,,788.42,394.21,,709.58,90,,,percent of total billed charges,90% of total Billed charges,816.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,394.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,197,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,611.03,155,,,Fee Schedule,155% of CMS OPPS Rate,394.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,394.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,638.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,586.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,586.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,361,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,692.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,455.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,611.03,155,,,Fee Schedule,155% of CMS OPPS Rate,394.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,1265.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1265.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,394.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,408,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,394.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,843.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,843.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197,1265.84,
27784-PF OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE,4321790,CDM,981,RC,27784,HCPCS,Outpatient,,,1390.84,695.42,,1251.76,90,,,percent of total billed charges,90% of total Billed charges,1389.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,695.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1077.89,155,,,Fee Schedule,155% of CMS OPPS Rate,695.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1015.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,695.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1142.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1142.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1064.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1064.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,641.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1390.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1255.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,840.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1077.89,155,,,Fee Schedule,155% of CMS OPPS Rate,695.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2153.86,155,,,Fee Schedule,155% of CMS OPPS Rate,2153.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,695.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,710.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,695.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1454.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1454.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,641.09,2153.86,
27786-PF CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ,4321789,CDM,981,RC,27786,HCPCS,Outpatient,,,558.18,279.09,,502.36,90,,,percent of total billed charges,90% of total Billed charges,581.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.28,90,,,Percent of total Billed charges,90% of total billed charges,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,432.57,155,,,Fee Schedule,155% of CMS OPPS Rate,279.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,279.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,459.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,417.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,417.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,254,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,492.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,317.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,432.57,155,,,Fee Schedule,155% of CMS OPPS Rate,279.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,901.15,155,,,Fee Schedule,155% of CMS OPPS Rate,901.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,279.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,340.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,279.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,622.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,901.15,
27788-PF CLTX DSTL FIBULAR FX LAT MALLS W/MANJ,4321788,CDM,981,RC,27788,HCPCS,Outpatient,,,755.7,377.85,,680.13,90,,,percent of total billed charges,90% of total Billed charges,790.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,377.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,159,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,585.67,155,,,Fee Schedule,155% of CMS OPPS Rate,377.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,377.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,618.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,569.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,569.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,755.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,671.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,442.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,585.67,155,,,Fee Schedule,155% of CMS OPPS Rate,377.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1225.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1225.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,377.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,159,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,490.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,377.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,839.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,839.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,159,1225.12,
27792-PF OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS,4321787,CDM,981,RC,27792,HCPCS,Outpatient,,,1260.72,630.36,,1134.65,90,,,percent of total billed charges,90% of total Billed charges,1262.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,977.04,155,,,Fee Schedule,155% of CMS OPPS Rate,630.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,630.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1039.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,967.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,967.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,655.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1260.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1141.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,760.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,977.04,155,,,Fee Schedule,155% of CMS OPPS Rate,630.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1957.51,155,,,Fee Schedule,155% of CMS OPPS Rate,1957.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,630.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,715.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,630.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1448.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1448.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,630.35,1957.51,
27808-PF CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ,4321786,CDM,981,RC,27808,HCPCS,Outpatient,,,592.04,296.02,,532.84,90,,,percent of total billed charges,90% of total Billed charges,617.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,296.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.83,155,,,Fee Schedule,155% of CMS OPPS Rate,296.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,484.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,265.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,458.83,155,,,Fee Schedule,155% of CMS OPPS Rate,296.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,957.13,155,,,Fee Schedule,155% of CMS OPPS Rate,957.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,296.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,339.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,296.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,654.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,265.28,957.13,
27810-PF CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ,4321785,CDM,981,RC,27810,HCPCS,Outpatient,,,841.44,420.72,,757.3,90,,,percent of total billed charges,90% of total Billed charges,880.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,420.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.12,155,,,Fee Schedule,155% of CMS OPPS Rate,420.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,604.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,420.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,679.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,679.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,628.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,628.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,402.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,841.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,494.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,652.12,155,,,Fee Schedule,155% of CMS OPPS Rate,420.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1364.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1364.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,420.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,478.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,420.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,934.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,934.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,402.62,1364.11,
27814-PF OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE,4321784,CDM,981,RC,27814,HCPCS,Outpatient,,,1497.82,748.91,,1348.04,90,,,percent of total billed charges,90% of total Billed charges,1500.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,748.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,450,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1160.8,155,,,Fee Schedule,155% of CMS OPPS Rate,748.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,748.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1232.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1232.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1150.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1150.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,748.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1497.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1357.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,910.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1160.8,155,,,Fee Schedule,155% of CMS OPPS Rate,748.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,2325.62,155,,,Fee Schedule,155% of CMS OPPS Rate,2325.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,748.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,450,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,862.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,748.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1567.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,450,2325.62,
27816-PF CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION,4321783,CDM,981,RC,27816,HCPCS,Outpatient,,,570.82,285.41,,513.74,90,,,percent of total billed charges,90% of total Billed charges,603.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,285.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.39,155,,,Fee Schedule,155% of CMS OPPS Rate,285.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,423.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,423.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,251.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,499.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,442.39,155,,,Fee Schedule,155% of CMS OPPS Rate,285.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,935.08,155,,,Fee Schedule,155% of CMS OPPS Rate,935.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,285.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,326.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,285.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,626.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,626.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,251.46,935.08,
27818-PF CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION,4321782,CDM,981,RC,27818,HCPCS,Outpatient,,,867.86,433.93,,781.07,90,,,percent of total billed charges,90% of total Billed charges,910.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,433.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,239,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,672.59,155,,,Fee Schedule,155% of CMS OPPS Rate,433.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,433.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,698.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,698.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,648.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,648.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,410.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,765.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,511.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,672.59,155,,,Fee Schedule,155% of CMS OPPS Rate,433.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1411.96,155,,,Fee Schedule,155% of CMS OPPS Rate,1411.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,433.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,239,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,520.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,433.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,954.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,954.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,239,1411.96,
27822-PF OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP,4321781,CDM,981,RC,27822,HCPCS,Outpatient,,,1698.86,849.43,,1528.97,90,,,percent of total billed charges,90% of total Billed charges,1707.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,849.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1316.6,155,,,Fee Schedule,155% of CMS OPPS Rate,849.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1237.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,849.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1391.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1391.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1289.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1289.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,820.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1698.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1521.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1010.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1316.6,155,,,Fee Schedule,155% of CMS OPPS Rate,849.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2645.97,155,,,Fee Schedule,155% of CMS OPPS Rate,2645.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,849.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,928.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,849.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1705.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1705.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,820.13,2645.97,
27823-PF OPEN TX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP,4321780,CDM,981,RC,27823,HCPCS,Outpatient,,,1920.12,960.06,,1728.11,90,,,percent of total billed charges,90% of total Billed charges,1927.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,960.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,497.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1488.09,155,,,Fee Schedule,155% of CMS OPPS Rate,960.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1399.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,960.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1574.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1574.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1465.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1465.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,934.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1920.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1728.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1156.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1488.09,155,,,Fee Schedule,155% of CMS OPPS Rate,960.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,2987.25,155,,,Fee Schedule,155% of CMS OPPS Rate,2987.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,960.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1038.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,960.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1942.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1942.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,497.5,2987.25,
27824-PF CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ,4321779,CDM,981,RC,27824,HCPCS,Outpatient,,,594.64,297.32,,535.18,90,,,percent of total billed charges,90% of total Billed charges,604.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.83,155,,,Fee Schedule,155% of CMS OPPS Rate,297.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,487.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,444.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,444.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,269.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,339.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.83,155,,,Fee Schedule,155% of CMS OPPS Rate,297.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,936.68,155,,,Fee Schedule,155% of CMS OPPS Rate,936.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,618.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,269.3,936.68,
27825-PF CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ,4321778,CDM,981,RC,27825,HCPCS,Outpatient,,,971.8,485.90,,874.62,90,,,percent of total billed charges,90% of total Billed charges,1017.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,485.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,753.13,155,,,Fee Schedule,155% of CMS OPPS Rate,485.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,485.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,793.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,793.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,739.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,739.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,469.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,872.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,585.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,753.13,155,,,Fee Schedule,155% of CMS OPPS Rate,485.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1576.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1576.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,485.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,540.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,485.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1094.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,469.62,1576.66,
27826-PF OPEN TREATMENT FRACTURE DISTAL TIBIA FIBUL,4321777,CDM,981,RC,27826,HCPCS,Outpatient,,,1660.92,830.46,,1494.83,90,,,percent of total billed charges,90% of total Billed charges,1666.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,830.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,374,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1287.2,155,,,Fee Schedule,155% of CMS OPPS Rate,830.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1215.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,830.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1367.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1267.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1267.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,774.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,830.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1495.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,989.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1287.2,155,,,Fee Schedule,155% of CMS OPPS Rate,830.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2583.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2583.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,830.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,374,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,822.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,830.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1697.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1697.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,374,2583.35,
27827-PF OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY,4321776,CDM,981,RC,27827,HCPCS,Outpatient,,,2184.44,1092.22,,1966,90,,,percent of total billed charges,90% of total Billed charges,2191.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1092.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,421,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1692.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1092.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1092.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1785.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1785.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1661.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1661.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1048.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1092.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2184.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1960.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1314.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1692.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1092.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3396.62,155,,,Fee Schedule,155% of CMS OPPS Rate,3396.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1092.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,421,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1094.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1092.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2201.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,421,3396.62,
27828-PF OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA,4321775,CDM,981,RC,27828,HCPCS,Outpatient,,,2596.96,1298.48,,2337.26,90,,,percent of total billed charges,90% of total Billed charges,2608.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1298.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,515,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2012.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1298.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1886.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1298.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2122.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2122.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1984.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1984.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1245.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2596.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2341.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1578.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2012.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1298.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,4042.91,155,,,Fee Schedule,155% of CMS OPPS Rate,4042.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1298.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,515,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1320,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1298.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,2639.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2639.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,515,4042.91,
27829-PF OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION,4321774,CDM,981,RC,27829,HCPCS,Outpatient,,,1371.34,685.67,,1234.21,90,,,percent of total billed charges,90% of total Billed charges,1376.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,685.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,374,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1062.79,155,,,Fee Schedule,155% of CMS OPPS Rate,685.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,685.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1125.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1039.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1039.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,609.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1371.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1226.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,809.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1062.79,155,,,Fee Schedule,155% of CMS OPPS Rate,685.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2133.75,155,,,Fee Schedule,155% of CMS OPPS Rate,2133.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,685.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,374,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,745.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,685.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1382.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,374,2133.75,
27830-PF CLTX PROX TIBFIB JT DISLC W/O ANES,4321773,CDM,981,RC,27830,HCPCS,Outpatient,,,702.78,351.39,,632.5,90,,,percent of total billed charges,90% of total Billed charges,729.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,544.65,155,,,Fee Schedule,155% of CMS OPPS Rate,351.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,572.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,302.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,618.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,407.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,544.65,155,,,Fee Schedule,155% of CMS OPPS Rate,351.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1131.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1131.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,351.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,351.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,754.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,1131.17,
27831-PF CLTX PROX TIBFIB JT DISLC REQ ANES,4321772,CDM,981,RC,27831,HCPCS,Outpatient,,,797.84,398.92,,718.06,90,,,percent of total billed charges,90% of total Billed charges,798.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,398.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,618.33,155,,,Fee Schedule,155% of CMS OPPS Rate,398.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,398.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,595.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,595.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,356.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,464.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,618.33,155,,,Fee Schedule,155% of CMS OPPS Rate,398.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1236.92,155,,,Fee Schedule,155% of CMS OPPS Rate,1236.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,398.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,146,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,382.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,398.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,798.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146,1236.92,
27832-PF OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB,4321771,CDM,981,RC,27832,HCPCS,Outpatient,,,1483.88,741.94,,1335.49,90,,,percent of total billed charges,90% of total Billed charges,1485.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,741.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1150.01,155,,,Fee Schedule,155% of CMS OPPS Rate,741.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1080.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1215.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1215.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1133.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1133.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,643.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1483.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1337.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,901.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1150.01,155,,,Fee Schedule,155% of CMS OPPS Rate,741.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,2302.93,155,,,Fee Schedule,155% of CMS OPPS Rate,2302.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,741.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,734.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,741.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1527.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1527.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,2302.93,
27840-PF SED TX ANKLE DISLOCATION W/O ANESTHESIA,4321770,CDM,981,RC,27840,HCPCS,Outpatient,,,760.34,380.17,,684.31,90,,,percent of total billed charges,90% of total Billed charges,755.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,89.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,589.26,155,,,Fee Schedule,155% of CMS OPPS Rate,380.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,603.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,559.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,559.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,659.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,438.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,589.26,155,,,Fee Schedule,155% of CMS OPPS Rate,380.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1170.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1170.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,380.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,397.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,380.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,716.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.5,1170.33,
27842-PF CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIX,4321769,CDM,981,RC,27842,HCPCS,Outpatient,,,962.2,481.10,,865.98,90,,,percent of total billed charges,90% of total Billed charges,968.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,745.69,155,,,Fee Schedule,155% of CMS OPPS Rate,481.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,481.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,790.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,790.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,734.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,734.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,456.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,962.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,866.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,577.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,745.69,155,,,Fee Schedule,155% of CMS OPPS Rate,481.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1500.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1500.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,481.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,488.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,481.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1000.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1500.66,
27846-PF OPTX ANKLE DISLOCATION W/O REPAIR/INTERNAL FIXJ,4321768,CDM,981,RC,27846,HCPCS,Outpatient,,,1407.48,703.74,,1266.73,90,,,percent of total billed charges,90% of total Billed charges,1415.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.8,155,,,Fee Schedule,155% of CMS OPPS Rate,703.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,703.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1147.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1147.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1073.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1073.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,710,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1407.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1267.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,846.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1090.8,155,,,Fee Schedule,155% of CMS OPPS Rate,703.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2194.43,155,,,Fee Schedule,155% of CMS OPPS Rate,2194.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,703.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,762.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,703.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1486.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1486.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,703.74,2194.43,
27848-PF OPTX ANKLE DISLOCATION W/REPAIR/INT/XTRNL FIXJ,4321767,CDM,981,RC,27848,HCPCS,Outpatient,,,1541.06,770.53,,1386.95,90,,,percent of total billed charges,90% of total Billed charges,1551.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,770.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1194.32,155,,,Fee Schedule,155% of CMS OPPS Rate,770.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1142.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,770.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1284.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1284.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1204.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1204.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,808.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1541.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1420.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,952.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1194.32,155,,,Fee Schedule,155% of CMS OPPS Rate,770.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2404.21,155,,,Fee Schedule,155% of CMS OPPS Rate,2404.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,770.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,863,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,770.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1661.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1661.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,770.53,2404.21,
27880- Amputate leg/through tib/fib,3435129,CDM,510,RC,27880,HCPCS,Outpatient,,,2425.23,1212.62,,2182.71,90,,,percent of total billed charges,90% of total Billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1940.18,80,,,Percent of total Billed charges,80% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2182.71,90,,,Percent of total Billed charges,90% of total billed charges,491.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2352.47,97,,,Percent of total billed charges,97% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2231.21,92,,,Percent of total billed charges,92% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2182.71,90,,,percent of total billed charges,90% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1697.66,70,,,percent of total billed charges,70% of total billed charges,2182.71,90,,,percent of total billed charges,90% of total billed charges,2303.97,95,,,percent of total billed charges,95% of total billed charges,2303.97,95,,,percent of total billed charges,95% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2085.7,86,,,percent of total billed charges,86% of total billed charges,1940.18,80,,,percent of total billed charges,80% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2352.47,97,,,percent of total billed charges,97% of total billed charges,2182.71,90,,,percent of total billed charges,90% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2352.47,97,,,percent of total billed charges,97% of total billed charges,2255.46,93,,,percent of total billed charges,93% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,446.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2352.47,97,,,percent of total billed charges,97% of total billed charges,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2425.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,446.5,2425.23,
27882 - Amputate Lower Leg thru Tibia&Fibula Open Circular,3899012,CDM,983,RC,27882,HCPCS,Outpatient,,,1591.03,795.52,,1431.93,90,,,percent of total billed charges,90% of total Billed charges,1189.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,590.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.03,155,,,Fee Schedule,155% of CMS OPPS Rate,590.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,590.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,995.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,995.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,926.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,926.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,608.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1093.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,785.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,916.03,155,,,Fee Schedule,155% of CMS OPPS Rate,590.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1843.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1843.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,590.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,814.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,590.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1266.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1266.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,590.99,1843.35,
27886- Re-amputate/leg/tibia/fibula,3435130,CDM,510,RC,27886,HCPCS,Outpatient,,,1729.38,864.69,,1556.44,90,,,percent of total billed charges,90% of total Billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1383.5,80,,,Percent of total Billed charges,80% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1556.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1677.5,97,,,Percent of total billed charges,97% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1591.03,92,,,Percent of total billed charges,92% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1556.44,90,,,percent of total billed charges,90% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1210.57,70,,,percent of total billed charges,70% of total billed charges,1556.44,90,,,percent of total billed charges,90% of total billed charges,1642.91,95,,,percent of total billed charges,95% of total billed charges,1642.91,95,,,percent of total billed charges,95% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1487.27,86,,,percent of total billed charges,86% of total billed charges,1383.5,80,,,percent of total billed charges,80% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1677.5,97,,,percent of total billed charges,97% of total billed charges,1556.44,90,,,percent of total billed charges,90% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1677.5,97,,,percent of total billed charges,97% of total billed charges,1608.32,93,,,percent of total billed charges,93% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1677.5,97,,,percent of total billed charges,97% of total billed charges,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1210.57,1729.38,
27899 - PF Unlisted Procedure Leg or Ankle,4315548,CDM,960,RC,27899,HCPCS,Outpatient,,,1802,901.00,,1621.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.6,1621.8,
28001- I&D/bursa/foot,3435133,CDM,510,RC,28001,HCPCS,Outpatient,,,440.31,220.16,,396.28,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,352.25,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.28,90,,,Percent of total Billed charges,90% of total billed charges,43.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,427.1,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,405.09,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,396.28,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,308.22,70,,,percent of total billed charges,70% of total billed charges,396.28,90,,,percent of total billed charges,90% of total billed charges,418.29,95,,,percent of total billed charges,95% of total billed charges,418.29,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,378.67,86,,,percent of total billed charges,86% of total billed charges,352.25,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,427.1,97,,,percent of total billed charges,97% of total billed charges,396.28,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.1,97,,,percent of total billed charges,97% of total billed charges,409.49,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,427.1,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.5,7310.49,
28002- I&D below fascia/foot/single bursa,3435134,CDM,510,RC,28002,HCPCS,Outpatient,,,631.59,315.80,,568.43,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,505.27,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,568.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,612.64,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,581.06,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,568.43,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,442.11,70,,,percent of total billed charges,70% of total billed charges,568.43,90,,,percent of total billed charges,90% of total billed charges,600.01,95,,,percent of total billed charges,95% of total billed charges,600.01,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,543.17,86,,,percent of total billed charges,86% of total billed charges,505.27,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,612.64,97,,,percent of total billed charges,97% of total billed charges,568.43,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.64,97,,,percent of total billed charges,97% of total billed charges,587.38,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,612.64,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,442.11,6993.46,
28003- I&D below fascia/foot/mult area,3435135,CDM,510,RC,28003,HCPCS,Outpatient,,,987.59,493.80,,888.83,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,790.07,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,957.96,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,908.58,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,888.83,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,691.31,70,,,percent of total billed charges,70% of total billed charges,888.83,90,,,percent of total billed charges,90% of total billed charges,938.21,95,,,percent of total billed charges,95% of total billed charges,938.21,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,849.33,86,,,percent of total billed charges,86% of total billed charges,790.07,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,957.96,97,,,percent of total billed charges,97% of total billed charges,888.83,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,957.96,97,,,percent of total billed charges,97% of total billed charges,918.46,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,957.96,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,691.31,14511.58,
28122- Part exc/tarsal/metatarsal,3435162,CDM,510,RC,28122,HCPCS,Outpatient,,,1489.07,744.54,,1340.16,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1191.26,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1340.16,90,,,Percent of total Billed charges,90% of total billed charges,288.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1444.4,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.94,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1340.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1042.35,70,,,percent of total billed charges,70% of total billed charges,1340.16,90,,,percent of total billed charges,90% of total billed charges,1414.62,95,,,percent of total billed charges,95% of total billed charges,1414.62,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1280.6,86,,,percent of total billed charges,86% of total billed charges,1191.26,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1444.4,97,,,percent of total billed charges,97% of total billed charges,1340.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.4,97,,,percent of total billed charges,97% of total billed charges,1384.84,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1444.4,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,262.5,14511.58,
28190- Remove foreign body/foot/subq,3435165,CDM,360,RC,28190,HCPCS,Outpatient,,,603.43,301.72,,543.09,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,482.74,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.09,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.33,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,555.16,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.09,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,422.4,70,,,percent of total billed charges,70% of total billed charges,543.09,90,,,percent of total billed charges,90% of total billed charges,573.26,95,,,percent of total billed charges,95% of total billed charges,573.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,518.95,86,,,percent of total billed charges,86% of total billed charges,482.74,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.33,97,,,percent of total billed charges,97% of total billed charges,543.09,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.33,97,,,percent of total billed charges,97% of total billed charges,561.19,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.33,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,3163.8,
28190-PF REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS,4321766,CDM,981,RC,28190,HCPCS,Outpatient,,,253.36,126.68,,228.02,90,,,percent of total billed charges,90% of total Billed charges,353.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.35,155,,,Fee Schedule,155% of CMS OPPS Rate,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,198.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,198.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.35,155,,,Fee Schedule,155% of CMS OPPS Rate,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.05,155,,,Fee Schedule,155% of CMS OPPS Rate,548.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,548.05,
28192- Remove foreign body/foot/deep,3435166,CDM,510,RC,28192,HCPCS,Outpatient,,,1150.91,575.46,,1035.82,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,920.73,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1035.82,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1116.38,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.84,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1035.82,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,805.64,70,,,percent of total billed charges,70% of total billed charges,1035.82,90,,,percent of total billed charges,90% of total billed charges,1093.36,95,,,percent of total billed charges,95% of total billed charges,1093.36,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,989.78,86,,,percent of total billed charges,86% of total billed charges,920.73,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1116.38,97,,,percent of total billed charges,97% of total billed charges,1035.82,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1116.38,97,,,percent of total billed charges,97% of total billed charges,1070.35,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.38,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,7310.49,
28193- Rmv foreign body/foot/complicated,3435167,CDM,510,RC,28193,HCPCS,Outpatient,,,1310.94,655.47,,1179.85,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.75,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.85,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1271.61,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.06,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1179.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,917.66,70,,,percent of total billed charges,70% of total billed charges,1179.85,90,,,percent of total billed charges,90% of total billed charges,1245.39,95,,,percent of total billed charges,95% of total billed charges,1245.39,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1127.41,86,,,percent of total billed charges,86% of total billed charges,1048.75,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1271.61,97,,,percent of total billed charges,97% of total billed charges,1179.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1271.61,97,,,percent of total billed charges,97% of total billed charges,1219.17,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1271.61,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,7310.49,
28208-PF REPAIR TENDON EXTENSOR FOOT 1/2 EACH TENDON,4321765,CDM,981,RC,28208,HCPCS,Outpatient,,,619.8,309.90,,557.82,90,,,percent of total billed charges,90% of total Billed charges,763.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,480.35,155,,,Fee Schedule,155% of CMS OPPS Rate,309.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,309.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,507.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,468.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,468.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,304.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,619.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,552.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,348.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,480.35,155,,,Fee Schedule,155% of CMS OPPS Rate,309.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1183.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,309.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,238,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,461.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,309.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,932.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,932.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,238,1183.02,
28400-PF CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION,4321764,CDM,981,RC,28400,HCPCS,Outpatient,,,440.4,220.20,,396.36,90,,,percent of total billed charges,90% of total Billed charges,455.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,341.31,155,,,Fee Schedule,155% of CMS OPPS Rate,220.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,364.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,329.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,329.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,206.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,388.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,246.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,341.31,155,,,Fee Schedule,155% of CMS OPPS Rate,220.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.75,155,,,Fee Schedule,155% of CMS OPPS Rate,705.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,220.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,140,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,292.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,490.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,140,705.75,
28405-PF CLOSED TX CALCANEAL FRACTURE W/MANIPULATION,4321763,CDM,981,RC,28405,HCPCS,Outpatient,,,792.12,396.06,,712.91,90,,,percent of total billed charges,90% of total Billed charges,772.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,396.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,216.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,613.88,155,,,Fee Schedule,155% of CMS OPPS Rate,396.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,499.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,561.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,517.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,517.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,343.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,611.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,390.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,613.88,155,,,Fee Schedule,155% of CMS OPPS Rate,396.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1196.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,396.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,427.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,396.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,788.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,216.5,1196.97,
28406-PF PRQ SKELETAL FIXJ CALCANEAL FRACTURE W/MANJ,4321762,CDM,981,RC,28406,HCPCS,Outpatient,,,1089.34,544.67,,980.41,90,,,percent of total billed charges,90% of total Billed charges,1091.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,544.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,216.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,844.24,155,,,Fee Schedule,155% of CMS OPPS Rate,544.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,544.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,867.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,798.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,798.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,504.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1089.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,941.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,616.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,844.24,155,,,Fee Schedule,155% of CMS OPPS Rate,544.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1691.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1691.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,544.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,558.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,544.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1056.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1056.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,216.5,1691.56,
28415-PF OPEN TREATMENT CALCANEAL FRACTURE,4321761,CDM,981,RC,28415,HCPCS,Outpatient,,,2193.1,1096.55,,1973.79,90,,,percent of total billed charges,90% of total Billed charges,2201.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1096.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1699.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1096.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1096.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1797.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1678.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1678.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1109.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1096.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1980.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1307.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1699.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1096.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,3411.84,155,,,Fee Schedule,155% of CMS OPPS Rate,3411.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1096.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1198.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1096.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2270.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2270.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301.5,3411.84,
28430-PF CLOSED TX TALUS FRACTURE W/O MANIPULATION,4321760,CDM,981,RC,28430,HCPCS,Outpatient,,,405.48,202.74,,364.93,90,,,percent of total billed charges,90% of total Billed charges,431.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,314.23,155,,,Fee Schedule,155% of CMS OPPS Rate,202.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,335.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,186.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,228.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,314.23,155,,,Fee Schedule,155% of CMS OPPS Rate,202.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.42,155,,,Fee Schedule,155% of CMS OPPS Rate,668.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,202.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,202.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,463.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111,668.42,
28435-PF CLOSED TX TALUS FRACTURE W/MANIPULATION,4321759,CDM,981,RC,28435,HCPCS,Outpatient,,,638,319.00,,574.2,90,,,percent of total billed charges,90% of total Billed charges,673.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,319,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,494.45,155,,,Fee Schedule,155% of CMS OPPS Rate,319,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,518.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,473.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,473.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,275.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,558.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,365.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,494.45,155,,,Fee Schedule,155% of CMS OPPS Rate,319,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1044.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,319,100,,,Fee Schedule,100% of CMS OPPS Rate ,145,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,332.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,319,100,,,Fee Schedule,100% of CMS OPPS Rate ,714,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,714,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,145,1044.65,
28436-PF PRQ SKELETAL FIXATION TALUS FRACTURE W/MAN,4321758,CDM,981,RC,28436,HCPCS,Outpatient,,,952.42,476.21,,857.18,90,,,percent of total billed charges,90% of total Billed charges,954.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.11,155,,,Fee Schedule,155% of CMS OPPS Rate,476.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,476.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,682.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,682.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,404.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,952.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,804.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,524.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,738.11,155,,,Fee Schedule,155% of CMS OPPS Rate,476.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1478.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1478.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,476.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,464.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,476.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,896.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,896.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,404.05,1478.95,
28445-PF OPEN TREATMENT TALUS FRACTURE,4321757,CDM,981,RC,28445,HCPCS,Outpatient,,,2036.34,1018.17,,1832.71,90,,,percent of total billed charges,90% of total Billed charges,2024.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1018.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,269,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1578.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1018.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1481.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1018.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1665.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1665.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1563.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1563.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1044.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1018.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2036.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1844.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1225.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1578.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1018.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3137.36,155,,,Fee Schedule,155% of CMS OPPS Rate,3137.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1018.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,269,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1096.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1018.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2150.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2150.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,269,3137.36,
28450-PF TX TARSAL BONE FX XCP TALUS&CALCN W/O MANJ,4321756,CDM,981,RC,28450,HCPCS,Outpatient,,,364.74,182.37,,328.27,90,,,percent of total billed charges,90% of total Billed charges,382.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.67,155,,,Fee Schedule,155% of CMS OPPS Rate,182.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,275.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,275.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,324.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,203.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.67,155,,,Fee Schedule,155% of CMS OPPS Rate,182.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.63,155,,,Fee Schedule,155% of CMS OPPS Rate,593.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,114,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114,593.63,
28455-PF TX TARSAL BONE FX XCP TALUS&CALCN W/MANJ,4321755,CDM,981,RC,28455,HCPCS,Outpatient,,,502.54,251.27,,452.29,90,,,percent of total billed charges,90% of total Billed charges,528.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,251.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,389.47,155,,,Fee Schedule,155% of CMS OPPS Rate,251.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,412.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,376.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,376.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,251.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,444.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,277.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,389.47,155,,,Fee Schedule,155% of CMS OPPS Rate,251.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,819.81,155,,,Fee Schedule,155% of CMS OPPS Rate,819.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,251.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,127,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,251.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,588.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,588.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127,819.81,
28456-PF PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MANJ,4321754,CDM,981,RC,28456,HCPCS,Outpatient,,,701.72,350.86,,631.55,90,,,percent of total billed charges,90% of total Billed charges,703.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,239.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,543.83,155,,,Fee Schedule,155% of CMS OPPS Rate,350.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,350.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,542.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,485.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,485.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,258.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,701.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,573.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,364.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,543.83,155,,,Fee Schedule,155% of CMS OPPS Rate,350.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1089.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,350.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,326.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,350.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,646,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,646,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,239.78,1089.71,
28465-PF OPEN TX TARSAL FRACTURE XCP TALUS & CALCANEUS EA,4321753,CDM,981,RC,28465,HCPCS,Outpatient,,,1227.44,613.72,,1104.7,90,,,percent of total billed charges,90% of total Billed charges,1232.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,613.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,951.27,155,,,Fee Schedule,155% of CMS OPPS Rate,613.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,613.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1012.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1012.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,937.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,937.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,587.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1227.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1106.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,713.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.27,155,,,Fee Schedule,155% of CMS OPPS Rate,613.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1910.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1910.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,613.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,613.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1231.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1231.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.5,1910.82,
28470-PF CLOSED TX METATARSAL FRACTURE W/O MANIPULATION,4321752,CDM,981,RC,28470,HCPCS,Outpatient,,,389.82,194.91,,350.84,90,,,percent of total billed charges,90% of total Billed charges,401.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,481.21,90,,,Percent of total Billed charges,90% of total billed charges,84.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,302.1,155,,,Fee Schedule,155% of CMS OPPS Rate,194.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,293.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,293.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,346.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,217.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,302.1,155,,,Fee Schedule,155% of CMS OPPS Rate,194.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.45,155,,,Fee Schedule,155% of CMS OPPS Rate,622.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,84.5,622.45,
28475-PF CLTX METAR FX W/MANJ,4321751,CDM,981,RC,28475,HCPCS,Outpatient,,,439.2,219.60,,395.28,90,,,percent of total billed charges,90% of total Billed charges,464.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,340.36,155,,,Fee Schedule,155% of CMS OPPS Rate,219.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,333.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,333.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,227.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,393.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,248.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,340.36,155,,,Fee Schedule,155% of CMS OPPS Rate,219.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.26,155,,,Fee Schedule,155% of CMS OPPS Rate,719.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,219.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,334.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,219.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,510.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118,719.26,
28476-PF PRQ SKEL FIXJ METAR FX W/MAN,4321750,CDM,981,RC,28476,HCPCS,Outpatient,,,735.9,367.95,,662.31,90,,,percent of total billed charges,90% of total Billed charges,737.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,367.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,277,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,570.32,155,,,Fee Schedule,155% of CMS OPPS Rate,367.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,367.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,588.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,529.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,529.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,320.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,625.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,394.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,570.32,155,,,Fee Schedule,155% of CMS OPPS Rate,367.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1142.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,367.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,277,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,367.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,691.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,277,1142.91,
28485-PF OPEN TREATMENT METATARSAL FRACTURE EACH,4321749,CDM,981,RC,28485,HCPCS,Outpatient,,,1080.6,540.30,,972.54,90,,,percent of total billed charges,90% of total Billed charges,1082.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,540.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,153.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,837.47,155,,,Fee Schedule,155% of CMS OPPS Rate,540.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,540.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,814.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,814.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,503.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,540.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,960.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,607.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,837.47,155,,,Fee Schedule,155% of CMS OPPS Rate,540.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1677.92,155,,,Fee Schedule,155% of CMS OPPS Rate,1677.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,540.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,516.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,540.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1073.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1073.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.5,1677.92,
28490-PF CLTX FX GRT TOE PHLX/PHLG W/O MANJ,4321748,CDM,981,RC,28490,HCPCS,Outpatient,,,237.26,118.63,,213.53,90,,,percent of total billed charges,90% of total Billed charges,251.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,183.88,155,,,Fee Schedule,155% of CMS OPPS Rate,118.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.88,155,,,Fee Schedule,155% of CMS OPPS Rate,118.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.17,155,,,Fee Schedule,155% of CMS OPPS Rate,389.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,282.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55,389.17,
28495-PF CLTX FX GRT TOE PHLX/PHLG W/MANJ,4321747,CDM,981,RC,28495,HCPCS,Outpatient,,,283.46,141.73,,255.11,90,,,percent of total billed charges,90% of total Billed charges,309.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.67,155,,,Fee Schedule,155% of CMS OPPS Rate,141.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,156.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.67,155,,,Fee Schedule,155% of CMS OPPS Rate,141.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.48,155,,,Fee Schedule,155% of CMS OPPS Rate,480.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,161.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.5,480.48,
28496-PF PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MANJ,4321746,CDM,981,RC,28496,HCPCS,Outpatient,,,471.1,235.55,,423.99,90,,,percent of total billed charges,90% of total Billed charges,650.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,235.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.09,155,,,Fee Schedule,155% of CMS OPPS Rate,235.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,385.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,348.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,348.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,214.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,411.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,260.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,365.09,155,,,Fee Schedule,155% of CMS OPPS Rate,235.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1007.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1007.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,235.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,479.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,235.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,860.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,214.56,1007.97,
28505-PF OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES,4321745,CDM,981,RC,28505,HCPCS,Outpatient,,,958.58,479.29,,862.72,90,,,percent of total billed charges,90% of total Billed charges,1107.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,166.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,742.88,155,,,Fee Schedule,155% of CMS OPPS Rate,479.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,479.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,797.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,740.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,740.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,446.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,958.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,874.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,557.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,742.88,155,,,Fee Schedule,155% of CMS OPPS Rate,479.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1716.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1716.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,479.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,556.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,479.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1340.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1340.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,166.5,1716.44,
28510-PF CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ,4321744,CDM,981,RC,28510,HCPCS,Outpatient,,,227.7,113.85,,204.93,90,,,percent of total billed charges,90% of total Billed charges,226.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,200.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,122.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.39,155,,,Fee Schedule,155% of CMS OPPS Rate,351.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,242.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,105.83,351.39,
28515-PF CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ,4321743,CDM,981,RC,28515,HCPCS,Outpatient,,,272.72,136.36,,245.45,90,,,percent of total billed charges,90% of total Billed charges,290.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,211.34,155,,,Fee Schedule,155% of CMS OPPS Rate,136.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,211.34,155,,,Fee Schedule,155% of CMS OPPS Rate,136.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.72,155,,,Fee Schedule,155% of CMS OPPS Rate,449.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,136.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,316.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.5,449.72,
28525-PF OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE,4321742,CDM,981,RC,28525,HCPCS,Outpatient,,,779.36,389.68,,701.42,90,,,percent of total billed charges,90% of total Billed charges,926.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,389.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.99,155,,,Fee Schedule,155% of CMS OPPS Rate,389.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,389.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,646.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,596.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,596.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,362.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,389.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,779.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,443.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,603.99,155,,,Fee Schedule,155% of CMS OPPS Rate,389.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1435.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1435.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,389.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,509.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,389.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1139.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1139.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,362.25,1435.5,
28540-PF CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES,4321741,CDM,981,RC,28540,HCPCS,Outpatient,,,334.06,167.03,,300.65,90,,,percent of total billed charges,90% of total Billed charges,351.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,258.9,155,,,Fee Schedule,155% of CMS OPPS Rate,167.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,279.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,172.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,298.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,258.9,155,,,Fee Schedule,155% of CMS OPPS Rate,167.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.04,155,,,Fee Schedule,155% of CMS OPPS Rate,545.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,167.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,167.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,403.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,545.04,
28545-PF CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES,4321740,CDM,981,RC,28545,HCPCS,Outpatient,,,522.44,261.22,,470.2,90,,,percent of total billed charges,90% of total Billed charges,555.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,261.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,404.89,155,,,Fee Schedule,155% of CMS OPPS Rate,261.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,384.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,384.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,211.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,404.89,155,,,Fee Schedule,155% of CMS OPPS Rate,261.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.89,155,,,Fee Schedule,155% of CMS OPPS Rate,860.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,261.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,264.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,261.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,583.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,860.89,
28546-PF PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MANJ,4321739,CDM,981,RC,28546,HCPCS,Outpatient,,,672.6,336.30,,605.34,90,,,percent of total billed charges,90% of total Billed charges,883.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,336.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,521.27,155,,,Fee Schedule,155% of CMS OPPS Rate,336.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,336.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,548.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,548.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,497.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,497.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,284.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,586.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,378.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,521.27,155,,,Fee Schedule,155% of CMS OPPS Rate,336.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1369.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1369.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,336.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,565.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,336.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1128.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1128.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1369.01,
28570-PF CLOSED TX TALOTARSAL JOINT DISLC W/O ANES,4321738,CDM,981,RC,28570,HCPCS,Outpatient,,,377.22,188.61,,339.5,90,,,percent of total billed charges,90% of total Billed charges,409.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,292.33,155,,,Fee Schedule,155% of CMS OPPS Rate,188.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,277.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,277.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,292.33,155,,,Fee Schedule,155% of CMS OPPS Rate,188.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.73,155,,,Fee Schedule,155% of CMS OPPS Rate,634.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,188.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,188.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,321.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,634.73,
28575-PF CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES,4321737,CDM,981,RC,28575,HCPCS,Outpatient,,,657.08,328.54,,591.37,90,,,percent of total billed charges,90% of total Billed charges,690.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,328.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,509.22,155,,,Fee Schedule,155% of CMS OPPS Rate,328.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,328.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,533.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,485.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,485.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,287.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,572.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,372.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,509.22,155,,,Fee Schedule,155% of CMS OPPS Rate,328.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1070.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1070.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,328.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,314.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,328.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,722.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,722.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,1070.55,
28576-PF PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MANJ,4321736,CDM,981,RC,28576,HCPCS,Outpatient,,,751.8,375.90,,676.62,90,,,percent of total billed charges,90% of total Billed charges,749.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,375.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.63,155,,,Fee Schedule,155% of CMS OPPS Rate,375.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,375.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,620.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,571.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,571.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,336.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,751.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,674.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,446.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,582.63,155,,,Fee Schedule,155% of CMS OPPS Rate,375.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1162.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,375.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,587.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,375.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,791.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,336.93,1162.41,
28600-PF CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES,4321735,CDM,981,RC,28600,HCPCS,Outpatient,,,355.64,177.82,,320.08,90,,,percent of total billed charges,90% of total Billed charges,381.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.61,155,,,Fee Schedule,155% of CMS OPPS Rate,177.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,295.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,197.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.61,155,,,Fee Schedule,155% of CMS OPPS Rate,177.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.46,155,,,Fee Schedule,155% of CMS OPPS Rate,591.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,436.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.5,591.46,
28605-PF CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES,4321734,CDM,981,RC,28605,HCPCS,Outpatient,,,586.6,293.30,,527.94,90,,,percent of total billed charges,90% of total Billed charges,618.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,454.62,155,,,Fee Schedule,155% of CMS OPPS Rate,293.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,477.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,432,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,432,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,509.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,454.62,155,,,Fee Schedule,155% of CMS OPPS Rate,293.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,958.38,155,,,Fee Schedule,155% of CMS OPPS Rate,958.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,293.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,262.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,293.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,571.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,571.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,958.38,
28606-PF PRQ SKEL FIXJ TARS JT DISLC W/MANJ,4321733,CDM,981,RC,28606,HCPCS,Outpatient,,,748.42,374.21,,673.58,90,,,percent of total billed charges,90% of total Billed charges,744.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,374.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,281,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,580.01,155,,,Fee Schedule,155% of CMS OPPS Rate,374.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,374.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,623.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,576.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,576.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,373.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,680,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,444.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,580.01,155,,,Fee Schedule,155% of CMS OPPS Rate,374.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1154.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1154.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,374.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,281,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,759.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,374.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,790.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,281,1154.05,
28630-PF CLTX METATARSOPHLNGL JT DISLC W/O ANES,4321732,CDM,981,RC,28630,HCPCS,Outpatient,,,217.26,108.63,,195.53,90,,,percent of total billed charges,90% of total Billed charges,255.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,168.38,155,,,Fee Schedule,155% of CMS OPPS Rate,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.38,155,,,Fee Schedule,155% of CMS OPPS Rate,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.67,155,,,Fee Schedule,155% of CMS OPPS Rate,395.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,306.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.5,395.67,
28635-PF CLTX METATARSOPHLNGL JT DISLC REQ ANES,4321731,CDM,981,RC,28635,HCPCS,Outpatient,,,259.24,129.62,,233.32,90,,,percent of total billed charges,90% of total Billed charges,294.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.9,155,,,Fee Schedule,155% of CMS OPPS Rate,129.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,196.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,196.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,147.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.9,155,,,Fee Schedule,155% of CMS OPPS Rate,129.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.03,155,,,Fee Schedule,155% of CMS OPPS Rate,457.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,163.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,358.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83,457.03,
28636-PF PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MANJ,4321730,CDM,981,RC,28636,HCPCS,Outpatient,,,384.1,192.05,,345.69,90,,,percent of total billed charges,90% of total Billed charges,487.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,297.66,155,,,Fee Schedule,155% of CMS OPPS Rate,192.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,319.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,296.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,296.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,195.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,349.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,227.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,297.66,155,,,Fee Schedule,155% of CMS OPPS Rate,192.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,755.16,155,,,Fee Schedule,155% of CMS OPPS Rate,755.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,139,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,515.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139,755.16,
28660-PF CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES,4321729,CDM,981,RC,28660,HCPCS,Outpatient,,,181.4,90.70,,163.26,90,,,percent of total billed charges,90% of total Billed charges,208.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,140.57,155,,,Fee Schedule,155% of CMS OPPS Rate,90.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,140.57,155,,,Fee Schedule,155% of CMS OPPS Rate,90.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,322.49,155,,,Fee Schedule,155% of CMS OPPS Rate,322.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,90.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,90.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,322.49,
28665-PF CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES,4321728,CDM,981,RC,28665,HCPCS,Outpatient,,,240.46,120.23,,216.41,90,,,percent of total billed charges,90% of total Billed charges,264.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.36,155,,,Fee Schedule,155% of CMS OPPS Rate,120.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,142.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,186.36,155,,,Fee Schedule,155% of CMS OPPS Rate,120.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.8,155,,,Fee Schedule,155% of CMS OPPS Rate,409.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,120.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,120.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,312.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.23,409.8,
28666-PF PRQ SKEL FIXJ INTERPHALANGEAL JOINT DISLC W/MANJ,4321727,CDM,981,RC,28666,HCPCS,Outpatient,,,337.9,168.95,,304.11,90,,,percent of total billed charges,90% of total Billed charges,340.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.87,155,,,Fee Schedule,155% of CMS OPPS Rate,168.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,247.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,247.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,184.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,179.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,261.87,155,,,Fee Schedule,155% of CMS OPPS Rate,168.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.04,155,,,Fee Schedule,155% of CMS OPPS Rate,528.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,168.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,572.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,168.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,168.95,572.61,
28805- Amputate foot/transmetatarsal,3435231,CDM,510,RC,28805,HCPCS,Outpatient,,,1872.91,936.46,,1685.62,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1498.33,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1685.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1816.72,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1723.08,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1685.62,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.04,70,,,percent of total billed charges,70% of total billed charges,1685.62,90,,,percent of total billed charges,90% of total billed charges,1779.26,95,,,percent of total billed charges,95% of total billed charges,1779.26,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1610.7,86,,,percent of total billed charges,86% of total billed charges,1498.33,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1816.72,97,,,percent of total billed charges,97% of total billed charges,1685.62,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1816.72,97,,,percent of total billed charges,97% of total billed charges,1741.81,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1816.72,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1311.04,14511.58,
"28810 Amputation, metatarsal, with toe, single",3621667,CDM,510,RC,28810,HCPCS,Outpatient,,,1109.8,554.90,,998.82,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,887.84,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.82,90,,,Percent of total Billed charges,90% of total billed charges,252.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1076.51,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.02,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,998.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,776.86,70,,,percent of total billed charges,70% of total billed charges,998.82,90,,,percent of total billed charges,90% of total billed charges,1054.31,95,,,percent of total billed charges,95% of total billed charges,1054.31,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,954.43,86,,,percent of total billed charges,86% of total billed charges,887.84,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1076.51,97,,,percent of total billed charges,97% of total billed charges,998.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.51,97,,,percent of total billed charges,97% of total billed charges,1032.11,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1076.51,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,229.5,14511.58,
28820- Amputate toe/metatarsophalang jnt,3435232,CDM,510,RC,28820,HCPCS,Outpatient,,,763.34,381.67,,687.01,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,610.67,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,687.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,740.44,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,702.27,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,687.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,534.34,70,,,percent of total billed charges,70% of total billed charges,687.01,90,,,percent of total billed charges,90% of total billed charges,725.17,95,,,percent of total billed charges,95% of total billed charges,725.17,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,656.47,86,,,percent of total billed charges,86% of total billed charges,610.67,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,740.44,97,,,percent of total billed charges,97% of total billed charges,687.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,740.44,97,,,percent of total billed charges,97% of total billed charges,709.91,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,740.44,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,534.34,14511.58,
28825-PF AMPUTATION TOE INTERPHALANGEAL JOINT,4321726,CDM,981,RC,28825,HCPCS,Outpatient,,,340.66,170.33,,306.59,90,,,percent of total billed charges,90% of total Billed charges,451.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264,155,,,Fee Schedule,155% of CMS OPPS Rate,170.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,590.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,546.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,546.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,340.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,409.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,264,155,,,Fee Schedule,155% of CMS OPPS Rate,170.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.95,155,,,Fee Schedule,155% of CMS OPPS Rate,699.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,170.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1165.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1165.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,170.32,1165.52,
29046-PF APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS,4321725,CDM,981,RC,29046,HCPCS,Outpatient,,,362.76,181.38,,326.48,90,,,percent of total billed charges,90% of total Billed charges,471.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,281.12,155,,,Fee Schedule,155% of CMS OPPS Rate,181.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,181.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,299.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,277.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,277.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,179.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,281.12,155,,,Fee Schedule,155% of CMS OPPS Rate,181.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.62,155,,,Fee Schedule,155% of CMS OPPS Rate,730.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,181.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,181.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,504.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,504.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,730.62,
29049-PF APPLICATION CAST FIGURE-OF-8,4321724,CDM,981,RC,29049,HCPCS,Outpatient,,,134.04,67.02,,120.64,90,,,percent of total billed charges,90% of total Billed charges,160.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.88,155,,,Fee Schedule,155% of CMS OPPS Rate,67.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,103.88,155,,,Fee Schedule,155% of CMS OPPS Rate,67.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.05,155,,,Fee Schedule,155% of CMS OPPS Rate,248.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,195.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,248.05,
29065-PF APPLICATION CAST SHOULDER HAND LONG ARM,4321723,CDM,981,RC,29065,HCPCS,Outpatient,,,132.12,66.06,,118.91,90,,,percent of total billed charges,90% of total Billed charges,156.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.47,90,,,Percent of total Billed charges,90% of total billed charges,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,102.38,155,,,Fee Schedule,155% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,100.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,100.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,102.38,155,,,Fee Schedule,155% of CMS OPPS Rate,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.53,155,,,Fee Schedule,155% of CMS OPPS Rate,242.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,242.53,
29075-PF APPLICATION CAST ELBOW FINGER SHORT ARM,4321722,CDM,981,RC,29075,HCPCS,Outpatient,,,121.56,60.78,,109.4,90,,,percent of total billed charges,90% of total Billed charges,141.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.01,90,,,Percent of total Billed charges,90% of total billed charges,45.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.21,155,,,Fee Schedule,155% of CMS OPPS Rate,60.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,90.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,90.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,94.21,155,,,Fee Schedule,155% of CMS OPPS Rate,60.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.51,155,,,Fee Schedule,155% of CMS OPPS Rate,219.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,60.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.5,219.51,
29085-PF APPLICATION CAST HAND & LOWER FOREARM GAUNTLET,4321721,CDM,981,RC,29085,HCPCS,Outpatient,,,130.08,65.04,,117.07,90,,,percent of total billed charges,90% of total Billed charges,154.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,100.81,155,,,Fee Schedule,155% of CMS OPPS Rate,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.81,155,,,Fee Schedule,155% of CMS OPPS Rate,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.4,155,,,Fee Schedule,155% of CMS OPPS Rate,239.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,187,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,187,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,239.4,
29105-PF APPLICATION LONG ARM SPLINT SHOULDER HAND,4321720,CDM,981,RC,29105,HCPCS,Outpatient,,,85.7,42.85,,77.13,90,,,percent of total billed charges,90% of total Billed charges,119.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,66.42,155,,,Fee Schedule,155% of CMS OPPS Rate,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,66.42,155,,,Fee Schedule,155% of CMS OPPS Rate,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.05,155,,,Fee Schedule,155% of CMS OPPS Rate,185.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,170,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33.5,185.05,
29125-PF APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC,4321719,CDM,981,RC,29125,HCPCS,Outpatient,,,78.02,39.01,,70.22,90,,,percent of total billed charges,90% of total Billed charges,99.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.92,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.47,155,,,Fee Schedule,155% of CMS OPPS Rate,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,45.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.47,155,,,Fee Schedule,155% of CMS OPPS Rate,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.27,155,,,Fee Schedule,155% of CMS OPPS Rate,154.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,136.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,154.27,
29126-PF APPLICATION SHORT ARM SPLINT DYNAMIC,4321718,CDM,981,RC,29126,HCPCS,Outpatient,,,94.88,47.44,,85.39,90,,,percent of total billed charges,90% of total Billed charges,119.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.53,155,,,Fee Schedule,155% of CMS OPPS Rate,47.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,54.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.53,155,,,Fee Schedule,155% of CMS OPPS Rate,47.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.54,155,,,Fee Schedule,155% of CMS OPPS Rate,184.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,156.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,184.54,
29130-PF APPLICATION FINGER SPLINT STATIC,4321717,CDM,981,RC,29130,HCPCS,Outpatient,,,58.78,29.39,,52.9,90,,,percent of total billed charges,90% of total Billed charges,68.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.55,155,,,Fee Schedule,155% of CMS OPPS Rate,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,36.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,45.55,155,,,Fee Schedule,155% of CMS OPPS Rate,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,80.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.6,106.69,
29131-PF APPLICATION FINGER SPLINT DYNAMIC,4321716,CDM,981,RC,29131,HCPCS,Outpatient,,,68.58,34.29,,61.72,90,,,percent of total billed charges,90% of total Billed charges,84.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.15,155,,,Fee Schedule,155% of CMS OPPS Rate,34.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.15,155,,,Fee Schedule,155% of CMS OPPS Rate,34.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.31,155,,,Fee Schedule,155% of CMS OPPS Rate,130.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,102.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.71,130.31,
29240-PF STRAPPING SHOULDER,4321715,CDM,981,RC,29240,HCPCS,Outpatient,,,35.72,17.86,,32.15,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,28.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,28.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,27.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.97,155,,,Fee Schedule,155% of CMS OPPS Rate,71.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,111.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.86,111.52,
29260-PF STRAPPING ELBOW/WRIST,4321714,CDM,981,RC,29260,HCPCS,Outpatient,,,38.22,19.11,,34.4,90,,,percent of total billed charges,90% of total Billed charges,47.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.47,155,,,Fee Schedule,155% of CMS OPPS Rate,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,21.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,29.47,155,,,Fee Schedule,155% of CMS OPPS Rate,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.66,155,,,Fee Schedule,155% of CMS OPPS Rate,73.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,102,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.01,102,
29280-PF STRAPPING HAND/FINGER,4321713,CDM,981,RC,29280,HCPCS,Outpatient,,,41.28,20.64,,37.15,90,,,percent of total billed charges,90% of total Billed charges,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.36,155,,,Fee Schedule,155% of CMS OPPS Rate,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,31.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,31.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,24.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,30.36,155,,,Fee Schedule,155% of CMS OPPS Rate,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.09,155,,,Fee Schedule,155% of CMS OPPS Rate,74.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,99.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.59,99.28,
29345-PF APPLICATION LONG LEG CAST THIGH-TOE,4321712,CDM,981,RC,29345,HCPCS,Outpatient,,,193.82,96.91,,174.44,90,,,percent of total billed charges,90% of total Billed charges,224.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.21,155,,,Fee Schedule,155% of CMS OPPS Rate,96.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,97.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,150.21,155,,,Fee Schedule,155% of CMS OPPS Rate,96.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.5,155,,,Fee Schedule,155% of CMS OPPS Rate,348.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,109.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,269.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,96.91,348.5,
29355-PF APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE,4321711,CDM,981,RC,29355,HCPCS,Outpatient,,,207.26,103.63,,186.53,90,,,percent of total billed charges,90% of total Billed charges,238.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.63,155,,,Fee Schedule,155% of CMS OPPS Rate,103.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,160.63,155,,,Fee Schedule,155% of CMS OPPS Rate,103.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,369.01,155,,,Fee Schedule,155% of CMS OPPS Rate,369.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,281.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.5,369.01,
29358-PF APPLICATION LONG LEG CAST BRACE,4321710,CDM,981,RC,29358,HCPCS,Outpatient,,,200.48,100.24,,180.43,90,,,percent of total billed charges,90% of total Billed charges,249.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,155.37,155,,,Fee Schedule,155% of CMS OPPS Rate,100.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,123.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,155.37,155,,,Fee Schedule,155% of CMS OPPS Rate,100.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.93,155,,,Fee Schedule,155% of CMS OPPS Rate,386.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,100.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,100.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,316.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.5,386.93,
29365-PF APPLICATION CYLINDER CAST THIGH ANKLE,4321709,CDM,981,RC,29365,HCPCS,Outpatient,,,169.06,84.53,,152.15,90,,,percent of total billed charges,90% of total Billed charges,200.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.02,155,,,Fee Schedule,155% of CMS OPPS Rate,84.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.02,155,,,Fee Schedule,155% of CMS OPPS Rate,84.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.06,155,,,Fee Schedule,155% of CMS OPPS Rate,310.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,243.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60,310.06,
29405-PF APPLICATION SHORT LEG CAST BELOW KNEE-TOE,4321708,CDM,981,RC,29405,HCPCS,Outpatient,,,117.83,58.92,,106.05,90,,,percent of total billed charges,90% of total Billed charges,130.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.9,90,,,Percent of total Billed charges,90% of total billed charges,50.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.03,155,,,Fee Schedule,155% of CMS OPPS Rate,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,66.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.03,155,,,Fee Schedule,155% of CMS OPPS Rate,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.54,155,,,Fee Schedule,155% of CMS OPPS Rate,202.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,175.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.5,202.54,
29435-PF APPLICATION PATELLAR TENDON BEARING CAST,4321707,CDM,981,RC,29435,HCPCS,Outpatient,,,157.16,78.58,,141.44,90,,,percent of total billed charges,90% of total Billed charges,184.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.8,155,,,Fee Schedule,155% of CMS OPPS Rate,78.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,83.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.8,155,,,Fee Schedule,155% of CMS OPPS Rate,78.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.84,155,,,Fee Schedule,155% of CMS OPPS Rate,285.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,78.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.02,285.84,
29440-PF ADDING WALKER PREVIOUSLY APPLIED CAST,4321706,CDM,981,RC,29440,HCPCS,Outpatient,,,54.3,27.15,,48.87,90,,,percent of total billed charges,90% of total Billed charges,67.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.08,155,,,Fee Schedule,155% of CMS OPPS Rate,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,42.08,155,,,Fee Schedule,155% of CMS OPPS Rate,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.39,155,,,Fee Schedule,155% of CMS OPPS Rate,104.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,89.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18,104.39,
29445-PF APPLICATION RIGID TOTAL CONTACT LEG CAST,4321705,CDM,981,RC,29445,HCPCS,Outpatient,,,200.11,100.06,,180.1,90,,,percent of total billed charges,90% of total Billed charges,218.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.58,155,,,Fee Schedule,155% of CMS OPPS Rate,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,118.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.58,155,,,Fee Schedule,155% of CMS OPPS Rate,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.28,155,,,Fee Schedule,155% of CMS OPPS Rate,339.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,278.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,95.86,339.28,
29450-PF APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG,4321704,CDM,981,RC,29450,HCPCS,Outpatient,,,221.88,110.94,,199.69,90,,,percent of total billed charges,90% of total Billed charges,251.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.94,155,,,Fee Schedule,155% of CMS OPPS Rate,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,181.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,171.94,155,,,Fee Schedule,155% of CMS OPPS Rate,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.31,155,,,Fee Schedule,155% of CMS OPPS Rate,389.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,142.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,110.93,389.31,
29505-PF APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES,4321703,CDM,981,RC,29505,HCPCS,Outpatient,,,100.2,50.10,,90.18,90,,,percent of total billed charges,90% of total Billed charges,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.64,155,,,Fee Schedule,155% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,74.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.64,155,,,Fee Schedule,155% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.24,155,,,Fee Schedule,155% of CMS OPPS Rate,202.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37,202.24,
29515-PF APPLICATION SHORT LEG SPLINT CALF FOOT,4321702,CDM,981,RC,29515,HCPCS,Outpatient,,,95.64,47.82,,86.08,90,,,percent of total billed charges,90% of total Billed charges,114.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.89,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.11,155,,,Fee Schedule,155% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.11,155,,,Fee Schedule,155% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.4,155,,,Fee Schedule,155% of CMS OPPS Rate,177.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,144.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,177.4,
29530-PF STRAPPING KNEE,4321701,CDM,981,RC,29530,HCPCS,Outpatient,,,35.72,17.86,,32.15,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,28.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,28.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,27.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.97,155,,,Fee Schedule,155% of CMS OPPS Rate,71.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.86,103.36,
29540-PF STRAPPING ANKLE &/FOOT,4321700,CDM,981,RC,29540,HCPCS,Outpatient,,,35.23,17.62,,31.71,90,,,percent of total billed charges,90% of total Billed charges,44.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.2,155,,,Fee Schedule,155% of CMS OPPS Rate,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,27.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,27.2,155,,,Fee Schedule,155% of CMS OPPS Rate,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.63,155,,,Fee Schedule,155% of CMS OPPS Rate,68.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,65.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.55,68.63,
29550-PF STRAPPING TOES,4321699,CDM,981,RC,29550,HCPCS,Outpatient,,,22.16,11.08,,19.94,90,,,percent of total billed charges,90% of total Billed charges,29.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.16,155,,,Fee Schedule,155% of CMS OPPS Rate,11.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,17.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,17.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,12.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,17.16,155,,,Fee Schedule,155% of CMS OPPS Rate,11.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.2,155,,,Fee Schedule,155% of CMS OPPS Rate,45.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,11.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,39.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.07,53.04,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,48.81,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,43.38,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,52.6,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,49.89,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,48.81,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,37.96,70,,,percent of total billed charges,70% of total billed charges,48.81,90,,,percent of total billed charges,90% of total billed charges,51.52,95,,,percent of total billed charges,95% of total billed charges,51.52,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,46.64,86,,,percent of total billed charges,86% of total billed charges,43.38,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,52.6,97,,,percent of total billed charges,97% of total billed charges,48.81,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.6,97,,,percent of total billed charges,97% of total billed charges,50.43,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.6,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.96,710.59,
29580-PF STRAPPING UNNA BOOT,4321373,CDM,981,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,48.81,90,,,percent of total billed charges,90% of total Billed charges,80.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.82,155,,,Fee Schedule,155% of CMS OPPS Rate,124.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.3,124.82,
29700-PF REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST,4321698,CDM,981,RC,29700,HCPCS,Outpatient,,,65.28,32.64,,58.75,90,,,percent of total billed charges,90% of total Billed charges,90.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.59,155,,,Fee Schedule,155% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.59,155,,,Fee Schedule,155% of CMS OPPS Rate,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.06,155,,,Fee Schedule,155% of CMS OPPS Rate,140.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,130.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.64,140.06,
29705-PF REMOVAL/BIVALVING FULL ARM/FULL LEG CAST,4321697,CDM,981,RC,29705,HCPCS,Outpatient,,,88.04,44.02,,79.24,90,,,percent of total billed charges,90% of total Billed charges,103.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.22,155,,,Fee Schedule,155% of CMS OPPS Rate,44.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.22,155,,,Fee Schedule,155% of CMS OPPS Rate,44.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.14,155,,,Fee Schedule,155% of CMS OPPS Rate,161.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,132.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.01,161.14,
29710-PF RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET,4321696,CDM,981,RC,29710,HCPCS,Outpatient,,,162.94,81.47,,146.65,90,,,percent of total billed charges,90% of total Billed charges,197.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.28,155,,,Fee Schedule,155% of CMS OPPS Rate,81.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,126.28,155,,,Fee Schedule,155% of CMS OPPS Rate,81.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.71,155,,,Fee Schedule,155% of CMS OPPS Rate,305.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,246.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.83,305.71,
29730-PF WINDOWING CAST,4321374,CDM,981,RC,29730,HCPCS,Outpatient,,,87.36,43.68,,78.62,90,,,percent of total billed charges,90% of total Billed charges,104.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.69,155,,,Fee Schedule,155% of CMS OPPS Rate,43.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,51.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.69,155,,,Fee Schedule,155% of CMS OPPS Rate,43.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.65,155,,,Fee Schedule,155% of CMS OPPS Rate,161.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,43.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,128.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.67,161.65,
30000-PF DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH,4321694,CDM,981,RC,30000,HCPCS,Outpatient,,,232.84,116.42,,209.56,90,,,percent of total billed charges,90% of total Billed charges,349.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,180.45,155,,,Fee Schedule,155% of CMS OPPS Rate,116.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,180.45,155,,,Fee Schedule,155% of CMS OPPS Rate,116.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,541.35,155,,,Fee Schedule,155% of CMS OPPS Rate,541.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,464.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51,541.35,
30020-PF DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM,4321693,CDM,981,RC,30020,HCPCS,Outpatient,,,234.58,117.29,,211.12,90,,,percent of total billed charges,90% of total Billed charges,351.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,181.8,155,,,Fee Schedule,155% of CMS OPPS Rate,117.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,173.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,173.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,181.8,155,,,Fee Schedule,155% of CMS OPPS Rate,117.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.4,155,,,Fee Schedule,155% of CMS OPPS Rate,545.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,117.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,117.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,470.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,470.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,545.4,
30300-PF REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE,4321692,CDM,981,RC,30300,HCPCS,Outpatient,,,233.6,116.80,,210.24,90,,,percent of total billed charges,90% of total Billed charges,312.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,181.02,155,,,Fee Schedule,155% of CMS OPPS Rate,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,161.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,161.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,181.02,155,,,Fee Schedule,155% of CMS OPPS Rate,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.66,155,,,Fee Schedule,155% of CMS OPPS Rate,483.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,458.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,483.66,
30310-PF REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES,4321691,CDM,981,RC,30310,HCPCS,Outpatient,,,393.7,196.85,,354.33,90,,,percent of total billed charges,90% of total Billed charges,396.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.12,155,,,Fee Schedule,155% of CMS OPPS Rate,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,302.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,290.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,290.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,163.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,213.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.12,155,,,Fee Schedule,155% of CMS OPPS Rate,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,614.09,155,,,Fee Schedule,155% of CMS OPPS Rate,614.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,614.09,
30801-PF ABLTJ SOFT TIS INFERIOR TURBINATES UNI/BI SUPFC,4321690,CDM,981,RC,30801,HCPCS,Outpatient,,,284.78,142.39,,256.3,90,,,percent of total billed charges,90% of total Billed charges,346.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,220.69,155,,,Fee Schedule,155% of CMS OPPS Rate,142.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,145.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,220.69,155,,,Fee Schedule,155% of CMS OPPS Rate,142.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.6,155,,,Fee Schedule,155% of CMS OPPS Rate,537.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,142.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,142.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38,537.6,
30802-PF ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL,4321689,CDM,981,RC,30802,HCPCS,Outpatient,,,385.6,192.80,,347.04,90,,,percent of total billed charges,90% of total Billed charges,455.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.82,155,,,Fee Schedule,155% of CMS OPPS Rate,192.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,290.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,280.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,280.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,298.82,155,,,Fee Schedule,155% of CMS OPPS Rate,192.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.09,155,,,Fee Schedule,155% of CMS OPPS Rate,706.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,588.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,588.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38,706.09,
30901-PF CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE,4321688,CDM,981,RC,30901,HCPCS,Outpatient,,,114.16,57.08,,102.74,90,,,percent of total billed charges,90% of total Billed charges,171.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.47,155,,,Fee Schedule,155% of CMS OPPS Rate,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.47,155,,,Fee Schedule,155% of CMS OPPS Rate,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.42,155,,,Fee Schedule,155% of CMS OPPS Rate,265.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,190.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27,265.42,
30903-PF CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX,4321687,CDM,981,RC,30903,HCPCS,Outpatient,,,156.4,78.20,,140.76,90,,,percent of total billed charges,90% of total Billed charges,234.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.21,155,,,Fee Schedule,155% of CMS OPPS Rate,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.21,155,,,Fee Schedule,155% of CMS OPPS Rate,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.63,155,,,Fee Schedule,155% of CMS OPPS Rate,363.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,253.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,406.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.5,406.64,
30905-PF CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST,4321686,CDM,981,RC,30905,HCPCS,Outpatient,,,212.5,106.25,,191.25,90,,,percent of total billed charges,90% of total Billed charges,318.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,164.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.06,155,,,Fee Schedule,155% of CMS OPPS Rate,494.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,298.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,503.2,
30906-PF CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ,4321685,CDM,981,RC,30906,HCPCS,Outpatient,,,265.1,132.55,,238.59,90,,,percent of total billed charges,90% of total Billed charges,397.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,205.44,155,,,Fee Schedule,155% of CMS OPPS Rate,132.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,246.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,165.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,205.44,155,,,Fee Schedule,155% of CMS OPPS Rate,132.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.34,155,,,Fee Schedule,155% of CMS OPPS Rate,616.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,132.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,264.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,132.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,566.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,566.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,616.34,
Endoscopy,3428425,CDM,490,RC,31231,HCPCS,Outpatient,,,131.25,65.63,,118.13,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,105,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.13,90,,,Percent of total Billed charges,90% of total billed charges,64.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,127.31,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,120.75,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,118.13,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,91.88,70,,,percent of total billed charges,70% of total billed charges,118.13,90,,,percent of total billed charges,90% of total billed charges,124.69,95,,,percent of total billed charges,95% of total billed charges,124.69,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.88,86,,,percent of total billed charges,86% of total billed charges,105,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,127.31,97,,,percent of total billed charges,97% of total billed charges,118.13,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.31,97,,,percent of total billed charges,97% of total billed charges,122.06,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.31,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.86,871.42,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,1115.29,557.65,,1003.76,90,,,percent of total billed charges,90% of total Billed charges,658.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,197,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,435.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1020.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,574.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197,1020.6,
31255 - NASAL/SINUS NDSC W/TOTAL ETHOIDECTOMY,4037483,CDM,983,RC,31255,HCPCS,Outpatient,,,853.62,426.81,,768.26,90,,,percent of total billed charges,90% of total Billed charges,639.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.31,155,,,Fee Schedule,155% of CMS OPPS Rate,318.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,470.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,493.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,493.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,316.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,637.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,581.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,385.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,494.31,155,,,Fee Schedule,155% of CMS OPPS Rate,318.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.83,155,,,Fee Schedule,155% of CMS OPPS Rate,991.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,318.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,702.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,318.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,842.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,842.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,316.8,991.83,
"31256 - Nasal/sinus endoscopy, surgical, with maxillary antrostomy",4037484,CDM,983,RC,31256,HCPCS,Outpatient,,,469.91,234.96,,422.92,90,,,percent of total billed charges,90% of total Billed charges,353.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.37,155,,,Fee Schedule,155% of CMS OPPS Rate,177.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,273,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,273,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,274.37,155,,,Fee Schedule,155% of CMS OPPS Rate,177.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.25,155,,,Fee Schedule,155% of CMS OPPS Rate,548.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,262.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,415.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,156.81,548.25,
31500-PF INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE,4321683,CDM,981,RC,31500,HCPCS,Outpatient,,,283.34,141.67,,255.01,90,,,percent of total billed charges,90% of total Billed charges,284.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.06,90,,,Percent of total Billed charges,90% of total billed charges,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.59,155,,,Fee Schedule,155% of CMS OPPS Rate,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,224.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,224.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.59,155,,,Fee Schedule,155% of CMS OPPS Rate,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.08,155,,,Fee Schedule,155% of CMS OPPS Rate,441.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72,441.08,
TRACH TUBE INSERT,3428532,CDM,981,RC,31500,HCPCS,Outpatient,,,380.04,190.02,,342.04,90,,,percent of total billed charges,90% of total Billed charges,284.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.06,90,,,Percent of total Billed charges,90% of total billed charges,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.59,155,,,Fee Schedule,155% of CMS OPPS Rate,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,224.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,224.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.59,155,,,Fee Schedule,155% of CMS OPPS Rate,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.08,155,,,Fee Schedule,155% of CMS OPPS Rate,441.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72,441.08,
31502-PF TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT,4321375,CDM,981,RC,31502,HCPCS,Outpatient,,,69.54,34.77,,62.59,90,,,percent of total billed charges,90% of total Billed charges,69.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.88,155,,,Fee Schedule,155% of CMS OPPS Rate,34.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.88,155,,,Fee Schedule,155% of CMS OPPS Rate,34.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.86,155,,,Fee Schedule,155% of CMS OPPS Rate,107.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,133.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,72.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.85,133.6,
31505 Diagnostic Laryncoscopy,3584869,CDM,960,RC,31505,HCPCS,Outpatient,,,226.36,113.18,,203.72,90,,,percent of total billed charges,90% of total Billed charges,131.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.59,155,,,Fee Schedule,155% of CMS OPPS Rate,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,72.59,155,,,Fee Schedule,155% of CMS OPPS Rate,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.51,155,,,Fee Schedule,155% of CMS OPPS Rate,204.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.32,204.51,
31505-PF LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX,4321682,CDM,981,RC,31505,HCPCS,Outpatient,,,93.66,46.83,,84.29,90,,,percent of total billed charges,90% of total Billed charges,131.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.59,155,,,Fee Schedule,155% of CMS OPPS Rate,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,72.59,155,,,Fee Schedule,155% of CMS OPPS Rate,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.51,155,,,Fee Schedule,155% of CMS OPPS Rate,204.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.32,204.51,
31511-PF LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BOD,4321681,CDM,981,RC,31511,HCPCS,Outpatient,,,261.32,130.66,,235.19,90,,,percent of total billed charges,90% of total Billed charges,333.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202.51,155,,,Fee Schedule,155% of CMS OPPS Rate,130.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,235.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,155.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202.51,155,,,Fee Schedule,155% of CMS OPPS Rate,130.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,516.75,155,,,Fee Schedule,155% of CMS OPPS Rate,516.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,193.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,428.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,428.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,103.36,516.75,
31515 - Laryngoscopy for Aspiration,4189305,CDM,960,RC,31515,HCPCS,Outpatient,,,479.89,239.95,,431.9,90,,,percent of total billed charges,90% of total Billed charges,310.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.14,90,,,Percent of total Billed charges,90% of total billed charges,70,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,168.53,155,,,Fee Schedule,155% of CMS OPPS Rate,108.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,158.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.53,155,,,Fee Schedule,155% of CMS OPPS Rate,108.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,481.8,155,,,Fee Schedule,155% of CMS OPPS Rate,481.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,420.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70,481.8,
31525- Laryngoscopy/diag/except newborn,3435866,CDM,510,RC,31525,HCPCS,Outpatient,,,636.4,318.20,,572.76,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,509.12,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,572.76,90,,,Percent of total Billed charges,90% of total billed charges,129.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,617.31,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,585.49,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,572.76,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,445.48,70,,,percent of total billed charges,70% of total billed charges,572.76,90,,,percent of total billed charges,90% of total billed charges,604.58,95,,,percent of total billed charges,95% of total billed charges,604.58,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,547.3,86,,,percent of total billed charges,86% of total billed charges,509.12,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,617.31,97,,,percent of total billed charges,97% of total billed charges,572.76,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,617.31,97,,,percent of total billed charges,97% of total billed charges,591.85,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,617.31,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118,7793.18,
31526- Laryngoscopy/diag/micro/telescope,3435867,CDM,510,RC,31526,HCPCS,Outpatient,,,407.59,203.80,,366.83,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,326.07,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.83,90,,,Percent of total Billed charges,90% of total billed charges,129.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,395.36,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,374.98,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,366.83,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,285.31,70,,,percent of total billed charges,70% of total billed charges,366.83,90,,,percent of total billed charges,90% of total billed charges,387.21,95,,,percent of total billed charges,95% of total billed charges,387.21,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,350.53,86,,,percent of total billed charges,86% of total billed charges,326.07,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,395.36,97,,,percent of total billed charges,97% of total billed charges,366.83,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.36,97,,,percent of total billed charges,97% of total billed charges,379.06,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,395.36,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118,7793.18,
31535- Laryngoscopy/operative/w biopsy,3435868,CDM,510,RC,31535,HCPCS,Outpatient,,,490.94,245.47,,441.85,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,392.75,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,476.21,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,451.66,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,441.85,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,343.66,70,,,percent of total billed charges,70% of total billed charges,441.85,90,,,percent of total billed charges,90% of total billed charges,466.39,95,,,percent of total billed charges,95% of total billed charges,466.39,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,422.21,86,,,percent of total billed charges,86% of total billed charges,392.75,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,476.21,97,,,percent of total billed charges,97% of total billed charges,441.85,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,476.21,97,,,percent of total billed charges,97% of total billed charges,456.57,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,476.21,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,343.66,16251.96,
31536- Laryngoscopy/w bx/micro/telescope,3435869,CDM,510,RC,31536,HCPCS,Outpatient,,,548.75,274.38,,493.88,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,439,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.88,90,,,Percent of total Billed charges,90% of total billed charges,215.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,532.29,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,504.85,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,493.88,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,384.13,70,,,percent of total billed charges,70% of total billed charges,493.88,90,,,percent of total billed charges,90% of total billed charges,521.31,95,,,percent of total billed charges,95% of total billed charges,521.31,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,471.93,86,,,percent of total billed charges,86% of total billed charges,439,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,532.29,97,,,percent of total billed charges,97% of total billed charges,493.88,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.29,97,,,percent of total billed charges,97% of total billed charges,510.34,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,532.29,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,196.06,16251.96,
31541- Laryngoscopy/exc tum/micro/telesco,3435870,CDM,510,RC,31541,HCPCS,Outpatient,,,687.09,343.55,,618.38,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,549.67,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.38,90,,,Percent of total Billed charges,90% of total billed charges,270.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,666.48,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,632.12,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,618.38,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,480.96,70,,,percent of total billed charges,70% of total billed charges,618.38,90,,,percent of total billed charges,90% of total billed charges,652.74,95,,,percent of total billed charges,95% of total billed charges,652.74,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,590.9,86,,,percent of total billed charges,86% of total billed charges,549.67,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,666.48,97,,,percent of total billed charges,97% of total billed charges,618.38,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.48,97,,,percent of total billed charges,97% of total billed charges,638.99,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.48,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246.26,16251.96,
31570- Laryngoscopy/direct w/injection,3435871,CDM,510,RC,31570,HCPCS,Outpatient,,,875.43,437.72,,787.89,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,700.34,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.89,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,849.17,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,805.4,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,787.89,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,612.8,70,,,percent of total billed charges,70% of total billed charges,787.89,90,,,percent of total billed charges,90% of total billed charges,831.66,95,,,percent of total billed charges,95% of total billed charges,831.66,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,752.87,86,,,percent of total billed charges,86% of total billed charges,700.34,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,849.17,97,,,percent of total billed charges,97% of total billed charges,787.89,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.17,97,,,percent of total billed charges,97% of total billed charges,814.15,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,849.17,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,16251.96,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,761,RC,31575,HCPCS,Outpatient,,,318.11,159.06,,286.3,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,254.49,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.3,90,,,Percent of total Billed charges,90% of total billed charges,75.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,308.57,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,292.66,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,286.3,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,222.68,70,,,percent of total billed charges,70% of total billed charges,286.3,90,,,percent of total billed charges,90% of total billed charges,302.2,95,,,percent of total billed charges,95% of total billed charges,302.2,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,273.57,86,,,percent of total billed charges,86% of total billed charges,254.49,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,308.57,97,,,percent of total billed charges,97% of total billed charges,286.3,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.57,97,,,percent of total billed charges,97% of total billed charges,295.84,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,308.57,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69,871.42,
"31575 Laryngoscopy, flexible; diagnostic",3584895,CDM,510,RC,31575,HCPCS,Outpatient,,,320.05,160.03,,288.05,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,256.04,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.05,90,,,Percent of total Billed charges,90% of total billed charges,75.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,310.45,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,294.45,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,288.05,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.04,70,,,percent of total billed charges,70% of total billed charges,288.05,90,,,percent of total billed charges,90% of total billed charges,304.05,95,,,percent of total billed charges,95% of total billed charges,304.05,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,275.24,86,,,percent of total billed charges,86% of total billed charges,256.04,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,310.45,97,,,percent of total billed charges,97% of total billed charges,288.05,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.45,97,,,percent of total billed charges,97% of total billed charges,297.65,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.45,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69,871.42,
31575-PF LARYNGOSCOPY FLEXIBLE DIAGNOSTIC,4321680,CDM,981,RC,31575,HCPCS,Outpatient,,,131.1,65.55,,117.99,90,,,percent of total billed charges,90% of total Billed charges,185.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.44,90,,,Percent of total Billed charges,90% of total billed charges,69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.59,155,,,Fee Schedule,155% of CMS OPPS Rate,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.59,155,,,Fee Schedule,155% of CMS OPPS Rate,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.11,155,,,Fee Schedule,155% of CMS OPPS Rate,288.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,128.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.85,288.11,
31577-PF LARYNGOSCOPY FLX RMVL FOREIGN BODY(S,4321679,CDM,981,RC,31577,HCPCS,Outpatient,,,262.7,131.35,,236.43,90,,,percent of total billed charges,90% of total Billed charges,390.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.58,155,,,Fee Schedule,155% of CMS OPPS Rate,131.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,156.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.58,155,,,Fee Schedule,155% of CMS OPPS Rate,131.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.14,155,,,Fee Schedule,155% of CMS OPPS Rate,605.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,258.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,496.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,496.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.02,605.14,
31599-PF UNLISTED PROCEDURE LARYNX,4321376,CDM,981,RC,31599,HCPCS,Outpatient,,,587,293.50,,528.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,528.3,
"31600 - (PF) Tracheostomy, planned (separate procedure);",3634897,CDM,510,RC,31600,HCPCS,Outpatient,,,817.75,408.88,,735.98,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,654.2,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,735.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,793.22,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,752.33,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,735.98,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,572.43,70,,,percent of total billed charges,70% of total billed charges,735.98,90,,,percent of total billed charges,90% of total billed charges,776.86,95,,,percent of total billed charges,95% of total billed charges,776.86,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,703.27,86,,,percent of total billed charges,86% of total billed charges,654.2,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,793.22,97,,,percent of total billed charges,97% of total billed charges,735.98,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,793.22,97,,,percent of total billed charges,97% of total billed charges,760.51,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,793.22,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,572.43,13869.87,
"31600-PF Tracheostomy, planned sep px",4322033,CDM,960,RC,31600,HCPCS,Outpatient,,,595.58,297.79,,536.02,90,,,percent of total billed charges,90% of total Billed charges,612.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,472.73,155,,,Fee Schedule,155% of CMS OPPS Rate,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,448.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,476.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,476.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,318,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,562.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,391.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,472.73,155,,,Fee Schedule,155% of CMS OPPS Rate,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,949.34,155,,,Fee Schedule,155% of CMS OPPS Rate,949.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,248,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,436.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,821.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,821.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,248,949.34,
31603- Tracheostomy/emergent/transtrach,3435872,CDM,510,RC,31603,HCPCS,Outpatient,,,859.5,429.75,,773.55,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,687.6,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,773.55,90,,,Percent of total Billed charges,90% of total billed charges,225.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,833.72,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,790.74,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,773.55,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,601.65,70,,,percent of total billed charges,70% of total billed charges,773.55,90,,,percent of total billed charges,90% of total billed charges,816.53,95,,,percent of total billed charges,95% of total billed charges,816.53,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,739.17,86,,,percent of total billed charges,86% of total billed charges,687.6,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,833.72,97,,,percent of total billed charges,97% of total billed charges,773.55,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,833.72,97,,,percent of total billed charges,97% of total billed charges,799.34,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,833.72,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,205.21,6767.35,
31603-PF TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL,4321377,CDM,981,RC,31603,HCPCS,Outpatient,,,641.5,320.75,,577.35,90,,,percent of total billed charges,90% of total Billed charges,643.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,205.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,497.15,155,,,Fee Schedule,155% of CMS OPPS Rate,320.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,417.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,320.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,469.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,499.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,499.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,178.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,641.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,589.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,405.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,497.15,155,,,Fee Schedule,155% of CMS OPPS Rate,320.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.09,155,,,Fee Schedule,155% of CMS OPPS Rate,998.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,320.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,319.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,320.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,465.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,465.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,178.31,998.09,
31605-PF TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE,4321678,CDM,981,RC,31605,HCPCS,Outpatient,,,670.54,335.27,,603.49,90,,,percent of total billed charges,90% of total Billed charges,673.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,168.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,519.65,155,,,Fee Schedule,155% of CMS OPPS Rate,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,335.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,489.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,526.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,526.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,620.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,519.65,155,,,Fee Schedule,155% of CMS OPPS Rate,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1044.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,147.22,1044.42,
31622-PF BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX,4321379,CDM,981,RC,31622,HCPCS,Outpatient,,,256.38,128.19,,230.74,90,,,percent of total billed charges,90% of total Billed charges,363.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.1,90,,,Percent of total Billed charges,90% of total billed charges,133.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.09,155,,,Fee Schedule,155% of CMS OPPS Rate,564.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.59,607.92,
31622-PF Dx Bronch Incl Fluor Gdnc/Wash,4322037,CDM,960,RC,31622,HCPCS,Outpatient,,,252.58,126.29,,227.32,90,,,percent of total billed charges,90% of total Billed charges,363.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.1,90,,,Percent of total Billed charges,90% of total billed charges,133.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.09,155,,,Fee Schedule,155% of CMS OPPS Rate,564.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.59,607.92,
Bronchoscopy ED,3428396,CDM,981,RC,31622,HCPCS,Outpatient,,,626.94,313.47,,564.25,90,,,percent of total billed charges,90% of total Billed charges,363.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.1,90,,,Percent of total Billed charges,90% of total billed charges,133.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,201.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198.69,155,,,Fee Schedule,155% of CMS OPPS Rate,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.09,155,,,Fee Schedule,155% of CMS OPPS Rate,564.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.59,607.92,
31623-DX BRONCHOSCOPE/BRUSH,3430809,CDM,510,RC,31623,HCPCS,Outpatient,,,699,349.50,,629.1,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,559.2,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,629.1,90,,,Percent of total Billed charges,90% of total billed charges,148.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,678.03,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,643.08,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,629.1,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,489.3,70,,,percent of total billed charges,70% of total billed charges,629.1,90,,,percent of total billed charges,90% of total billed charges,664.05,95,,,percent of total billed charges,95% of total billed charges,664.05,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,601.14,86,,,percent of total billed charges,86% of total billed charges,559.2,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,678.03,97,,,percent of total billed charges,97% of total billed charges,629.1,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,678.03,97,,,percent of total billed charges,97% of total billed charges,650.07,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,678.03,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.15,7793.18,
31623-PF Dx Bronch Incl Fluor Gdnc/Brush,4322038,CDM,960,RC,31623,HCPCS,Outpatient,,,249.32,124.66,,224.39,90,,,percent of total billed charges,90% of total Billed charges,376.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,135.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,197.49,155,,,Fee Schedule,155% of CMS OPPS Rate,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,197.49,155,,,Fee Schedule,155% of CMS OPPS Rate,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.93,155,,,Fee Schedule,155% of CMS OPPS Rate,583.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,639.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,639.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,108.45,639.2,
31624-DX BRONCHOSCOPY/LAVAGE,3430810,CDM,510,RC,31624,HCPCS,Outpatient,,,648,324.00,,583.2,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,518.4,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.2,90,,,Percent of total Billed charges,90% of total billed charges,148.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,628.56,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,596.16,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,583.2,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,453.6,70,,,percent of total billed charges,70% of total billed charges,583.2,90,,,percent of total billed charges,90% of total billed charges,615.6,95,,,percent of total billed charges,95% of total billed charges,615.6,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,557.28,86,,,percent of total billed charges,86% of total billed charges,518.4,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,628.56,97,,,percent of total billed charges,97% of total billed charges,583.2,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,628.56,97,,,percent of total billed charges,97% of total billed charges,602.64,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,628.56,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.15,7793.18,
31624-PF Dx Bronch Incl Fluor Gdnc/Lavage,4322039,CDM,960,RC,31624,HCPCS,Outpatient,,,252.46,126.23,,227.21,90,,,percent of total billed charges,90% of total Billed charges,373.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,135.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,201.28,155,,,Fee Schedule,155% of CMS OPPS Rate,129.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,195.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,204.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,204.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,152.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,201.28,155,,,Fee Schedule,155% of CMS OPPS Rate,129.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,578.96,155,,,Fee Schedule,155% of CMS OPPS Rate,578.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,412.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,603.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,108.47,603.16,
31625-BRONCHOSCOPY W BIOPSY,3430811,CDM,510,RC,31625,HCPCS,Outpatient,,,890.34,445.17,,801.31,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,712.27,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,801.31,90,,,Percent of total Billed charges,90% of total billed charges,173.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,863.63,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,819.11,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,801.31,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,623.24,70,,,percent of total billed charges,70% of total billed charges,801.31,90,,,percent of total billed charges,90% of total billed charges,845.82,95,,,percent of total billed charges,95% of total billed charges,845.82,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,765.69,86,,,percent of total billed charges,86% of total billed charges,712.27,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,863.63,97,,,percent of total billed charges,97% of total billed charges,801.31,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.63,97,,,percent of total billed charges,97% of total billed charges,828.02,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,863.63,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157.81,7793.18,
31625-PF Bronch w/Bx,4322040,CDM,960,RC,31625,HCPCS,Outpatient,,,295.9,147.95,,266.31,90,,,percent of total billed charges,90% of total Billed charges,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.41,90,,,Percent of total Billed charges,90% of total billed charges,157.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,234.13,155,,,Fee Schedule,155% of CMS OPPS Rate,151.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,238.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,238.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,281.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,177.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,234.13,155,,,Fee Schedule,155% of CMS OPPS Rate,151.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.77,155,,,Fee Schedule,155% of CMS OPPS Rate,692.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,151.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,421.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,151.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,650.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,126.62,723.41,
"31626 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with pl",3712915,CDM,510,RC,31626,HCPCS,Outpatient,,,1999.57,999.79,,1799.61,90,,,percent of total billed charges,90% of total Billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1599.66,80,,,Percent of total Billed charges,80% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1799.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1939.58,97,,,Percent of total billed charges,97% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1839.6,92,,,Percent of total billed charges,92% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,14937.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5619.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23813.03,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30162.79,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1799.61,90,,,percent of total billed charges,90% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,1399.7,70,,,percent of total billed charges,70% of total billed charges,1799.61,90,,,percent of total billed charges,90% of total billed charges,1899.59,95,,,percent of total billed charges,95% of total billed charges,1899.59,95,,,percent of total billed charges,95% of total billed charges,5619.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11238.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1719.63,86,,,percent of total billed charges,86% of total billed charges,1599.66,80,,,percent of total billed charges,80% of total billed charges,5624.65,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1939.58,97,,,percent of total billed charges,97% of total billed charges,1799.61,90,,,percent of total billed charges,90% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1939.58,97,,,percent of total billed charges,97% of total billed charges,1859.6,93,,,percent of total billed charges,93% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1939.58,97,,,percent of total billed charges,97% of total billed charges,5619.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,5619.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4776.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1399.7,30162.79,
31626-PF Bronch w/Markers,4322041,CDM,960,RC,31626,HCPCS,Outpatient,,,375.82,187.91,,338.24,90,,,percent of total billed charges,90% of total Billed charges,567.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,167.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.96,155,,,Fee Schedule,155% of CMS OPPS Rate,191.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,303.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,303.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,358.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,231.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.96,155,,,Fee Schedule,155% of CMS OPPS Rate,191.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,879.49,155,,,Fee Schedule,155% of CMS OPPS Rate,879.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,419.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,886.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,160.61,886.04,
"31627 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with co",3712966,CDM,510,RC,31627,HCPCS,Outpatient,,,2744.72,1372.36,,2470.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2195.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2470.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2662.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2525.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1752.84,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2158.78,78.65,,,percent of total billed charges,78.65% of total billed charges,2451.9,89.33,,,percent of total billed charges,89.33% of total billed charges,2470.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1921.3,70,,,percent of total billed charges,70% of total billed charges,2470.25,90,,,percent of total billed charges,90% of total billed charges,2607.48,95,,,percent of total billed charges,95% of total billed charges,2607.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2360.46,86,,,percent of total billed charges,86% of total billed charges,2195.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2662.38,97,,,percent of total billed charges,97% of total billed charges,2470.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2662.38,97,,,percent of total billed charges,97% of total billed charges,2552.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2662.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1752.84,2662.38,
31627-PF Bronch w/CPTR Image-Guid Navigation,4322042,CDM,960,RC,31627,HCPCS,Outpatient,,,183.74,91.87,,165.37,90,,,percent of total billed charges,90% of total Billed charges,277.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.45,155,,,Fee Schedule,155% of CMS OPPS Rate,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,145.45,155,,,Fee Schedule,155% of CMS OPPS Rate,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,430.25,155,,,Fee Schedule,155% of CMS OPPS Rate,430.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1129.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2544.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2544.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.11,2544.56,
"31628 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572799,CDM,960,RC,31628,HCPCS,Outpatient,,,948.2,474.10,,853.38,90,,,percent of total billed charges,90% of total Billed charges,526.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,175.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,263.78,155,,,Fee Schedule,155% of CMS OPPS Rate,170.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,140.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,316.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,196.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,263.78,155,,,Fee Schedule,155% of CMS OPPS Rate,170.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.43,155,,,Fee Schedule,155% of CMS OPPS Rate,816.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,170.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,511.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,739.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,739.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,140.84,853.38,
31629-BRONCH W/TRANSBRONCHIAL NEEDLE ASP,3430812,CDM,510,RC,31629,HCPCS,Outpatient,,,1155.33,577.67,,1039.8,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,924.26,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.8,90,,,Percent of total Billed charges,90% of total billed charges,206.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1120.67,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1062.9,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1039.8,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,808.73,70,,,percent of total billed charges,70% of total billed charges,1039.8,90,,,percent of total billed charges,90% of total billed charges,1097.56,95,,,percent of total billed charges,95% of total billed charges,1097.56,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,993.58,86,,,percent of total billed charges,86% of total billed charges,924.26,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1120.67,97,,,percent of total billed charges,97% of total billed charges,1039.8,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1120.67,97,,,percent of total billed charges,97% of total billed charges,1074.46,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1120.67,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.39,16251.96,
"31632 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572792,CDM,976,RC,31632,HCPCS,Outpatient,,,167.88,83.94,,151.09,90,,,percent of total billed charges,90% of total Billed charges,111.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.74,155,,,Fee Schedule,155% of CMS OPPS Rate,48.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.74,155,,,Fee Schedule,155% of CMS OPPS Rate,48.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.58,155,,,Fee Schedule,155% of CMS OPPS Rate,172.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,48.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.81,172.58,
"31633 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with trans",3572793,CDM,976,RC,31633,HCPCS,Outpatient,,,208.63,104.32,,187.77,90,,,percent of total billed charges,90% of total Billed charges,139.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.92,155,,,Fee Schedule,155% of CMS OPPS Rate,61.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,96.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,70.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,94.92,155,,,Fee Schedule,155% of CMS OPPS Rate,61.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.5,155,,,Fee Schedule,155% of CMS OPPS Rate,216.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,61.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,174.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.06,216.5,
31635-PF BRONCHOSCOPY W/REMOVAL FOREIGN BODY,4321677,CDM,981,RC,31635,HCPCS,Outpatient,,,339.62,169.81,,305.66,90,,,percent of total billed charges,90% of total Billed charges,452.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,169.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,263.19,155,,,Fee Schedule,155% of CMS OPPS Rate,169.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,169.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,268.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,268.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,141.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,316.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,263.19,155,,,Fee Schedule,155% of CMS OPPS Rate,169.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,700.62,155,,,Fee Schedule,155% of CMS OPPS Rate,700.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,169.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,403.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,169.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,668.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,141.54,700.62,
31640-PF Bronch w/Tumor Excise,4322043,CDM,960,RC,31640,HCPCS,Outpatient,,,468.68,234.34,,421.81,90,,,percent of total billed charges,90% of total Billed charges,487.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,179,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,374.62,155,,,Fee Schedule,155% of CMS OPPS Rate,241.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,383.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,383.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,200.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,451.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,289.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,374.62,155,,,Fee Schedule,155% of CMS OPPS Rate,241.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,755.87,155,,,Fee Schedule,155% of CMS OPPS Rate,755.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,241.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,179,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,426.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,241.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,525.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,179,755.87,
31641-PF Bronch Treat Blockage,4322044,CDM,960,RC,31641,HCPCS,Outpatient,,,481.72,240.86,,433.55,90,,,percent of total billed charges,90% of total Billed charges,500.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,383.84,155,,,Fee Schedule,155% of CMS OPPS Rate,247.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,391.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,391.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,204.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,495.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,462.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,296.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,383.84,155,,,Fee Schedule,155% of CMS OPPS Rate,247.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.71,155,,,Fee Schedule,155% of CMS OPPS Rate,775.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,247.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,452.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,247.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,204.87,775.71,
31645-BRONCHOSCOPY CLEAR AIRWAYS,3430813,CDM,510,RC,31645,HCPCS,Outpatient,,,692.94,346.47,,623.65,90,,,percent of total billed charges,90% of total Billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,554.35,80,,,Percent of total Billed charges,80% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.65,90,,,Percent of total Billed charges,90% of total billed charges,162.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,672.15,97,,,Percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,637.5,92,,,Percent of total billed charges,92% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,3859.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6152.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7793.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,623.65,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,485.06,70,,,percent of total billed charges,70% of total billed charges,623.65,90,,,percent of total billed charges,90% of total billed charges,658.29,95,,,percent of total billed charges,95% of total billed charges,658.29,95,,,percent of total billed charges,95% of total billed charges,1451.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2903.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,595.93,86,,,percent of total billed charges,86% of total billed charges,554.35,80,,,percent of total billed charges,80% of total billed charges,1479.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,672.15,97,,,percent of total billed charges,97% of total billed charges,623.65,90,,,percent of total billed charges,90% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,672.15,97,,,percent of total billed charges,97% of total billed charges,644.43,93,,,percent of total billed charges,93% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,672.15,97,,,percent of total billed charges,97% of total billed charges,1451.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1234.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,147.8,7793.18,
31646- Bronch/asp/tracheobronch tree/subs,3435873,CDM,510,RC,31646,HCPCS,Outpatient,,,371.06,185.53,,333.95,90,,,percent of total billed charges,90% of total Billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate,296.85,80,,,Percent of total Billed charges,80% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.95,90,,,Percent of total Billed charges,90% of total billed charges,141.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,359.93,97,,,Percent of total billed charges,97% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate,341.38,92,,,Percent of total billed charges,92% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate,910.51,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1451.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1838.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,333.95,90,,,percent of total billed charges,90% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate,259.74,70,,,percent of total billed charges,70% of total billed charges,333.95,90,,,percent of total billed charges,90% of total billed charges,352.51,95,,,percent of total billed charges,95% of total billed charges,352.51,95,,,percent of total billed charges,95% of total billed charges,342.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,319.11,86,,,percent of total billed charges,86% of total billed charges,296.85,80,,,percent of total billed charges,80% of total billed charges,390.68,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,359.93,97,,,percent of total billed charges,97% of total billed charges,333.95,90,,,percent of total billed charges,90% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.93,97,,,percent of total billed charges,97% of total billed charges,345.09,93,,,percent of total billed charges,93% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,359.93,97,,,percent of total billed charges,97% of total billed charges,342.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.14,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.44,1838.6,
31647-PF Bronchial Valve Init Insert,4322045,CDM,960,RC,31647,HCPCS,Outpatient,,,388.5,194.25,,349.65,90,,,percent of total billed charges,90% of total Billed charges,403.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,199.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.53,155,,,Fee Schedule,155% of CMS OPPS Rate,199.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,323.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,323.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,246.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.53,155,,,Fee Schedule,155% of CMS OPPS Rate,199.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.76,155,,,Fee Schedule,155% of CMS OPPS Rate,624.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,199.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,207.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,199.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.37,624.76,
31648-PF Bronchial Valve Init Remov,4322046,CDM,960,RC,31648,HCPCS,Outpatient,,,374.84,187.42,,337.36,90,,,percent of total billed charges,90% of total Billed charges,386.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.76,155,,,Fee Schedule,155% of CMS OPPS Rate,190.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,291.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,307.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,307.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,199.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,236.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,295.76,155,,,Fee Schedule,155% of CMS OPPS Rate,190.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.95,155,,,Fee Schedule,155% of CMS OPPS Rate,598.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,190.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,215.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,190.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.81,598.95,
31652-BRONCH EBUS SAMPLNG 1/2 NODE,3430814,CDM,510,RC,31652,HCPCS,Outpatient,,,3190.08,1595.04,,2871.07,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.06,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2871.07,90,,,Percent of total Billed charges,90% of total billed charges,208.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3094.38,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2934.87,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2871.07,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2233.06,70,,,percent of total billed charges,70% of total billed charges,2871.07,90,,,percent of total billed charges,90% of total billed charges,3030.58,95,,,percent of total billed charges,95% of total billed charges,3030.58,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2743.47,86,,,percent of total billed charges,86% of total billed charges,2552.06,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3094.38,97,,,percent of total billed charges,97% of total billed charges,2871.07,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3094.38,97,,,percent of total billed charges,97% of total billed charges,2966.77,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3094.38,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.91,16251.96,
31652-PF Bronch Ebus Sampling 1/2 Node,4322034,CDM,960,RC,31652,HCPCS,Outpatient,,,417.38,208.69,,375.64,90,,,percent of total billed charges,90% of total Billed charges,631.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,214.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,332.2,155,,,Fee Schedule,155% of CMS OPPS Rate,214.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,214.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,338.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,338.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,202.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,428.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,399.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,332.2,155,,,Fee Schedule,155% of CMS OPPS Rate,214.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,979.14,155,,,Fee Schedule,155% of CMS OPPS Rate,979.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,214.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,214.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.91,979.14,
"31653 - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with endob",3572800,CDM,960,RC,31653,HCPCS,Outpatient,,,3316.32,1658.16,,2984.69,90,,,percent of total billed charges,90% of total Billed charges,1484.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,209.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,368.56,155,,,Fee Schedule,155% of CMS OPPS Rate,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,357.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,376.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,376.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,222.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,443.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,280.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,368.56,155,,,Fee Schedule,155% of CMS OPPS Rate,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,2301.47,155,,,Fee Schedule,155% of CMS OPPS Rate,2301.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1015.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.63,2984.69,
31653-PF Bronch Ebus Samploing 3/> Node,4322035,CDM,960,RC,31653,HCPCS,Outpatient,,,463.26,231.63,,416.93,90,,,percent of total billed charges,90% of total Billed charges,701.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,209.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,368.56,155,,,Fee Schedule,155% of CMS OPPS Rate,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,357.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,376.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,376.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,222.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,475.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,443.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,280.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,368.56,155,,,Fee Schedule,155% of CMS OPPS Rate,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1086.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1086.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1015.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,237.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.63,1086.61,
"31654 - PF Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tr",3712969,CDM,510,RC,31654,HCPCS,Outpatient,,,308.38,154.19,,277.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,246.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,277.54,90,,,Percent of total Billed charges,90% of total billed charges,60.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,283.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,196.94,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,242.55,78.65,,,percent of total billed charges,78.65% of total billed charges,275.48,89.33,,,percent of total billed charges,89.33% of total billed charges,277.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.87,70,,,percent of total billed charges,70% of total billed charges,277.54,90,,,percent of total billed charges,90% of total billed charges,292.96,95,,,percent of total billed charges,95% of total billed charges,292.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.21,86,,,percent of total billed charges,86% of total billed charges,246.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,299.13,97,,,percent of total billed charges,97% of total billed charges,277.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.13,97,,,percent of total billed charges,97% of total billed charges,286.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,299.13,
31654-PF Bronch Ebus Ivn Perph Les,4322036,CDM,960,RC,31654,HCPCS,Outpatient,,,127.3,63.65,,114.57,90,,,percent of total billed charges,90% of total Billed charges,180.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,100.49,155,,,Fee Schedule,155% of CMS OPPS Rate,64.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.49,155,,,Fee Schedule,155% of CMS OPPS Rate,64.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.21,155,,,Fee Schedule,155% of CMS OPPS Rate,280.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,64.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,280.21,
31720-PF CATHETER ASPIRATION NASOTRACHEAL SPX,4321676,CDM,981,RC,31720,HCPCS,Outpatient,,,95.6,47.80,,86.04,90,,,percent of total billed charges,90% of total Billed charges,105.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.09,155,,,Fee Schedule,155% of CMS OPPS Rate,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.09,155,,,Fee Schedule,155% of CMS OPPS Rate,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.05,155,,,Fee Schedule,155% of CMS OPPS Rate,164.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,106.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,105.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,164.05,
Nasotracheal Suction,1879111,CDM,410,RC,31720,HCPCS,Outpatient,,,154.37,77.19,,138.93,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,123.5,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.93,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,149.74,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,142.02,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,138.93,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,108.06,70,,,percent of total billed charges,70% of total billed charges,138.93,90,,,percent of total billed charges,90% of total billed charges,146.65,95,,,percent of total billed charges,95% of total billed charges,146.65,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,132.76,86,,,percent of total billed charges,86% of total billed charges,123.5,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,149.74,97,,,percent of total billed charges,97% of total billed charges,138.93,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.74,97,,,percent of total billed charges,97% of total billed charges,143.56,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.74,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,933.58,
Bedside Bronchoscopy,1151013,CDM,410,RC,31725,HCPCS,Outpatient,,,209.29,104.65,,188.36,90,,,percent of total billed charges,90% of total Billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,167.43,80,,,Percent of total Billed charges,80% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,188.36,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,203.01,97,,,Percent of total billed charges,97% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,192.55,92,,,Percent of total billed charges,92% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,188.36,90,,,percent of total billed charges,90% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,146.5,70,,,percent of total billed charges,70% of total billed charges,188.36,90,,,percent of total billed charges,90% of total billed charges,198.83,95,,,percent of total billed charges,95% of total billed charges,198.83,95,,,percent of total billed charges,95% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.99,86,,,percent of total billed charges,86% of total billed charges,167.43,80,,,percent of total billed charges,80% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.01,97,,,percent of total billed charges,97% of total billed charges,188.36,90,,,percent of total billed charges,90% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.01,97,,,percent of total billed charges,97% of total billed charges,194.64,93,,,percent of total billed charges,93% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.01,97,,,percent of total billed charges,97% of total billed charges,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,209.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,33,209.29,
32097- Thoracotomy w/bx/nod/mass/unilat,3435875,CDM,510,RC,32097,HCPCS,Outpatient,,,2142.18,1071.09,,1927.96,90,,,percent of total billed charges,90% of total Billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1713.74,80,,,Percent of total Billed charges,80% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1927.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2077.91,97,,,Percent of total billed charges,97% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1970.81,92,,,Percent of total billed charges,92% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1927.96,90,,,percent of total billed charges,90% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1499.53,70,,,percent of total billed charges,70% of total billed charges,1927.96,90,,,percent of total billed charges,90% of total billed charges,2035.07,95,,,percent of total billed charges,95% of total billed charges,2035.07,95,,,percent of total billed charges,95% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1842.27,86,,,percent of total billed charges,86% of total billed charges,1713.74,80,,,percent of total billed charges,80% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2077.91,97,,,percent of total billed charges,97% of total billed charges,1927.96,90,,,percent of total billed charges,90% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2077.91,97,,,percent of total billed charges,97% of total billed charges,1992.23,93,,,percent of total billed charges,93% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2077.91,97,,,percent of total billed charges,97% of total billed charges,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2142.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1499.53,2142.18,
32098 - PF Thoracotomy w/Biopsy of Pleura,4309275,CDM,960,RC,32098,HCPCS,Outpatient,,,1604.27,802.14,,1443.84,90,,,percent of total billed charges,90% of total Billed charges,1518.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,756.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.93,155,,,Fee Schedule,155% of CMS OPPS Rate,756.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1262.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1262.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1180.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1180.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,660.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1513.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1393.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1002.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1172.93,155,,,Fee Schedule,155% of CMS OPPS Rate,756.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2354.2,155,,,Fee Schedule,155% of CMS OPPS Rate,2354.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,756.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,714.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,756.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.94,2354.2,
32100- Thoracotomy w/exploration,3435876,CDM,510,RC,32100,HCPCS,Outpatient,,,2163.49,1081.75,,1947.14,90,,,percent of total billed charges,90% of total Billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1730.79,80,,,Percent of total Billed charges,80% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.14,90,,,Percent of total Billed charges,90% of total billed charges,584.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2098.59,97,,,Percent of total billed charges,97% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1990.41,92,,,Percent of total billed charges,92% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.14,90,,,percent of total billed charges,90% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1514.44,70,,,percent of total billed charges,70% of total billed charges,1947.14,90,,,percent of total billed charges,90% of total billed charges,2055.32,95,,,percent of total billed charges,95% of total billed charges,2055.32,95,,,percent of total billed charges,95% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1860.6,86,,,percent of total billed charges,86% of total billed charges,1730.79,80,,,percent of total billed charges,80% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2098.59,97,,,percent of total billed charges,97% of total billed charges,1947.14,90,,,percent of total billed charges,90% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2098.59,97,,,percent of total billed charges,97% of total billed charges,2012.05,93,,,percent of total billed charges,93% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,531.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2098.59,97,,,percent of total billed charges,97% of total billed charges,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2163.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,531.5,2163.49,
32100-PF Thoracotomy w/ Exploration,4322047,CDM,960,RC,32100,HCPCS,Outpatient,,,1583.9,791.95,,1425.51,90,,,percent of total billed charges,90% of total Billed charges,1618.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1935.82,90,,,Percent of total Billed charges,90% of total billed charges,531.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1247.56,155,,,Fee Schedule,155% of CMS OPPS Rate,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1195.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,804.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1344.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1344.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1257.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1257.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,683.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1483.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1065.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1247.56,155,,,Fee Schedule,155% of CMS OPPS Rate,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,2508.57,155,,,Fee Schedule,155% of CMS OPPS Rate,2508.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,531.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,960.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1963.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1963.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,531.5,2508.57,
32110- Thoracot/control trauma hemorrhag,3435877,CDM,510,RC,32110,HCPCS,Outpatient,,,3941.71,1970.86,,3547.54,90,,,percent of total billed charges,90% of total Billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3153.37,80,,,Percent of total Billed charges,80% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3823.46,97,,,Percent of total billed charges,97% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3626.37,92,,,Percent of total billed charges,92% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.54,90,,,percent of total billed charges,90% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2759.2,70,,,percent of total billed charges,70% of total billed charges,3547.54,90,,,percent of total billed charges,90% of total billed charges,3744.62,95,,,percent of total billed charges,95% of total billed charges,3744.62,95,,,percent of total billed charges,95% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3389.87,86,,,percent of total billed charges,86% of total billed charges,3153.37,80,,,percent of total billed charges,80% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3823.46,97,,,percent of total billed charges,97% of total billed charges,3547.54,90,,,percent of total billed charges,90% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3823.46,97,,,percent of total billed charges,97% of total billed charges,3665.79,93,,,percent of total billed charges,93% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3823.46,97,,,percent of total billed charges,97% of total billed charges,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3941.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2759.2,3941.71,
32140 - THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC,4037485,CDM,983,RC,32140,HCPCS,Outpatient,,,2642.23,1321.12,,2378.01,90,,,percent of total billed charges,90% of total Billed charges,1978.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,985.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,621,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1527.26,155,,,Fee Schedule,155% of CMS OPPS Rate,985.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1461.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1643.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1643.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1535.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1535.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,795.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1970.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1811.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1302.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1527.26,155,,,Fee Schedule,155% of CMS OPPS Rate,985.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3067.3,155,,,Fee Schedule,155% of CMS OPPS Rate,3067.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,985.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,621,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1139.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,985.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,2032.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2032.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,621,3067.3,
32160-PF THORACOTOMY W/CARDIAC MASSAGE,4321383,CDM,981,RC,32160,HCPCS,Outpatient,,,1582.64,791.32,,1424.38,90,,,percent of total billed charges,90% of total Billed charges,1588.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,791.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,572.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1226.53,155,,,Fee Schedule,155% of CMS OPPS Rate,791.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,791.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1320.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1228.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1228.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,637.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,791.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1582.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1450.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1033.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1226.53,155,,,Fee Schedule,155% of CMS OPPS Rate,791.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,2461.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2461.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,791.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,572.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,721.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,791.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1604.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1604.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,572.57,2461.8,
32220- Pulmonary decortication/total,3435878,CDM,510,RC,32220,HCPCS,Outpatient,,,4256.41,2128.21,,3830.77,90,,,percent of total billed charges,90% of total Billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3405.13,80,,,Percent of total Billed charges,80% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3830.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4128.72,97,,,Percent of total billed charges,97% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3915.9,92,,,Percent of total billed charges,92% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3830.77,90,,,percent of total billed charges,90% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2979.49,70,,,percent of total billed charges,70% of total billed charges,3830.77,90,,,percent of total billed charges,90% of total billed charges,4043.59,95,,,percent of total billed charges,95% of total billed charges,4043.59,95,,,percent of total billed charges,95% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3660.51,86,,,percent of total billed charges,86% of total billed charges,3405.13,80,,,percent of total billed charges,80% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4128.72,97,,,percent of total billed charges,97% of total billed charges,3830.77,90,,,percent of total billed charges,90% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4128.72,97,,,percent of total billed charges,97% of total billed charges,3958.46,93,,,percent of total billed charges,93% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4128.72,97,,,percent of total billed charges,97% of total billed charges,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4256.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2979.49,4256.41,
32225- Pulmonary decortication/partial,3435879,CDM,510,RC,32225,HCPCS,Outpatient,,,2664.41,1332.21,,2397.97,90,,,percent of total billed charges,90% of total Billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.53,80,,,Percent of total Billed charges,80% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2397.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2584.48,97,,,Percent of total billed charges,97% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2451.26,92,,,Percent of total billed charges,92% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2397.97,90,,,percent of total billed charges,90% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1865.09,70,,,percent of total billed charges,70% of total billed charges,2397.97,90,,,percent of total billed charges,90% of total billed charges,2531.19,95,,,percent of total billed charges,95% of total billed charges,2531.19,95,,,percent of total billed charges,95% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2291.39,86,,,percent of total billed charges,86% of total billed charges,2131.53,80,,,percent of total billed charges,80% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2584.48,97,,,percent of total billed charges,97% of total billed charges,2397.97,90,,,percent of total billed charges,90% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2584.48,97,,,percent of total billed charges,97% of total billed charges,2477.9,93,,,percent of total billed charges,93% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2584.48,97,,,percent of total billed charges,97% of total billed charges,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2664.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1865.09,2664.41,
32310-PF Pleurectomy Parietal Sep Px,4322048,CDM,960,RC,32310,HCPCS,Outpatient,,,1794.92,897.46,,1615.43,90,,,percent of total billed charges,90% of total Billed charges,1834.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,912.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,749,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1414.82,155,,,Fee Schedule,155% of CMS OPPS Rate,912.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1346.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,912.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1514.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1514.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1413.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1413.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,737.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,912.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1825.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1667.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1194.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1414.82,155,,,Fee Schedule,155% of CMS OPPS Rate,912.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,2843.34,155,,,Fee Schedule,155% of CMS OPPS Rate,2843.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,912.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,749,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1035.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,912.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1882.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,737.31,2843.34,
32320-PF Decort & Parietal Pleurectomy,4322049,CDM,960,RC,32320,HCPCS,Outpatient,,,3134.96,1567.48,,2821.46,90,,,percent of total billed charges,90% of total Billed charges,3210.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1598.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,800,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2477.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1598.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2359.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1598.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2653.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2483.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2483.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1288.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1598.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3196.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2930.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2110.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2477.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1598.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,4976.4,155,,,Fee Schedule,155% of CMS OPPS Rate,4976.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1598.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,800,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1629.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1598.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,3295.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3295.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,800,4976.4,
CT add Needle Bx Chest Lining,645122,CDM,360,RC,32400,HCPCS,Outpatient,,,417.16,208.58,,375.44,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,333.73,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.44,90,,,Percent of total Billed charges,90% of total billed charges,89.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,404.65,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,383.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,375.44,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,292.01,70,,,percent of total billed charges,70% of total billed charges,375.44,90,,,percent of total billed charges,90% of total billed charges,396.3,95,,,percent of total billed charges,95% of total billed charges,396.3,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,358.76,86,,,percent of total billed charges,86% of total billed charges,333.73,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,404.65,97,,,percent of total billed charges,97% of total billed charges,375.44,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,404.65,97,,,percent of total billed charges,97% of total billed charges,387.96,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,404.65,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81.04,7310.49,
Read,4181196,CDM,972,RC,32400,HCPCS,Outpatient,,,166.87,83.44,,150.18,90,,,percent of total billed charges,90% of total Billed charges,241.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.81,155,,,Fee Schedule,155% of CMS OPPS Rate,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,128.81,155,,,Fee Schedule,155% of CMS OPPS Rate,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.5,155,,,Fee Schedule,155% of CMS OPPS Rate,374.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,288.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.08,374.5,
32408-PF CORE NDL BX LNG/MED PERQ,4321675,CDM,981,RC,32408,HCPCS,Outpatient,,,298.96,149.48,,269.06,90,,,percent of total billed charges,90% of total Billed charges,448.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,155,,,Fee Schedule,155% of CMS OPPS Rate,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.69,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,155,,,Fee Schedule,155% of CMS OPPS Rate,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.08,155,,,Fee Schedule,155% of CMS OPPS Rate,695.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.69,695.08,
CT add Needle Bx Lung or Mediastinum,645124,CDM,360,RC,32408,HCPCS,Outpatient,,,2053.46,1026.73,,1848.11,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.77,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1848.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1991.86,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1889.18,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1848.11,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1437.42,70,,,percent of total billed charges,70% of total billed charges,1848.11,90,,,percent of total billed charges,90% of total billed charges,1950.79,95,,,percent of total billed charges,95% of total billed charges,1950.79,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1765.98,86,,,percent of total billed charges,86% of total billed charges,1642.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1991.86,97,,,percent of total billed charges,97% of total billed charges,1848.11,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1991.86,97,,,percent of total billed charges,97% of total billed charges,1909.72,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1991.86,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1157.67,7310.49,
Read,4181200,CDM,972,RC,32408,HCPCS,Outpatient,,,821.38,410.69,,739.24,90,,,percent of total billed charges,90% of total Billed charges,955.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,155,,,Fee Schedule,155% of CMS OPPS Rate,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.41,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,155,,,Fee Schedule,155% of CMS OPPS Rate,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1481.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1481.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.48,1481.35,
32440-PF Rmv Lung Pneumonectomy,4322050,CDM,960,RC,32440,HCPCS,Outpatient,,,3072.52,1536.26,,2765.27,90,,,percent of total billed charges,90% of total Billed charges,3145.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1563.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2423.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1563.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2313.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1563.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2601.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2601.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2441.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2441.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1261.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1563.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3127,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2880.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2081.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2423.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1563.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,4875,155,,,Fee Schedule,155% of CMS OPPS Rate,4875,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1563.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1660.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1563.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,3227.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3227.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4875,
32480- Lung removal/single lobe/lobectomy,3435881,CDM,510,RC,32480,HCPCS,Outpatient,,,3967.66,1983.83,,3570.89,90,,,percent of total billed charges,90% of total Billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3174.13,80,,,Percent of total Billed charges,80% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3570.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3848.63,97,,,Percent of total billed charges,97% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3650.25,92,,,Percent of total billed charges,92% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3570.89,90,,,percent of total billed charges,90% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2777.36,70,,,percent of total billed charges,70% of total billed charges,3570.89,90,,,percent of total billed charges,90% of total billed charges,3769.28,95,,,percent of total billed charges,95% of total billed charges,3769.28,95,,,percent of total billed charges,95% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3412.19,86,,,percent of total billed charges,86% of total billed charges,3174.13,80,,,percent of total billed charges,80% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3848.63,97,,,percent of total billed charges,97% of total billed charges,3570.89,90,,,percent of total billed charges,90% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3848.63,97,,,percent of total billed charges,97% of total billed charges,3689.92,93,,,percent of total billed charges,93% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3848.63,97,,,percent of total billed charges,97% of total billed charges,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3967.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2777.36,3967.66,
32480-PF Rmvl Lung oth thn Pneumonect 1 Lobe,4322051,CDM,960,RC,32480,HCPCS,Outpatient,,,2895.92,1447.96,,2606.33,90,,,percent of total billed charges,90% of total Billed charges,2967.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1475.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,3552.25,90,,,Percent of total Billed charges,90% of total billed charges,997,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2286.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1475.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2184.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1475.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2457.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2457.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2306.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2306.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1192.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1475.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2950.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2721.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1968.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2286.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1475.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,4599.28,155,,,Fee Schedule,155% of CMS OPPS Rate,4599.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1475.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,997,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1508.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1475.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,3059.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3059.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,997,4599.28,
32482-PF Bilobectomy,4322052,CDM,960,RC,32482,HCPCS,Outpatient,,,3093.42,1546.71,,2784.08,90,,,percent of total billed charges,90% of total Billed charges,3170.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1575.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2442.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1575.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2341.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1575.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2633.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2633.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2469.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2469.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1275.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3151.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2914.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2105.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2442.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1575.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,4914.62,155,,,Fee Schedule,155% of CMS OPPS Rate,4914.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1575.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1561.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1575.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,3272.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3272.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4914.62,
32484- Lung removal/sng seg/segmentectomy,3435882,CDM,510,RC,32484,HCPCS,Outpatient,,,3850.92,1925.46,,3465.83,90,,,percent of total billed charges,90% of total Billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3080.74,80,,,Percent of total Billed charges,80% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3735.39,97,,,Percent of total billed charges,97% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3542.85,92,,,Percent of total billed charges,92% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.83,90,,,percent of total billed charges,90% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2695.64,70,,,percent of total billed charges,70% of total billed charges,3465.83,90,,,percent of total billed charges,90% of total billed charges,3658.37,95,,,percent of total billed charges,95% of total billed charges,3658.37,95,,,percent of total billed charges,95% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3311.79,86,,,percent of total billed charges,86% of total billed charges,3080.74,80,,,percent of total billed charges,80% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3735.39,97,,,percent of total billed charges,97% of total billed charges,3465.83,90,,,percent of total billed charges,90% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3735.39,97,,,percent of total billed charges,97% of total billed charges,3581.36,93,,,percent of total billed charges,93% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3735.39,97,,,percent of total billed charges,97% of total billed charges,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3850.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2695.64,3850.92,
32484-PF Rmvl lung oth thn pneumonect 1 segemntect,4322072,CDM,960,RC,32484,HCPCS,Outpatient,,,2810.12,1405.06,,2529.11,90,,,percent of total billed charges,90% of total Billed charges,2879.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1431.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2219.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1431.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2117.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1431.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2381.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2381.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2240.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2240.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1157.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2863.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2644.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1918.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2219.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1431.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,4463.94,155,,,Fee Schedule,155% of CMS OPPS Rate,4463.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1431.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1589.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1431.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,2966.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2966.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4463.94,
32486-PF Sleeve Lobectomy,4322053,CDM,960,RC,32486,HCPCS,Outpatient,,,4607.44,2303.72,,4146.7,90,,,percent of total billed charges,90% of total Billed charges,4716.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2347.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3638.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2347.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3480.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2347.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3914.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3914.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3696.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3696.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1896.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2347.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4694.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4362.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3179.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3638.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2347.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,7310.9,155,,,Fee Schedule,155% of CMS OPPS Rate,7310.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2347.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2295.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2347.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,4869.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4869.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,7310.9,
32501-PF Repair Bronchus Add-On,4322054,CDM,960,RC,32501,HCPCS,Outpatient,,,481.44,240.72,,433.3,90,,,percent of total billed charges,90% of total Billed charges,491.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,379.67,155,,,Fee Schedule,155% of CMS OPPS Rate,244.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,385.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,385.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,454.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,379.67,155,,,Fee Schedule,155% of CMS OPPS Rate,244.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.14,155,,,Fee Schedule,155% of CMS OPPS Rate,762.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,244.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,244.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,507.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,507.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197.42,762.14,
32505- Thorocotomy/wedge resect/initial,3435883,CDM,510,RC,32505,HCPCS,Outpatient,,,2486.88,1243.44,,2238.19,90,,,percent of total billed charges,90% of total Billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1989.5,80,,,Percent of total Billed charges,80% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2238.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2412.27,97,,,Percent of total billed charges,97% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2287.93,92,,,Percent of total billed charges,92% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2238.19,90,,,percent of total billed charges,90% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1740.82,70,,,percent of total billed charges,70% of total billed charges,2238.19,90,,,percent of total billed charges,90% of total billed charges,2362.54,95,,,percent of total billed charges,95% of total billed charges,2362.54,95,,,percent of total billed charges,95% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2138.72,86,,,percent of total billed charges,86% of total billed charges,1989.5,80,,,percent of total billed charges,80% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2412.27,97,,,percent of total billed charges,97% of total billed charges,2238.19,90,,,percent of total billed charges,90% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2412.27,97,,,percent of total billed charges,97% of total billed charges,2312.8,93,,,percent of total billed charges,93% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2412.27,97,,,percent of total billed charges,97% of total billed charges,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1740.82,2486.88,
32550- Pleural cath insert/cuff/tunneled,3435884,CDM,510,RC,32550,HCPCS,Outpatient,,,2013.72,1006.86,,1812.35,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.98,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.31,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.62,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.35,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.6,70,,,percent of total billed charges,70% of total billed charges,1812.35,90,,,percent of total billed charges,90% of total billed charges,1913.03,95,,,percent of total billed charges,95% of total billed charges,1913.03,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.8,86,,,percent of total billed charges,86% of total billed charges,1610.98,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.31,97,,,percent of total billed charges,97% of total billed charges,1812.35,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.31,97,,,percent of total billed charges,97% of total billed charges,1872.76,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.31,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1409.6,17267.34,
32550-PF Insert Indwel Tunn Pleural Cath,4322073,CDM,960,RC,32550,HCPCS,Outpatient,,,390.78,195.39,,351.7,90,,,percent of total billed charges,90% of total Billed charges,591.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,200.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.36,155,,,Fee Schedule,155% of CMS OPPS Rate,200.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,318.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,318.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,375.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,250.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,311.36,155,,,Fee Schedule,155% of CMS OPPS Rate,200.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,917.07,155,,,Fee Schedule,155% of CMS OPPS Rate,917.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,200.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,713.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,200.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1515.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1515.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,167.13,1515.72,
32551 - PF Tube Thoracostomy Incl Water Seal,4311493,CDM,960,RC,32551,HCPCS,Outpatient,,,368.49,184.25,,331.64,90,,,percent of total billed charges,90% of total Billed charges,313.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.53,155,,,Fee Schedule,155% of CMS OPPS Rate,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,246.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,246.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,290.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,240.53,155,,,Fee Schedule,155% of CMS OPPS Rate,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.88,155,,,Fee Schedule,155% of CMS OPPS Rate,485.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,200.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.39,485.88,
32551- Chest tube instert/open w/drainage,3435885,CDM,510,RC,32551,HCPCS,Outpatient,,,420.95,210.48,,378.86,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,336.76,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,408.32,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,387.27,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,378.86,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,294.67,70,,,percent of total billed charges,70% of total billed charges,378.86,90,,,percent of total billed charges,90% of total billed charges,399.9,95,,,percent of total billed charges,95% of total billed charges,399.9,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,362.02,86,,,percent of total billed charges,86% of total billed charges,336.76,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,408.32,97,,,percent of total billed charges,97% of total billed charges,378.86,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.32,97,,,percent of total billed charges,97% of total billed charges,391.48,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,408.32,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,294.67,7253.45,
32551-PF TUBE THORACOSTOMY INCLUDES WATER SEA,4321674,CDM,981,RC,32551,HCPCS,Outpatient,,,310.38,155.19,,279.34,90,,,percent of total billed charges,90% of total Billed charges,313.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.53,155,,,Fee Schedule,155% of CMS OPPS Rate,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,246.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,246.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,310.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,290.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,240.53,155,,,Fee Schedule,155% of CMS OPPS Rate,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.88,155,,,Fee Schedule,155% of CMS OPPS Rate,485.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,200.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.39,485.88,
32552- Rmv tunneled pleural cath w/cuff,3435886,CDM,510,RC,32552,HCPCS,Outpatient,,,471.99,236.00,,424.79,90,,,percent of total billed charges,90% of total Billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,377.59,80,,,Percent of total Billed charges,80% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,457.83,97,,,Percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,434.23,92,,,Percent of total billed charges,92% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.26,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,424.79,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,330.39,70,,,percent of total billed charges,70% of total billed charges,424.79,90,,,percent of total billed charges,90% of total billed charges,448.39,95,,,percent of total billed charges,95% of total billed charges,448.39,95,,,percent of total billed charges,95% of total billed charges,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,405.91,86,,,percent of total billed charges,86% of total billed charges,377.59,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.83,97,,,percent of total billed charges,97% of total billed charges,424.79,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.83,97,,,percent of total billed charges,97% of total billed charges,438.95,93,,,percent of total billed charges,93% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,457.83,97,,,percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,330.39,2820.26,
32552-PF Rmv Indwel Tunn Pleural Cath w/cuff,4322074,CDM,960,RC,32552,HCPCS,Outpatient,,,297.34,148.67,,267.61,90,,,percent of total billed charges,90% of total Billed charges,329.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.86,155,,,Fee Schedule,155% of CMS OPPS Rate,152.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,238.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,238.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,235.86,155,,,Fee Schedule,155% of CMS OPPS Rate,152.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.96,155,,,Fee Schedule,155% of CMS OPPS Rate,510.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,183.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,377.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127.14,510.96,
32554- Thoracentesis w/o image guide,3435887,CDM,510,RC,32554,HCPCS,Outpatient,,,599.36,299.68,,539.42,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,479.49,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,581.38,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,551.41,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,539.42,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,419.55,70,,,percent of total billed charges,70% of total billed charges,539.42,90,,,percent of total billed charges,90% of total billed charges,569.39,95,,,percent of total billed charges,95% of total billed charges,569.39,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,515.45,86,,,percent of total billed charges,86% of total billed charges,479.49,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,581.38,97,,,percent of total billed charges,97% of total billed charges,539.42,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.38,97,,,percent of total billed charges,97% of total billed charges,557.4,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,581.38,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,419.55,2820.25,
32554-PF THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING,4321402,CDM,981,RC,32554,HCPCS,Outpatient,,,174.32,87.16,,156.89,90,,,percent of total billed charges,90% of total Billed charges,261.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.08,155,,,Fee Schedule,155% of CMS OPPS Rate,87.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,75.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,135.08,155,,,Fee Schedule,155% of CMS OPPS Rate,87.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.28,155,,,Fee Schedule,155% of CMS OPPS Rate,405.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,87.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,487.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,87.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.38,487.13,
32555- Thoracentesis/image guide,3435888,CDM,360,RC,32555,HCPCS,Outpatient,,,798.68,399.34,,718.81,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,638.94,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,718.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,774.72,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,734.79,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,718.81,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,559.08,70,,,percent of total billed charges,70% of total billed charges,718.81,90,,,percent of total billed charges,90% of total billed charges,758.75,95,,,percent of total billed charges,95% of total billed charges,758.75,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,686.86,86,,,percent of total billed charges,86% of total billed charges,638.94,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,774.72,97,,,percent of total billed charges,97% of total billed charges,718.81,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,774.72,97,,,percent of total billed charges,97% of total billed charges,742.77,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,774.72,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
32555-PF THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,4321673,CDM,981,RC,32555,HCPCS,Outpatient,,,214.14,107.07,,192.73,90,,,percent of total billed charges,90% of total Billed charges,321.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.86,155,,,Fee Schedule,155% of CMS OPPS Rate,497.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,562.44,
CT add Thoracentesis,645110,CDM,360,RC,32555,HCPCS,Outpatient,,,768.74,384.37,,691.87,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,614.99,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,745.68,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,707.24,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,691.87,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,538.12,70,,,percent of total billed charges,70% of total billed charges,691.87,90,,,percent of total billed charges,90% of total billed charges,730.3,95,,,percent of total billed charges,95% of total billed charges,730.3,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,661.12,86,,,percent of total billed charges,86% of total billed charges,614.99,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,745.68,97,,,percent of total billed charges,97% of total billed charges,691.87,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,745.68,97,,,percent of total billed charges,97% of total billed charges,714.93,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,745.68,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
Read,2964113,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351393,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351395,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351914,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351916,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351989,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
Read,3351991,CDM,972,RC,32555,HCPCS,Outpatient,,,307.5,153.75,,276.75,90,,,percent of total billed charges,90% of total Billed charges,407.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.94,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.45,155,,,Fee Schedule,155% of CMS OPPS Rate,631.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,562.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.32,631.45,
US add Thoracentesis,645146,CDM,360,RC,32555,HCPCS,Outpatient,,,768.74,384.37,,691.87,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,614.99,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,745.68,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,707.24,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,691.87,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,538.12,70,,,percent of total billed charges,70% of total billed charges,691.87,90,,,percent of total billed charges,90% of total billed charges,730.3,95,,,percent of total billed charges,95% of total billed charges,730.3,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,661.12,86,,,percent of total billed charges,86% of total billed charges,614.99,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,745.68,97,,,percent of total billed charges,97% of total billed charges,691.87,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,745.68,97,,,percent of total billed charges,97% of total billed charges,714.93,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,745.68,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
32556- Pleural drain/cath/perc w/o image,3435889,CDM,510,RC,32556,HCPCS,Outpatient,,,1859.58,929.79,,1673.62,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.66,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1673.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1803.79,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.81,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1673.62,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1301.71,70,,,percent of total billed charges,70% of total billed charges,1673.62,90,,,percent of total billed charges,90% of total billed charges,1766.6,95,,,percent of total billed charges,95% of total billed charges,1766.6,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1599.24,86,,,percent of total billed charges,86% of total billed charges,1487.66,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1803.79,97,,,percent of total billed charges,97% of total billed charges,1673.62,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1803.79,97,,,percent of total billed charges,97% of total billed charges,1729.41,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1803.79,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1301.71,8490.45,
"32557 - Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance",3760897,CDM,983,RC,32557,HCPCS,Outpatient,,,1667.93,833.97,,1501.14,90,,,percent of total billed charges,90% of total Billed charges,773.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.18,155,,,Fee Schedule,155% of CMS OPPS Rate,146.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,140.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,174.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,227.18,155,,,Fee Schedule,155% of CMS OPPS Rate,146.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1199.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1199.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,146.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,836.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,146.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.94,1501.14,
32560- Instill agent/chest tube/pleurodesis,3435890,CDM,510,RC,32560,HCPCS,Outpatient,,,652.99,326.50,,587.69,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,522.39,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,633.4,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,600.75,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,587.69,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,457.09,70,,,percent of total billed charges,70% of total billed charges,587.69,90,,,percent of total billed charges,90% of total billed charges,620.34,95,,,percent of total billed charges,95% of total billed charges,620.34,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,561.57,86,,,percent of total billed charges,86% of total billed charges,522.39,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,633.4,97,,,percent of total billed charges,97% of total billed charges,587.69,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,633.4,97,,,percent of total billed charges,97% of total billed charges,607.28,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,633.4,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
32560-PF Instl via Chst Tub/Cath Agnt for Pleurodesis,4322075,CDM,960,RC,32560,HCPCS,Outpatient,,,147.78,73.89,,133,90,,,percent of total billed charges,90% of total Billed charges,223.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.95,155,,,Fee Schedule,155% of CMS OPPS Rate,75.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,121.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,121.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,143.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,116.95,155,,,Fee Schedule,155% of CMS OPPS Rate,75.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.01,155,,,Fee Schedule,155% of CMS OPPS Rate,346.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,75.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,302.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,476,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,476,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.45,476,
32561-PF Lyse Chest Fibrin Init Day,4322076,CDM,960,RC,32561,HCPCS,Outpatient,,,129.28,64.64,,116.35,90,,,percent of total billed charges,90% of total Billed charges,159.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.73,155,,,Fee Schedule,155% of CMS OPPS Rate,66.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,103.73,155,,,Fee Schedule,155% of CMS OPPS Rate,66.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.73,155,,,Fee Schedule,155% of CMS OPPS Rate,246.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,66.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.39,246.73,
32562-PF Lyse Chest Fibrin Subq Day,4322077,CDM,960,RC,32562,HCPCS,Outpatient,,,115.44,57.72,,103.9,90,,,percent of total billed charges,90% of total Billed charges,140.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.05,155,,,Fee Schedule,155% of CMS OPPS Rate,59.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.05,155,,,Fee Schedule,155% of CMS OPPS Rate,59.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.27,155,,,Fee Schedule,155% of CMS OPPS Rate,218.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.97,218.27,
32606-PF Thoracoscopy w/Bx Mediastinal Spc,4322078,CDM,960,RC,32606,HCPCS,Outpatient,,,906.54,453.27,,815.89,90,,,percent of total billed charges,90% of total Billed charges,928.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,461.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,423.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,715.51,155,,,Fee Schedule,155% of CMS OPPS Rate,461.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,769.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,769.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,726.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,726.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,373.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,856.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,624,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,715.51,155,,,Fee Schedule,155% of CMS OPPS Rate,461.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1438.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1438.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,461.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,516.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,461.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,954.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,954.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,373.36,1438.85,
32607- Thoracoscopy/bx infiltrate/unilat,3435891,CDM,510,RC,32607,HCPCS,Outpatient,,,824.48,412.24,,742.03,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,659.58,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,799.75,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,758.52,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,742.03,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,577.14,70,,,percent of total billed charges,70% of total billed charges,742.03,90,,,percent of total billed charges,90% of total billed charges,783.26,95,,,percent of total billed charges,95% of total billed charges,783.26,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,709.05,86,,,percent of total billed charges,86% of total billed charges,659.58,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,799.75,97,,,percent of total billed charges,97% of total billed charges,742.03,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,799.75,97,,,percent of total billed charges,97% of total billed charges,766.77,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,799.75,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,577.14,25409.89,
32607-PF Thoracoscopy w/Dx Bx of Lung Infiltrate Uni,4322079,CDM,960,RC,32607,HCPCS,Outpatient,,,602.44,301.22,,542.2,90,,,percent of total billed charges,90% of total Billed charges,617.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.52,155,,,Fee Schedule,155% of CMS OPPS Rate,307.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,512.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,482.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,482.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,269.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,569.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,413.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,476.52,155,,,Fee Schedule,155% of CMS OPPS Rate,307.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,957.05,155,,,Fee Schedule,155% of CMS OPPS Rate,957.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,292.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.13,957.05,
32608- Thoracoscopy/bx nodule/mass/unilat,3435892,CDM,510,RC,32608,HCPCS,Outpatient,,,1016.85,508.43,,915.17,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,813.48,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,986.34,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,935.5,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,915.17,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,711.8,70,,,percent of total billed charges,70% of total billed charges,915.17,90,,,percent of total billed charges,90% of total billed charges,966.01,95,,,percent of total billed charges,95% of total billed charges,966.01,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,874.49,86,,,percent of total billed charges,86% of total billed charges,813.48,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,986.34,97,,,percent of total billed charges,97% of total billed charges,915.17,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,986.34,97,,,percent of total billed charges,97% of total billed charges,945.67,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,986.34,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,711.8,25409.89,
32609- Thoracoscopy/bx pleura,3435893,CDM,510,RC,32609,HCPCS,Outpatient,,,682.09,341.05,,613.88,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,545.67,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,661.63,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,627.52,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,613.88,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,477.46,70,,,percent of total billed charges,70% of total billed charges,613.88,90,,,percent of total billed charges,90% of total billed charges,647.99,95,,,percent of total billed charges,95% of total billed charges,647.99,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,586.6,86,,,percent of total billed charges,86% of total billed charges,545.67,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,661.63,97,,,percent of total billed charges,97% of total billed charges,613.88,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.63,97,,,percent of total billed charges,97% of total billed charges,634.34,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,661.63,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,477.46,25409.89,
32609-PF Thoracoscopy w/ Bx of Pluera,4322080,CDM,960,RC,32609,HCPCS,Outpatient,,,498.14,249.07,,448.33,90,,,percent of total billed charges,90% of total Billed charges,510.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.59,155,,,Fee Schedule,155% of CMS OPPS Rate,253.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,427.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,427.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,400.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,400.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,472.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,336.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,393.59,155,,,Fee Schedule,155% of CMS OPPS Rate,253.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.15,155,,,Fee Schedule,155% of CMS OPPS Rate,791.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.81,791.15,
32650- Thoracoscopy/surg/pleurodesis,3435894,CDM,510,RC,32650,HCPCS,Outpatient,,,1772.12,886.06,,1594.91,90,,,percent of total billed charges,90% of total Billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1417.7,80,,,Percent of total Billed charges,80% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1718.96,97,,,Percent of total billed charges,97% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1630.35,92,,,Percent of total billed charges,92% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.91,90,,,percent of total billed charges,90% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1240.48,70,,,percent of total billed charges,70% of total billed charges,1594.91,90,,,percent of total billed charges,90% of total billed charges,1683.51,95,,,percent of total billed charges,95% of total billed charges,1683.51,95,,,percent of total billed charges,95% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1524.02,86,,,percent of total billed charges,86% of total billed charges,1417.7,80,,,percent of total billed charges,80% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.96,97,,,percent of total billed charges,97% of total billed charges,1594.91,90,,,percent of total billed charges,90% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.96,97,,,percent of total billed charges,97% of total billed charges,1648.07,93,,,percent of total billed charges,93% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1718.96,97,,,percent of total billed charges,97% of total billed charges,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1772.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1240.48,1772.12,
32650-PF Thoracoscopy w/ Pluerodesis,4322081,CDM,960,RC,32650,HCPCS,Outpatient,,,1300.26,650.13,,1170.23,90,,,percent of total billed charges,90% of total Billed charges,1326.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,660.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,546.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1023.73,155,,,Fee Schedule,155% of CMS OPPS Rate,660.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,660.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1104.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1104.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1026.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1026.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,536.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1320.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1210.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,861.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1023.73,155,,,Fee Schedule,155% of CMS OPPS Rate,660.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2056.62,155,,,Fee Schedule,155% of CMS OPPS Rate,2056.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,660.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,759.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,660.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1366.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,536.82,2056.62,
32651- Thoracoscopy/surg/part pulm decort,3435895,CDM,510,RC,32651,HCPCS,Outpatient,,,2928.01,1464.01,,2635.21,90,,,percent of total billed charges,90% of total Billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2342.41,80,,,Percent of total Billed charges,80% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2840.17,97,,,Percent of total billed charges,97% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2693.77,92,,,Percent of total billed charges,92% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.21,90,,,percent of total billed charges,90% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2049.61,70,,,percent of total billed charges,70% of total billed charges,2635.21,90,,,percent of total billed charges,90% of total billed charges,2781.61,95,,,percent of total billed charges,95% of total billed charges,2781.61,95,,,percent of total billed charges,95% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2518.09,86,,,percent of total billed charges,86% of total billed charges,2342.41,80,,,percent of total billed charges,80% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2840.17,97,,,percent of total billed charges,97% of total billed charges,2635.21,90,,,percent of total billed charges,90% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2840.17,97,,,percent of total billed charges,97% of total billed charges,2723.05,93,,,percent of total billed charges,93% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2840.17,97,,,percent of total billed charges,97% of total billed charges,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2928.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2049.61,2928.01,
32651-PF Thoracoscopy w/prtl Pulm Decortication,4322082,CDM,960,RC,32651,HCPCS,Outpatient,,,2141.4,1070.70,,1927.26,90,,,percent of total billed charges,90% of total Billed charges,2191.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1090.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,793.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1690.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1090.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1616.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1090.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1818.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1703.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1703.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,883.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2180.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2009.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1449.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1690.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1090.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3396.78,155,,,Fee Schedule,155% of CMS OPPS Rate,3396.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1090.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,793.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1060.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1090.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2254.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2254.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,793.14,3396.78,
32652- Thoracoscopy/tot pulm decorticatio,3435896,CDM,510,RC,32652,HCPCS,Outpatient,,,4451.93,2225.97,,4006.74,90,,,percent of total billed charges,90% of total Billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3561.54,80,,,Percent of total Billed charges,80% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4006.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4318.37,97,,,Percent of total billed charges,97% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4095.78,92,,,Percent of total billed charges,92% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4006.74,90,,,percent of total billed charges,90% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.35,70,,,percent of total billed charges,70% of total billed charges,4006.74,90,,,percent of total billed charges,90% of total billed charges,4229.33,95,,,percent of total billed charges,95% of total billed charges,4229.33,95,,,percent of total billed charges,95% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3828.66,86,,,percent of total billed charges,86% of total billed charges,3561.54,80,,,percent of total billed charges,80% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4318.37,97,,,percent of total billed charges,97% of total billed charges,4006.74,90,,,percent of total billed charges,90% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4318.37,97,,,percent of total billed charges,97% of total billed charges,4140.29,93,,,percent of total billed charges,93% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4318.37,97,,,percent of total billed charges,97% of total billed charges,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.35,4451.93,
"32655- Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure wh",3566781,CDM,510,RC,32655,HCPCS,Outpatient,,,2552.64,1276.32,,2297.38,90,,,percent of total billed charges,90% of total Billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2042.11,80,,,Percent of total Billed charges,80% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2297.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2476.06,97,,,Percent of total billed charges,97% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2348.43,92,,,Percent of total billed charges,92% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2297.38,90,,,percent of total billed charges,90% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1786.85,70,,,percent of total billed charges,70% of total billed charges,2297.38,90,,,percent of total billed charges,90% of total billed charges,2425.01,95,,,percent of total billed charges,95% of total billed charges,2425.01,95,,,percent of total billed charges,95% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2195.27,86,,,percent of total billed charges,86% of total billed charges,2042.11,80,,,percent of total billed charges,80% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2476.06,97,,,percent of total billed charges,97% of total billed charges,2297.38,90,,,percent of total billed charges,90% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2476.06,97,,,percent of total billed charges,97% of total billed charges,2373.96,93,,,percent of total billed charges,93% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2476.06,97,,,percent of total billed charges,97% of total billed charges,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2552.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1786.85,2552.64,
32655-PF Thorcoscopy w/Resect Bullae w/wo Plueral Px,4322083,CDM,960,RC,32655,HCPCS,Outpatient,,,1869.48,934.74,,1682.53,90,,,percent of total billed charges,90% of total Billed charges,1912.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,952.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,801.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1476.62,155,,,Fee Schedule,155% of CMS OPPS Rate,952.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,952.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1586.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1586.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1483.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1483.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,771.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1905.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1750.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1260.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1476.62,155,,,Fee Schedule,155% of CMS OPPS Rate,952.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,2964.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2964.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,952.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,801.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1141.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,952.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1967.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1967.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,771.28,2964.44,
32656- Thoracoscopy/parietal pleurectomy,3435897,CDM,510,RC,32656,HCPCS,Outpatient,,,2141.96,1070.98,,1927.76,90,,,percent of total billed charges,90% of total Billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1713.57,80,,,Percent of total Billed charges,80% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1927.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2077.7,97,,,Percent of total billed charges,97% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1970.6,92,,,Percent of total billed charges,92% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1927.76,90,,,percent of total billed charges,90% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1499.37,70,,,percent of total billed charges,70% of total billed charges,1927.76,90,,,percent of total billed charges,90% of total billed charges,2034.86,95,,,percent of total billed charges,95% of total billed charges,2034.86,95,,,percent of total billed charges,95% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1842.09,86,,,percent of total billed charges,86% of total billed charges,1713.57,80,,,percent of total billed charges,80% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2077.7,97,,,percent of total billed charges,97% of total billed charges,1927.76,90,,,percent of total billed charges,90% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2077.7,97,,,percent of total billed charges,97% of total billed charges,1992.02,93,,,percent of total billed charges,93% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2077.7,97,,,percent of total billed charges,97% of total billed charges,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1499.37,2141.96,
32656-PF Thorcoscopy w/Parietal Pleurectomy,4322084,CDM,960,RC,32656,HCPCS,Outpatient,,,1566.38,783.19,,1409.74,90,,,percent of total billed charges,90% of total Billed charges,1603.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,798.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,752.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1237.02,155,,,Fee Schedule,155% of CMS OPPS Rate,798.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1183.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,798.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1330.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1240.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1240.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,646.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1596.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1463.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1047.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1237.02,155,,,Fee Schedule,155% of CMS OPPS Rate,798.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2485.47,155,,,Fee Schedule,155% of CMS OPPS Rate,2485.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,798.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,752.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1117.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,798.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1636.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1636.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,646.39,2485.47,
32658- Thoracoscopy/rmv clot/pericard sac,3435898,CDM,510,RC,32658,HCPCS,Outpatient,,,1901.38,950.69,,1711.24,90,,,percent of total billed charges,90% of total Billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1521.1,80,,,Percent of total Billed charges,80% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1711.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1844.34,97,,,Percent of total billed charges,97% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1749.27,92,,,Percent of total billed charges,92% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1711.24,90,,,percent of total billed charges,90% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1330.97,70,,,percent of total billed charges,70% of total billed charges,1711.24,90,,,percent of total billed charges,90% of total billed charges,1806.31,95,,,percent of total billed charges,95% of total billed charges,1806.31,95,,,percent of total billed charges,95% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1635.19,86,,,percent of total billed charges,86% of total billed charges,1521.1,80,,,percent of total billed charges,80% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1844.34,97,,,percent of total billed charges,97% of total billed charges,1711.24,90,,,percent of total billed charges,90% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1844.34,97,,,percent of total billed charges,97% of total billed charges,1768.28,93,,,percent of total billed charges,93% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1844.34,97,,,percent of total billed charges,97% of total billed charges,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1901.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1330.97,1901.38,
32658-PF Thoracoscopy w/Rmvl Clot/FB frm Pericard Sac,4322085,CDM,960,RC,32658,HCPCS,Outpatient,,,1394.24,697.12,,1254.82,90,,,percent of total billed charges,90% of total Billed charges,1424.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1100.48,155,,,Fee Schedule,155% of CMS OPPS Rate,709.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,709.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1184.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1103.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1103.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,576.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1419.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1301.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,932.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1100.48,155,,,Fee Schedule,155% of CMS OPPS Rate,709.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2208.69,155,,,Fee Schedule,155% of CMS OPPS Rate,2208.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,709.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,675.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1135.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,709.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1458.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1458.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,576.09,2208.69,
"32659- Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardi",3569383,CDM,510,RC,32659,HCPCS,Outpatient,,,1946.52,973.26,,1751.87,90,,,percent of total billed charges,90% of total Billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1557.22,80,,,Percent of total Billed charges,80% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1751.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1888.12,97,,,Percent of total billed charges,97% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1790.8,92,,,Percent of total billed charges,92% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1751.87,90,,,percent of total billed charges,90% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1362.56,70,,,percent of total billed charges,70% of total billed charges,1751.87,90,,,percent of total billed charges,90% of total billed charges,1849.19,95,,,percent of total billed charges,95% of total billed charges,1849.19,95,,,percent of total billed charges,95% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1674.01,86,,,percent of total billed charges,86% of total billed charges,1557.22,80,,,percent of total billed charges,80% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1888.12,97,,,percent of total billed charges,97% of total billed charges,1751.87,90,,,percent of total billed charges,90% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1888.12,97,,,percent of total billed charges,97% of total billed charges,1810.26,93,,,percent of total billed charges,93% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1888.12,97,,,percent of total billed charges,97% of total billed charges,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1362.56,1946.52,
32659-PF Thoracoscopy w/Sac Drainage,4322087,CDM,960,RC,32659,HCPCS,Outpatient,,,1430.24,715.12,,1287.22,90,,,percent of total billed charges,90% of total Billed charges,1459.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,686.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,727.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,727.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1213.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1213.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1129.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1129.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,590.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1454.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1332.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,953.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,727.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2261.74,155,,,Fee Schedule,155% of CMS OPPS Rate,2261.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,727.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1114.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,727.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1501.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1501.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,590.54,2261.74,
32662- Thoracoscopy/exc med cyst/tum/mass,3435899,CDM,510,RC,32662,HCPCS,Outpatient,,,2382.39,1191.20,,2144.15,90,,,percent of total billed charges,90% of total Billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1905.91,80,,,Percent of total Billed charges,80% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2144.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2310.92,97,,,Percent of total billed charges,97% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2191.8,92,,,Percent of total billed charges,92% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2144.15,90,,,percent of total billed charges,90% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1667.67,70,,,percent of total billed charges,70% of total billed charges,2144.15,90,,,percent of total billed charges,90% of total billed charges,2263.27,95,,,percent of total billed charges,95% of total billed charges,2263.27,95,,,percent of total billed charges,95% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2048.86,86,,,percent of total billed charges,86% of total billed charges,1905.91,80,,,percent of total billed charges,80% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2310.92,97,,,percent of total billed charges,97% of total billed charges,2144.15,90,,,percent of total billed charges,90% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2310.92,97,,,percent of total billed charges,97% of total billed charges,2215.62,93,,,percent of total billed charges,93% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2310.92,97,,,percent of total billed charges,97% of total billed charges,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1667.67,2382.39,
32663-PF Thoracoscopy w/Lobectomy,4322088,CDM,960,RC,32663,HCPCS,Outpatient,,,2740.16,1370.08,,2466.14,90,,,percent of total billed charges,90% of total Billed charges,2806.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1396.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2164.47,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2066.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1396.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2324.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2324.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2184.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2184.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1130.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1396.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2792.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2577.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1865.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2164.47,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,4349.9,155,,,Fee Schedule,155% of CMS OPPS Rate,4349.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1396.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1515.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1396.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2879.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2879.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4349.9,
32664- Thoracoscopy/thoracic sympathectom,3435900,CDM,510,RC,32664,HCPCS,Outpatient,,,2262.77,1131.39,,2036.49,90,,,percent of total billed charges,90% of total Billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1810.22,80,,,Percent of total Billed charges,80% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2036.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.89,97,,,Percent of total billed charges,97% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2081.75,92,,,Percent of total billed charges,92% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2036.49,90,,,percent of total billed charges,90% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1583.94,70,,,percent of total billed charges,70% of total billed charges,2036.49,90,,,percent of total billed charges,90% of total billed charges,2149.63,95,,,percent of total billed charges,95% of total billed charges,2149.63,95,,,percent of total billed charges,95% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.98,86,,,percent of total billed charges,86% of total billed charges,1810.22,80,,,percent of total billed charges,80% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.89,97,,,percent of total billed charges,97% of total billed charges,2036.49,90,,,percent of total billed charges,90% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.89,97,,,percent of total billed charges,97% of total billed charges,2104.38,93,,,percent of total billed charges,93% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2194.89,97,,,percent of total billed charges,97% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1583.94,2262.77,
32665- Thoracoscopy/surg/esophagomyotomy,3435901,CDM,510,RC,32665,HCPCS,Outpatient,,,3296.95,1648.48,,2967.26,90,,,percent of total billed charges,90% of total Billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2637.56,80,,,Percent of total Billed charges,80% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3198.04,97,,,Percent of total billed charges,97% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3033.19,92,,,Percent of total billed charges,92% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.26,90,,,percent of total billed charges,90% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2307.87,70,,,percent of total billed charges,70% of total billed charges,2967.26,90,,,percent of total billed charges,90% of total billed charges,3132.1,95,,,percent of total billed charges,95% of total billed charges,3132.1,95,,,percent of total billed charges,95% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2835.38,86,,,percent of total billed charges,86% of total billed charges,2637.56,80,,,percent of total billed charges,80% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3198.04,97,,,percent of total billed charges,97% of total billed charges,2967.26,90,,,percent of total billed charges,90% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3198.04,97,,,percent of total billed charges,97% of total billed charges,3066.16,93,,,percent of total billed charges,93% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3198.04,97,,,percent of total billed charges,97% of total billed charges,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3296.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2307.87,3296.95,
32666- Thoracoscopy/surg/wedg resect/init,3435902,CDM,510,RC,32666,HCPCS,Outpatient,,,2319.15,1159.58,,2087.24,90,,,percent of total billed charges,90% of total Billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1855.32,80,,,Percent of total Billed charges,80% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2087.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2249.58,97,,,Percent of total billed charges,97% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2133.62,92,,,Percent of total billed charges,92% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2087.24,90,,,percent of total billed charges,90% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1623.41,70,,,percent of total billed charges,70% of total billed charges,2087.24,90,,,percent of total billed charges,90% of total billed charges,2203.19,95,,,percent of total billed charges,95% of total billed charges,2203.19,95,,,percent of total billed charges,95% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1994.47,86,,,percent of total billed charges,86% of total billed charges,1855.32,80,,,percent of total billed charges,80% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2249.58,97,,,percent of total billed charges,97% of total billed charges,2087.24,90,,,percent of total billed charges,90% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2249.58,97,,,percent of total billed charges,97% of total billed charges,2156.81,93,,,percent of total billed charges,93% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2249.58,97,,,percent of total billed charges,97% of total billed charges,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2319.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1623.41,2319.15,
32666-PF Thoracoscopy w/Wedge Resect Init Uni,4322089,CDM,960,RC,32666,HCPCS,Outpatient,,,1698.42,849.21,,1528.58,90,,,percent of total billed charges,90% of total Billed charges,1736.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1339.73,155,,,Fee Schedule,155% of CMS OPPS Rate,864.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,864.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1441.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1441.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1345.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1345.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,759.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,864.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1728.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1587.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1137.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1339.73,155,,,Fee Schedule,155% of CMS OPPS Rate,864.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,2691.45,155,,,Fee Schedule,155% of CMS OPPS Rate,2691.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,864.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,818.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,864.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.08,2691.45,
32667- Thoracoscopy/surg/wedge resect,3435903,CDM,510,RC,32667,HCPCS,Outpatient,,,424.95,212.48,,382.46,90,,,percent of total billed charges,90% of total Billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,339.96,80,,,Percent of total Billed charges,80% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,382.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,412.2,97,,,Percent of total billed charges,97% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,390.95,92,,,Percent of total billed charges,92% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,382.46,90,,,percent of total billed charges,90% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,297.47,70,,,percent of total billed charges,70% of total billed charges,382.46,90,,,percent of total billed charges,90% of total billed charges,403.7,95,,,percent of total billed charges,95% of total billed charges,403.7,95,,,percent of total billed charges,95% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,365.46,86,,,percent of total billed charges,86% of total billed charges,339.96,80,,,percent of total billed charges,80% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.2,97,,,percent of total billed charges,97% of total billed charges,382.46,90,,,percent of total billed charges,90% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,412.2,97,,,percent of total billed charges,97% of total billed charges,395.2,93,,,percent of total billed charges,93% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,412.2,97,,,percent of total billed charges,97% of total billed charges,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,424.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,297.47,424.95,
32667-PF Thoracoscopy w/Wedge Resect Addl,4322090,CDM,960,RC,32667,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,317.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,155,,,Fee Schedule,155% of CMS OPPS Rate,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,247.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,247.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,213.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,244.3,155,,,Fee Schedule,155% of CMS OPPS Rate,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.97,155,,,Fee Schedule,155% of CMS OPPS Rate,491.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.53,491.97,
32668- Thoracoscopy/surg/wedg/lung resect,3435904,CDM,510,RC,32668,HCPCS,Outpatient,,,426.05,213.03,,383.45,90,,,percent of total billed charges,90% of total Billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,340.84,80,,,Percent of total Billed charges,80% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,383.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,413.27,97,,,Percent of total billed charges,97% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,391.97,92,,,Percent of total billed charges,92% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,383.45,90,,,percent of total billed charges,90% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,298.24,70,,,percent of total billed charges,70% of total billed charges,383.45,90,,,percent of total billed charges,90% of total billed charges,404.75,95,,,percent of total billed charges,95% of total billed charges,404.75,95,,,percent of total billed charges,95% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,366.4,86,,,percent of total billed charges,86% of total billed charges,340.84,80,,,percent of total billed charges,80% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,413.27,97,,,percent of total billed charges,97% of total billed charges,383.45,90,,,percent of total billed charges,90% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,413.27,97,,,percent of total billed charges,97% of total billed charges,396.23,93,,,percent of total billed charges,93% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,413.27,97,,,percent of total billed charges,97% of total billed charges,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,426.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,298.24,426.05,
32668-PF Thoracoscopy w/Dx Wedge Resect Diag,4322091,CDM,960,RC,32668,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,317.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,155,,,Fee Schedule,155% of CMS OPPS Rate,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,247.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,247.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,213.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,244.3,155,,,Fee Schedule,155% of CMS OPPS Rate,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.62,155,,,Fee Schedule,155% of CMS OPPS Rate,492.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.47,492.62,
32669-PF Thoracoscopy w/Segmentectomy,4322092,CDM,960,RC,32669,HCPCS,Outpatient,,,2629.52,1314.76,,2366.57,90,,,percent of total billed charges,90% of total Billed charges,2691.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1339.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2076.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1339.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1339.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2232.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2232.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2097.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2097.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1167.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1339.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2679,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2474.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1793.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2076.23,155,,,Fee Schedule,155% of CMS OPPS Rate,1339.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,4172.07,155,,,Fee Schedule,155% of CMS OPPS Rate,4172.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1339.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1265.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1339.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.89,4172.07,
32670-PF Thoracoscopy w/Bilobectomy,4322093,CDM,960,RC,32670,HCPCS,Outpatient,,,3136.24,1568.12,,2822.62,90,,,percent of total billed charges,90% of total Billed charges,3221.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1603.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2484.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1603.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2370.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1603.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2666.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2666.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2508,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2508,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1392.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3206.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2959.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2144.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2484.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1603.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,4993.64,155,,,Fee Schedule,155% of CMS OPPS Rate,4993.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1603.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1512.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1603.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1392.92,4993.64,
32671-PF Thoracoscopy w/Pneumonectomy,4322094,CDM,960,RC,32671,HCPCS,Outpatient,,,3481.4,1740.70,,3133.26,90,,,percent of total billed charges,90% of total Billed charges,3564.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1774.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2751,155,,,Fee Schedule,155% of CMS OPPS Rate,1774.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2624.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1774.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2951.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2951.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2782.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2782.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1546.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1774.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3549.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3283.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2389.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2751,155,,,Fee Schedule,155% of CMS OPPS Rate,1774.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,5525.01,155,,,Fee Schedule,155% of CMS OPPS Rate,5525.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1774.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1681.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1774.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1546.64,5525.01,
32673 - PF Thoracoscopy Resect w/Thymus Uni/Bilat,4301613,CDM,960,RC,32673,HCPCS,Outpatient,,,2569.14,1284.57,,2312.23,90,,,percent of total billed charges,90% of total Billed charges,2434.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1211.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,970.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1878.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1211.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2022.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2022.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1896.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1896.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1041.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2423.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2238.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1617.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1878.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,3773.71,155,,,Fee Schedule,155% of CMS OPPS Rate,3773.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1211.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,970.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1128.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1211.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.6,3773.71,
32674 - Thoracoscopy Lymph Node Exc PF,4231109,CDM,960,RC,32674,HCPCS,Outpatient,,,457.41,228.71,,411.67,90,,,percent of total billed charges,90% of total Billed charges,434.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,334.41,155,,,Fee Schedule,155% of CMS OPPS Rate,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,401.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,295.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,334.41,155,,,Fee Schedule,155% of CMS OPPS Rate,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.6,155,,,Fee Schedule,155% of CMS OPPS Rate,673.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,673.6,
32674-PF Thoracoscopy Lymph Node Exc,4322095,CDM,960,RC,32674,HCPCS,Outpatient,,,425.22,212.61,,382.7,90,,,percent of total billed charges,90% of total Billed charges,434.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,334.41,155,,,Fee Schedule,155% of CMS OPPS Rate,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,401.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,295.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,334.41,155,,,Fee Schedule,155% of CMS OPPS Rate,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.6,155,,,Fee Schedule,155% of CMS OPPS Rate,673.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,215.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,673.6,
32701-PF Thorax Stereotactic Rad Target w/Tx,4322096,CDM,960,RC,32701,HCPCS,Outpatient,,,409.88,204.94,,368.89,90,,,percent of total billed charges,90% of total Billed charges,426.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,210.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,178.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,326.96,155,,,Fee Schedule,155% of CMS OPPS Rate,210.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,210.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,223.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,335.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,335.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,189.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,396.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,279.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,326.96,155,,,Fee Schedule,155% of CMS OPPS Rate,210.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.76,155,,,Fee Schedule,155% of CMS OPPS Rate,661.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,210.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,207.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,210.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.67,661.76,
32998-PF Ablate Pulm Tumor Perq RF,4322097,CDM,960,RC,32998,HCPCS,Outpatient,,,833.54,416.77,,750.19,90,,,percent of total billed charges,90% of total Billed charges,1263.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,212.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,666.66,155,,,Fee Schedule,155% of CMS OPPS Rate,430.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,430.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,734.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,679.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,679.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,801.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,506.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,666.66,155,,,Fee Schedule,155% of CMS OPPS Rate,430.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1958.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1958.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,430.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3315.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,430.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,5464.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,5464.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,212.09,5464.48,
"33010- Pericardiocentesis, initial",3430823,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,569.12,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,505.89,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,581.77,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,442.65,70,,,percent of total billed charges,70% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,543.83,86,,,percent of total billed charges,86% of total billed charges,505.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.39,97,,,percent of total billed charges,97% of total billed charges,588.09,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,442.65,7253.45,
33010-PERICARDIOCENTESIS,3431747,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,569.12,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,505.89,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,581.77,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,442.65,70,,,percent of total billed charges,70% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,543.83,86,,,percent of total billed charges,86% of total billed charges,505.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.39,97,,,percent of total billed charges,97% of total billed charges,588.09,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,442.65,7253.45,
33016-Pericardiocentesis,3586871,CDM,481,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,569.12,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,505.89,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,581.77,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,442.65,70,,,percent of total billed charges,70% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,600.74,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,543.83,86,,,percent of total billed charges,86% of total billed charges,505.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,569.12,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.39,97,,,percent of total billed charges,97% of total billed charges,588.09,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,613.39,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,442.65,7253.45,
"33016-PERICARDIOCENTSIS, W/IMAGING",3430627,CDM,481,RC,33016,HCPCS,Outpatient,,,619.39,309.70,,557.45,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,495.51,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.81,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,569.84,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,557.45,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,433.57,70,,,percent of total billed charges,70% of total billed charges,557.45,90,,,percent of total billed charges,90% of total billed charges,588.42,95,,,percent of total billed charges,95% of total billed charges,588.42,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.68,86,,,percent of total billed charges,86% of total billed charges,495.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,600.81,97,,,percent of total billed charges,97% of total billed charges,557.45,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.81,97,,,percent of total billed charges,97% of total billed charges,576.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.81,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.57,7253.45,
33016-PF Pericardiocentesis,3586870,CDM,960,RC,33016,HCPCS,Outpatient,,,632.36,316.18,,569.12,90,,,percent of total billed charges,90% of total Billed charges,471.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.27,155,,,Fee Schedule,155% of CMS OPPS Rate,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,371.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,371.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,438.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,314.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,362.27,155,,,Fee Schedule,155% of CMS OPPS Rate,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.84,155,,,Fee Schedule,155% of CMS OPPS Rate,730.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,266.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.01,730.84,
33016-PF PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,4321403,CDM,981,RC,33016,HCPCS,Outpatient,,,467.46,233.73,,420.71,90,,,percent of total billed charges,90% of total Billed charges,471.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.27,155,,,Fee Schedule,155% of CMS OPPS Rate,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,371.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,371.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,438.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,314.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,362.27,155,,,Fee Schedule,155% of CMS OPPS Rate,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.84,155,,,Fee Schedule,155% of CMS OPPS Rate,730.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,266.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,233.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.01,730.84,
Pericardiocentesis,604580,CDM,481,RC,33016,HCPCS,Outpatient,,,619.39,309.70,,557.45,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,495.51,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.81,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,569.84,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,557.45,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,433.57,70,,,percent of total billed charges,70% of total billed charges,557.45,90,,,percent of total billed charges,90% of total billed charges,588.42,95,,,percent of total billed charges,95% of total billed charges,588.42,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.68,86,,,percent of total billed charges,86% of total billed charges,495.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,600.81,97,,,percent of total billed charges,97% of total billed charges,557.45,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.81,97,,,percent of total billed charges,97% of total billed charges,576.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.81,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.57,7253.45,
"33017 - Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluorosc",3572784,CDM,960,RC,33017,HCPCS,Outpatient,,,661.46,330.73,,595.31,90,,,percent of total billed charges,90% of total Billed charges,493.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,321.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.62,155,,,Fee Schedule,155% of CMS OPPS Rate,765.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,276.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.31,765.62,
33017 - PerQ Prcrd DRG 6yr+ w/o Congenital Car Anomoly,3899022,CDM,983,RC,33017,HCPCS,Outpatient,,,661.46,330.73,,595.31,90,,,percent of total billed charges,90% of total Billed charges,493.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,321.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.62,155,,,Fee Schedule,155% of CMS OPPS Rate,765.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,276.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.31,765.62,
33017-Pericardiocentesis with indwelling catheter,4271112,CDM,481,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,467.9,90,,,percent of total billed charges,90% of total Billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,415.91,80,,,Percent of total Billed charges,80% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,504.29,97,,,Percent of total billed charges,97% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,478.3,92,,,Percent of total billed charges,92% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.9,90,,,percent of total billed charges,90% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,363.92,70,,,percent of total billed charges,70% of total billed charges,467.9,90,,,percent of total billed charges,90% of total billed charges,493.9,95,,,percent of total billed charges,95% of total billed charges,493.9,95,,,percent of total billed charges,95% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,447.11,86,,,percent of total billed charges,86% of total billed charges,415.91,80,,,percent of total billed charges,80% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.29,97,,,percent of total billed charges,97% of total billed charges,467.9,90,,,percent of total billed charges,90% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.29,97,,,percent of total billed charges,97% of total billed charges,483.5,93,,,percent of total billed charges,93% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,504.29,97,,,percent of total billed charges,97% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,363.92,519.89,
33017-PF Pericardiocentesis with indwelling catheter,4271113,CDM,960,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,467.9,90,,,percent of total billed charges,90% of total Billed charges,493.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,321.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.62,155,,,Fee Schedule,155% of CMS OPPS Rate,765.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,276.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.31,765.62,
33017-PF PERQ PRCRD DRG 6YR+ W/O CONGENITAL CAR ANOMALY,4321405,CDM,981,RC,33017,HCPCS,Outpatient,,,490.46,245.23,,441.41,90,,,percent of total billed charges,90% of total Billed charges,493.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,384.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,321.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,380.11,155,,,Fee Schedule,155% of CMS OPPS Rate,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.62,155,,,Fee Schedule,155% of CMS OPPS Rate,765.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,276.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,245.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.31,765.62,
Pericardiocentesis with indwelling catheter,,,761,RC,33017,HCPCS,Outpatient,,,519.89,259.95,,467.9,90,,,percent of total billed charges,90% of total Billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,415.91,80,,,Percent of total Billed charges,80% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,504.29,97,,,Percent of total billed charges,97% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,478.3,92,,,Percent of total billed charges,92% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.9,90,,,percent of total billed charges,90% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,363.92,70,,,percent of total billed charges,70% of total billed charges,467.9,90,,,percent of total billed charges,90% of total billed charges,493.9,95,,,percent of total billed charges,95% of total billed charges,493.9,95,,,percent of total billed charges,95% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,447.11,86,,,percent of total billed charges,86% of total billed charges,415.91,80,,,percent of total billed charges,80% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.29,97,,,percent of total billed charges,97% of total billed charges,467.9,90,,,percent of total billed charges,90% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.29,97,,,percent of total billed charges,97% of total billed charges,483.5,93,,,percent of total billed charges,93% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,504.29,97,,,percent of total billed charges,97% of total billed charges,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,519.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,363.92,519.89,
33018-PF PERQ PRCRD DRG 0-5YR/ANY AGE W/CGEN CAR ANOMALY,4321408,CDM,981,RC,33018,HCPCS,Outpatient,,,577.04,288.52,,519.34,90,,,percent of total billed charges,90% of total Billed charges,583.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,288.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.21,155,,,Fee Schedule,155% of CMS OPPS Rate,288.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,288.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,408.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,436.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,436.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,248.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,515.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,357.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,447.21,155,,,Fee Schedule,155% of CMS OPPS Rate,288.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,904.07,155,,,Fee Schedule,155% of CMS OPPS Rate,904.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,288.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,315.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,288.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.99,904.07,
"33019 - Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guida",3572785,CDM,960,RC,33019,HCPCS,Outpatient,,,573.09,286.55,,515.78,90,,,percent of total billed charges,90% of total Billed charges,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.36,155,,,Fee Schedule,155% of CMS OPPS Rate,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,355.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,355.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,202.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,419.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,295.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,323.36,155,,,Fee Schedule,155% of CMS OPPS Rate,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,657.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,255.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.77,657.37,
33019-PF PERQ PERICARDIAL DRG W/INSJ NDWELLG CATH W/CT,4321413,CDM,981,RC,33019,HCPCS,Outpatient,,,417.24,208.62,,375.52,90,,,percent of total billed charges,90% of total Billed charges,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.36,155,,,Fee Schedule,155% of CMS OPPS Rate,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,355.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,355.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,202.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,417.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,295.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,323.36,155,,,Fee Schedule,155% of CMS OPPS Rate,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,657.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,255.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,208.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.77,657.37,
33020- Pericardiotomy/clot/for bod remove,3430824,CDM,510,RC,33020,HCPCS,Outpatient,,,2217.83,1108.92,,1996.05,90,,,percent of total billed charges,90% of total Billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1774.26,80,,,Percent of total Billed charges,80% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1996.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2151.3,97,,,Percent of total billed charges,97% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2040.4,92,,,Percent of total billed charges,92% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1996.05,90,,,percent of total billed charges,90% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1552.48,70,,,percent of total billed charges,70% of total billed charges,1996.05,90,,,percent of total billed charges,90% of total billed charges,2106.94,95,,,percent of total billed charges,95% of total billed charges,2106.94,95,,,percent of total billed charges,95% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1907.33,86,,,percent of total billed charges,86% of total billed charges,1774.26,80,,,percent of total billed charges,80% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2151.3,97,,,percent of total billed charges,97% of total billed charges,1996.05,90,,,percent of total billed charges,90% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2151.3,97,,,percent of total billed charges,97% of total billed charges,2062.58,93,,,percent of total billed charges,93% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2151.3,97,,,percent of total billed charges,97% of total billed charges,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1552.48,2217.83,
33025- Pericard window/part resect/drain,3430825,CDM,510,RC,33025,HCPCS,Outpatient,,,2055.3,1027.65,,1849.77,90,,,percent of total billed charges,90% of total Billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1644.24,80,,,Percent of total Billed charges,80% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1993.64,97,,,Percent of total billed charges,97% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1890.88,92,,,Percent of total billed charges,92% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.77,90,,,percent of total billed charges,90% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1438.71,70,,,percent of total billed charges,70% of total billed charges,1849.77,90,,,percent of total billed charges,90% of total billed charges,1952.54,95,,,percent of total billed charges,95% of total billed charges,1952.54,95,,,percent of total billed charges,95% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1767.56,86,,,percent of total billed charges,86% of total billed charges,1644.24,80,,,percent of total billed charges,80% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.64,97,,,percent of total billed charges,97% of total billed charges,1849.77,90,,,percent of total billed charges,90% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.64,97,,,percent of total billed charges,97% of total billed charges,1911.43,93,,,percent of total billed charges,93% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1993.64,97,,,percent of total billed charges,97% of total billed charges,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2055.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1438.71,2055.3,
33025- Pericardial Window (Cath Lab),4233154,CDM,481,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,1461.72,90,,,percent of total billed charges,90% of total Billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1299.3,80,,,Percent of total Billed charges,80% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1461.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1575.41,97,,,Percent of total billed charges,97% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1494.2,92,,,Percent of total billed charges,92% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1461.72,90,,,percent of total billed charges,90% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1136.89,70,,,percent of total billed charges,70% of total billed charges,1461.72,90,,,percent of total billed charges,90% of total billed charges,1542.92,95,,,percent of total billed charges,95% of total billed charges,1542.92,95,,,percent of total billed charges,95% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1396.75,86,,,percent of total billed charges,86% of total billed charges,1299.3,80,,,percent of total billed charges,80% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1575.41,97,,,percent of total billed charges,97% of total billed charges,1461.72,90,,,percent of total billed charges,90% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1575.41,97,,,percent of total billed charges,97% of total billed charges,1510.44,93,,,percent of total billed charges,93% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1575.41,97,,,percent of total billed charges,97% of total billed charges,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1624.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1136.89,1624.13,
33025-PF Incicision of Heart Sac,4322098,CDM,960,RC,33025,HCPCS,Outpatient,,,1504.72,752.36,,1354.25,90,,,percent of total billed charges,90% of total Billed charges,1538.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1279.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1279.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,644.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1532.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1413.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1018.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2385.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2385.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1651.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1651.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,2385.36,
33025-PF Pericardial Window (Cath Lab),4233155,CDM,960,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,1461.72,90,,,percent of total billed charges,90% of total Billed charges,1538.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1279.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1279.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,644.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1532.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1413.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1018.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2385.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2385.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1651.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1651.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,2385.36,
Pericardial Window (Cath Lab),,,960,RC,33025,HCPCS,Outpatient,,,1624.13,812.07,,1461.72,90,,,percent of total billed charges,90% of total Billed charges,1538.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1279.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1279.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1198.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,644.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1532.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1413.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1018.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1187.44,155,,,Fee Schedule,155% of CMS OPPS Rate,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2385.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2385.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,766.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1651.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1651.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,2385.36,
33031- Pericardiectomy/sub or com/w bypas,3430828,CDM,510,RC,33031,HCPCS,Outpatient,,,6654.35,3327.18,,5988.92,90,,,percent of total billed charges,90% of total Billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5323.48,80,,,Percent of total Billed charges,80% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5988.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6454.72,97,,,Percent of total billed charges,97% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6122,92,,,Percent of total billed charges,92% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5988.92,90,,,percent of total billed charges,90% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4658.05,70,,,percent of total billed charges,70% of total billed charges,5988.92,90,,,percent of total billed charges,90% of total billed charges,6321.63,95,,,percent of total billed charges,95% of total billed charges,6321.63,95,,,percent of total billed charges,95% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5722.74,86,,,percent of total billed charges,86% of total billed charges,5323.48,80,,,percent of total billed charges,80% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6454.72,97,,,percent of total billed charges,97% of total billed charges,5988.92,90,,,percent of total billed charges,90% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6454.72,97,,,percent of total billed charges,97% of total billed charges,6188.55,93,,,percent of total billed charges,93% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6454.72,97,,,percent of total billed charges,97% of total billed charges,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6654.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4658.05,6654.35,
33120- Exc intracard tumor/resect/bypass,3430829,CDM,510,RC,33120,HCPCS,Outpatient,,,5632.27,2816.14,,5069.04,90,,,percent of total billed charges,90% of total Billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4505.82,80,,,Percent of total Billed charges,80% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5069.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5463.3,97,,,Percent of total billed charges,97% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5181.69,92,,,Percent of total billed charges,92% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5069.04,90,,,percent of total billed charges,90% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3942.59,70,,,percent of total billed charges,70% of total billed charges,5069.04,90,,,percent of total billed charges,90% of total billed charges,5350.66,95,,,percent of total billed charges,95% of total billed charges,5350.66,95,,,percent of total billed charges,95% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4843.75,86,,,percent of total billed charges,86% of total billed charges,4505.82,80,,,percent of total billed charges,80% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5463.3,97,,,percent of total billed charges,97% of total billed charges,5069.04,90,,,percent of total billed charges,90% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5463.3,97,,,percent of total billed charges,97% of total billed charges,5238.01,93,,,percent of total billed charges,93% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5463.3,97,,,percent of total billed charges,97% of total billed charges,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5632.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3942.59,5632.27,
33202- Insert epicardial lead/open,3430830,CDM,510,RC,33202,HCPCS,Outpatient,,,2060.96,1030.48,,1854.86,90,,,percent of total billed charges,90% of total Billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1648.77,80,,,Percent of total Billed charges,80% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1854.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1999.13,97,,,Percent of total billed charges,97% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1896.08,92,,,Percent of total billed charges,92% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1854.86,90,,,percent of total billed charges,90% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1442.67,70,,,percent of total billed charges,70% of total billed charges,1854.86,90,,,percent of total billed charges,90% of total billed charges,1957.91,95,,,percent of total billed charges,95% of total billed charges,1957.91,95,,,percent of total billed charges,95% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1772.43,86,,,percent of total billed charges,86% of total billed charges,1648.77,80,,,percent of total billed charges,80% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1999.13,97,,,percent of total billed charges,97% of total billed charges,1854.86,90,,,percent of total billed charges,90% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1999.13,97,,,percent of total billed charges,97% of total billed charges,1916.69,93,,,percent of total billed charges,93% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1999.13,97,,,percent of total billed charges,97% of total billed charges,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2060.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1442.67,2060.96,
33206- Insertion/replace PPM/atrial lead,3430628,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,1089.56,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,968.5,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1174.3,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,847.43,70,,,percent of total billed charges,70% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1041.13,86,,,percent of total billed charges,86% of total billed charges,968.5,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1174.3,97,,,percent of total billed charges,97% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.3,97,,,percent of total billed charges,97% of total billed charges,1125.88,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1174.3,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,847.43,50354.06,
33206-INSERT PM W/LEADS SGL CHBR ATRIAL,3431748,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,1089.56,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,968.5,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1174.3,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,847.43,70,,,percent of total billed charges,70% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1041.13,86,,,percent of total billed charges,86% of total billed charges,968.5,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1174.3,97,,,percent of total billed charges,97% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.3,97,,,percent of total billed charges,97% of total billed charges,1125.88,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1174.3,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,847.43,50354.06,
33206-Pacemaker Insertion Single,3431749,CDM,481,RC,33206,HCPCS,Outpatient,,,1210.62,605.31,,1089.56,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,968.5,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1174.3,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,847.43,70,,,percent of total billed charges,70% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,1150.09,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1041.13,86,,,percent of total billed charges,86% of total billed charges,968.5,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1174.3,97,,,percent of total billed charges,97% of total billed charges,1089.56,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.3,97,,,percent of total billed charges,97% of total billed charges,1125.88,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1174.3,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,847.43,50354.06,
Pacemaker Insertion Single,,,761,RC,33206,HCPCS,Outpatient,,,1187.28,593.64,,1068.55,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,949.82,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1151.66,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1092.3,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1068.55,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,831.1,70,,,percent of total billed charges,70% of total billed charges,1068.55,90,,,percent of total billed charges,90% of total billed charges,1127.92,95,,,percent of total billed charges,95% of total billed charges,1127.92,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1021.06,86,,,percent of total billed charges,86% of total billed charges,949.82,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1151.66,97,,,percent of total billed charges,97% of total billed charges,1068.55,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.66,97,,,percent of total billed charges,97% of total billed charges,1104.17,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1151.66,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,831.1,50354.06,
33207- Insert new or repl PPM w/vent lead,3430629,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,1149.43,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.71,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.43,90,,,Percent of total Billed charges,90% of total billed charges,507.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1238.83,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1174.97,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,894,70,,,percent of total billed charges,70% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1098.34,86,,,percent of total billed charges,86% of total billed charges,1021.71,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1238.83,97,,,percent of total billed charges,97% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1238.83,97,,,percent of total billed charges,97% of total billed charges,1187.74,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1238.83,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,461.18,50354.06,
33207-INSERT PM W/LEADS SGL CHBR VENTRICL,3431750,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,1149.43,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.71,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.43,90,,,Percent of total Billed charges,90% of total billed charges,507.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1238.83,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1174.97,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,894,70,,,percent of total billed charges,70% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1098.34,86,,,percent of total billed charges,86% of total billed charges,1021.71,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1238.83,97,,,percent of total billed charges,97% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1238.83,97,,,percent of total billed charges,97% of total billed charges,1187.74,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1238.83,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,461.18,50354.06,
33207-Pacemaker Insertion Single,3431751,CDM,481,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,1149.43,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.71,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.43,90,,,Percent of total Billed charges,90% of total billed charges,507.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1238.83,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1174.97,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,894,70,,,percent of total billed charges,70% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,1213.28,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1098.34,86,,,percent of total billed charges,86% of total billed charges,1021.71,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1238.83,97,,,percent of total billed charges,97% of total billed charges,1149.43,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1238.83,97,,,percent of total billed charges,97% of total billed charges,1187.74,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1238.83,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,461.18,50354.06,
33207-PF INSERT PM W/LEADS SGL CHBR VENTRICL,3580862,CDM,960,RC,33207,HCPCS,Outpatient,,,1277.14,638.57,,1149.43,90,,,percent of total billed charges,90% of total Billed charges,953.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,472.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,461.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,732.96,155,,,Fee Schedule,155% of CMS OPPS Rate,472.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,800.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,742.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,742.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,389.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,876.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,621.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,732.96,155,,,Fee Schedule,155% of CMS OPPS Rate,472.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1477.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1477.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,472.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,710.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,472.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,966.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,966.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,389.44,1477.34,
33208- Insert new or repl PPM w/A&V leads,3430630,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.05,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.68,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.72,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.41,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,970.42,70,,,percent of total billed charges,70% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.23,86,,,percent of total billed charges,86% of total billed charges,1109.05,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.72,97,,,percent of total billed charges,97% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.72,97,,,percent of total billed charges,97% of total billed charges,1289.27,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.72,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
33208- PF HIS Bundle Pacemaker Insertion,3690972,CDM,960,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,1034.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,513.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,463.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,795.2,155,,,Fee Schedule,155% of CMS OPPS Rate,513.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,513.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,869.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,807.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,807.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,422.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1026.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,953.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,677.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,795.2,155,,,Fee Schedule,155% of CMS OPPS Rate,513.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1603.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1603.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,513.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,674.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,513.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1043.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,422.62,1603.2,
33208-HIS Bundle Pacemaker Insertion,3690971,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.05,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.68,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.72,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.41,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,970.42,70,,,percent of total billed charges,70% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.23,86,,,percent of total billed charges,86% of total billed charges,1109.05,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.72,97,,,percent of total billed charges,97% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.72,97,,,percent of total billed charges,97% of total billed charges,1289.27,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.72,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
33208-INSERT PM W/LEADS DUAL CHAMBER,3431752,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.05,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.68,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.72,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.41,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,970.42,70,,,percent of total billed charges,70% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.23,86,,,percent of total billed charges,86% of total billed charges,1109.05,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.72,97,,,percent of total billed charges,97% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.72,97,,,percent of total billed charges,97% of total billed charges,1289.27,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.72,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
33208-Pacemaker Insertion Biv,3431753,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.05,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.68,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.72,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.41,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,970.42,70,,,percent of total billed charges,70% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.23,86,,,percent of total billed charges,86% of total billed charges,1109.05,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.72,97,,,percent of total billed charges,97% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.72,97,,,percent of total billed charges,97% of total billed charges,1289.27,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.72,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
33208-Pacemaker Insertion Dual,3431754,CDM,481,RC,33208,HCPCS,Outpatient,,,1386.31,693.16,,1247.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.05,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.68,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.72,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.41,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,970.42,70,,,percent of total billed charges,70% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,1316.99,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.23,86,,,percent of total billed charges,86% of total billed charges,1109.05,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.72,97,,,percent of total billed charges,97% of total billed charges,1247.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.72,97,,,percent of total billed charges,97% of total billed charges,1289.27,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.72,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
HIS Bundle Pacemaker Insertion,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1223.58,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.62,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1223.58,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1318.74,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,951.67,70,,,percent of total billed charges,70% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1169.2,86,,,percent of total billed charges,86% of total billed charges,1087.62,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1318.74,97,,,percent of total billed charges,97% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.74,97,,,percent of total billed charges,97% of total billed charges,1264.36,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1318.74,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
Pacemaker Insertion Biv,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1223.58,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.62,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1223.58,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1318.74,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,951.67,70,,,percent of total billed charges,70% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1169.2,86,,,percent of total billed charges,86% of total billed charges,1087.62,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1318.74,97,,,percent of total billed charges,97% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.74,97,,,percent of total billed charges,97% of total billed charges,1264.36,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1318.74,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
Pacemaker Insertion Dual,,,761,RC,33208,HCPCS,Outpatient,,,1359.53,679.77,,1223.58,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.62,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1223.58,90,,,Percent of total Billed charges,90% of total billed charges,509.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1318.74,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.77,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,951.67,70,,,percent of total billed charges,70% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,1291.55,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1169.2,86,,,percent of total billed charges,86% of total billed charges,1087.62,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1318.74,97,,,percent of total billed charges,97% of total billed charges,1223.58,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.74,97,,,percent of total billed charges,97% of total billed charges,1264.36,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1318.74,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,463.07,50354.06,
33210- Insert/repla temp pace or sgn lead,3430631,CDM,481,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,392.15,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,348.58,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.15,90,,,Percent of total Billed charges,90% of total billed charges,181.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,422.65,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,400.86,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,392.15,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,305,70,,,percent of total billed charges,70% of total billed charges,392.15,90,,,percent of total billed charges,90% of total billed charges,413.93,95,,,percent of total billed charges,95% of total billed charges,413.93,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.72,86,,,percent of total billed charges,86% of total billed charges,348.58,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.65,97,,,percent of total billed charges,97% of total billed charges,392.15,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.65,97,,,percent of total billed charges,97% of total billed charges,405.22,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,422.65,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,164.9,39794.54,
33210-INSERTION TEMPORARY PACEMAKER,3431755,CDM,481,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,392.15,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,348.58,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.15,90,,,Percent of total Billed charges,90% of total billed charges,181.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,422.65,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,400.86,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,392.15,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,305,70,,,percent of total billed charges,70% of total billed charges,392.15,90,,,percent of total billed charges,90% of total billed charges,413.93,95,,,percent of total billed charges,95% of total billed charges,413.93,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.72,86,,,percent of total billed charges,86% of total billed charges,348.58,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.65,97,,,percent of total billed charges,97% of total billed charges,392.15,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.65,97,,,percent of total billed charges,97% of total billed charges,405.22,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,422.65,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,164.9,39794.54,
33210-PF INSERTION TEMPORARY PACEMAKER,3580863,CDM,960,RC,33210,HCPCS,Outpatient,,,435.72,217.86,,392.15,90,,,percent of total billed charges,90% of total Billed charges,325.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.19,155,,,Fee Schedule,155% of CMS OPPS Rate,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,256.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,256.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,302.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.19,155,,,Fee Schedule,155% of CMS OPPS Rate,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,504.15,155,,,Fee Schedule,155% of CMS OPPS Rate,504.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,359.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,133.78,504.15,
33210-PF INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH,4321416,CDM,981,RC,33210,HCPCS,Outpatient,,,322.82,161.41,,290.54,90,,,percent of total billed charges,90% of total Billed charges,325.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.19,155,,,Fee Schedule,155% of CMS OPPS Rate,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,256.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,256.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,302.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.19,155,,,Fee Schedule,155% of CMS OPPS Rate,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,504.15,155,,,Fee Schedule,155% of CMS OPPS Rate,504.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,359.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,133.78,504.15,
Temporary Pacemaker Insertion,604627,CDM,481,RC,33210,HCPCS,Outpatient,,,427.74,213.87,,384.97,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,342.19,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.97,90,,,Percent of total Billed charges,90% of total billed charges,181.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,414.91,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,393.52,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,384.97,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,299.42,70,,,percent of total billed charges,70% of total billed charges,384.97,90,,,percent of total billed charges,90% of total billed charges,406.35,95,,,percent of total billed charges,95% of total billed charges,406.35,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,367.86,86,,,percent of total billed charges,86% of total billed charges,342.19,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,414.91,97,,,percent of total billed charges,97% of total billed charges,384.97,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,97,,,percent of total billed charges,97% of total billed charges,397.8,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,414.91,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,164.9,39794.54,
33211- Insert/replace temp dual electrode,3430831,CDM,510,RC,33211,HCPCS,Outpatient,,,455.22,227.61,,409.7,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,364.18,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,441.56,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,418.8,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,409.7,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,318.65,70,,,percent of total billed charges,70% of total billed charges,409.7,90,,,percent of total billed charges,90% of total billed charges,432.46,95,,,percent of total billed charges,95% of total billed charges,432.46,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,391.49,86,,,percent of total billed charges,86% of total billed charges,364.18,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,441.56,97,,,percent of total billed charges,97% of total billed charges,409.7,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.56,97,,,percent of total billed charges,97% of total billed charges,423.35,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,441.56,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,318.65,39794.54,
33212- Ins pace gen only/exist singl lead,3430832,CDM,481,RC,33212,HCPCS,Outpatient,,,856.65,428.33,,770.99,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,685.32,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,770.99,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,830.95,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.12,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,770.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,599.66,70,,,percent of total billed charges,70% of total billed charges,770.99,90,,,percent of total billed charges,90% of total billed charges,813.82,95,,,percent of total billed charges,95% of total billed charges,813.82,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,736.72,86,,,percent of total billed charges,86% of total billed charges,685.32,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,830.95,97,,,percent of total billed charges,97% of total billed charges,770.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.95,97,,,percent of total billed charges,97% of total billed charges,796.68,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,830.95,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,39794.54,
33212-Pacemaker Change Single,3431756,CDM,481,RC,33212,HCPCS,Outpatient,,,856.65,428.33,,770.99,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,685.32,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,770.99,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,830.95,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,788.12,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,770.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,599.66,70,,,percent of total billed charges,70% of total billed charges,770.99,90,,,percent of total billed charges,90% of total billed charges,813.82,95,,,percent of total billed charges,95% of total billed charges,813.82,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,736.72,86,,,percent of total billed charges,86% of total billed charges,685.32,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,830.95,97,,,percent of total billed charges,97% of total billed charges,770.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.95,97,,,percent of total billed charges,97% of total billed charges,796.68,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,830.95,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,39794.54,
Pacemaker Change Single,,,761,RC,33212,HCPCS,Outpatient,,,838.65,419.33,,754.79,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,670.92,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.79,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,813.49,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,771.56,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,754.79,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,587.06,70,,,percent of total billed charges,70% of total billed charges,754.79,90,,,percent of total billed charges,90% of total billed charges,796.72,95,,,percent of total billed charges,95% of total billed charges,796.72,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,721.24,86,,,percent of total billed charges,86% of total billed charges,670.92,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,813.49,97,,,percent of total billed charges,97% of total billed charges,754.79,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.49,97,,,percent of total billed charges,97% of total billed charges,779.94,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,813.49,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,39794.54,
Replacement of Pacemaker Single,604665,CDM,481,RC,33212,HCPCS,Outpatient,,,838.65,419.33,,754.79,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,670.92,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.79,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,813.49,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,771.56,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,754.79,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,587.06,70,,,percent of total billed charges,70% of total billed charges,754.79,90,,,percent of total billed charges,90% of total billed charges,796.72,95,,,percent of total billed charges,95% of total billed charges,796.72,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,721.24,86,,,percent of total billed charges,86% of total billed charges,670.92,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,813.49,97,,,percent of total billed charges,97% of total billed charges,754.79,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.49,97,,,percent of total billed charges,97% of total billed charges,779.94,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,813.49,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,39794.54,
33213- Ins pace gen only/exist dual leads,3430833,CDM,481,RC,33213,HCPCS,Outpatient,,,893.79,446.90,,804.41,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,715.03,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,866.98,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,822.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,804.41,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,625.65,70,,,percent of total billed charges,70% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,768.66,86,,,percent of total billed charges,86% of total billed charges,715.03,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,866.98,97,,,percent of total billed charges,97% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,866.98,97,,,percent of total billed charges,97% of total billed charges,831.22,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,866.98,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,625.65,50354.06,
33228-Insert Generator Dual,3431757,CDM,481,RC,33213,HCPCS,Outpatient,,,893.79,446.90,,804.41,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,715.03,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,866.98,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,822.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,804.41,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,625.65,70,,,percent of total billed charges,70% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,768.66,86,,,percent of total billed charges,86% of total billed charges,715.03,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,866.98,97,,,percent of total billed charges,97% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,866.98,97,,,percent of total billed charges,97% of total billed charges,831.22,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,866.98,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,625.65,50354.06,
Insert Generator Dual,,,761,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,790.06,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,702.27,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.5,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,807.61,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,614.49,70,,,percent of total billed charges,70% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,754.94,86,,,percent of total billed charges,86% of total billed charges,702.27,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,851.5,97,,,percent of total billed charges,97% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,851.5,97,,,percent of total billed charges,97% of total billed charges,816.39,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,851.5,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,614.49,50354.06,
Pacemaker Change Dual,,,761,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,790.06,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,702.27,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.5,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,807.61,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,614.49,70,,,percent of total billed charges,70% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,754.94,86,,,percent of total billed charges,86% of total billed charges,702.27,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,851.5,97,,,percent of total billed charges,97% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,851.5,97,,,percent of total billed charges,97% of total billed charges,816.39,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,851.5,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,614.49,50354.06,
Replacement of Pacemaker Dual,604667,CDM,481,RC,33213,HCPCS,Outpatient,,,877.84,438.92,,790.06,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,702.27,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.5,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,807.61,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,614.49,70,,,percent of total billed charges,70% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,833.95,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,754.94,86,,,percent of total billed charges,86% of total billed charges,702.27,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,851.5,97,,,percent of total billed charges,97% of total billed charges,790.06,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,851.5,97,,,percent of total billed charges,97% of total billed charges,816.39,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,851.5,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,614.49,50354.06,
33214- PPM upgrade single to dual chamber,3430834,CDM,510,RC,33214,HCPCS,Outpatient,,,1273.47,636.74,,1146.12,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.78,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1146.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1235.27,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.59,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1146.12,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,891.43,70,,,percent of total billed charges,70% of total billed charges,1146.12,90,,,percent of total billed charges,90% of total billed charges,1209.8,95,,,percent of total billed charges,95% of total billed charges,1209.8,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1095.18,86,,,percent of total billed charges,86% of total billed charges,1018.78,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1235.27,97,,,percent of total billed charges,97% of total billed charges,1146.12,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.27,97,,,percent of total billed charges,97% of total billed charges,1184.33,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1235.27,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,891.43,50354.06,
"33214-PF Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and",4271116,CDM,960,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,901.32,90,,,percent of total billed charges,90% of total Billed charges,951.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,472.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,732.19,155,,,Fee Schedule,155% of CMS OPPS Rate,472.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,472.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,798.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,738.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,738.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,386.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,944.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,871.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,615.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,732.19,155,,,Fee Schedule,155% of CMS OPPS Rate,472.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1474.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,472.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,506.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,472.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,960.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,960.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,386.65,1474.42,
"33214-Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and/or",4271115,CDM,481,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,901.32,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,801.18,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,901.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,971.43,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,921.35,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,901.32,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,701.03,70,,,percent of total billed charges,70% of total billed charges,901.32,90,,,percent of total billed charges,90% of total billed charges,951.4,95,,,percent of total billed charges,95% of total billed charges,951.4,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,861.26,86,,,percent of total billed charges,86% of total billed charges,801.18,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,971.43,97,,,percent of total billed charges,97% of total billed charges,901.32,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,971.43,97,,,percent of total billed charges,97% of total billed charges,931.37,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,971.43,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,701.03,50354.06,
"Upgrade PM system single to dual chamber. Incl. removal, testing, insertion of new lead and/or Gen.",,,761,RC,33214,HCPCS,Outpatient,,,1001.47,500.74,,901.32,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,801.18,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,901.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,971.43,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,921.35,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,901.32,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,701.03,70,,,percent of total billed charges,70% of total billed charges,901.32,90,,,percent of total billed charges,90% of total billed charges,951.4,95,,,percent of total billed charges,95% of total billed charges,951.4,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,861.26,86,,,percent of total billed charges,86% of total billed charges,801.18,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,971.43,97,,,percent of total billed charges,97% of total billed charges,901.32,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,971.43,97,,,percent of total billed charges,97% of total billed charges,931.37,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,971.43,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,701.03,50354.06,
33215- Reposition RA or RV lead/PM/ICD,3430632,CDM,481,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,741.07,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,658.73,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,798.71,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,757.54,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,741.07,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,576.39,70,,,percent of total billed charges,70% of total billed charges,741.07,90,,,percent of total billed charges,90% of total billed charges,782.24,95,,,percent of total billed charges,95% of total billed charges,782.24,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,708.13,86,,,percent of total billed charges,86% of total billed charges,658.73,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,798.71,97,,,percent of total billed charges,97% of total billed charges,741.07,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.71,97,,,percent of total billed charges,97% of total billed charges,765.77,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,798.71,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,576.39,14522.85,
33215-LEAD REPOSITION PACING LEAD ICD/PM,3431759,CDM,481,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,741.07,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,658.73,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,798.71,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,757.54,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,741.07,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,576.39,70,,,percent of total billed charges,70% of total billed charges,741.07,90,,,percent of total billed charges,90% of total billed charges,782.24,95,,,percent of total billed charges,95% of total billed charges,782.24,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,708.13,86,,,percent of total billed charges,86% of total billed charges,658.73,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,798.71,97,,,percent of total billed charges,97% of total billed charges,741.07,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.71,97,,,percent of total billed charges,97% of total billed charges,765.77,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,798.71,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,576.39,14522.85,
33215-PF LEAD REPOSITION PACING LEAD ICD/PM,3580864,CDM,960,RC,33215,HCPCS,Outpatient,,,823.41,411.71,,741.07,90,,,percent of total billed charges,90% of total Billed charges,615.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,306.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,288,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,474.52,155,,,Fee Schedule,155% of CMS OPPS Rate,306.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,518.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,479.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,479.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,251.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,612.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,565.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,399.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,474.52,155,,,Fee Schedule,155% of CMS OPPS Rate,306.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,954.44,155,,,Fee Schedule,155% of CMS OPPS Rate,954.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,306.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,288,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,386.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,306.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,603.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,251.63,954.44,
Repositioning of Pacemaker Leads,604649,CDM,481,RC,33215,HCPCS,Outpatient,,,811.3,405.65,,730.17,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,649.04,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,786.96,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,746.4,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,730.17,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,567.91,70,,,percent of total billed charges,70% of total billed charges,730.17,90,,,percent of total billed charges,90% of total billed charges,770.74,95,,,percent of total billed charges,95% of total billed charges,770.74,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,697.72,86,,,percent of total billed charges,86% of total billed charges,649.04,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,786.96,97,,,percent of total billed charges,97% of total billed charges,730.17,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,786.96,97,,,percent of total billed charges,97% of total billed charges,754.51,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,786.96,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,567.91,14522.85,
33216- Insert single lead PPM or ICD,3430633,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-LEAD INSERT SINGLE TRANSV ICD/PM,3431760,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-Lead Insertion RA no generator,3431761,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-Lead Insertion RV no generator,3431762,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-Lead Revision LV or Multiples,3431763,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-Lead Revision RA or Multiples,3431764,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33216-Lead Revision RV or Multiples,3431765,CDM,481,RC,33216,HCPCS,Outpatient,,,984.75,492.38,,886.28,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.8,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.28,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.21,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,905.97,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,689.33,70,,,percent of total billed charges,70% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,935.51,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,846.89,86,,,percent of total billed charges,86% of total billed charges,787.8,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,955.21,97,,,percent of total billed charges,97% of total billed charges,886.28,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.21,97,,,percent of total billed charges,97% of total billed charges,915.82,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.21,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
Lead Insertion RA no generator,,,761,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,871.27,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,774.46,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.27,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,939.04,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,890.63,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,677.66,70,,,percent of total billed charges,70% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,832.55,86,,,percent of total billed charges,86% of total billed charges,774.46,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,939.04,97,,,percent of total billed charges,97% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,939.04,97,,,percent of total billed charges,97% of total billed charges,900.31,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,939.04,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
Lead Insertion RV no generator,,,761,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,871.27,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,774.46,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.27,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,939.04,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,890.63,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,677.66,70,,,percent of total billed charges,70% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,832.55,86,,,percent of total billed charges,86% of total billed charges,774.46,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,939.04,97,,,percent of total billed charges,97% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,939.04,97,,,percent of total billed charges,97% of total billed charges,900.31,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,939.04,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
Repositioning of Single AICD Lead,604651,CDM,481,RC,33216,HCPCS,Outpatient,,,968.08,484.04,,871.27,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,774.46,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.27,90,,,Percent of total Billed charges,90% of total billed charges,392.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,939.04,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,890.63,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,677.66,70,,,percent of total billed charges,70% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,919.68,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,832.55,86,,,percent of total billed charges,86% of total billed charges,774.46,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,939.04,97,,,percent of total billed charges,97% of total billed charges,871.27,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,939.04,97,,,percent of total billed charges,97% of total billed charges,900.31,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,939.04,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.68,39794.54,
33217- Ins 2 trans ven electrodes PPM/ICD,3430634,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,878.54,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,780.93,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.88,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,898.07,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,683.31,70,,,percent of total billed charges,70% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.5,86,,,percent of total billed charges,86% of total billed charges,780.93,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,946.88,97,,,percent of total billed charges,97% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.88,97,,,percent of total billed charges,97% of total billed charges,907.83,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,946.88,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.31,39794.54,
33217-Lead Insertion dual no generator,3431766,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,878.54,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,780.93,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.88,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,898.07,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,683.31,70,,,percent of total billed charges,70% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.5,86,,,percent of total billed charges,86% of total billed charges,780.93,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,946.88,97,,,percent of total billed charges,97% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.88,97,,,percent of total billed charges,97% of total billed charges,907.83,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,946.88,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.31,39794.54,
33217-Lead Insertion multiple no generator,3431767,CDM,481,RC,33217,HCPCS,Outpatient,,,976.16,488.08,,878.54,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,780.93,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.88,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,898.07,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,683.31,70,,,percent of total billed charges,70% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,927.35,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.5,86,,,percent of total billed charges,86% of total billed charges,780.93,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,946.88,97,,,percent of total billed charges,97% of total billed charges,878.54,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.88,97,,,percent of total billed charges,97% of total billed charges,907.83,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,946.88,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.31,39794.54,
Lead Insertion dual no generator,,,761,RC,33217,HCPCS,Outpatient,,,958.82,479.41,,862.94,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,767.06,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,930.06,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,882.11,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,862.94,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,671.17,70,,,percent of total billed charges,70% of total billed charges,862.94,90,,,percent of total billed charges,90% of total billed charges,910.88,95,,,percent of total billed charges,95% of total billed charges,910.88,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,824.59,86,,,percent of total billed charges,86% of total billed charges,767.06,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,930.06,97,,,percent of total billed charges,97% of total billed charges,862.94,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.06,97,,,percent of total billed charges,97% of total billed charges,891.7,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,930.06,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,671.17,39794.54,
33218- Repair single lead PPM/ICD,3430835,CDM,510,RC,33218,HCPCS,Outpatient,,,1028.9,514.45,,926.01,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,823.12,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,926.01,90,,,Percent of total Billed charges,90% of total billed charges,400.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,998.03,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,946.59,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,926.01,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,720.23,70,,,percent of total billed charges,70% of total billed charges,926.01,90,,,percent of total billed charges,90% of total billed charges,977.46,95,,,percent of total billed charges,95% of total billed charges,977.46,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,884.85,86,,,percent of total billed charges,86% of total billed charges,823.12,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,998.03,97,,,percent of total billed charges,97% of total billed charges,926.01,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.03,97,,,percent of total billed charges,97% of total billed charges,956.88,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,998.03,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,364.42,16336.2,
"33218-PF Repair of single transvenous electrode, pacemaker or ICD",4271244,CDM,960,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,729.64,90,,,percent of total billed charges,90% of total Billed charges,769.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,382.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,364.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,592.72,155,,,Fee Schedule,155% of CMS OPPS Rate,382.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,643.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,591.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,591.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,315.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,764.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,697.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,487.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,592.72,155,,,Fee Schedule,155% of CMS OPPS Rate,382.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1192.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1192.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,382.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,382.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,776.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,776.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,315.43,1192.4,
"33218-Repair of single transvenous electrode, pacemaker or ICD",4271243,CDM,481,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,729.64,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,648.57,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,729.64,90,,,Percent of total Billed charges,90% of total billed charges,400.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,786.39,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,745.85,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,729.64,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,567.5,70,,,percent of total billed charges,70% of total billed charges,729.64,90,,,percent of total billed charges,90% of total billed charges,770.17,95,,,percent of total billed charges,95% of total billed charges,770.17,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,697.21,86,,,percent of total billed charges,86% of total billed charges,648.57,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,786.39,97,,,percent of total billed charges,97% of total billed charges,729.64,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,786.39,97,,,percent of total billed charges,97% of total billed charges,753.96,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.39,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,364.42,16336.2,
"Repair of single transvenous electrode, pacemaker or ICD",4271245,CDM,761,RC,33218,HCPCS,Outpatient,,,810.71,405.36,,729.64,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,648.57,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,729.64,90,,,Percent of total Billed charges,90% of total billed charges,400.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,786.39,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,745.85,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,729.64,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,567.5,70,,,percent of total billed charges,70% of total billed charges,729.64,90,,,percent of total billed charges,90% of total billed charges,770.17,95,,,percent of total billed charges,95% of total billed charges,770.17,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,697.21,86,,,percent of total billed charges,86% of total billed charges,648.57,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,786.39,97,,,percent of total billed charges,97% of total billed charges,729.64,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,786.39,97,,,percent of total billed charges,97% of total billed charges,753.96,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.39,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,364.42,16336.2,
33220- Repair 2 leads PPM/ICD,3430836,CDM,510,RC,33220,HCPCS,Outpatient,,,1003.08,501.54,,902.77,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,802.46,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,902.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,972.99,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,922.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,902.77,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,702.16,70,,,percent of total billed charges,70% of total billed charges,902.77,90,,,percent of total billed charges,90% of total billed charges,952.93,95,,,percent of total billed charges,95% of total billed charges,952.93,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,862.65,86,,,percent of total billed charges,86% of total billed charges,802.46,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,972.99,97,,,percent of total billed charges,97% of total billed charges,902.77,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,972.99,97,,,percent of total billed charges,97% of total billed charges,932.86,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,972.99,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,702.16,16336.2,
"33220-PF Repair of 2 transvenous electrodes, pacemaker or ICD",4271247,CDM,960,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,707.49,90,,,percent of total billed charges,90% of total Billed charges,747.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,336.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,574.74,155,,,Fee Schedule,155% of CMS OPPS Rate,370.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,579.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,579.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,315.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,684.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,483.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,574.74,155,,,Fee Schedule,155% of CMS OPPS Rate,370.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1159.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1159.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,336.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,436.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,782.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,782.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,315.56,1159.37,
"33220-Repair of 2 transvenous electrodes, pacemaker or ICD",4271246,CDM,481,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,707.49,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,628.88,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,762.52,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,723.21,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,707.49,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,550.27,70,,,percent of total billed charges,70% of total billed charges,707.49,90,,,percent of total billed charges,90% of total billed charges,746.8,95,,,percent of total billed charges,95% of total billed charges,746.8,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,676.05,86,,,percent of total billed charges,86% of total billed charges,628.88,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,762.52,97,,,percent of total billed charges,97% of total billed charges,707.49,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.52,97,,,percent of total billed charges,97% of total billed charges,731.07,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,762.52,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,550.27,16336.2,
"Repair of 2 transvenous electrodes, pacemaker or ICD",4271248,CDM,761,RC,33220,HCPCS,Outpatient,,,786.1,393.05,,707.49,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,628.88,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,762.52,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,723.21,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,707.49,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,550.27,70,,,percent of total billed charges,70% of total billed charges,707.49,90,,,percent of total billed charges,90% of total billed charges,746.8,95,,,percent of total billed charges,95% of total billed charges,746.8,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,676.05,86,,,percent of total billed charges,86% of total billed charges,628.88,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,762.52,97,,,percent of total billed charges,97% of total billed charges,707.49,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.52,97,,,percent of total billed charges,97% of total billed charges,731.07,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,762.52,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,550.27,16336.2,
33221-Insert Generator  Biventricular,3431768,CDM,481,RC,33221,HCPCS,Outpatient,,,957.15,478.58,,861.44,90,,,percent of total billed charges,90% of total Billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,765.72,80,,,Percent of total Billed charges,80% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,861.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,928.44,97,,,Percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,880.58,92,,,Percent of total billed charges,92% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,45079.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71865.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,91028.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,861.44,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,670.01,70,,,percent of total billed charges,70% of total billed charges,861.44,90,,,percent of total billed charges,90% of total billed charges,909.29,95,,,percent of total billed charges,95% of total billed charges,909.29,95,,,percent of total billed charges,95% of total billed charges,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33918.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,823.15,86,,,percent of total billed charges,86% of total billed charges,765.72,80,,,percent of total billed charges,80% of total billed charges,18933.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,928.44,97,,,percent of total billed charges,97% of total billed charges,861.44,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,928.44,97,,,percent of total billed charges,97% of total billed charges,890.15,93,,,percent of total billed charges,93% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,928.44,97,,,percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,16959.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14415.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,670.01,91028.42,
33221-Pacemaker Change Biventricular,3431769,CDM,481,RC,33221,HCPCS,Outpatient,,,957.15,478.58,,861.44,90,,,percent of total billed charges,90% of total Billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,765.72,80,,,Percent of total Billed charges,80% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,861.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,928.44,97,,,Percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,880.58,92,,,Percent of total billed charges,92% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,45079.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71865.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,91028.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,861.44,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,670.01,70,,,percent of total billed charges,70% of total billed charges,861.44,90,,,percent of total billed charges,90% of total billed charges,909.29,95,,,percent of total billed charges,95% of total billed charges,909.29,95,,,percent of total billed charges,95% of total billed charges,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33918.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,823.15,86,,,percent of total billed charges,86% of total billed charges,765.72,80,,,percent of total billed charges,80% of total billed charges,18933.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,928.44,97,,,percent of total billed charges,97% of total billed charges,861.44,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,928.44,97,,,percent of total billed charges,97% of total billed charges,890.15,93,,,percent of total billed charges,93% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,928.44,97,,,percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,16959.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14415.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,670.01,91028.42,
Insert Generator Biventricular,3427150,CDM,960,RC,33221,HCPCS,Outpatient,,,935.61,467.81,,842.05,90,,,percent of total billed charges,90% of total Billed charges,712.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,282.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,547.23,155,,,Fee Schedule,155% of CMS OPPS Rate,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,603.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,555.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,555.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,655.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,461.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,547.23,155,,,Fee Schedule,155% of CMS OPPS Rate,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1105.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1105.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.66,1105.1,
Pacemaker Change Biventricular,3427130,CDM,960,RC,33221,HCPCS,Outpatient,,,935.61,467.81,,842.05,90,,,percent of total billed charges,90% of total Billed charges,712.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,282.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,547.23,155,,,Fee Schedule,155% of CMS OPPS Rate,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,536.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,603.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,603.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,555.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,555.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,655.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,461.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,547.23,155,,,Fee Schedule,155% of CMS OPPS Rate,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1105.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1105.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,353.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.66,1105.1,
33222- Relocate skin pocket/PPM,3430635,CDM,481,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,810.05,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,720.05,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.05,90,,,Percent of total Billed charges,90% of total billed charges,364.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,873.06,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,828.06,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,810.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,630.04,70,,,percent of total billed charges,70% of total billed charges,810.05,90,,,percent of total billed charges,90% of total billed charges,855.06,95,,,percent of total billed charges,95% of total billed charges,855.06,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,774.05,86,,,percent of total billed charges,86% of total billed charges,720.05,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,873.06,97,,,percent of total billed charges,97% of total billed charges,810.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,873.06,97,,,percent of total billed charges,97% of total billed charges,837.06,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,873.06,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,331.2,8413.78,
33222-PF Pocket Relocation- Pacemaker,3882894,CDM,960,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,810.05,90,,,percent of total billed charges,90% of total Billed charges,672.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,331.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,518.54,155,,,Fee Schedule,155% of CMS OPPS Rate,334.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,565.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,516.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,516.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,272.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,609.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,422.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,518.54,155,,,Fee Schedule,155% of CMS OPPS Rate,334.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1043.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,334.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,455.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,334.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,684.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,684.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,272.49,1043.12,
33222-Pocket Relocation- Pacemaker,3882893,CDM,481,RC,33222,HCPCS,Outpatient,,,900.06,450.03,,810.05,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,720.05,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.05,90,,,Percent of total Billed charges,90% of total billed charges,364.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,873.06,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,828.06,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,810.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,630.04,70,,,percent of total billed charges,70% of total billed charges,810.05,90,,,percent of total billed charges,90% of total billed charges,855.06,95,,,percent of total billed charges,95% of total billed charges,855.06,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,774.05,86,,,percent of total billed charges,86% of total billed charges,720.05,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,873.06,97,,,percent of total billed charges,97% of total billed charges,810.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,873.06,97,,,percent of total billed charges,97% of total billed charges,837.06,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,873.06,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,331.2,8413.78,
Pocket Relocation- Pacemaker,,,761,RC,33222,HCPCS,Outpatient,,,886.53,443.27,,797.88,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,709.22,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.88,90,,,Percent of total Billed charges,90% of total billed charges,364.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,859.93,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,815.61,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,797.88,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,620.57,70,,,percent of total billed charges,70% of total billed charges,797.88,90,,,percent of total billed charges,90% of total billed charges,842.2,95,,,percent of total billed charges,95% of total billed charges,842.2,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,762.42,86,,,percent of total billed charges,86% of total billed charges,709.22,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,859.93,97,,,percent of total billed charges,97% of total billed charges,797.88,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.93,97,,,percent of total billed charges,97% of total billed charges,824.47,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,859.93,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,331.2,8413.78,
33223- Relocate skin pocket/ICD,3430636,CDM,510,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,978.09,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,869.42,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1054.17,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,999.83,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,978.09,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,760.74,70,,,percent of total billed charges,70% of total billed charges,978.09,90,,,percent of total billed charges,90% of total billed charges,1032.43,95,,,percent of total billed charges,95% of total billed charges,1032.43,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,934.62,86,,,percent of total billed charges,86% of total billed charges,869.42,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054.17,97,,,percent of total billed charges,97% of total billed charges,978.09,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.17,97,,,percent of total billed charges,97% of total billed charges,1010.7,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1054.17,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,760.74,8413.78,
33223-PF Relocation/revision of ICD pocket,3872930,CDM,960,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,978.09,90,,,percent of total billed charges,90% of total Billed charges,811.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,402.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,395.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,623.89,155,,,Fee Schedule,155% of CMS OPPS Rate,402.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,607.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,402.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,683.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,330.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,521.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,623.89,155,,,Fee Schedule,155% of CMS OPPS Rate,402.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1257.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1257.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,402.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,540.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,402.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,816.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,330.28,1257.31,
33223-Relocation/revision of ICD pocket,3872928,CDM,481,RC,33223,HCPCS,Outpatient,,,1086.77,543.39,,978.09,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,869.42,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1054.17,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,999.83,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,978.09,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,760.74,70,,,percent of total billed charges,70% of total billed charges,978.09,90,,,percent of total billed charges,90% of total billed charges,1032.43,95,,,percent of total billed charges,95% of total billed charges,1032.43,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,934.62,86,,,percent of total billed charges,86% of total billed charges,869.42,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054.17,97,,,percent of total billed charges,97% of total billed charges,978.09,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.17,97,,,percent of total billed charges,97% of total billed charges,1010.7,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1054.17,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,760.74,8413.78,
Pocket Relocation - ICD,,,761,RC,33223,HCPCS,Outpatient,,,1066.68,533.34,,960.01,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,853.34,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,960.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1034.68,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,981.35,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,960.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,746.68,70,,,percent of total billed charges,70% of total billed charges,960.01,90,,,percent of total billed charges,90% of total billed charges,1013.35,95,,,percent of total billed charges,95% of total billed charges,1013.35,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,917.34,86,,,percent of total billed charges,86% of total billed charges,853.34,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1034.68,97,,,percent of total billed charges,97% of total billed charges,960.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1034.68,97,,,percent of total billed charges,97% of total billed charges,992.01,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1034.68,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,746.68,8413.78,
33224- Insert LV lead to existing PPM/ICD,3430637,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1242.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.6,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1339.33,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,966.53,70,,,percent of total billed charges,70% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.45,86,,,percent of total billed charges,86% of total billed charges,1104.6,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.33,97,,,percent of total billed charges,97% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.33,97,,,percent of total billed charges,97% of total billed charges,1284.1,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1339.33,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,966.53,50354.06,
33224-BIV LEAD INSERT W OR W/O GEN CHANGE,3431770,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1242.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.6,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1339.33,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,966.53,70,,,percent of total billed charges,70% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.45,86,,,percent of total billed charges,86% of total billed charges,1104.6,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.33,97,,,percent of total billed charges,97% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.33,97,,,percent of total billed charges,97% of total billed charges,1284.1,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1339.33,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,966.53,50354.06,
33224-Lead Insertion LV no generator,3431771,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1242.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.6,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1339.33,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,966.53,70,,,percent of total billed charges,70% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.45,86,,,percent of total billed charges,86% of total billed charges,1104.6,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.33,97,,,percent of total billed charges,97% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.33,97,,,percent of total billed charges,97% of total billed charges,1284.1,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1339.33,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,966.53,50354.06,
33224-Lead Insertion multiple no generator,3431772,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1242.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.6,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1339.33,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,966.53,70,,,percent of total billed charges,70% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.45,86,,,percent of total billed charges,86% of total billed charges,1104.6,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.33,97,,,percent of total billed charges,97% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.33,97,,,percent of total billed charges,97% of total billed charges,1284.1,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1339.33,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,966.53,50354.06,
33224-Pocket Revision,3431773,CDM,481,RC,33224,HCPCS,Outpatient,,,1380.75,690.38,,1242.68,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.6,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1339.33,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,966.53,70,,,percent of total billed charges,70% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,1311.71,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.45,86,,,percent of total billed charges,86% of total billed charges,1104.6,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.33,97,,,percent of total billed charges,97% of total billed charges,1242.68,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.33,97,,,percent of total billed charges,97% of total billed charges,1284.1,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1339.33,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,966.53,50354.06,
Insertion of LV Lead (Upgrade),604663,CDM,481,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1218.47,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1083.09,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1218.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1313.24,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.55,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,947.7,70,,,percent of total billed charges,70% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1164.32,86,,,percent of total billed charges,86% of total billed charges,1083.09,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1313.24,97,,,percent of total billed charges,97% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.24,97,,,percent of total billed charges,97% of total billed charges,1259.09,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1313.24,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,947.7,50354.06,
Lead Insertion LV no generator,,,761,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1218.47,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1083.09,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1218.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1313.24,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.55,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,947.7,70,,,percent of total billed charges,70% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1164.32,86,,,percent of total billed charges,86% of total billed charges,1083.09,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1313.24,97,,,percent of total billed charges,97% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.24,97,,,percent of total billed charges,97% of total billed charges,1259.09,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1313.24,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,947.7,50354.06,
Pocket Revision,,,761,RC,33224,HCPCS,Outpatient,,,1353.86,676.93,,1218.47,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1083.09,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1218.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1313.24,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.55,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,947.7,70,,,percent of total billed charges,70% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,1286.17,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1164.32,86,,,percent of total billed charges,86% of total billed charges,1083.09,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1313.24,97,,,percent of total billed charges,97% of total billed charges,1218.47,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.24,97,,,percent of total billed charges,97% of total billed charges,1259.09,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1313.24,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,947.7,50354.06,
33225- Insert LV lead w ICD/PPM insert,3431774,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,1131.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1006.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1131.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1157.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,803.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,989.17,78.65,,,percent of total billed charges,78.65% of total billed charges,1123.48,89.33,,,percent of total billed charges,89.33% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,880.36,70,,,percent of total billed charges,70% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.58,86,,,percent of total billed charges,86% of total billed charges,1006.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1169.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.16,1219.92,
33225-BIV LEAD INSERT NEW SYS,3431775,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,1131.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1006.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1131.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1157.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,803.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,989.17,78.65,,,percent of total billed charges,78.65% of total billed charges,1123.48,89.33,,,percent of total billed charges,89.33% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,880.36,70,,,percent of total billed charges,70% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.58,86,,,percent of total billed charges,86% of total billed charges,1006.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1169.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.16,1219.92,
33225-Defibrillator Insertion Biv,3431776,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,1131.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1006.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1131.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1157.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,803.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,989.17,78.65,,,percent of total billed charges,78.65% of total billed charges,1123.48,89.33,,,percent of total billed charges,89.33% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,880.36,70,,,percent of total billed charges,70% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.58,86,,,percent of total billed charges,86% of total billed charges,1006.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1169.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.16,1219.92,
33225-Pacemaker Insertion Biv,3431777,CDM,481,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,1131.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1006.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1131.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1157.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,803.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,989.17,78.65,,,percent of total billed charges,78.65% of total billed charges,1123.48,89.33,,,percent of total billed charges,89.33% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,880.36,70,,,percent of total billed charges,70% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,1194.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1081.58,86,,,percent of total billed charges,86% of total billed charges,1006.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1131.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,1169.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1219.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.16,1219.92,
33225-PF Insert LV lead w ICD/PPM insert,3580865,CDM,960,RC,33225,HCPCS,Outpatient,,,1257.65,628.83,,1131.89,90,,,percent of total billed charges,90% of total Billed charges,936.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,463.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,335.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,717.96,155,,,Fee Schedule,155% of CMS OPPS Rate,463.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,463.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,784.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,736.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,736.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,381.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,926.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,869.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,626.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,717.96,155,,,Fee Schedule,155% of CMS OPPS Rate,463.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1450.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1450.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,463.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,527.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,463.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,911.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,911.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,335.96,1450.97,
Bi V Lead (Initial Initial),604669,CDM,481,RC,33225,HCPCS,Outpatient,,,1227.48,613.74,,1104.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,981.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1104.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1190.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1129.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,783.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,965.44,78.65,,,percent of total billed charges,78.65% of total billed charges,1096.53,89.33,,,percent of total billed charges,89.33% of total billed charges,1104.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,859.24,70,,,percent of total billed charges,70% of total billed charges,1104.73,90,,,percent of total billed charges,90% of total billed charges,1166.11,95,,,percent of total billed charges,95% of total billed charges,1166.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1055.63,86,,,percent of total billed charges,86% of total billed charges,981.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1190.66,97,,,percent of total billed charges,97% of total billed charges,1104.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1190.66,97,,,percent of total billed charges,97% of total billed charges,1141.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.9,1190.66,
33226- Repos prev impltd card venous sys electrode,3569474,CDM,481,RC,33226,HCPCS,Outpatient,,,1324.43,662.22,,1191.99,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.54,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1284.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1218.48,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1191.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,927.1,70,,,percent of total billed charges,70% of total billed charges,1191.99,90,,,percent of total billed charges,90% of total billed charges,1258.21,95,,,percent of total billed charges,95% of total billed charges,1258.21,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1139.01,86,,,percent of total billed charges,86% of total billed charges,1059.54,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1284.7,97,,,percent of total billed charges,97% of total billed charges,1191.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1284.7,97,,,percent of total billed charges,97% of total billed charges,1231.72,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1284.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,927.1,14522.85,
"33226-LV Lead Reposition including removal, insert and/or repl. of existing generator",4271118,CDM,481,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,928.57,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,825.39,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,928.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1000.79,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,949.2,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,928.57,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,722.22,70,,,percent of total billed charges,70% of total billed charges,928.57,90,,,percent of total billed charges,90% of total billed charges,980.15,95,,,percent of total billed charges,95% of total billed charges,980.15,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,887.3,86,,,percent of total billed charges,86% of total billed charges,825.39,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1000.79,97,,,percent of total billed charges,97% of total billed charges,928.57,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.79,97,,,percent of total billed charges,97% of total billed charges,959.52,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000.79,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,722.22,14522.85,
"33226-PF LV Lead Reposition including removal, insert and/or repl. of existing generator",4271119,CDM,960,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,928.57,90,,,percent of total billed charges,90% of total Billed charges,984.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,486.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,364.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,754.34,155,,,Fee Schedule,155% of CMS OPPS Rate,486.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,736.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,486.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,827.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,776.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,776.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,402.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,973.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,915.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,658.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,754.34,155,,,Fee Schedule,155% of CMS OPPS Rate,486.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1526.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1526.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,486.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,443.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,486.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,975.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,975.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,364.74,1526.27,
"LV Lead Reposition including removal, insert and/or repl. of existing generator",,,761,RC,33226,HCPCS,Outpatient,,,1031.74,515.87,,928.57,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,825.39,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,928.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1000.79,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,949.2,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,928.57,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,722.22,70,,,percent of total billed charges,70% of total billed charges,928.57,90,,,percent of total billed charges,90% of total billed charges,980.15,95,,,percent of total billed charges,95% of total billed charges,980.15,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,887.3,86,,,percent of total billed charges,86% of total billed charges,825.39,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1000.79,97,,,percent of total billed charges,97% of total billed charges,928.57,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.79,97,,,percent of total billed charges,97% of total billed charges,959.52,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000.79,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,722.22,14522.85,
33227- Remove/replace PM gen only/sg lead,3430837,CDM,481,RC,33227,HCPCS,Outpatient,,,900.5,450.25,,810.45,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,720.4,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,873.49,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,828.46,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,810.45,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,630.35,70,,,percent of total billed charges,70% of total billed charges,810.45,90,,,percent of total billed charges,90% of total billed charges,855.48,95,,,percent of total billed charges,95% of total billed charges,855.48,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,774.43,86,,,percent of total billed charges,86% of total billed charges,720.4,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,873.49,97,,,percent of total billed charges,97% of total billed charges,810.45,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,873.49,97,,,percent of total billed charges,97% of total billed charges,837.47,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,873.49,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,630.35,39794.54,
33227-REMOVE & INSERT PM GEN SINGLE,3431778,CDM,481,RC,33227,HCPCS,Outpatient,,,900.5,450.25,,810.45,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,720.4,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,873.49,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,828.46,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,810.45,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,630.35,70,,,percent of total billed charges,70% of total billed charges,810.45,90,,,percent of total billed charges,90% of total billed charges,855.48,95,,,percent of total billed charges,95% of total billed charges,855.48,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,774.43,86,,,percent of total billed charges,86% of total billed charges,720.4,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,873.49,97,,,percent of total billed charges,97% of total billed charges,810.45,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,873.49,97,,,percent of total billed charges,97% of total billed charges,837.47,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,873.49,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,630.35,39794.54,
33228- Remove/replac pacer gen/dual sys,3430638,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,849.27,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,754.9,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,915.32,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,868.14,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,660.54,70,,,percent of total billed charges,70% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,811.52,86,,,percent of total billed charges,86% of total billed charges,754.9,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,915.32,97,,,percent of total billed charges,97% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.32,97,,,percent of total billed charges,97% of total billed charges,877.58,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,915.32,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,660.54,50354.06,
33228-Pacemaker Change Dual,3431758,CDM,481,RC,33228,HCPCS,Outpatient,,,943.82,471.91,,849.44,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,755.06,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,915.51,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,868.31,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,849.44,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,660.67,70,,,percent of total billed charges,70% of total billed charges,849.44,90,,,percent of total billed charges,90% of total billed charges,896.63,95,,,percent of total billed charges,95% of total billed charges,896.63,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,811.69,86,,,percent of total billed charges,86% of total billed charges,755.06,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,915.51,97,,,percent of total billed charges,97% of total billed charges,849.44,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.51,97,,,percent of total billed charges,97% of total billed charges,877.75,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,915.51,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,660.67,50354.06,
33228-PF REMOVE & INSERT PM GEN DUAL,3580866,CDM,960,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,849.27,90,,,percent of total billed charges,90% of total Billed charges,703.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,281.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,539.79,155,,,Fee Schedule,155% of CMS OPPS Rate,348.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,591.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,545.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,545.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,303.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,644.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,454.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,539.79,155,,,Fee Schedule,155% of CMS OPPS Rate,348.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1089.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,348.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,348.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.34,1089.79,
33228-REMOVE & INSERT PM GEN DUAL,3431779,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,849.27,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,754.9,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,915.32,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,868.14,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,660.54,70,,,percent of total billed charges,70% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,811.52,86,,,percent of total billed charges,86% of total billed charges,754.9,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,915.32,97,,,percent of total billed charges,97% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.32,97,,,percent of total billed charges,97% of total billed charges,877.58,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,915.32,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,660.54,50354.06,
33228-Remove/Insert PPM Gen Dual,3560670,CDM,481,RC,33228,HCPCS,Outpatient,,,943.63,471.82,,849.27,90,,,percent of total billed charges,90% of total Billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,754.9,80,,,Percent of total Billed charges,80% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,915.32,97,,,Percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,868.14,92,,,Percent of total billed charges,92% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,24936.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39753.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,50354.06,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,660.54,70,,,percent of total billed charges,70% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,896.45,95,,,percent of total billed charges,95% of total billed charges,9381.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18762.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,811.52,86,,,percent of total billed charges,86% of total billed charges,754.9,80,,,percent of total billed charges,80% of total billed charges,10599.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,915.32,97,,,percent of total billed charges,97% of total billed charges,849.27,90,,,percent of total billed charges,90% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.32,97,,,percent of total billed charges,97% of total billed charges,877.58,93,,,percent of total billed charges,93% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,915.32,97,,,percent of total billed charges,97% of total billed charges,9381.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9381.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7974.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,660.54,50354.06,
33229- Remov/replac PM gen only/mult lead,3430838,CDM,481,RC,33229,HCPCS,Outpatient,,,995.34,497.67,,895.81,90,,,percent of total billed charges,90% of total Billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,796.27,80,,,Percent of total Billed charges,80% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,895.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,965.48,97,,,Percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,915.71,92,,,Percent of total billed charges,92% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,45079.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71865.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,91028.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,895.81,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,696.74,70,,,percent of total billed charges,70% of total billed charges,895.81,90,,,percent of total billed charges,90% of total billed charges,945.57,95,,,percent of total billed charges,95% of total billed charges,945.57,95,,,percent of total billed charges,95% of total billed charges,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33918.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,855.99,86,,,percent of total billed charges,86% of total billed charges,796.27,80,,,percent of total billed charges,80% of total billed charges,18933.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,965.48,97,,,percent of total billed charges,97% of total billed charges,895.81,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,965.48,97,,,percent of total billed charges,97% of total billed charges,925.67,93,,,percent of total billed charges,93% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,965.48,97,,,percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,16959.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14415.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,696.74,91028.42,
33229-REMOVE & INSERT PM GEN MULTI,3431780,CDM,481,RC,33229,HCPCS,Outpatient,,,995.34,497.67,,895.81,90,,,percent of total billed charges,90% of total Billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,796.27,80,,,Percent of total Billed charges,80% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,895.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,965.48,97,,,Percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,915.71,92,,,Percent of total billed charges,92% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,45079.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71865.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,91028.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,895.81,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,696.74,70,,,percent of total billed charges,70% of total billed charges,895.81,90,,,percent of total billed charges,90% of total billed charges,945.57,95,,,percent of total billed charges,95% of total billed charges,945.57,95,,,percent of total billed charges,95% of total billed charges,16959.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33918.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,855.99,86,,,percent of total billed charges,86% of total billed charges,796.27,80,,,percent of total billed charges,80% of total billed charges,18933.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,965.48,97,,,percent of total billed charges,97% of total billed charges,895.81,90,,,percent of total billed charges,90% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,965.48,97,,,percent of total billed charges,97% of total billed charges,925.67,93,,,percent of total billed charges,93% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,965.48,97,,,percent of total billed charges,97% of total billed charges,16959.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,16959.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14415.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,696.74,91028.42,
33230-Defibrillator Change Dual,3431781,CDM,481,RC,33230,HCPCS,Outpatient,,,1022.19,511.10,,919.97,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,817.75,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,919.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,991.52,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,940.41,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,919.97,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,715.53,70,,,percent of total billed charges,70% of total billed charges,919.97,90,,,percent of total billed charges,90% of total billed charges,971.08,95,,,percent of total billed charges,95% of total billed charges,971.08,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,879.08,86,,,percent of total billed charges,86% of total billed charges,817.75,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,991.52,97,,,percent of total billed charges,97% of total billed charges,919.97,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.52,97,,,percent of total billed charges,97% of total billed charges,950.64,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,991.52,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,715.53,111242.21,
Defibrillator Change Dual,,,761,RC,33230,HCPCS,Outpatient,,,1000.22,500.11,,900.2,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,800.18,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,900.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,970.21,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,920.2,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,900.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,700.15,70,,,percent of total billed charges,70% of total billed charges,900.2,90,,,percent of total billed charges,90% of total billed charges,950.21,95,,,percent of total billed charges,95% of total billed charges,950.21,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,860.19,86,,,percent of total billed charges,86% of total billed charges,800.18,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,970.21,97,,,percent of total billed charges,97% of total billed charges,900.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,970.21,97,,,percent of total billed charges,97% of total billed charges,930.2,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,970.21,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,700.15,111242.21,
33231-Defibrillator Change Biv,3431782,CDM,481,RC,33231,HCPCS,Outpatient,,,1061.72,530.86,,955.55,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,849.38,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1029.87,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,976.78,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,955.55,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,743.2,70,,,percent of total billed charges,70% of total billed charges,955.55,90,,,percent of total billed charges,90% of total billed charges,1008.63,95,,,percent of total billed charges,95% of total billed charges,1008.63,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,913.08,86,,,percent of total billed charges,86% of total billed charges,849.38,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1029.87,97,,,percent of total billed charges,97% of total billed charges,955.55,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1029.87,97,,,percent of total billed charges,97% of total billed charges,987.4,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1029.87,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,743.2,156376.18,
Defibrillator Change Biv,,,761,RC,33231,HCPCS,Outpatient,,,1042.51,521.26,,938.26,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,834.01,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1011.23,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,959.11,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,938.26,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,729.76,70,,,percent of total billed charges,70% of total billed charges,938.26,90,,,percent of total billed charges,90% of total billed charges,990.38,95,,,percent of total billed charges,95% of total billed charges,990.38,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,896.56,86,,,percent of total billed charges,86% of total billed charges,834.01,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1011.23,97,,,percent of total billed charges,97% of total billed charges,938.26,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.23,97,,,percent of total billed charges,97% of total billed charges,969.53,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1011.23,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,729.76,156376.18,
33233- Remove PPM generator only,3430639,CDM,481,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,549.98,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,488.87,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,549.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.76,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,562.2,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,549.98,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,427.76,70,,,percent of total billed charges,70% of total billed charges,549.98,90,,,percent of total billed charges,90% of total billed charges,580.54,95,,,percent of total billed charges,95% of total billed charges,580.54,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,525.54,86,,,percent of total billed charges,86% of total billed charges,488.87,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,592.76,97,,,percent of total billed charges,97% of total billed charges,549.98,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.76,97,,,percent of total billed charges,97% of total billed charges,568.31,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,592.76,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,427.76,39794.54,
33233-PF Remove PPM generator only,3580867,CDM,960,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,549.98,90,,,percent of total billed charges,90% of total Billed charges,456.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,351.71,155,,,Fee Schedule,155% of CMS OPPS Rate,226.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,226.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,384.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,348.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,348.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,186.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,411.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,282.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,351.71,155,,,Fee Schedule,155% of CMS OPPS Rate,226.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.87,155,,,Fee Schedule,155% of CMS OPPS Rate,707.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,226.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,226.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,465.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,465.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,186.23,707.87,
33233-Remove PPM generator only,3562983,CDM,481,RC,33233,HCPCS,Outpatient,,,611.09,305.55,,549.98,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,488.87,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,549.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.76,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,562.2,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,549.98,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,427.76,70,,,percent of total billed charges,70% of total billed charges,549.98,90,,,percent of total billed charges,90% of total billed charges,580.54,95,,,percent of total billed charges,95% of total billed charges,580.54,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,525.54,86,,,percent of total billed charges,86% of total billed charges,488.87,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,592.76,97,,,percent of total billed charges,97% of total billed charges,549.98,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.76,97,,,percent of total billed charges,97% of total billed charges,568.31,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,592.76,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,427.76,39794.54,
Removal of Pacemaker,604673,CDM,481,RC,33233,HCPCS,Outpatient,,,601.34,300.67,,541.21,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,481.07,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,541.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,583.3,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,553.23,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,541.21,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,420.94,70,,,percent of total billed charges,70% of total billed charges,541.21,90,,,percent of total billed charges,90% of total billed charges,571.27,95,,,percent of total billed charges,95% of total billed charges,571.27,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.15,86,,,percent of total billed charges,86% of total billed charges,481.07,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,583.3,97,,,percent of total billed charges,97% of total billed charges,541.21,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.3,97,,,percent of total billed charges,97% of total billed charges,559.25,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,583.3,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,420.94,39794.54,
33234-Lead Revision LV or Multiples,3431783,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,1160.58,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.62,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1250.84,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.37,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,902.67,70,,,percent of total billed charges,70% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1109,86,,,percent of total billed charges,86% of total billed charges,1031.62,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1250.84,97,,,percent of total billed charges,97% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.84,97,,,percent of total billed charges,97% of total billed charges,1199.26,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1250.84,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,902.67,16336.21,
33234-Lead Revision RA or Multiples,3431784,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,1160.58,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.62,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1250.84,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.37,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,902.67,70,,,percent of total billed charges,70% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1109,86,,,percent of total billed charges,86% of total billed charges,1031.62,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1250.84,97,,,percent of total billed charges,97% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.84,97,,,percent of total billed charges,97% of total billed charges,1199.26,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1250.84,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,902.67,16336.21,
33234-Lead Revision RV or Multiples,3431785,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,1160.58,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.62,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1250.84,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.37,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,902.67,70,,,percent of total billed charges,70% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1109,86,,,percent of total billed charges,86% of total billed charges,1031.62,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1250.84,97,,,percent of total billed charges,97% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.84,97,,,percent of total billed charges,97% of total billed charges,1199.26,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1250.84,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,902.67,16336.21,
33234-PM LEAD-REMOVAL OF SINGLE TRANS EXT,3431786,CDM,481,RC,33234,HCPCS,Outpatient,,,1289.53,644.77,,1160.58,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.62,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1160.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1250.84,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.37,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,902.67,70,,,percent of total billed charges,70% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,1225.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1109,86,,,percent of total billed charges,86% of total billed charges,1031.62,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1250.84,97,,,percent of total billed charges,97% of total billed charges,1160.58,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.84,97,,,percent of total billed charges,97% of total billed charges,1199.26,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1250.84,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,902.67,16336.21,
Device Extraction,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,1138.15,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.69,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1226.67,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.44,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,885.23,70,,,percent of total billed charges,70% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.56,86,,,percent of total billed charges,86% of total billed charges,1011.69,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.67,97,,,percent of total billed charges,97% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.67,97,,,percent of total billed charges,97% of total billed charges,1176.09,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.67,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,885.23,16336.21,
Lead Revision LV or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,1138.15,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.69,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1226.67,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.44,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,885.23,70,,,percent of total billed charges,70% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.56,86,,,percent of total billed charges,86% of total billed charges,1011.69,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.67,97,,,percent of total billed charges,97% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.67,97,,,percent of total billed charges,97% of total billed charges,1176.09,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.67,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,885.23,16336.21,
Lead Revision RA or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,1138.15,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.69,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1226.67,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.44,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,885.23,70,,,percent of total billed charges,70% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.56,86,,,percent of total billed charges,86% of total billed charges,1011.69,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.67,97,,,percent of total billed charges,97% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.67,97,,,percent of total billed charges,97% of total billed charges,1176.09,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.67,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,885.23,16336.21,
Lead Revision RV or Multiples,,,761,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,1138.15,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.69,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1226.67,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.44,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,885.23,70,,,percent of total billed charges,70% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.56,86,,,percent of total billed charges,86% of total billed charges,1011.69,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.67,97,,,percent of total billed charges,97% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.67,97,,,percent of total billed charges,97% of total billed charges,1176.09,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.67,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,885.23,16336.21,
Removal of Single Lead,604675,CDM,481,RC,33234,HCPCS,Outpatient,,,1264.61,632.31,,1138.15,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.69,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1226.67,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.44,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,885.23,70,,,percent of total billed charges,70% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,1201.38,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.56,86,,,percent of total billed charges,86% of total billed charges,1011.69,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.67,97,,,percent of total billed charges,97% of total billed charges,1138.15,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.67,97,,,percent of total billed charges,97% of total billed charges,1176.09,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.67,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,885.23,16336.21,
33235-PF PPM Lead Removal- Dual,3580868,CDM,960,RC,33235,HCPCS,Outpatient,,,1692.62,846.31,,1523.36,90,,,percent of total billed charges,90% of total Billed charges,1263.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,365.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,972.28,155,,,Fee Schedule,155% of CMS OPPS Rate,627.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1063.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1063.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,981.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,981.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,516.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1254.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1157.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,814.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,972.28,155,,,Fee Schedule,155% of CMS OPPS Rate,627.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1958.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1958.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,627.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,365.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,655.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1259.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1259.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365.24,1958.81,
33235-PPM Lead Removal- Dual,3570627,CDM,481,RC,33235,HCPCS,Outpatient,,,1692.62,846.31,,1523.36,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1354.1,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1523.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1641.84,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1557.21,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1523.36,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1184.83,70,,,percent of total billed charges,70% of total billed charges,1523.36,90,,,percent of total billed charges,90% of total billed charges,1607.99,95,,,percent of total billed charges,95% of total billed charges,1607.99,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1455.65,86,,,percent of total billed charges,86% of total billed charges,1354.1,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1641.84,97,,,percent of total billed charges,97% of total billed charges,1523.36,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1641.84,97,,,percent of total billed charges,97% of total billed charges,1574.14,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1641.84,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1184.83,16336.21,
Removal of Dual Leads,604677,CDM,481,RC,33235,HCPCS,Outpatient,,,1662.32,831.16,,1496.09,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.86,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1496.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.45,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1529.33,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1496.09,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.62,70,,,percent of total billed charges,70% of total billed charges,1496.09,90,,,percent of total billed charges,90% of total billed charges,1579.2,95,,,percent of total billed charges,95% of total billed charges,1579.2,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.6,86,,,percent of total billed charges,86% of total billed charges,1329.86,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.45,97,,,percent of total billed charges,97% of total billed charges,1496.09,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.45,97,,,percent of total billed charges,97% of total billed charges,1545.96,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.45,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.62,16336.21,
33238 - (PF) Removal of permanent transvenous electrode(s) by thoracotomy,3634898,CDM,510,RC,33238,HCPCS,Outpatient,,,2521.79,1260.90,,2269.61,90,,,percent of total billed charges,90% of total Billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2017.43,80,,,Percent of total Billed charges,80% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2269.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2446.14,97,,,Percent of total billed charges,97% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2320.05,92,,,Percent of total billed charges,92% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2269.61,90,,,percent of total billed charges,90% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1765.25,70,,,percent of total billed charges,70% of total billed charges,2269.61,90,,,percent of total billed charges,90% of total billed charges,2395.7,95,,,percent of total billed charges,95% of total billed charges,2395.7,95,,,percent of total billed charges,95% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2168.74,86,,,percent of total billed charges,86% of total billed charges,2017.43,80,,,percent of total billed charges,80% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.14,97,,,percent of total billed charges,97% of total billed charges,2269.61,90,,,percent of total billed charges,90% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.14,97,,,percent of total billed charges,97% of total billed charges,2345.26,93,,,percent of total billed charges,93% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2446.14,97,,,percent of total billed charges,97% of total billed charges,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2521.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1765.25,2521.79,
33240- Insert ICD gen only/exist sng lead,3430640,CDM,481,RC,33240,HCPCS,Outpatient,,,976.66,488.33,,878.99,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,781.33,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,947.36,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,898.53,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.99,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,683.66,70,,,percent of total billed charges,70% of total billed charges,878.99,90,,,percent of total billed charges,90% of total billed charges,927.83,95,,,percent of total billed charges,95% of total billed charges,927.83,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.93,86,,,percent of total billed charges,86% of total billed charges,781.33,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,947.36,97,,,percent of total billed charges,97% of total billed charges,878.99,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,947.36,97,,,percent of total billed charges,97% of total billed charges,908.29,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,947.36,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.66,111242.21,
33240-Defibrillator Change Single,3431787,CDM,481,RC,33240,HCPCS,Outpatient,,,976.66,488.33,,878.99,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,781.33,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,947.36,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,898.53,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.99,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,683.66,70,,,percent of total billed charges,70% of total billed charges,878.99,90,,,percent of total billed charges,90% of total billed charges,927.83,95,,,percent of total billed charges,95% of total billed charges,927.83,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.93,86,,,percent of total billed charges,86% of total billed charges,781.33,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,947.36,97,,,percent of total billed charges,97% of total billed charges,878.99,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,947.36,97,,,percent of total billed charges,97% of total billed charges,908.29,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,947.36,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.66,111242.21,
Defibrillator Change Single,,,761,RC,33240,HCPCS,Outpatient,,,956.7,478.35,,861.03,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,765.36,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,861.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,928,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,880.16,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,861.03,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,669.69,70,,,percent of total billed charges,70% of total billed charges,861.03,90,,,percent of total billed charges,90% of total billed charges,908.87,95,,,percent of total billed charges,95% of total billed charges,908.87,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,822.76,86,,,percent of total billed charges,86% of total billed charges,765.36,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,928,97,,,percent of total billed charges,97% of total billed charges,861.03,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,928,97,,,percent of total billed charges,97% of total billed charges,889.73,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,928,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,669.69,111242.21,
33241- Remove ICD generator only,3430641,CDM,481,RC,33241,HCPCS,Outpatient,,,566.8,283.40,,510.12,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,453.44,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,549.8,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,521.46,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,510.12,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,396.76,70,,,percent of total billed charges,70% of total billed charges,510.12,90,,,percent of total billed charges,90% of total billed charges,538.46,95,,,percent of total billed charges,95% of total billed charges,538.46,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,487.45,86,,,percent of total billed charges,86% of total billed charges,453.44,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,549.8,97,,,percent of total billed charges,97% of total billed charges,510.12,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,549.8,97,,,percent of total billed charges,97% of total billed charges,527.12,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,549.8,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,396.76,16336.21,
33241-PF Pulse Generator REMOVAL ONLY-Single/Dual,3948915,CDM,983,RC,33241,HCPCS,Outpatient,,,566.8,283.40,,510.12,90,,,percent of total billed charges,90% of total Billed charges,422.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,172.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,324.38,155,,,Fee Schedule,155% of CMS OPPS Rate,209.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,356.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,324.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,324.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,264.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,324.38,155,,,Fee Schedule,155% of CMS OPPS Rate,209.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.75,155,,,Fee Schedule,155% of CMS OPPS Rate,654.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,209.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,209.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,436.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,172.18,654.75,
33241-Pulse Generator REMOVAL ONLY-Single/Dual,3948914,CDM,481,RC,33241,HCPCS,Outpatient,,,566.8,283.40,,510.12,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,453.44,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,549.8,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,521.46,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,510.12,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,396.76,70,,,percent of total billed charges,70% of total billed charges,510.12,90,,,percent of total billed charges,90% of total billed charges,538.46,95,,,percent of total billed charges,95% of total billed charges,538.46,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,487.45,86,,,percent of total billed charges,86% of total billed charges,453.44,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,549.8,97,,,percent of total billed charges,97% of total billed charges,510.12,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,549.8,97,,,percent of total billed charges,97% of total billed charges,527.12,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,549.8,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,396.76,16336.21,
33241-Subcutaneous ICD Removal,3431788,CDM,481,RC,33241,HCPCS,Outpatient,,,459.19,229.60,,413.27,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,367.35,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,445.41,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,422.45,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,413.27,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,321.43,70,,,percent of total billed charges,70% of total billed charges,413.27,90,,,percent of total billed charges,90% of total billed charges,436.23,95,,,percent of total billed charges,95% of total billed charges,436.23,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,394.9,86,,,percent of total billed charges,86% of total billed charges,367.35,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,445.41,97,,,percent of total billed charges,97% of total billed charges,413.27,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.41,97,,,percent of total billed charges,97% of total billed charges,427.05,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,445.41,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,321.43,16336.21,
Pulse Generator REMOVAL ONLY-Single/Dual,,,761,RC,33241,HCPCS,Outpatient,,,554.59,277.30,,499.13,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,443.67,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,537.95,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,388.21,70,,,percent of total billed charges,70% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,476.95,86,,,percent of total billed charges,86% of total billed charges,443.67,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,537.95,97,,,percent of total billed charges,97% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.95,97,,,percent of total billed charges,97% of total billed charges,515.77,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,537.95,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,388.21,16336.21,
Removal of AICD,604681,CDM,481,RC,33241,HCPCS,Outpatient,,,554.59,277.30,,499.13,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,443.67,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,537.95,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,388.21,70,,,percent of total billed charges,70% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,476.95,86,,,percent of total billed charges,86% of total billed charges,443.67,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,537.95,97,,,percent of total billed charges,97% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.95,97,,,percent of total billed charges,97% of total billed charges,515.77,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,537.95,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,388.21,16336.21,
Subcutaneous ICD Removal,,,761,RC,33241,HCPCS,Outpatient,,,554.59,277.30,,499.13,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,443.67,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,537.95,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,510.22,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,388.21,70,,,percent of total billed charges,70% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,526.86,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,476.95,86,,,percent of total billed charges,86% of total billed charges,443.67,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,537.95,97,,,percent of total billed charges,97% of total billed charges,499.13,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.95,97,,,percent of total billed charges,97% of total billed charges,515.77,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,537.95,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,388.21,16336.21,
33244- Transven remove sgn/dual ICD leads,3430642,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,2076.68,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.94,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2076.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2238.2,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.19,70,,,percent of total billed charges,70% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1984.38,86,,,percent of total billed charges,86% of total billed charges,1845.94,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2238.2,97,,,percent of total billed charges,97% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.2,97,,,percent of total billed charges,97% of total billed charges,2145.9,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2238.2,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1615.19,16336.21,
33244-ICD LEAD-REMOVAL SINGLE OR DUAL,3431789,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,2076.68,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.94,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2076.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2238.2,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.19,70,,,percent of total billed charges,70% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1984.38,86,,,percent of total billed charges,86% of total billed charges,1845.94,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2238.2,97,,,percent of total billed charges,97% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.2,97,,,percent of total billed charges,97% of total billed charges,2145.9,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2238.2,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1615.19,16336.21,
33244-Lead Extraction  RV entire system,3431790,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,2076.68,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.94,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2076.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2238.2,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.19,70,,,percent of total billed charges,70% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1984.38,86,,,percent of total billed charges,86% of total billed charges,1845.94,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2238.2,97,,,percent of total billed charges,97% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.2,97,,,percent of total billed charges,97% of total billed charges,2145.9,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2238.2,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1615.19,16336.21,
33244-Lead Extraction LV entire system,3431791,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,2076.68,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.94,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2076.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2238.2,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.19,70,,,percent of total billed charges,70% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1984.38,86,,,percent of total billed charges,86% of total billed charges,1845.94,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2238.2,97,,,percent of total billed charges,97% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.2,97,,,percent of total billed charges,97% of total billed charges,2145.9,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2238.2,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1615.19,16336.21,
33244-Lead Extraction RA entire system,3431792,CDM,481,RC,33244,HCPCS,Outpatient,,,2307.42,1153.71,,2076.68,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.94,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2076.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2238.2,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.83,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.19,70,,,percent of total billed charges,70% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,2192.05,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1984.38,86,,,percent of total billed charges,86% of total billed charges,1845.94,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2238.2,97,,,percent of total billed charges,97% of total billed charges,2076.68,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2238.2,97,,,percent of total billed charges,97% of total billed charges,2145.9,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2238.2,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1615.19,16336.21,
Lead Extraction LV entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,2035.86,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.66,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2035.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.21,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.1,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.45,70,,,percent of total billed charges,70% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.38,86,,,percent of total billed charges,86% of total billed charges,1809.66,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2194.21,97,,,percent of total billed charges,97% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2194.21,97,,,percent of total billed charges,97% of total billed charges,2103.73,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2194.21,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1583.45,16336.21,
Lead Extraction RA entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,2035.86,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.66,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2035.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.21,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.1,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.45,70,,,percent of total billed charges,70% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.38,86,,,percent of total billed charges,86% of total billed charges,1809.66,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2194.21,97,,,percent of total billed charges,97% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2194.21,97,,,percent of total billed charges,97% of total billed charges,2103.73,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2194.21,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1583.45,16336.21,
Lead Extraction RV entire system,,,761,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,2035.86,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.66,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2035.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.21,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.1,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.45,70,,,percent of total billed charges,70% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.38,86,,,percent of total billed charges,86% of total billed charges,1809.66,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2194.21,97,,,percent of total billed charges,97% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2194.21,97,,,percent of total billed charges,97% of total billed charges,2103.73,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2194.21,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1583.45,16336.21,
Removal ICD Single Lead,1503099,CDM,481,RC,33244,HCPCS,Outpatient,,,2262.07,1131.04,,2035.86,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.66,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2035.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.21,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,2081.1,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.45,70,,,percent of total billed charges,70% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,2148.97,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.38,86,,,percent of total billed charges,86% of total billed charges,1809.66,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2194.21,97,,,percent of total billed charges,97% of total billed charges,2035.86,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2194.21,97,,,percent of total billed charges,97% of total billed charges,2103.73,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2194.21,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1583.45,16336.21,
33249- Insert/repla ICD w/sg or dual lead,3430643,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
33249-Defibrillator Insertion  Dual,3431793,CDM,481,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
33249-Defibrillator Insertion Biv,3431794,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
33249-Defibrillator Insertion Single,3431795,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
33249-ICD Sys Dual/Single w Lead Ins/Repl,3560659,CDM,481,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
33249-ICD SYS SINGLE/DUAL INSERT/REPLACE,3431796,CDM,480,RC,33249,HCPCS,Outpatient,,,2446.24,1223.12,,2201.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2372.85,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.54,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.37,70,,,percent of total billed charges,70% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,2323.93,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.77,86,,,percent of total billed charges,86% of total billed charges,1956.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.85,97,,,percent of total billed charges,97% of total billed charges,2201.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.85,97,,,percent of total billed charges,97% of total billed charges,2275,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2372.85,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1712.37,156376.18,
Defibrillator Insertion Biv,,,761,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,2154.09,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1914.74,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2154.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2321.63,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.96,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2154.09,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.4,70,,,percent of total billed charges,70% of total billed charges,2154.09,90,,,percent of total billed charges,90% of total billed charges,2273.76,95,,,percent of total billed charges,95% of total billed charges,2273.76,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2058.35,86,,,percent of total billed charges,86% of total billed charges,1914.74,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2321.63,97,,,percent of total billed charges,97% of total billed charges,2154.09,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2321.63,97,,,percent of total billed charges,97% of total billed charges,2225.89,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2321.63,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1675.4,156376.18,
Defibrillator Insertion Dual,,,761,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,2154.09,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1914.74,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2154.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2321.63,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.96,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2154.09,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.4,70,,,percent of total billed charges,70% of total billed charges,2154.09,90,,,percent of total billed charges,90% of total billed charges,2273.76,95,,,percent of total billed charges,95% of total billed charges,2273.76,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2058.35,86,,,percent of total billed charges,86% of total billed charges,1914.74,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2321.63,97,,,percent of total billed charges,97% of total billed charges,2154.09,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2321.63,97,,,percent of total billed charges,97% of total billed charges,2225.89,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2321.63,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1675.4,156376.18,
Defibrillator Insertion Single,3427131,CDM,960,RC,33249,HCPCS,Outpatient,,,2393.43,1196.72,,2154.09,90,,,percent of total billed charges,90% of total Billed charges,1823.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,903.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,839.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1399.93,155,,,Fee Schedule,155% of CMS OPPS Rate,903.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1360.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,903.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1530.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1530.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1419.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1419.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,742.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,903.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1806.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1675.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1187.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1399.93,155,,,Fee Schedule,155% of CMS OPPS Rate,903.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2825.73,155,,,Fee Schedule,155% of CMS OPPS Rate,2825.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,903.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,839.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1249.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,903.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1795.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1795.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,742.77,2825.73,
33254- Modified Maze/limited,3430839,CDM,510,RC,33254,HCPCS,Outpatient,,,3644.77,1822.39,,3280.29,90,,,percent of total billed charges,90% of total Billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2915.82,80,,,Percent of total Billed charges,80% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3280.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3535.43,97,,,Percent of total billed charges,97% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3353.19,92,,,Percent of total billed charges,92% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3280.29,90,,,percent of total billed charges,90% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2551.34,70,,,percent of total billed charges,70% of total billed charges,3280.29,90,,,percent of total billed charges,90% of total billed charges,3462.53,95,,,percent of total billed charges,95% of total billed charges,3462.53,95,,,percent of total billed charges,95% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3134.5,86,,,percent of total billed charges,86% of total billed charges,2915.82,80,,,percent of total billed charges,80% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3535.43,97,,,percent of total billed charges,97% of total billed charges,3280.29,90,,,percent of total billed charges,90% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3535.43,97,,,percent of total billed charges,97% of total billed charges,3389.64,93,,,percent of total billed charges,93% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3535.43,97,,,percent of total billed charges,97% of total billed charges,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3644.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2551.34,3644.77,
33257- Modified Maze/limited /w other op,3430644,CDM,510,RC,33257,HCPCS,Outpatient,,,1546.81,773.41,,1392.13,90,,,percent of total billed charges,90% of total Billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1237.45,80,,,Percent of total Billed charges,80% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1392.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1500.41,97,,,Percent of total billed charges,97% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1423.07,92,,,Percent of total billed charges,92% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1392.13,90,,,percent of total billed charges,90% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.77,70,,,percent of total billed charges,70% of total billed charges,1392.13,90,,,percent of total billed charges,90% of total billed charges,1469.47,95,,,percent of total billed charges,95% of total billed charges,1469.47,95,,,percent of total billed charges,95% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1330.26,86,,,percent of total billed charges,86% of total billed charges,1237.45,80,,,percent of total billed charges,80% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1500.41,97,,,percent of total billed charges,97% of total billed charges,1392.13,90,,,percent of total billed charges,90% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1500.41,97,,,percent of total billed charges,97% of total billed charges,1438.53,93,,,percent of total billed charges,93% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1500.41,97,,,percent of total billed charges,97% of total billed charges,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.77,1546.81,
33259- Maze/extensive/w/card/pulm bypass,3430645,CDM,510,RC,33259,HCPCS,Outpatient,,,2250.7,1125.35,,2025.63,90,,,percent of total billed charges,90% of total Billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1800.56,80,,,Percent of total Billed charges,80% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2025.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2183.18,97,,,Percent of total billed charges,97% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2070.64,92,,,Percent of total billed charges,92% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2025.63,90,,,percent of total billed charges,90% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1575.49,70,,,percent of total billed charges,70% of total billed charges,2025.63,90,,,percent of total billed charges,90% of total billed charges,2138.17,95,,,percent of total billed charges,95% of total billed charges,2138.17,95,,,percent of total billed charges,95% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1935.6,86,,,percent of total billed charges,86% of total billed charges,1800.56,80,,,percent of total billed charges,80% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2183.18,97,,,percent of total billed charges,97% of total billed charges,2025.63,90,,,percent of total billed charges,90% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2183.18,97,,,percent of total billed charges,97% of total billed charges,2093.15,93,,,percent of total billed charges,93% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2183.18,97,,,percent of total billed charges,97% of total billed charges,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1575.49,2250.7,
33262- Remove/replac ICD gen only/sg lead,3430840,CDM,481,RC,33262,HCPCS,Outpatient,,,992.44,496.22,,893.2,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,793.95,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,893.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,962.67,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,913.04,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,893.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,694.71,70,,,percent of total billed charges,70% of total billed charges,893.2,90,,,percent of total billed charges,90% of total billed charges,942.82,95,,,percent of total billed charges,95% of total billed charges,942.82,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,853.5,86,,,percent of total billed charges,86% of total billed charges,793.95,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,962.67,97,,,percent of total billed charges,97% of total billed charges,893.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.67,97,,,percent of total billed charges,97% of total billed charges,922.97,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,962.67,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,694.71,111242.21,
33262-REMOVE & INSERT ICD GEN SINGLE,3431797,CDM,481,RC,33262,HCPCS,Outpatient,,,992.44,496.22,,893.2,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,793.95,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,893.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,962.67,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,913.04,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,893.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,694.71,70,,,percent of total billed charges,70% of total billed charges,893.2,90,,,percent of total billed charges,90% of total billed charges,942.82,95,,,percent of total billed charges,95% of total billed charges,942.82,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,853.5,86,,,percent of total billed charges,86% of total billed charges,793.95,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,962.67,97,,,percent of total billed charges,97% of total billed charges,893.2,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.67,97,,,percent of total billed charges,97% of total billed charges,922.97,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,962.67,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,694.71,111242.21,
33262-Subcutaneous ICD Change,3431798,CDM,481,RC,33262,HCPCS,Outpatient,,,811.88,405.94,,730.69,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,649.5,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,787.52,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,746.93,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,730.69,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,568.32,70,,,percent of total billed charges,70% of total billed charges,730.69,90,,,percent of total billed charges,90% of total billed charges,771.29,95,,,percent of total billed charges,95% of total billed charges,771.29,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,698.22,86,,,percent of total billed charges,86% of total billed charges,649.5,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,787.52,97,,,percent of total billed charges,97% of total billed charges,730.69,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.52,97,,,percent of total billed charges,97% of total billed charges,755.05,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,787.52,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,568.32,111242.21,
Subcutaneous ICD Change,,,761,RC,33262,HCPCS,Outpatient,,,972.69,486.35,,875.42,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,778.15,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,875.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,943.51,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,894.87,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,875.42,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,680.88,70,,,percent of total billed charges,70% of total billed charges,875.42,90,,,percent of total billed charges,90% of total billed charges,924.06,95,,,percent of total billed charges,95% of total billed charges,924.06,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,836.51,86,,,percent of total billed charges,86% of total billed charges,778.15,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,943.51,97,,,percent of total billed charges,97% of total billed charges,875.42,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.51,97,,,percent of total billed charges,97% of total billed charges,904.6,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,943.51,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,680.88,111242.21,
33263- Remov/replac ICD gen/dual lead sys,3430646,CDM,481,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,929.6,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,826.31,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1001.9,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,950.26,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,929.6,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,723.02,70,,,percent of total billed charges,70% of total billed charges,929.6,90,,,percent of total billed charges,90% of total billed charges,981.25,95,,,percent of total billed charges,95% of total billed charges,981.25,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.29,86,,,percent of total billed charges,86% of total billed charges,826.31,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1001.9,97,,,percent of total billed charges,97% of total billed charges,929.6,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1001.9,97,,,percent of total billed charges,97% of total billed charges,960.59,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1001.9,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.02,111242.21,
33263-PF REMOVE & INSERT ICD GEN DUAL,3580869,CDM,960,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,929.6,90,,,percent of total billed charges,90% of total Billed charges,769.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,304.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,590.94,155,,,Fee Schedule,155% of CMS OPPS Rate,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,381.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,597.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,597.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,328.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,705.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,495.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,590.94,155,,,Fee Schedule,155% of CMS OPPS Rate,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1192.96,155,,,Fee Schedule,155% of CMS OPPS Rate,1192.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.98,1192.96,
33263-PF Subcutaneous ICD Change,3580870,CDM,960,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,929.6,90,,,percent of total billed charges,90% of total Billed charges,769.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,304.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,590.94,155,,,Fee Schedule,155% of CMS OPPS Rate,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,381.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,597.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,597.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,328.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,705.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,495.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,590.94,155,,,Fee Schedule,155% of CMS OPPS Rate,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1192.96,155,,,Fee Schedule,155% of CMS OPPS Rate,1192.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,381.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.98,1192.96,
33263-REMOVE & INSERT ICD GEN DUAL,3431799,CDM,481,RC,33263,HCPCS,Outpatient,,,1032.89,516.45,,929.6,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,826.31,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1001.9,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,950.26,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,929.6,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,723.02,70,,,percent of total billed charges,70% of total billed charges,929.6,90,,,percent of total billed charges,90% of total billed charges,981.25,95,,,percent of total billed charges,95% of total billed charges,981.25,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.29,86,,,percent of total billed charges,86% of total billed charges,826.31,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1001.9,97,,,percent of total billed charges,97% of total billed charges,929.6,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1001.9,97,,,percent of total billed charges,97% of total billed charges,960.59,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1001.9,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.02,111242.21,
33263-Subcutaneous ICD Change,3431800,CDM,481,RC,33263,HCPCS,Outpatient,,,844.52,422.26,,760.07,90,,,percent of total billed charges,90% of total Billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,675.62,80,,,Percent of total Billed charges,80% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,760.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,819.18,97,,,Percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,776.96,92,,,Percent of total billed charges,92% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,55089.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87823.91,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,111242.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,760.07,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,591.16,70,,,percent of total billed charges,70% of total billed charges,760.07,90,,,percent of total billed charges,90% of total billed charges,802.29,95,,,percent of total billed charges,95% of total billed charges,802.29,95,,,percent of total billed charges,95% of total billed charges,20724.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41449.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,726.29,86,,,percent of total billed charges,86% of total billed charges,675.62,80,,,percent of total billed charges,80% of total billed charges,23482.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,819.18,97,,,percent of total billed charges,97% of total billed charges,760.07,90,,,percent of total billed charges,90% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,819.18,97,,,percent of total billed charges,97% of total billed charges,785.4,93,,,percent of total billed charges,93% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,819.18,97,,,percent of total billed charges,97% of total billed charges,20724.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,20724.96,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17616.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,591.16,111242.21,
33264- Remov/replac ICD gen/mult lead sys,3430647,CDM,481,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,968.86,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,861.21,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,968.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1044.21,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,990.39,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,968.86,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,753.56,70,,,percent of total billed charges,70% of total billed charges,968.86,90,,,percent of total billed charges,90% of total billed charges,1022.68,95,,,percent of total billed charges,95% of total billed charges,1022.68,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,925.8,86,,,percent of total billed charges,86% of total billed charges,861.21,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1044.21,97,,,percent of total billed charges,97% of total billed charges,968.86,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.21,97,,,percent of total billed charges,97% of total billed charges,1001.15,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1044.21,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,753.56,156376.18,
33264-PF REMOVE & INSERT ICD GEN MULTI,3580871,CDM,960,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,968.86,90,,,percent of total billed charges,90% of total Billed charges,802.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,316.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,616.13,155,,,Fee Schedule,155% of CMS OPPS Rate,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,397.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,676.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,341.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,737.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,520.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,616.13,155,,,Fee Schedule,155% of CMS OPPS Rate,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1243.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1243.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,368.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.66,1243.57,
33264-PF Subcutaneous ICD Change,3580872,CDM,960,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,968.86,90,,,percent of total billed charges,90% of total Billed charges,802.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,316.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,616.13,155,,,Fee Schedule,155% of CMS OPPS Rate,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,397.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,676.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,676.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,341.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,737.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,520.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,616.13,155,,,Fee Schedule,155% of CMS OPPS Rate,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1243.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1243.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,368.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,397.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.66,1243.57,
33264-REMOVE & INSERT ICD GEN MULTI,3431801,CDM,481,RC,33264,HCPCS,Outpatient,,,1076.51,538.26,,968.86,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,861.21,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,968.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1044.21,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,990.39,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,968.86,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,753.56,70,,,percent of total billed charges,70% of total billed charges,968.86,90,,,percent of total billed charges,90% of total billed charges,1022.68,95,,,percent of total billed charges,95% of total billed charges,1022.68,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,925.8,86,,,percent of total billed charges,86% of total billed charges,861.21,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1044.21,97,,,percent of total billed charges,97% of total billed charges,968.86,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.21,97,,,percent of total billed charges,97% of total billed charges,1001.15,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1044.21,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,753.56,156376.18,
33264-Subcutaneous ICD Change,3431802,CDM,481,RC,33264,HCPCS,Outpatient,,,883.59,441.80,,795.23,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,706.87,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,795.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,857.08,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,812.9,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,795.23,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,618.51,70,,,percent of total billed charges,70% of total billed charges,795.23,90,,,percent of total billed charges,90% of total billed charges,839.41,95,,,percent of total billed charges,95% of total billed charges,839.41,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,759.89,86,,,percent of total billed charges,86% of total billed charges,706.87,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,857.08,97,,,percent of total billed charges,97% of total billed charges,795.23,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.08,97,,,percent of total billed charges,97% of total billed charges,821.74,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,857.08,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,618.51,156376.18,
33268 - PF Excl LAA Opn TM Strnt/Thrcm Any Method,4301614,CDM,960,RC,33268,HCPCS,Outpatient,,,277.49,138.75,,249.74,90,,,percent of total billed charges,90% of total Billed charges,263.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.88,155,,,Fee Schedule,155% of CMS OPPS Rate,130.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.25,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.88,155,,,Fee Schedule,155% of CMS OPPS Rate,130.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.03,155,,,Fee Schedule,155% of CMS OPPS Rate,409.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.25,409.03,
33269 - PF Exclusion L ATR Appendage Thorascopic-Any method,4361840,CDM,960,RC,33269,HCPCS,Outpatient,,,1645.64,822.82,,1481.08,90,,,percent of total billed charges,90% of total Billed charges,1650.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,818.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.83,155,,,Fee Schedule,155% of CMS OPPS Rate,818.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.69,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1637.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1268.83,155,,,Fee Schedule,155% of CMS OPPS Rate,818.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2558.38,155,,,Fee Schedule,155% of CMS OPPS Rate,2558.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,818.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,818.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.69,2558.38,
33270- Inser/repla ICD w/lead/ thres test,3430648,CDM,481,RC,33270,HCPCS,Outpatient,,,1501.09,750.55,,1350.98,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1200.87,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1350.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1456.06,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1381,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1350.98,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.76,70,,,percent of total billed charges,70% of total billed charges,1350.98,90,,,percent of total billed charges,90% of total billed charges,1426.04,95,,,percent of total billed charges,95% of total billed charges,1426.04,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1290.94,86,,,percent of total billed charges,86% of total billed charges,1200.87,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1456.06,97,,,percent of total billed charges,97% of total billed charges,1350.98,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1456.06,97,,,percent of total billed charges,97% of total billed charges,1396.01,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1456.06,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1050.76,156376.18,
33270-INSERT/REPLACE OF S-ICD SYSTEM,3431803,CDM,481,RC,33270,HCPCS,Outpatient,,,1501.09,750.55,,1350.98,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1200.87,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1350.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1456.06,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1381,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1350.98,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.76,70,,,percent of total billed charges,70% of total billed charges,1350.98,90,,,percent of total billed charges,90% of total billed charges,1426.04,95,,,percent of total billed charges,95% of total billed charges,1426.04,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1290.94,86,,,percent of total billed charges,86% of total billed charges,1200.87,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1456.06,97,,,percent of total billed charges,97% of total billed charges,1350.98,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1456.06,97,,,percent of total billed charges,97% of total billed charges,1396.01,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1456.06,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1050.76,156376.18,
33270-Subcutaneous ICD Insertion,3431804,CDM,481,RC,33270,HCPCS,Outpatient,,,1236.24,618.12,,1112.62,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,988.99,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1112.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1199.15,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1137.34,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1112.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,865.37,70,,,percent of total billed charges,70% of total billed charges,1112.62,90,,,percent of total billed charges,90% of total billed charges,1174.43,95,,,percent of total billed charges,95% of total billed charges,1174.43,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1063.17,86,,,percent of total billed charges,86% of total billed charges,988.99,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1199.15,97,,,percent of total billed charges,97% of total billed charges,1112.62,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1199.15,97,,,percent of total billed charges,97% of total billed charges,1149.7,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1199.15,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,865.37,156376.18,
Subcutaneous ICD Insertion,,,761,RC,33270,HCPCS,Outpatient,,,1471.23,735.62,,1324.11,90,,,percent of total billed charges,90% of total Billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.98,80,,,Percent of total Billed charges,80% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1324.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1427.09,97,,,Percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.53,92,,,Percent of total billed charges,92% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,77440.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123456.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,156376.18,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1324.11,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.86,70,,,percent of total billed charges,70% of total billed charges,1324.11,90,,,percent of total billed charges,90% of total billed charges,1397.67,95,,,percent of total billed charges,95% of total billed charges,1397.67,95,,,percent of total billed charges,95% of total billed charges,29133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58267.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.26,86,,,percent of total billed charges,86% of total billed charges,1176.98,80,,,percent of total billed charges,80% of total billed charges,33376.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1427.09,97,,,percent of total billed charges,97% of total billed charges,1324.11,90,,,percent of total billed charges,90% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1427.09,97,,,percent of total billed charges,97% of total billed charges,1368.24,93,,,percent of total billed charges,93% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1427.09,97,,,percent of total billed charges,97% of total billed charges,29133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,29133.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,24763.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1029.86,156376.18,
33271-Lead Insert Subq defib lead only no gen,3431805,CDM,481,RC,33271,HCPCS,Outpatient,,,1209.28,604.64,,1088.35,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,967.42,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1088.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1173,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.54,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1088.35,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,846.5,70,,,percent of total billed charges,70% of total billed charges,1088.35,90,,,percent of total billed charges,90% of total billed charges,1148.82,95,,,percent of total billed charges,95% of total billed charges,1148.82,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1039.98,86,,,percent of total billed charges,86% of total billed charges,967.42,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1173,97,,,percent of total billed charges,97% of total billed charges,1088.35,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173,97,,,percent of total billed charges,97% of total billed charges,1124.63,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1173,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,846.5,39794.54,
Lead Insert Subq defib lead only no gen,,,761,RC,33271,HCPCS,Outpatient,,,1186.14,593.07,,1067.53,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,948.91,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1067.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1150.56,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.25,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1067.53,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,830.3,70,,,percent of total billed charges,70% of total billed charges,1067.53,90,,,percent of total billed charges,90% of total billed charges,1126.83,95,,,percent of total billed charges,95% of total billed charges,1126.83,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1020.08,86,,,percent of total billed charges,86% of total billed charges,948.91,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1150.56,97,,,percent of total billed charges,97% of total billed charges,1067.53,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.56,97,,,percent of total billed charges,97% of total billed charges,1103.11,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1150.56,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,830.3,39794.54,
33272-PF Subcutaneous ICD Removal,3580873,CDM,960,RC,33272,HCPCS,Outpatient,,,922.44,461.22,,830.2,90,,,percent of total billed charges,90% of total Billed charges,688.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.11,155,,,Fee Schedule,155% of CMS OPPS Rate,341.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,578.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,534.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,534.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,384.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,443.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,529.11,155,,,Fee Schedule,155% of CMS OPPS Rate,341.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1066.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,341.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,403.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,341.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.36,1066.76,
33272-Subcutaneous ICD Removal,3431806,CDM,481,RC,33272,HCPCS,Outpatient,,,922.44,461.22,,830.2,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,737.95,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,894.77,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,848.64,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.17,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,830.2,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,645.71,70,,,percent of total billed charges,70% of total billed charges,830.2,90,,,percent of total billed charges,90% of total billed charges,876.32,95,,,percent of total billed charges,95% of total billed charges,876.32,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,793.3,86,,,percent of total billed charges,86% of total billed charges,737.95,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,894.77,97,,,percent of total billed charges,97% of total billed charges,830.2,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,894.77,97,,,percent of total billed charges,97% of total billed charges,857.87,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,894.77,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,645.71,16336.21,
33273- Repos prev implntd SQ implantable defib elect,3569418,CDM,510,RC,33273,HCPCS,Outpatient,,,1063.94,531.97,,957.55,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,851.15,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,957.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1032.02,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,978.82,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,957.55,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,744.76,70,,,percent of total billed charges,70% of total billed charges,957.55,90,,,percent of total billed charges,90% of total billed charges,1010.74,95,,,percent of total billed charges,95% of total billed charges,1010.74,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,914.99,86,,,percent of total billed charges,86% of total billed charges,851.15,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1032.02,97,,,percent of total billed charges,97% of total billed charges,957.55,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1032.02,97,,,percent of total billed charges,97% of total billed charges,989.46,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1032.02,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,744.76,16336.2,
33273-PF Reposition of previously implanted SubQ ICD lead,4271122,CDM,960,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,753.28,90,,,percent of total billed charges,90% of total Billed charges,794.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,394.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.92,155,,,Fee Schedule,155% of CMS OPPS Rate,394.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,394.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,666.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,666.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,618.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,618.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,339.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,394.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,789.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,729.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,518.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,611.92,155,,,Fee Schedule,155% of CMS OPPS Rate,394.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1232.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1232.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,394.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,446.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,394.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.52,1232.03,
33273-Reposition of previously implanted SubQ ICD lead,4271121,CDM,481,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,753.28,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,669.58,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,811.87,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,770.02,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.28,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,585.89,70,,,percent of total billed charges,70% of total billed charges,753.28,90,,,percent of total billed charges,90% of total billed charges,795.13,95,,,percent of total billed charges,95% of total billed charges,795.13,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,719.8,86,,,percent of total billed charges,86% of total billed charges,669.58,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,811.87,97,,,percent of total billed charges,97% of total billed charges,753.28,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.87,97,,,percent of total billed charges,97% of total billed charges,778.39,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,811.87,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,585.89,16336.2,
Reposition of previously implanted SubQ ICD lead,,,761,RC,33273,HCPCS,Outpatient,,,836.98,418.49,,753.28,90,,,percent of total billed charges,90% of total Billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,669.58,80,,,Percent of total Billed charges,80% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,811.87,97,,,Percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,770.02,92,,,Percent of total billed charges,92% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,8090.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12897.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16336.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.28,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,585.89,70,,,percent of total billed charges,70% of total billed charges,753.28,90,,,percent of total billed charges,90% of total billed charges,795.13,95,,,percent of total billed charges,95% of total billed charges,795.13,95,,,percent of total billed charges,95% of total billed charges,3043.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6087.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,719.8,86,,,percent of total billed charges,86% of total billed charges,669.58,80,,,percent of total billed charges,80% of total billed charges,3085.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,811.87,97,,,percent of total billed charges,97% of total billed charges,753.28,90,,,percent of total billed charges,90% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.87,97,,,percent of total billed charges,97% of total billed charges,778.39,93,,,percent of total billed charges,93% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,811.87,97,,,percent of total billed charges,97% of total billed charges,3043.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,3043.51,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2586.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,585.89,16336.2,
33274 - Single Chamber Leadless Pacemaker Insertion/Replacem,4185320,CDM,481,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,2063.96,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.63,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2063.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2224.49,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2109.83,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2063.96,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.3,70,,,percent of total billed charges,70% of total billed charges,2063.96,90,,,percent of total billed charges,90% of total billed charges,2178.63,95,,,percent of total billed charges,95% of total billed charges,2178.63,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1972.23,86,,,percent of total billed charges,86% of total billed charges,1834.63,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2224.49,97,,,percent of total billed charges,97% of total billed charges,2063.96,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2224.49,97,,,percent of total billed charges,97% of total billed charges,2132.76,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2224.49,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1605.3,83742.97,
33274-PF Single Chamber Leadless Pacemaker Insertion/Replace,4185321,CDM,960,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,2063.96,90,,,percent of total billed charges,90% of total Billed charges,956.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,474.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.78,155,,,Fee Schedule,155% of CMS OPPS Rate,474.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,474.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,811.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,811.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,751.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,751.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,440.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,948.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,887.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,627.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,734.78,155,,,Fee Schedule,155% of CMS OPPS Rate,474.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1483.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1483.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,474.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,554.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,474.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.09,2063.96,
Single Chamber Leadless Pacemaker Insertion/Replacement/ or Removal and Replacement,,,761,RC,33274,HCPCS,Outpatient,,,2293.29,1146.65,,2063.96,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1834.63,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2063.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2224.49,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2109.83,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2063.96,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.3,70,,,percent of total billed charges,70% of total billed charges,2063.96,90,,,percent of total billed charges,90% of total billed charges,2178.63,95,,,percent of total billed charges,95% of total billed charges,2178.63,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1972.23,86,,,percent of total billed charges,86% of total billed charges,1834.63,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2224.49,97,,,percent of total billed charges,97% of total billed charges,2063.96,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2224.49,97,,,percent of total billed charges,97% of total billed charges,2132.76,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2224.49,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1605.3,83742.97,
33275 - PF Removal of Permanent Leadless Pacemaker,4185324,CDM,960,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,2165.99,90,,,percent of total billed charges,90% of total Billed charges,1005.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,498.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.61,155,,,Fee Schedule,155% of CMS OPPS Rate,498.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,789.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,498.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,888.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,888.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,824.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,824.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,467.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,996.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,972.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,690.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,772.61,155,,,Fee Schedule,155% of CMS OPPS Rate,498.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1558.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1558.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,498.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,498.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.64,2165.99,
33275 - Removal of Permanent Leadless Pacemaker,4185323,CDM,481,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,2165.99,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1925.32,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2165.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2334.45,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2214.12,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2165.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.66,70,,,percent of total billed charges,70% of total billed charges,2165.99,90,,,percent of total billed charges,90% of total billed charges,2286.32,95,,,percent of total billed charges,95% of total billed charges,2286.32,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2069.72,86,,,percent of total billed charges,86% of total billed charges,1925.32,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2334.45,97,,,percent of total billed charges,97% of total billed charges,2165.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2334.45,97,,,percent of total billed charges,97% of total billed charges,2238.18,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2334.45,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1684.66,14522.85,
Removal of Permanent Leadless Pacemaker,,,761,RC,33275,HCPCS,Outpatient,,,2406.65,1203.33,,2165.99,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1925.32,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2165.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2334.45,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2214.12,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2165.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.66,70,,,percent of total billed charges,70% of total billed charges,2165.99,90,,,percent of total billed charges,90% of total billed charges,2286.32,95,,,percent of total billed charges,95% of total billed charges,2286.32,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2069.72,86,,,percent of total billed charges,86% of total billed charges,1925.32,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2334.45,97,,,percent of total billed charges,97% of total billed charges,2165.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2334.45,97,,,percent of total billed charges,97% of total billed charges,2238.18,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2334.45,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1684.66,14522.85,
"33285 - PF Insertion, subcutaneous cardiac rhythm monitor, including programming",3712970,CDM,510,RC,33285,HCPCS,Outpatient,,,10857.77,5428.89,,9771.99,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,8686.22,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,9771.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10532.04,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,9989.15,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9771.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7600.44,70,,,percent of total billed charges,70% of total billed charges,9771.99,90,,,percent of total billed charges,90% of total billed charges,10314.88,95,,,percent of total billed charges,95% of total billed charges,10314.88,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9337.68,86,,,percent of total billed charges,86% of total billed charges,8686.22,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10532.04,97,,,percent of total billed charges,97% of total billed charges,9771.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,10532.04,97,,,percent of total billed charges,97% of total billed charges,10097.73,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10532.04,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6301.82,39794.54,
33285-Loop Recorder Insertion,3431807,CDM,481,RC,33285,HCPCS,Outpatient,,,10857.77,5428.89,,9771.99,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,8686.22,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,9771.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10532.04,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,9989.15,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9771.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7600.44,70,,,percent of total billed charges,70% of total billed charges,9771.99,90,,,percent of total billed charges,90% of total billed charges,10314.88,95,,,percent of total billed charges,95% of total billed charges,10314.88,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9337.68,86,,,percent of total billed charges,86% of total billed charges,8686.22,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10532.04,97,,,percent of total billed charges,97% of total billed charges,9771.99,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,10532.04,97,,,percent of total billed charges,97% of total billed charges,10097.73,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10532.04,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6301.82,39794.54,
Loop Recorder Insertion,,,761,RC,33285,HCPCS,Outpatient,,,10106.52,5053.26,,9095.87,90,,,percent of total billed charges,90% of total Billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,8085.22,80,,,Percent of total Billed charges,80% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,9095.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9803.32,97,,,Percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,9298,92,,,Percent of total billed charges,92% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,19707.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31417.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39794.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9095.87,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7074.56,70,,,percent of total billed charges,70% of total billed charges,9095.87,90,,,percent of total billed charges,90% of total billed charges,9601.19,95,,,percent of total billed charges,95% of total billed charges,9601.19,95,,,percent of total billed charges,95% of total billed charges,7413.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14827.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8691.61,86,,,percent of total billed charges,86% of total billed charges,8085.22,80,,,percent of total billed charges,80% of total billed charges,7900.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9803.32,97,,,percent of total billed charges,97% of total billed charges,9095.87,90,,,percent of total billed charges,90% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,9803.32,97,,,percent of total billed charges,97% of total billed charges,9399.06,93,,,percent of total billed charges,93% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9803.32,97,,,percent of total billed charges,97% of total billed charges,7413.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,7413.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6301.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6301.82,39794.54,
"33286 - PF Removal, subcutaneous cardiac rhythm monitor",3712971,CDM,510,RC,33286,HCPCS,Outpatient,,,345.28,172.64,,310.75,90,,,percent of total billed charges,90% of total Billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,276.22,80,,,Percent of total Billed charges,80% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,334.92,97,,,Percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,317.66,92,,,Percent of total billed charges,92% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,310.75,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,241.7,70,,,percent of total billed charges,70% of total billed charges,310.75,90,,,percent of total billed charges,90% of total billed charges,328.02,95,,,percent of total billed charges,95% of total billed charges,328.02,95,,,percent of total billed charges,95% of total billed charges,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,296.94,86,,,percent of total billed charges,86% of total billed charges,276.22,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,334.92,97,,,percent of total billed charges,97% of total billed charges,310.75,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.92,97,,,percent of total billed charges,97% of total billed charges,321.11,93,,,percent of total billed charges,93% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,334.92,97,,,percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,241.7,3163.81,
33286-Loop Recorder Removal,3431808,CDM,481,RC,33286,HCPCS,Outpatient,,,345.28,172.64,,310.75,90,,,percent of total billed charges,90% of total Billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,276.22,80,,,Percent of total Billed charges,80% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,334.92,97,,,Percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,317.66,92,,,Percent of total billed charges,92% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,310.75,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,241.7,70,,,percent of total billed charges,70% of total billed charges,310.75,90,,,percent of total billed charges,90% of total billed charges,328.02,95,,,percent of total billed charges,95% of total billed charges,328.02,95,,,percent of total billed charges,95% of total billed charges,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,296.94,86,,,percent of total billed charges,86% of total billed charges,276.22,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,334.92,97,,,percent of total billed charges,97% of total billed charges,310.75,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.92,97,,,percent of total billed charges,97% of total billed charges,321.11,93,,,percent of total billed charges,93% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,334.92,97,,,percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,241.7,3163.81,
Loop Recorder Removal,,,761,RC,33286,HCPCS,Outpatient,,,335.54,167.77,,301.99,90,,,percent of total billed charges,90% of total Billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,268.43,80,,,Percent of total Billed charges,80% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,325.47,97,,,Percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,308.7,92,,,Percent of total billed charges,92% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,301.99,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,234.88,70,,,percent of total billed charges,70% of total billed charges,301.99,90,,,percent of total billed charges,90% of total billed charges,318.76,95,,,percent of total billed charges,95% of total billed charges,318.76,95,,,percent of total billed charges,95% of total billed charges,589.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,288.56,86,,,percent of total billed charges,86% of total billed charges,268.43,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,325.47,97,,,percent of total billed charges,97% of total billed charges,301.99,90,,,percent of total billed charges,90% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.47,97,,,percent of total billed charges,97% of total billed charges,312.05,93,,,percent of total billed charges,93% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,325.47,97,,,percent of total billed charges,97% of total billed charges,589.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,234.88,3163.81,
33289-CARDIO MEMS IMPLANT,3431809,CDM,483,RC,33289,HCPCS,Outpatient,,,897.79,448.90,,808.01,90,,,percent of total billed charges,90% of total Billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,718.23,80,,,Percent of total Billed charges,80% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,870.86,97,,,Percent of total billed charges,97% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,825.97,92,,,Percent of total billed charges,92% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,65921.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105093.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,133116.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,808.01,90,,,percent of total billed charges,90% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,628.45,70,,,percent of total billed charges,70% of total billed charges,808.01,90,,,percent of total billed charges,90% of total billed charges,852.9,95,,,percent of total billed charges,95% of total billed charges,852.9,95,,,percent of total billed charges,95% of total billed charges,24800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49600.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,772.1,86,,,percent of total billed charges,86% of total billed charges,718.23,80,,,percent of total billed charges,80% of total billed charges,29487.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,870.86,97,,,percent of total billed charges,97% of total billed charges,808.01,90,,,percent of total billed charges,90% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,870.86,97,,,percent of total billed charges,97% of total billed charges,834.94,93,,,percent of total billed charges,93% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,870.86,97,,,percent of total billed charges,97% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,24800.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21080.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,628.45,133116.17,
33289-CardioMEMS,3431810,CDM,481,RC,33289,HCPCS,Outpatient,,,897.79,448.90,,808.01,90,,,percent of total billed charges,90% of total Billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,718.23,80,,,Percent of total Billed charges,80% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,870.86,97,,,Percent of total billed charges,97% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,825.97,92,,,Percent of total billed charges,92% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,65921.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105093.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,133116.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,808.01,90,,,percent of total billed charges,90% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,628.45,70,,,percent of total billed charges,70% of total billed charges,808.01,90,,,percent of total billed charges,90% of total billed charges,852.9,95,,,percent of total billed charges,95% of total billed charges,852.9,95,,,percent of total billed charges,95% of total billed charges,24800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49600.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,772.1,86,,,percent of total billed charges,86% of total billed charges,718.23,80,,,percent of total billed charges,80% of total billed charges,29487.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,870.86,97,,,percent of total billed charges,97% of total billed charges,808.01,90,,,percent of total billed charges,90% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,870.86,97,,,percent of total billed charges,97% of total billed charges,834.94,93,,,percent of total billed charges,93% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,870.86,97,,,percent of total billed charges,97% of total billed charges,24800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,24800.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21080.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,628.45,133116.17,
CardioMEMS,3427123,CDM,960,RC,33289,HCPCS,Outpatient,,,877.31,438.66,,789.58,90,,,percent of total billed charges,90% of total Billed charges,668.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.14,155,,,Fee Schedule,155% of CMS OPPS Rate,331.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,549.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,515.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,515.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,293.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,608.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,435.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,513.14,155,,,Fee Schedule,155% of CMS OPPS Rate,331.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1036.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1036.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,331.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,373.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,331.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.32,1036.41,
33300 - PF Repair of cardiac wound; without bypass,3715389,CDM,510,RC,33300,HCPCS,Outpatient,,,6578.49,3289.25,,5920.64,90,,,percent of total billed charges,90% of total Billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5262.79,80,,,Percent of total Billed charges,80% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5920.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6381.14,97,,,Percent of total billed charges,97% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6052.21,92,,,Percent of total billed charges,92% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5920.64,90,,,percent of total billed charges,90% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4604.94,70,,,percent of total billed charges,70% of total billed charges,5920.64,90,,,percent of total billed charges,90% of total billed charges,6249.57,95,,,percent of total billed charges,95% of total billed charges,6249.57,95,,,percent of total billed charges,95% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5657.5,86,,,percent of total billed charges,86% of total billed charges,5262.79,80,,,percent of total billed charges,80% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6381.14,97,,,percent of total billed charges,97% of total billed charges,5920.64,90,,,percent of total billed charges,90% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6381.14,97,,,percent of total billed charges,97% of total billed charges,6118,93,,,percent of total billed charges,93% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6381.14,97,,,percent of total billed charges,97% of total billed charges,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6578.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4604.94,6578.49,
33310 - Cardiot Expl W/Rmbl FB Atr/Ventr Thrmb w/o BYP,4113108,CDM,975,RC,33310,HCPCS,Outpatient,,,2794.84,1397.42,,2515.36,90,,,percent of total billed charges,90% of total Billed charges,2337.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1160.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,720,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1799.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1160.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1160.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1942.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1942.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1821.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1821.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,952.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1160.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2321.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2149.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1548.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1799.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1160.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,3623.54,155,,,Fee Schedule,155% of CMS OPPS Rate,3623.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1160.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,720,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1277.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1160.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,2398.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2398.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,720,3623.54,
33322 - Suture repair of aorta or great vessels; with cardiopulmonary bypass,3783269,CDM,510,RC,33322,HCPCS,Outpatient,,,3722.87,1861.44,,3350.58,90,,,percent of total billed charges,90% of total Billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2978.3,80,,,Percent of total Billed charges,80% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3350.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3611.18,97,,,Percent of total billed charges,97% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3425.04,92,,,Percent of total billed charges,92% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3350.58,90,,,percent of total billed charges,90% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2606.01,70,,,percent of total billed charges,70% of total billed charges,3350.58,90,,,percent of total billed charges,90% of total billed charges,3536.73,95,,,percent of total billed charges,95% of total billed charges,3536.73,95,,,percent of total billed charges,95% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3201.67,86,,,percent of total billed charges,86% of total billed charges,2978.3,80,,,percent of total billed charges,80% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3611.18,97,,,percent of total billed charges,97% of total billed charges,3350.58,90,,,percent of total billed charges,90% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3611.18,97,,,percent of total billed charges,97% of total billed charges,3462.27,93,,,percent of total billed charges,93% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3611.18,97,,,percent of total billed charges,97% of total billed charges,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3722.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2606.01,3722.87,
33340 - PF - Percutaneous transcatheter closure of the left atrial appendage with endocardial implan,3640908,CDM,510,RC,33340,HCPCS,Outpatient,,,2110.39,1055.20,,1899.35,90,,,percent of total billed charges,90% of total Billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1688.31,80,,,Percent of total Billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2047.08,97,,,Percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1941.56,92,,,Percent of total billed charges,92% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,70,,,percent of total billed charges,70% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1814.94,86,,,percent of total billed charges,86% of total billed charges,1688.31,80,,,percent of total billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1962.66,93,,,percent of total billed charges,93% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2047.08,97,,,percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,2110.39,
33340 -Peri-Device Leak,4123188,CDM,481,RC,33340,HCPCS,Outpatient,,,1884.28,942.14,,1695.85,90,,,percent of total billed charges,90% of total Billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1507.42,80,,,Percent of total Billed charges,80% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1695.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1827.75,97,,,Percent of total billed charges,97% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1733.54,92,,,Percent of total billed charges,92% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1695.85,90,,,percent of total billed charges,90% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1319,70,,,percent of total billed charges,70% of total billed charges,1695.85,90,,,percent of total billed charges,90% of total billed charges,1790.07,95,,,percent of total billed charges,95% of total billed charges,1790.07,95,,,percent of total billed charges,95% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1620.48,86,,,percent of total billed charges,86% of total billed charges,1507.42,80,,,percent of total billed charges,80% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1827.75,97,,,percent of total billed charges,97% of total billed charges,1695.85,90,,,percent of total billed charges,90% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1827.75,97,,,percent of total billed charges,97% of total billed charges,1752.38,93,,,percent of total billed charges,93% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1827.75,97,,,percent of total billed charges,97% of total billed charges,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1884.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1319,1884.28,
33340-LAAO Closure (Amulet),3431812,CDM,481,RC,33340,HCPCS,Outpatient,,,2110.39,1055.20,,1899.35,90,,,percent of total billed charges,90% of total Billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1688.31,80,,,Percent of total Billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2047.08,97,,,Percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1941.56,92,,,Percent of total billed charges,92% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,70,,,percent of total billed charges,70% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1814.94,86,,,percent of total billed charges,86% of total billed charges,1688.31,80,,,percent of total billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1962.66,93,,,percent of total billed charges,93% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2047.08,97,,,percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,2110.39,
33340-LAAO Closure (Watchman),3431811,CDM,481,RC,33340,HCPCS,Outpatient,,,2110.39,1055.20,,1899.35,90,,,percent of total billed charges,90% of total Billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1688.31,80,,,Percent of total Billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2047.08,97,,,Percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1941.56,92,,,Percent of total billed charges,92% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,70,,,percent of total billed charges,70% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2004.87,95,,,percent of total billed charges,95% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1814.94,86,,,percent of total billed charges,86% of total billed charges,1688.31,80,,,percent of total billed charges,80% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1899.35,90,,,percent of total billed charges,90% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2047.08,97,,,percent of total billed charges,97% of total billed charges,1962.66,93,,,percent of total billed charges,93% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2047.08,97,,,percent of total billed charges,97% of total billed charges,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2110.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1477.27,2110.39,
33340-PF Peri-Device Leak,4123189,CDM,960,RC,33340,HCPCS,Outpatient,,,1884.28,942.14,,1695.85,90,,,percent of total billed charges,90% of total Billed charges,1571.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.41,155,,,Fee Schedule,155% of CMS OPPS Rate,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1318.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1318.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1237.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1237.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,709.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1459.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1050.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1206.41,155,,,Fee Schedule,155% of CMS OPPS Rate,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,2436.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2436.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,901.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.42,2436.46,
LAAO Closure,,,761,RC,33340,HCPCS,Outpatient,,,2062.58,1031.29,,1856.32,90,,,percent of total billed charges,90% of total Billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1650.06,80,,,Percent of total Billed charges,80% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2000.7,97,,,Percent of total billed charges,97% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1897.57,92,,,Percent of total billed charges,92% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.32,90,,,percent of total billed charges,90% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1443.81,70,,,percent of total billed charges,70% of total billed charges,1856.32,90,,,percent of total billed charges,90% of total billed charges,1959.45,95,,,percent of total billed charges,95% of total billed charges,1959.45,95,,,percent of total billed charges,95% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1773.82,86,,,percent of total billed charges,86% of total billed charges,1650.06,80,,,percent of total billed charges,80% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2000.7,97,,,percent of total billed charges,97% of total billed charges,1856.32,90,,,percent of total billed charges,90% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2000.7,97,,,percent of total billed charges,97% of total billed charges,1918.2,93,,,percent of total billed charges,93% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2000.7,97,,,percent of total billed charges,97% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1443.81,2062.58,
Peri-Device Leak,,,761,RC,33340,HCPCS,Outpatient,,,2062.58,1031.29,,1856.32,90,,,percent of total billed charges,90% of total Billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1650.06,80,,,Percent of total Billed charges,80% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2000.7,97,,,Percent of total billed charges,97% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1897.57,92,,,Percent of total billed charges,92% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.32,90,,,percent of total billed charges,90% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1443.81,70,,,percent of total billed charges,70% of total billed charges,1856.32,90,,,percent of total billed charges,90% of total billed charges,1959.45,95,,,percent of total billed charges,95% of total billed charges,1959.45,95,,,percent of total billed charges,95% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1773.82,86,,,percent of total billed charges,86% of total billed charges,1650.06,80,,,percent of total billed charges,80% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2000.7,97,,,percent of total billed charges,97% of total billed charges,1856.32,90,,,percent of total billed charges,90% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2000.7,97,,,percent of total billed charges,97% of total billed charges,1918.2,93,,,percent of total billed charges,93% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2000.7,97,,,percent of total billed charges,97% of total billed charges,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2062.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1443.81,2062.58,
33361- TAVR w/value percut fem approach,3560643,CDM,481,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2934.38,90,,,percent of total billed charges,90% of total Billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.34,80,,,Percent of total Billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3162.61,97,,,Percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2999.59,92,,,Percent of total billed charges,92% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,70,,,percent of total billed charges,70% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2803.96,86,,,percent of total billed charges,86% of total billed charges,2608.34,80,,,percent of total billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,3032.19,93,,,percent of total billed charges,93% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3162.61,97,,,percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,3260.42,
33361- TAVR/perc femoral artery,3430649,CDM,360,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2934.38,90,,,percent of total billed charges,90% of total Billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.34,80,,,Percent of total Billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3162.61,97,,,Percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2999.59,92,,,Percent of total billed charges,92% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,70,,,percent of total billed charges,70% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2803.96,86,,,percent of total billed charges,86% of total billed charges,2608.34,80,,,percent of total billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,3032.19,93,,,percent of total billed charges,93% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3162.61,97,,,percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,3260.42,
33361-TAVR Femoral,3431813,CDM,360,RC,33361,HCPCS,Outpatient,,,3260.42,1630.21,,2934.38,90,,,percent of total billed charges,90% of total Billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.34,80,,,Percent of total Billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3162.61,97,,,Percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2999.59,92,,,Percent of total billed charges,92% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,70,,,percent of total billed charges,70% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3097.4,95,,,percent of total billed charges,95% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2803.96,86,,,percent of total billed charges,86% of total billed charges,2608.34,80,,,percent of total billed charges,80% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,2934.38,90,,,percent of total billed charges,90% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3162.61,97,,,percent of total billed charges,97% of total billed charges,3032.19,93,,,percent of total billed charges,93% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3162.61,97,,,percent of total billed charges,97% of total billed charges,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3260.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2282.29,3260.42,
TAVR Femoral,3427284,CDM,960,RC,33361,HCPCS,Outpatient,,,3195.4,1597.70,,2875.86,90,,,percent of total billed charges,90% of total Billed charges,2431.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1205.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1126.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1868.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1797.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2021.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2021.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1910.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1910.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1148.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2254.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1641.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1868.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3769.32,155,,,Fee Schedule,155% of CMS OPPS Rate,3769.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1205.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1126.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1254.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1205.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.17,3769.32,
33362-TAVR Open Femoral,3431814,CDM,481,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,3200.47,90,,,percent of total billed charges,90% of total Billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2844.86,80,,,Percent of total Billed charges,80% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3449.4,97,,,Percent of total billed charges,97% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3271.59,92,,,Percent of total billed charges,92% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.47,90,,,percent of total billed charges,90% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2489.26,70,,,percent of total billed charges,70% of total billed charges,3200.47,90,,,percent of total billed charges,90% of total billed charges,3378.28,95,,,percent of total billed charges,95% of total billed charges,3378.28,95,,,percent of total billed charges,95% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3058.23,86,,,percent of total billed charges,86% of total billed charges,2844.86,80,,,percent of total billed charges,80% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3449.4,97,,,percent of total billed charges,97% of total billed charges,3200.47,90,,,percent of total billed charges,90% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3449.4,97,,,percent of total billed charges,97% of total billed charges,3307.15,93,,,percent of total billed charges,93% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3449.4,97,,,percent of total billed charges,97% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2489.26,3556.08,
"33362-TAVR, OPEN FEMORAL ARTERY APPROACH",3430845,CDM,510,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,3200.47,90,,,percent of total billed charges,90% of total Billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2844.86,80,,,Percent of total Billed charges,80% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3449.4,97,,,Percent of total billed charges,97% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3271.59,92,,,Percent of total billed charges,92% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.47,90,,,percent of total billed charges,90% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2489.26,70,,,percent of total billed charges,70% of total billed charges,3200.47,90,,,percent of total billed charges,90% of total billed charges,3378.28,95,,,percent of total billed charges,95% of total billed charges,3378.28,95,,,percent of total billed charges,95% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3058.23,86,,,percent of total billed charges,86% of total billed charges,2844.86,80,,,percent of total billed charges,80% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3449.4,97,,,percent of total billed charges,97% of total billed charges,3200.47,90,,,percent of total billed charges,90% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3449.4,97,,,percent of total billed charges,97% of total billed charges,3307.15,93,,,percent of total billed charges,93% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3449.4,97,,,percent of total billed charges,97% of total billed charges,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3556.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2489.26,3556.08,
TAVR Open Femoral,,,960,RC,33362,HCPCS,Outpatient,,,3556.08,1778.04,,3200.47,90,,,percent of total billed charges,90% of total Billed charges,2653.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1316.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1229.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2039.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1316.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1958.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1316.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2202.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2202.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2083.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2083.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1256.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1316.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2632.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2458.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1793.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2039.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1316.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,4112.55,155,,,Fee Schedule,155% of CMS OPPS Rate,4112.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1316.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1229.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1372.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1316.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.75,4112.55,
33363-TAVR Open Axillary,3431815,CDM,481,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,3318.53,90,,,percent of total billed charges,90% of total Billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.81,80,,,Percent of total Billed charges,80% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3576.64,97,,,Percent of total billed charges,97% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3392.28,92,,,Percent of total billed charges,92% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.53,90,,,percent of total billed charges,90% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2581.08,70,,,percent of total billed charges,70% of total billed charges,3318.53,90,,,percent of total billed charges,90% of total billed charges,3502.9,95,,,percent of total billed charges,95% of total billed charges,3502.9,95,,,percent of total billed charges,95% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3171.04,86,,,percent of total billed charges,86% of total billed charges,2949.81,80,,,percent of total billed charges,80% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3576.64,97,,,percent of total billed charges,97% of total billed charges,3318.53,90,,,percent of total billed charges,90% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3576.64,97,,,percent of total billed charges,97% of total billed charges,3429.15,93,,,percent of total billed charges,93% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3576.64,97,,,percent of total billed charges,97% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2581.08,3687.26,
"33363-TAVR,OPEN AXILLARY APPROACH",3430846,CDM,510,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,3318.53,90,,,percent of total billed charges,90% of total Billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.81,80,,,Percent of total Billed charges,80% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3576.64,97,,,Percent of total billed charges,97% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3392.28,92,,,Percent of total billed charges,92% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.53,90,,,percent of total billed charges,90% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2581.08,70,,,percent of total billed charges,70% of total billed charges,3318.53,90,,,percent of total billed charges,90% of total billed charges,3502.9,95,,,percent of total billed charges,95% of total billed charges,3502.9,95,,,percent of total billed charges,95% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3171.04,86,,,percent of total billed charges,86% of total billed charges,2949.81,80,,,percent of total billed charges,80% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3576.64,97,,,percent of total billed charges,97% of total billed charges,3318.53,90,,,percent of total billed charges,90% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3576.64,97,,,percent of total billed charges,97% of total billed charges,3429.15,93,,,percent of total billed charges,93% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3576.64,97,,,percent of total billed charges,97% of total billed charges,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3687.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2581.08,3687.26,
TAVR Open Axillary,3427286,CDM,960,RC,33363,HCPCS,Outpatient,,,3687.26,1843.63,,3318.53,90,,,percent of total billed charges,90% of total Billed charges,2749.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1362.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1275.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2112.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1362.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2030.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1362.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2283.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2283.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2160.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2160.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1300.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2725.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2549.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1857.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2112.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1362.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,4261.54,155,,,Fee Schedule,155% of CMS OPPS Rate,4261.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1362.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1421.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1362.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1275.5,4261.54,
33364-TAVR Open Illiac,3431816,CDM,481,RC,33364,HCPCS,Outpatient,,,3694.07,1847.04,,3324.66,90,,,percent of total billed charges,90% of total Billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2955.26,80,,,Percent of total Billed charges,80% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3324.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3583.25,97,,,Percent of total billed charges,97% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3398.54,92,,,Percent of total billed charges,92% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3324.66,90,,,percent of total billed charges,90% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.85,70,,,percent of total billed charges,70% of total billed charges,3324.66,90,,,percent of total billed charges,90% of total billed charges,3509.37,95,,,percent of total billed charges,95% of total billed charges,3509.37,95,,,percent of total billed charges,95% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3176.9,86,,,percent of total billed charges,86% of total billed charges,2955.26,80,,,percent of total billed charges,80% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3583.25,97,,,percent of total billed charges,97% of total billed charges,3324.66,90,,,percent of total billed charges,90% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3583.25,97,,,percent of total billed charges,97% of total billed charges,3435.49,93,,,percent of total billed charges,93% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3583.25,97,,,percent of total billed charges,97% of total billed charges,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.07,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.85,3694.07,
TAVR Open Illiac,,,960,RC,33364,HCPCS,Outpatient,,,3694.07,1847.04,,3324.66,90,,,percent of total billed charges,90% of total Billed charges,2755,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1365.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1343.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2117.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1365.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2030.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1365.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2284.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2284.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2167.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2167.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1384.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2731.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2557.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1873.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2117.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1365.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,4270.25,155,,,Fee Schedule,155% of CMS OPPS Rate,4270.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1365.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1343.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1511.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1365.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1343.39,4270.25,
33365-TAVR Transaortic Approach,3431817,CDM,481,RC,33365,HCPCS,Outpatient,,,3845.84,1922.92,,3461.26,90,,,percent of total billed charges,90% of total Billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3076.67,80,,,Percent of total Billed charges,80% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3461.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3730.46,97,,,Percent of total billed charges,97% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3538.17,92,,,Percent of total billed charges,92% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3461.26,90,,,percent of total billed charges,90% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2692.09,70,,,percent of total billed charges,70% of total billed charges,3461.26,90,,,percent of total billed charges,90% of total billed charges,3653.55,95,,,percent of total billed charges,95% of total billed charges,3653.55,95,,,percent of total billed charges,95% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3307.42,86,,,percent of total billed charges,86% of total billed charges,3076.67,80,,,percent of total billed charges,80% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3730.46,97,,,percent of total billed charges,97% of total billed charges,3461.26,90,,,percent of total billed charges,90% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3730.46,97,,,percent of total billed charges,97% of total billed charges,3576.63,93,,,percent of total billed charges,93% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3730.46,97,,,percent of total billed charges,97% of total billed charges,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3845.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2692.09,3845.84,
TAVR Transaortic Approach,,,960,RC,33365,HCPCS,Outpatient,,,3845.84,1922.92,,3461.26,90,,,percent of total billed charges,90% of total Billed charges,2868.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1422.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1477.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2204.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1422.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2145.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1422.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2413.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2413.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2278.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2278.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1519.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1422.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2844.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2689.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1954.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2204.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1422.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,4446.19,155,,,Fee Schedule,155% of CMS OPPS Rate,4446.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1422.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1477.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1661.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1422.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1422.34,4446.19,
33366-TAVR Transapical Perfusion,3431818,CDM,481,RC,33366,HCPCS,Outpatient,,,4239.75,2119.88,,3815.78,90,,,percent of total billed charges,90% of total Billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3391.8,80,,,Percent of total Billed charges,80% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4112.56,97,,,Percent of total billed charges,97% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3900.57,92,,,Percent of total billed charges,92% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.78,90,,,percent of total billed charges,90% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.83,70,,,percent of total billed charges,70% of total billed charges,3815.78,90,,,percent of total billed charges,90% of total billed charges,4027.76,95,,,percent of total billed charges,95% of total billed charges,4027.76,95,,,percent of total billed charges,95% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3646.19,86,,,percent of total billed charges,86% of total billed charges,3391.8,80,,,percent of total billed charges,80% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.56,97,,,percent of total billed charges,97% of total billed charges,3815.78,90,,,percent of total billed charges,90% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.56,97,,,percent of total billed charges,97% of total billed charges,3942.97,93,,,percent of total billed charges,93% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4112.56,97,,,percent of total billed charges,97% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.83,4239.75,
TAVR Transapical Perfusion,,,761,RC,33366,HCPCS,Outpatient,,,4239.75,2119.88,,3815.78,90,,,percent of total billed charges,90% of total Billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3391.8,80,,,Percent of total Billed charges,80% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4112.56,97,,,Percent of total billed charges,97% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3900.57,92,,,Percent of total billed charges,92% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.78,90,,,percent of total billed charges,90% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.83,70,,,percent of total billed charges,70% of total billed charges,3815.78,90,,,percent of total billed charges,90% of total billed charges,4027.76,95,,,percent of total billed charges,95% of total billed charges,4027.76,95,,,percent of total billed charges,95% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3646.19,86,,,percent of total billed charges,86% of total billed charges,3391.8,80,,,percent of total billed charges,80% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.56,97,,,percent of total billed charges,97% of total billed charges,3815.78,90,,,percent of total billed charges,90% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.56,97,,,percent of total billed charges,97% of total billed charges,3942.97,93,,,percent of total billed charges,93% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4112.56,97,,,percent of total billed charges,97% of total billed charges,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.83,4239.75,
33367-TAVR w Perc Cannulation,3431819,CDM,481,RC,33367,HCPCS,Outpatient,,,1659.1,829.55,,1493.19,90,,,percent of total billed charges,90% of total Billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1327.28,80,,,Percent of total Billed charges,80% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1493.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1609.33,97,,,Percent of total billed charges,97% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1526.37,92,,,Percent of total billed charges,92% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1493.19,90,,,percent of total billed charges,90% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1161.37,70,,,percent of total billed charges,70% of total billed charges,1493.19,90,,,percent of total billed charges,90% of total billed charges,1576.15,95,,,percent of total billed charges,95% of total billed charges,1576.15,95,,,percent of total billed charges,95% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1426.83,86,,,percent of total billed charges,86% of total billed charges,1327.28,80,,,percent of total billed charges,80% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1609.33,97,,,percent of total billed charges,97% of total billed charges,1493.19,90,,,percent of total billed charges,90% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1609.33,97,,,percent of total billed charges,97% of total billed charges,1542.96,93,,,percent of total billed charges,93% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1609.33,97,,,percent of total billed charges,97% of total billed charges,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1659.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1161.37,1659.1,
TAVR w Perc Cannulation,,,960,RC,33367,HCPCS,Outpatient,,,1659.1,829.55,,1493.19,90,,,percent of total billed charges,90% of total Billed charges,1236.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,612.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,521.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,949.47,155,,,Fee Schedule,155% of CMS OPPS Rate,612.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,934.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,612.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1051.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1051.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,533.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1177.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,864.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,949.47,155,,,Fee Schedule,155% of CMS OPPS Rate,612.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1916.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1916.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,612.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,521.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,612.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.86,1916.48,
33368-TAVR w Perfusion w Open Peripheral,3431820,CDM,481,RC,33368,HCPCS,Outpatient,,,2010.43,1005.22,,1809.39,90,,,percent of total billed charges,90% of total Billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1608.34,80,,,Percent of total Billed charges,80% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1809.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1950.12,97,,,Percent of total billed charges,97% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.6,92,,,Percent of total billed charges,92% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1809.39,90,,,percent of total billed charges,90% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1407.3,70,,,percent of total billed charges,70% of total billed charges,1809.39,90,,,percent of total billed charges,90% of total billed charges,1909.91,95,,,percent of total billed charges,95% of total billed charges,1909.91,95,,,percent of total billed charges,95% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1728.97,86,,,percent of total billed charges,86% of total billed charges,1608.34,80,,,percent of total billed charges,80% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.12,97,,,percent of total billed charges,97% of total billed charges,1809.39,90,,,percent of total billed charges,90% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.12,97,,,percent of total billed charges,97% of total billed charges,1869.7,93,,,percent of total billed charges,93% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1950.12,97,,,percent of total billed charges,97% of total billed charges,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2010.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1407.3,2010.43,
TAVR w Perfusion w Open Peripheral,,,960,RC,33368,HCPCS,Outpatient,,,2010.43,1005.22,,1809.39,90,,,percent of total billed charges,90% of total Billed charges,1497.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,741.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,620.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1149.71,155,,,Fee Schedule,155% of CMS OPPS Rate,741.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1240.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1240.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1180.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1180.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,646.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1483.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1393.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1025.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1149.71,155,,,Fee Schedule,155% of CMS OPPS Rate,741.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2321.48,155,,,Fee Schedule,155% of CMS OPPS Rate,2321.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,741.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,708.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,741.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.86,2321.48,
33369-TAVR w Perfusion w Central Cannulation,3431821,CDM,481,RC,33369,HCPCS,Outpatient,,,2652.14,1326.07,,2386.93,90,,,percent of total billed charges,90% of total Billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2121.71,80,,,Percent of total Billed charges,80% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2386.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2572.58,97,,,Percent of total billed charges,97% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2439.97,92,,,Percent of total billed charges,92% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2386.93,90,,,percent of total billed charges,90% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.5,70,,,percent of total billed charges,70% of total billed charges,2386.93,90,,,percent of total billed charges,90% of total billed charges,2519.53,95,,,percent of total billed charges,95% of total billed charges,2519.53,95,,,percent of total billed charges,95% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2280.84,86,,,percent of total billed charges,86% of total billed charges,2121.71,80,,,percent of total billed charges,80% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2572.58,97,,,percent of total billed charges,97% of total billed charges,2386.93,90,,,percent of total billed charges,90% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2572.58,97,,,percent of total billed charges,97% of total billed charges,2466.49,93,,,percent of total billed charges,93% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2572.58,97,,,percent of total billed charges,97% of total billed charges,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.5,2652.14,
TAVR w Perfusion w Central Cannulation,,,960,RC,33369,HCPCS,Outpatient,,,2652.14,1326.07,,2386.93,90,,,percent of total billed charges,90% of total Billed charges,1976.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,979.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,819.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1517.92,155,,,Fee Schedule,155% of CMS OPPS Rate,979.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,979.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1636.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1636.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1558.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1558.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,853.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1838.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1352.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1517.92,155,,,Fee Schedule,155% of CMS OPPS Rate,979.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,3063.71,155,,,Fee Schedule,155% of CMS OPPS Rate,3063.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,979.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,819.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,935.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,979.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.7,3063.71,
33370-Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,4271124,CDM,481,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,255.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,226.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,255.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,275.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,260.99,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,181.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,223.12,78.65,,,percent of total billed charges,78.65% of total billed charges,253.42,89.33,,,percent of total billed charges,89.33% of total billed charges,255.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.58,70,,,percent of total billed charges,70% of total billed charges,255.31,90,,,percent of total billed charges,90% of total billed charges,269.5,95,,,percent of total billed charges,95% of total billed charges,269.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.96,86,,,percent of total billed charges,86% of total billed charges,226.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,275.17,97,,,percent of total billed charges,97% of total billed charges,255.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,275.17,97,,,percent of total billed charges,97% of total billed charges,263.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.16,275.17,
33370-PF Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,4271125,CDM,960,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,255.31,90,,,percent of total billed charges,90% of total Billed charges,267.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.39,155,,,Fee Schedule,155% of CMS OPPS Rate,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.39,155,,,Fee Schedule,155% of CMS OPPS Rate,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.03,155,,,Fee Schedule,155% of CMS OPPS Rate,415.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.1,415.03,
Cerebral Embolic Protection (Plcmnt and Rmvl) during TAVR,,,960,RC,33370,HCPCS,Outpatient,,,283.68,141.84,,255.31,90,,,percent of total billed charges,90% of total Billed charges,267.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.39,155,,,Fee Schedule,155% of CMS OPPS Rate,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.39,155,,,Fee Schedule,155% of CMS OPPS Rate,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.03,155,,,Fee Schedule,155% of CMS OPPS Rate,415.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.1,415.03,
33390-VALVULOPLASTY AORTIC VALVE,3430848,CDM,960,RC,33390,HCPCS,Outpatient,,,4076.25,2038.13,,3668.63,90,,,percent of total billed charges,90% of total Billed charges,3871.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1922.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1566.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2980.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1922.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2858.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1922.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3214.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3214.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3032.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3032.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1688.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3845.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3578.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2603.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2980.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1922.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,6001.29,155,,,Fee Schedule,155% of CMS OPPS Rate,6001.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1922.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1566.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2154.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1922.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1566.7,6001.29,
33405- Replac AV w/bypas/other pros valve,3430650,CDM,510,RC,33405,HCPCS,Outpatient,,,6104.03,3052.02,,5493.63,90,,,percent of total billed charges,90% of total Billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4883.22,80,,,Percent of total Billed charges,80% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5493.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5920.91,97,,,Percent of total billed charges,97% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5615.71,92,,,Percent of total billed charges,92% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5493.63,90,,,percent of total billed charges,90% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4272.82,70,,,percent of total billed charges,70% of total billed charges,5493.63,90,,,percent of total billed charges,90% of total billed charges,5798.83,95,,,percent of total billed charges,95% of total billed charges,5798.83,95,,,percent of total billed charges,95% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5249.47,86,,,percent of total billed charges,86% of total billed charges,4883.22,80,,,percent of total billed charges,80% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5920.91,97,,,percent of total billed charges,97% of total billed charges,5493.63,90,,,percent of total billed charges,90% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5920.91,97,,,percent of total billed charges,97% of total billed charges,5676.75,93,,,percent of total billed charges,93% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5920.91,97,,,percent of total billed charges,97% of total billed charges,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6104.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4272.82,6104.03,
33410- Replace AV w/bypas/stentless valve,3430651,CDM,510,RC,33410,HCPCS,Outpatient,,,6833.44,3416.72,,6150.1,90,,,percent of total billed charges,90% of total Billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5466.75,80,,,Percent of total Billed charges,80% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6150.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6628.44,97,,,Percent of total billed charges,97% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6286.76,92,,,Percent of total billed charges,92% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6150.1,90,,,percent of total billed charges,90% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4783.41,70,,,percent of total billed charges,70% of total billed charges,6150.1,90,,,percent of total billed charges,90% of total billed charges,6491.77,95,,,percent of total billed charges,95% of total billed charges,6491.77,95,,,percent of total billed charges,95% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5876.76,86,,,percent of total billed charges,86% of total billed charges,5466.75,80,,,percent of total billed charges,80% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6628.44,97,,,percent of total billed charges,97% of total billed charges,6150.1,90,,,percent of total billed charges,90% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6628.44,97,,,percent of total billed charges,97% of total billed charges,6355.1,93,,,percent of total billed charges,93% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6628.44,97,,,percent of total billed charges,97% of total billed charges,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6833.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4783.41,6833.44,
33411-REPLACE AORTIC VALVE W/AORTIC ANN,3430851,CDM,960,RC,33411,HCPCS,Outpatient,,,7103.8,3551.90,,6393.42,90,,,percent of total billed charges,90% of total Billed charges,6747.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3350.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,5193.8,155,,,Fee Schedule,155% of CMS OPPS Rate,3350.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4978.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3350.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5599.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5599.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5298.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5298.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2710.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3350.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6701.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6252.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,4573.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,5193.8,155,,,Fee Schedule,155% of CMS OPPS Rate,3350.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,10459.18,155,,,Fee Schedule,155% of CMS OPPS Rate,10459.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,3350.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3106.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3350.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,7021.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,7021.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,10459.18,
33415- Resect/incis/subva tissue/subva AS,3430853,CDM,510,RC,33415,HCPCS,Outpatient,,,5459.96,2729.98,,4913.96,90,,,percent of total billed charges,90% of total Billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4367.97,80,,,Percent of total Billed charges,80% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4913.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5296.16,97,,,Percent of total billed charges,97% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5023.16,92,,,Percent of total billed charges,92% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4913.96,90,,,percent of total billed charges,90% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3821.97,70,,,percent of total billed charges,70% of total billed charges,4913.96,90,,,percent of total billed charges,90% of total billed charges,5186.96,95,,,percent of total billed charges,95% of total billed charges,5186.96,95,,,percent of total billed charges,95% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4695.57,86,,,percent of total billed charges,86% of total billed charges,4367.97,80,,,percent of total billed charges,80% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5296.16,97,,,percent of total billed charges,97% of total billed charges,4913.96,90,,,percent of total billed charges,90% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5296.16,97,,,percent of total billed charges,97% of total billed charges,5077.76,93,,,percent of total billed charges,93% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5296.16,97,,,percent of total billed charges,97% of total billed charges,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5459.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3821.97,5459.96,
33416- Ventriculomyotomy/IHSS,3430854,CDM,510,RC,33416,HCPCS,Outpatient,,,5431.94,2715.97,,4888.75,90,,,percent of total billed charges,90% of total Billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4345.55,80,,,Percent of total Billed charges,80% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4888.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5268.98,97,,,Percent of total billed charges,97% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4997.38,92,,,Percent of total billed charges,92% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4888.75,90,,,percent of total billed charges,90% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3802.36,70,,,percent of total billed charges,70% of total billed charges,4888.75,90,,,percent of total billed charges,90% of total billed charges,5160.34,95,,,percent of total billed charges,95% of total billed charges,5160.34,95,,,percent of total billed charges,95% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4671.47,86,,,percent of total billed charges,86% of total billed charges,4345.55,80,,,percent of total billed charges,80% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5268.98,97,,,percent of total billed charges,97% of total billed charges,4888.75,90,,,percent of total billed charges,90% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5268.98,97,,,percent of total billed charges,97% of total billed charges,5051.7,93,,,percent of total billed charges,93% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5268.98,97,,,percent of total billed charges,97% of total billed charges,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5431.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3802.36,5431.94,
"33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when",3623384,CDM,510,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,4342.33,90,,,percent of total billed charges,90% of total Billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3859.85,80,,,Percent of total Billed charges,80% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4342.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4680.07,97,,,Percent of total billed charges,97% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4438.83,92,,,Percent of total billed charges,92% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4342.33,90,,,percent of total billed charges,90% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.37,70,,,percent of total billed charges,70% of total billed charges,4342.33,90,,,percent of total billed charges,90% of total billed charges,4583.57,95,,,percent of total billed charges,95% of total billed charges,4583.57,95,,,percent of total billed charges,95% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4149.34,86,,,percent of total billed charges,86% of total billed charges,3859.85,80,,,percent of total billed charges,80% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.07,97,,,percent of total billed charges,97% of total billed charges,4342.33,90,,,percent of total billed charges,90% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.07,97,,,percent of total billed charges,97% of total billed charges,4487.07,93,,,percent of total billed charges,93% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4680.07,97,,,percent of total billed charges,97% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.37,4824.81,
33418-Transcatheter mitral valve repair; initial prosthesis,3561520,CDM,481,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,4342.33,90,,,percent of total billed charges,90% of total Billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3859.85,80,,,Percent of total Billed charges,80% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4342.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4680.07,97,,,Percent of total billed charges,97% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4438.83,92,,,Percent of total billed charges,92% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4342.33,90,,,percent of total billed charges,90% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.37,70,,,percent of total billed charges,70% of total billed charges,4342.33,90,,,percent of total billed charges,90% of total billed charges,4583.57,95,,,percent of total billed charges,95% of total billed charges,4583.57,95,,,percent of total billed charges,95% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4149.34,86,,,percent of total billed charges,86% of total billed charges,3859.85,80,,,percent of total billed charges,80% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.07,97,,,percent of total billed charges,97% of total billed charges,4342.33,90,,,percent of total billed charges,90% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.07,97,,,percent of total billed charges,97% of total billed charges,4487.07,93,,,percent of total billed charges,93% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4680.07,97,,,percent of total billed charges,97% of total billed charges,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4824.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.37,4824.81,
Mitra Clip,,,761,RC,33418,HCPCS,Outpatient,,,4724.08,2362.04,,4251.67,90,,,percent of total billed charges,90% of total Billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3779.26,80,,,Percent of total Billed charges,80% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4251.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4582.36,97,,,Percent of total billed charges,97% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4346.15,92,,,Percent of total billed charges,92% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4251.67,90,,,percent of total billed charges,90% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.86,70,,,percent of total billed charges,70% of total billed charges,4251.67,90,,,percent of total billed charges,90% of total billed charges,4487.88,95,,,percent of total billed charges,95% of total billed charges,4487.88,95,,,percent of total billed charges,95% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4062.71,86,,,percent of total billed charges,86% of total billed charges,3779.26,80,,,percent of total billed charges,80% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4582.36,97,,,percent of total billed charges,97% of total billed charges,4251.67,90,,,percent of total billed charges,90% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4582.36,97,,,percent of total billed charges,97% of total billed charges,4393.39,93,,,percent of total billed charges,93% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4582.36,97,,,percent of total billed charges,97% of total billed charges,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4724.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.86,4724.08,
33419-PF Transcatheter mitral valve repair; additional prosthesis,3580874,CDM,960,RC,33419,HCPCS,Outpatient,,,1142.85,571.43,,1028.57,90,,,percent of total billed charges,90% of total Billed charges,851.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.71,155,,,Fee Schedule,155% of CMS OPPS Rate,421.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,421.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,708.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,668.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,668.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,427.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,843.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,788.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,569.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,653.71,155,,,Fee Schedule,155% of CMS OPPS Rate,421.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1319.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1319.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,421.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,489.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,421.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.75,1319.83,
33419-Transcatheter mitral valve repair; additional prosthesis,3561521,CDM,481,RC,33419,HCPCS,Outpatient,,,1142.85,571.43,,1028.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,914.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1028.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1108.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1051.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,729.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,898.88,78.65,,,percent of total billed charges,78.65% of total billed charges,1020.93,89.33,,,percent of total billed charges,89.33% of total billed charges,1028.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,800,70,,,percent of total billed charges,70% of total billed charges,1028.57,90,,,percent of total billed charges,90% of total billed charges,1085.71,95,,,percent of total billed charges,95% of total billed charges,1085.71,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.85,86,,,percent of total billed charges,86% of total billed charges,914.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1108.56,97,,,percent of total billed charges,97% of total billed charges,1028.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1108.56,97,,,percent of total billed charges,97% of total billed charges,1062.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.85,1108.56,
33422- Valvotomy/MV/open ht/bypass,3430855,CDM,510,RC,33422,HCPCS,Outpatient,,,4464.79,2232.40,,4018.31,90,,,percent of total billed charges,90% of total Billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3571.83,80,,,Percent of total Billed charges,80% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4018.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4330.85,97,,,Percent of total billed charges,97% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4107.61,92,,,Percent of total billed charges,92% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4018.31,90,,,percent of total billed charges,90% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.35,70,,,percent of total billed charges,70% of total billed charges,4018.31,90,,,percent of total billed charges,90% of total billed charges,4241.55,95,,,percent of total billed charges,95% of total billed charges,4241.55,95,,,percent of total billed charges,95% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3839.72,86,,,percent of total billed charges,86% of total billed charges,3571.83,80,,,percent of total billed charges,80% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4330.85,97,,,percent of total billed charges,97% of total billed charges,4018.31,90,,,percent of total billed charges,90% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4330.85,97,,,percent of total billed charges,97% of total billed charges,4152.25,93,,,percent of total billed charges,93% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4330.85,97,,,percent of total billed charges,97% of total billed charges,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4464.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.35,4464.79,
33426- TMVR w/prosthetic ring,3430652,CDM,510,RC,33426,HCPCS,Outpatient,,,4948.42,2474.21,,4453.58,90,,,percent of total billed charges,90% of total Billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3958.74,80,,,Percent of total Billed charges,80% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4453.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4799.97,97,,,Percent of total billed charges,97% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4552.55,92,,,Percent of total billed charges,92% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4453.58,90,,,percent of total billed charges,90% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3463.89,70,,,percent of total billed charges,70% of total billed charges,4453.58,90,,,percent of total billed charges,90% of total billed charges,4701,95,,,percent of total billed charges,95% of total billed charges,4701,95,,,percent of total billed charges,95% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4255.64,86,,,percent of total billed charges,86% of total billed charges,3958.74,80,,,percent of total billed charges,80% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4799.97,97,,,percent of total billed charges,97% of total billed charges,4453.58,90,,,percent of total billed charges,90% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4799.97,97,,,percent of total billed charges,97% of total billed charges,4602.03,93,,,percent of total billed charges,93% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4799.97,97,,,percent of total billed charges,97% of total billed charges,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4948.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3463.89,4948.42,
33427- TMVR w/rad reconst w or w/o ring,3430653,CDM,510,RC,33427,HCPCS,Outpatient,,,6550.88,3275.44,,5895.79,90,,,percent of total billed charges,90% of total Billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5240.7,80,,,Percent of total Billed charges,80% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5895.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6354.35,97,,,Percent of total billed charges,97% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6026.81,92,,,Percent of total billed charges,92% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5895.79,90,,,percent of total billed charges,90% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4585.62,70,,,percent of total billed charges,70% of total billed charges,5895.79,90,,,percent of total billed charges,90% of total billed charges,6223.34,95,,,percent of total billed charges,95% of total billed charges,6223.34,95,,,percent of total billed charges,95% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5633.76,86,,,percent of total billed charges,86% of total billed charges,5240.7,80,,,percent of total billed charges,80% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6354.35,97,,,percent of total billed charges,97% of total billed charges,5895.79,90,,,percent of total billed charges,90% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6354.35,97,,,percent of total billed charges,97% of total billed charges,6092.32,93,,,percent of total billed charges,93% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6354.35,97,,,percent of total billed charges,97% of total billed charges,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6550.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4585.62,6550.88,
33430- Mitral valve replacement w/bypass,3430654,CDM,510,RC,33430,HCPCS,Outpatient,,,7530.23,3765.12,,6777.21,90,,,percent of total billed charges,90% of total Billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6024.18,80,,,Percent of total Billed charges,80% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6777.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7304.32,97,,,Percent of total billed charges,97% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6927.81,92,,,Percent of total billed charges,92% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6777.21,90,,,percent of total billed charges,90% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5271.16,70,,,percent of total billed charges,70% of total billed charges,6777.21,90,,,percent of total billed charges,90% of total billed charges,7153.72,95,,,percent of total billed charges,95% of total billed charges,7153.72,95,,,percent of total billed charges,95% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6476,86,,,percent of total billed charges,86% of total billed charges,6024.18,80,,,percent of total billed charges,80% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7304.32,97,,,percent of total billed charges,97% of total billed charges,6777.21,90,,,percent of total billed charges,90% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7304.32,97,,,percent of total billed charges,97% of total billed charges,7003.11,93,,,percent of total billed charges,93% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7304.32,97,,,percent of total billed charges,97% of total billed charges,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7530.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5271.16,7530.23,
33463- Valvuloplasty/TV w/o ring insert,3430655,CDM,510,RC,33463,HCPCS,Outpatient,,,8239.5,4119.75,,7415.55,90,,,percent of total billed charges,90% of total Billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6591.6,80,,,Percent of total Billed charges,80% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7415.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7992.32,97,,,Percent of total billed charges,97% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7580.34,92,,,Percent of total billed charges,92% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7415.55,90,,,percent of total billed charges,90% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5767.65,70,,,percent of total billed charges,70% of total billed charges,7415.55,90,,,percent of total billed charges,90% of total billed charges,7827.53,95,,,percent of total billed charges,95% of total billed charges,7827.53,95,,,percent of total billed charges,95% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7085.97,86,,,percent of total billed charges,86% of total billed charges,6591.6,80,,,percent of total billed charges,80% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7992.32,97,,,percent of total billed charges,97% of total billed charges,7415.55,90,,,percent of total billed charges,90% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7992.32,97,,,percent of total billed charges,97% of total billed charges,7662.74,93,,,percent of total billed charges,93% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7992.32,97,,,percent of total billed charges,97% of total billed charges,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8239.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5767.65,8239.5,
33464- Valvuloplasty/TV w/ring insertion,3430656,CDM,510,RC,33464,HCPCS,Outpatient,,,6549.21,3274.61,,5894.29,90,,,percent of total billed charges,90% of total Billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5239.37,80,,,Percent of total Billed charges,80% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5894.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6352.73,97,,,Percent of total billed charges,97% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6025.27,92,,,Percent of total billed charges,92% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5894.29,90,,,percent of total billed charges,90% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4584.45,70,,,percent of total billed charges,70% of total billed charges,5894.29,90,,,percent of total billed charges,90% of total billed charges,6221.75,95,,,percent of total billed charges,95% of total billed charges,6221.75,95,,,percent of total billed charges,95% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5632.32,86,,,percent of total billed charges,86% of total billed charges,5239.37,80,,,percent of total billed charges,80% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6352.73,97,,,percent of total billed charges,97% of total billed charges,5894.29,90,,,percent of total billed charges,90% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6352.73,97,,,percent of total billed charges,97% of total billed charges,6090.77,93,,,percent of total billed charges,93% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6352.73,97,,,percent of total billed charges,97% of total billed charges,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6549.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4584.45,6549.21,
"33465 - Replacement, tricuspid valve, with cardiopulmonary bypass",4169572,CDM,983,RC,33465,HCPCS,Outpatient,,,6612.87,3306.44,,5951.58,90,,,percent of total billed charges,90% of total Billed charges,5536.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2751.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,4264.64,155,,,Fee Schedule,155% of CMS OPPS Rate,2751.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4083.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2751.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4593.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4593.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,4339.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,4339.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2228.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2751.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5502.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5120.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3725.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,4264.64,155,,,Fee Schedule,155% of CMS OPPS Rate,2751.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,8581.48,155,,,Fee Schedule,155% of CMS OPPS Rate,8581.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2751.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2497.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2751.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,5764.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,5764.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,8581.48,
33465-REPLACE TRICUSPID VALVE,3430856,CDM,510,RC,33465,HCPCS,Outpatient,,,7406.42,3703.21,,6665.78,90,,,percent of total billed charges,90% of total Billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5925.14,80,,,Percent of total Billed charges,80% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6665.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7184.23,97,,,Percent of total billed charges,97% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6813.91,92,,,Percent of total billed charges,92% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6665.78,90,,,percent of total billed charges,90% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5184.49,70,,,percent of total billed charges,70% of total billed charges,6665.78,90,,,percent of total billed charges,90% of total billed charges,7036.1,95,,,percent of total billed charges,95% of total billed charges,7036.1,95,,,percent of total billed charges,95% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6369.52,86,,,percent of total billed charges,86% of total billed charges,5925.14,80,,,percent of total billed charges,80% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7184.23,97,,,percent of total billed charges,97% of total billed charges,6665.78,90,,,percent of total billed charges,90% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7184.23,97,,,percent of total billed charges,97% of total billed charges,6887.97,93,,,percent of total billed charges,93% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7184.23,97,,,percent of total billed charges,97% of total billed charges,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7406.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5184.49,7406.42,
33508- Endoscopy/surgical/vein harvest,3430657,CDM,510,RC,33508,HCPCS,Outpatient,,,44.46,22.23,,40.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,35.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,40.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,40.9,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,28.39,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,34.97,78.65,,,percent of total billed charges,78.65% of total billed charges,39.72,89.33,,,percent of total billed charges,89.33% of total billed charges,40.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31.12,70,,,percent of total billed charges,70% of total billed charges,40.01,90,,,percent of total billed charges,90% of total billed charges,42.24,95,,,percent of total billed charges,95% of total billed charges,42.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.24,86,,,percent of total billed charges,86% of total billed charges,35.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,43.13,97,,,percent of total billed charges,97% of total billed charges,40.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.13,97,,,percent of total billed charges,97% of total billed charges,41.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.39,43.13,
"33510- CABG,single coronary venous graft",3430658,CDM,510,RC,33510,HCPCS,Outpatient,,,5198.06,2599.03,,4678.25,90,,,percent of total billed charges,90% of total Billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4158.45,80,,,Percent of total Billed charges,80% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4678.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5042.12,97,,,Percent of total billed charges,97% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4782.22,92,,,Percent of total billed charges,92% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4678.25,90,,,percent of total billed charges,90% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3638.64,70,,,percent of total billed charges,70% of total billed charges,4678.25,90,,,percent of total billed charges,90% of total billed charges,4938.16,95,,,percent of total billed charges,95% of total billed charges,4938.16,95,,,percent of total billed charges,95% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4470.33,86,,,percent of total billed charges,86% of total billed charges,4158.45,80,,,percent of total billed charges,80% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5042.12,97,,,percent of total billed charges,97% of total billed charges,4678.25,90,,,percent of total billed charges,90% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5042.12,97,,,percent of total billed charges,97% of total billed charges,4834.2,93,,,percent of total billed charges,93% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5042.12,97,,,percent of total billed charges,97% of total billed charges,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5198.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3638.64,5198.06,
33511- CABG/vein only/2 cor venous gfts,3430857,CDM,510,RC,33511,HCPCS,Outpatient,,,5707.6,2853.80,,5136.84,90,,,percent of total billed charges,90% of total Billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4566.08,80,,,Percent of total Billed charges,80% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5136.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5536.37,97,,,Percent of total billed charges,97% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5250.99,92,,,Percent of total billed charges,92% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5136.84,90,,,percent of total billed charges,90% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3995.32,70,,,percent of total billed charges,70% of total billed charges,5136.84,90,,,percent of total billed charges,90% of total billed charges,5422.22,95,,,percent of total billed charges,95% of total billed charges,5422.22,95,,,percent of total billed charges,95% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4908.54,86,,,percent of total billed charges,86% of total billed charges,4566.08,80,,,percent of total billed charges,80% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5536.37,97,,,percent of total billed charges,97% of total billed charges,5136.84,90,,,percent of total billed charges,90% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5536.37,97,,,percent of total billed charges,97% of total billed charges,5308.07,93,,,percent of total billed charges,93% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5536.37,97,,,percent of total billed charges,97% of total billed charges,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5707.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3995.32,5707.6,
33512- CABG/vein only/3 cor venous gfts,3430858,CDM,510,RC,33512,HCPCS,Outpatient,,,6509.71,3254.86,,5858.74,90,,,percent of total billed charges,90% of total Billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5207.77,80,,,Percent of total Billed charges,80% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5858.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6314.42,97,,,Percent of total billed charges,97% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5988.93,92,,,Percent of total billed charges,92% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5858.74,90,,,percent of total billed charges,90% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4556.8,70,,,percent of total billed charges,70% of total billed charges,5858.74,90,,,percent of total billed charges,90% of total billed charges,6184.22,95,,,percent of total billed charges,95% of total billed charges,6184.22,95,,,percent of total billed charges,95% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5598.35,86,,,percent of total billed charges,86% of total billed charges,5207.77,80,,,percent of total billed charges,80% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6314.42,97,,,percent of total billed charges,97% of total billed charges,5858.74,90,,,percent of total billed charges,90% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6314.42,97,,,percent of total billed charges,97% of total billed charges,6054.03,93,,,percent of total billed charges,93% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6314.42,97,,,percent of total billed charges,97% of total billed charges,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6509.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4556.8,6509.71,
33513- CABG/vein only/4 cor venous gfts,3430859,CDM,510,RC,33513,HCPCS,Outpatient,,,6672.45,3336.23,,6005.21,90,,,percent of total billed charges,90% of total Billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5337.96,80,,,Percent of total Billed charges,80% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6005.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6472.28,97,,,Percent of total billed charges,97% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6138.65,92,,,Percent of total billed charges,92% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6005.21,90,,,percent of total billed charges,90% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4670.72,70,,,percent of total billed charges,70% of total billed charges,6005.21,90,,,percent of total billed charges,90% of total billed charges,6338.83,95,,,percent of total billed charges,95% of total billed charges,6338.83,95,,,percent of total billed charges,95% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5738.31,86,,,percent of total billed charges,86% of total billed charges,5337.96,80,,,percent of total billed charges,80% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6472.28,97,,,percent of total billed charges,97% of total billed charges,6005.21,90,,,percent of total billed charges,90% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6472.28,97,,,percent of total billed charges,97% of total billed charges,6205.38,93,,,percent of total billed charges,93% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6472.28,97,,,percent of total billed charges,97% of total billed charges,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6672.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4670.72,6672.45,
33517- CABG venous & art 1 vein graft,3430659,CDM,510,RC,33517,HCPCS,Outpatient,,,508.39,254.20,,457.55,90,,,percent of total billed charges,90% of total Billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,406.71,80,,,Percent of total Billed charges,80% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,457.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,493.14,97,,,Percent of total billed charges,97% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,467.72,92,,,Percent of total billed charges,92% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,457.55,90,,,percent of total billed charges,90% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,355.87,70,,,percent of total billed charges,70% of total billed charges,457.55,90,,,percent of total billed charges,90% of total billed charges,482.97,95,,,percent of total billed charges,95% of total billed charges,482.97,95,,,percent of total billed charges,95% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,437.22,86,,,percent of total billed charges,86% of total billed charges,406.71,80,,,percent of total billed charges,80% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,493.14,97,,,percent of total billed charges,97% of total billed charges,457.55,90,,,percent of total billed charges,90% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,493.14,97,,,percent of total billed charges,97% of total billed charges,472.8,93,,,percent of total billed charges,93% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,493.14,97,,,percent of total billed charges,97% of total billed charges,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,508.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,355.87,508.39,
33518- CABG venous & art 2 vein graft,3430660,CDM,510,RC,33518,HCPCS,Outpatient,,,1111.41,555.71,,1000.27,90,,,percent of total billed charges,90% of total Billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,889.13,80,,,Percent of total Billed charges,80% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1078.07,97,,,Percent of total billed charges,97% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1022.5,92,,,Percent of total billed charges,92% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000.27,90,,,percent of total billed charges,90% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.99,70,,,percent of total billed charges,70% of total billed charges,1000.27,90,,,percent of total billed charges,90% of total billed charges,1055.84,95,,,percent of total billed charges,95% of total billed charges,1055.84,95,,,percent of total billed charges,95% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,955.81,86,,,percent of total billed charges,86% of total billed charges,889.13,80,,,percent of total billed charges,80% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1078.07,97,,,percent of total billed charges,97% of total billed charges,1000.27,90,,,percent of total billed charges,90% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1078.07,97,,,percent of total billed charges,97% of total billed charges,1033.61,93,,,percent of total billed charges,93% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1078.07,97,,,percent of total billed charges,97% of total billed charges,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1111.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.99,1111.41,
33519- CABG venous & art 3 vein graft,3430661,CDM,510,RC,33519,HCPCS,Outpatient,,,1473.32,736.66,,1325.99,90,,,percent of total billed charges,90% of total Billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1178.66,80,,,Percent of total Billed charges,80% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1325.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1429.12,97,,,Percent of total billed charges,97% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1355.45,92,,,Percent of total billed charges,92% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1325.99,90,,,percent of total billed charges,90% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1031.32,70,,,percent of total billed charges,70% of total billed charges,1325.99,90,,,percent of total billed charges,90% of total billed charges,1399.65,95,,,percent of total billed charges,95% of total billed charges,1399.65,95,,,percent of total billed charges,95% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1267.06,86,,,percent of total billed charges,86% of total billed charges,1178.66,80,,,percent of total billed charges,80% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1429.12,97,,,percent of total billed charges,97% of total billed charges,1325.99,90,,,percent of total billed charges,90% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1429.12,97,,,percent of total billed charges,97% of total billed charges,1370.19,93,,,percent of total billed charges,93% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1429.12,97,,,percent of total billed charges,97% of total billed charges,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1031.32,1473.32,
33521- CABG venous & art 4 vein graft,3430662,CDM,510,RC,33521,HCPCS,Outpatient,,,1766.42,883.21,,1589.78,90,,,percent of total billed charges,90% of total Billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1413.14,80,,,Percent of total Billed charges,80% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1589.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1713.43,97,,,Percent of total billed charges,97% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1625.11,92,,,Percent of total billed charges,92% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1589.78,90,,,percent of total billed charges,90% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1236.49,70,,,percent of total billed charges,70% of total billed charges,1589.78,90,,,percent of total billed charges,90% of total billed charges,1678.1,95,,,percent of total billed charges,95% of total billed charges,1678.1,95,,,percent of total billed charges,95% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1519.12,86,,,percent of total billed charges,86% of total billed charges,1413.14,80,,,percent of total billed charges,80% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1713.43,97,,,percent of total billed charges,97% of total billed charges,1589.78,90,,,percent of total billed charges,90% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1713.43,97,,,percent of total billed charges,97% of total billed charges,1642.77,93,,,percent of total billed charges,93% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1713.43,97,,,percent of total billed charges,97% of total billed charges,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1236.49,1766.42,
33522- CABG venous & art 5 vein graft,3430663,CDM,510,RC,33522,HCPCS,Outpatient,,,1982.69,991.35,,1784.42,90,,,percent of total billed charges,90% of total Billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1586.15,80,,,Percent of total Billed charges,80% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1784.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1923.21,97,,,Percent of total billed charges,97% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1824.07,92,,,Percent of total billed charges,92% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1784.42,90,,,percent of total billed charges,90% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1387.88,70,,,percent of total billed charges,70% of total billed charges,1784.42,90,,,percent of total billed charges,90% of total billed charges,1883.56,95,,,percent of total billed charges,95% of total billed charges,1883.56,95,,,percent of total billed charges,95% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1705.11,86,,,percent of total billed charges,86% of total billed charges,1586.15,80,,,percent of total billed charges,80% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1923.21,97,,,percent of total billed charges,97% of total billed charges,1784.42,90,,,percent of total billed charges,90% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1923.21,97,,,percent of total billed charges,97% of total billed charges,1843.9,93,,,percent of total billed charges,93% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1923.21,97,,,percent of total billed charges,97% of total billed charges,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1387.88,1982.69,
33523- CABG venous & art 6 vein graft,3430664,CDM,510,RC,33523,HCPCS,Outpatient,,,2244.48,1122.24,,2020.03,90,,,percent of total billed charges,90% of total Billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1795.58,80,,,Percent of total Billed charges,80% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2020.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2177.15,97,,,Percent of total billed charges,97% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2064.92,92,,,Percent of total billed charges,92% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2020.03,90,,,percent of total billed charges,90% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1571.14,70,,,percent of total billed charges,70% of total billed charges,2020.03,90,,,percent of total billed charges,90% of total billed charges,2132.26,95,,,percent of total billed charges,95% of total billed charges,2132.26,95,,,percent of total billed charges,95% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1930.25,86,,,percent of total billed charges,86% of total billed charges,1795.58,80,,,percent of total billed charges,80% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.15,97,,,percent of total billed charges,97% of total billed charges,2020.03,90,,,percent of total billed charges,90% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2177.15,97,,,percent of total billed charges,97% of total billed charges,2087.37,93,,,percent of total billed charges,93% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2177.15,97,,,percent of total billed charges,97% of total billed charges,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1571.14,2244.48,
33530- CABG/valve reop >1 mo p org proced,3430665,CDM,510,RC,33530,HCPCS,Outpatient,,,1420.17,710.09,,1278.15,90,,,percent of total billed charges,90% of total Billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1136.14,80,,,Percent of total Billed charges,80% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1278.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1377.56,97,,,Percent of total billed charges,97% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1306.56,92,,,Percent of total billed charges,92% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1278.15,90,,,percent of total billed charges,90% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,994.12,70,,,percent of total billed charges,70% of total billed charges,1278.15,90,,,percent of total billed charges,90% of total billed charges,1349.16,95,,,percent of total billed charges,95% of total billed charges,1349.16,95,,,percent of total billed charges,95% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1221.35,86,,,percent of total billed charges,86% of total billed charges,1136.14,80,,,percent of total billed charges,80% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1377.56,97,,,percent of total billed charges,97% of total billed charges,1278.15,90,,,percent of total billed charges,90% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1377.56,97,,,percent of total billed charges,97% of total billed charges,1320.76,93,,,percent of total billed charges,93% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1377.56,97,,,percent of total billed charges,97% of total billed charges,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1420.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,994.12,1420.17,
"33533- CABG,single artery graft",3430666,CDM,510,RC,33533,HCPCS,Outpatient,,,5027.93,2513.97,,4525.14,90,,,percent of total billed charges,90% of total Billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4022.34,80,,,Percent of total Billed charges,80% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4525.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4877.09,97,,,Percent of total billed charges,97% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4625.7,92,,,Percent of total billed charges,92% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4525.14,90,,,percent of total billed charges,90% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3519.55,70,,,percent of total billed charges,70% of total billed charges,4525.14,90,,,percent of total billed charges,90% of total billed charges,4776.53,95,,,percent of total billed charges,95% of total billed charges,4776.53,95,,,percent of total billed charges,95% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4324.02,86,,,percent of total billed charges,86% of total billed charges,4022.34,80,,,percent of total billed charges,80% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4877.09,97,,,percent of total billed charges,97% of total billed charges,4525.14,90,,,percent of total billed charges,90% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4877.09,97,,,percent of total billed charges,97% of total billed charges,4675.97,93,,,percent of total billed charges,93% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4877.09,97,,,percent of total billed charges,97% of total billed charges,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5027.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3519.55,5027.93,
"33534- CABG, 2 arterial grafts",3430667,CDM,510,RC,33534,HCPCS,Outpatient,,,5907.17,2953.59,,5316.45,90,,,percent of total billed charges,90% of total Billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4725.74,80,,,Percent of total Billed charges,80% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5316.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5729.95,97,,,Percent of total billed charges,97% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5434.6,92,,,Percent of total billed charges,92% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5316.45,90,,,percent of total billed charges,90% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4135.02,70,,,percent of total billed charges,70% of total billed charges,5316.45,90,,,percent of total billed charges,90% of total billed charges,5611.81,95,,,percent of total billed charges,95% of total billed charges,5611.81,95,,,percent of total billed charges,95% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5080.17,86,,,percent of total billed charges,86% of total billed charges,4725.74,80,,,percent of total billed charges,80% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5729.95,97,,,percent of total billed charges,97% of total billed charges,5316.45,90,,,percent of total billed charges,90% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5729.95,97,,,percent of total billed charges,97% of total billed charges,5493.67,93,,,percent of total billed charges,93% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5729.95,97,,,percent of total billed charges,97% of total billed charges,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5907.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4135.02,5907.17,
"33535- CABG, 3 arterial grafts",3430668,CDM,510,RC,33535,HCPCS,Outpatient,,,6581.65,3290.83,,5923.49,90,,,percent of total billed charges,90% of total Billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5265.32,80,,,Percent of total Billed charges,80% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5923.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6384.2,97,,,Percent of total billed charges,97% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6055.12,92,,,Percent of total billed charges,92% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5923.49,90,,,percent of total billed charges,90% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4607.16,70,,,percent of total billed charges,70% of total billed charges,5923.49,90,,,percent of total billed charges,90% of total billed charges,6252.57,95,,,percent of total billed charges,95% of total billed charges,6252.57,95,,,percent of total billed charges,95% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5660.22,86,,,percent of total billed charges,86% of total billed charges,5265.32,80,,,percent of total billed charges,80% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6384.2,97,,,percent of total billed charges,97% of total billed charges,5923.49,90,,,percent of total billed charges,90% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6384.2,97,,,percent of total billed charges,97% of total billed charges,6120.93,93,,,percent of total billed charges,93% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6384.2,97,,,percent of total billed charges,97% of total billed charges,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6581.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4607.16,6581.65,
33545- Rpr postinfarc VSD/w w/o myo resec,3430862,CDM,510,RC,33545,HCPCS,Outpatient,,,8270.99,4135.50,,7443.89,90,,,percent of total billed charges,90% of total Billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6616.79,80,,,Percent of total Billed charges,80% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7443.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8022.86,97,,,Percent of total billed charges,97% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7609.31,92,,,Percent of total billed charges,92% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7443.89,90,,,percent of total billed charges,90% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5789.69,70,,,percent of total billed charges,70% of total billed charges,7443.89,90,,,percent of total billed charges,90% of total billed charges,7857.44,95,,,percent of total billed charges,95% of total billed charges,7857.44,95,,,percent of total billed charges,95% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7113.05,86,,,percent of total billed charges,86% of total billed charges,6616.79,80,,,percent of total billed charges,80% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8022.86,97,,,percent of total billed charges,97% of total billed charges,7443.89,90,,,percent of total billed charges,90% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8022.86,97,,,percent of total billed charges,97% of total billed charges,7692.02,93,,,percent of total billed charges,93% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8022.86,97,,,percent of total billed charges,97% of total billed charges,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8270.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5789.69,8270.99,
33548- Ventricular restoration proc/surg,3430863,CDM,510,RC,33548,HCPCS,Outpatient,,,7989.63,3994.82,,7190.67,90,,,percent of total billed charges,90% of total Billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6391.7,80,,,Percent of total Billed charges,80% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7190.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7749.94,97,,,Percent of total billed charges,97% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7350.46,92,,,Percent of total billed charges,92% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7190.67,90,,,percent of total billed charges,90% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5592.74,70,,,percent of total billed charges,70% of total billed charges,7190.67,90,,,percent of total billed charges,90% of total billed charges,7590.15,95,,,percent of total billed charges,95% of total billed charges,7590.15,95,,,percent of total billed charges,95% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6871.08,86,,,percent of total billed charges,86% of total billed charges,6391.7,80,,,percent of total billed charges,80% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7749.94,97,,,percent of total billed charges,97% of total billed charges,7190.67,90,,,percent of total billed charges,90% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7749.94,97,,,percent of total billed charges,97% of total billed charges,7430.36,93,,,percent of total billed charges,93% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7749.94,97,,,percent of total billed charges,97% of total billed charges,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7989.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5592.74,7989.63,
33572- Open cor endarterect w CABG/ea ves,3430669,CDM,510,RC,33572,HCPCS,Outpatient,,,622.76,311.38,,560.48,90,,,percent of total billed charges,90% of total Billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,498.21,80,,,Percent of total Billed charges,80% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,604.08,97,,,Percent of total billed charges,97% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,572.94,92,,,Percent of total billed charges,92% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,560.48,90,,,percent of total billed charges,90% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,435.93,70,,,percent of total billed charges,70% of total billed charges,560.48,90,,,percent of total billed charges,90% of total billed charges,591.62,95,,,percent of total billed charges,95% of total billed charges,591.62,95,,,percent of total billed charges,95% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,535.57,86,,,percent of total billed charges,86% of total billed charges,498.21,80,,,percent of total billed charges,80% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,604.08,97,,,percent of total billed charges,97% of total billed charges,560.48,90,,,percent of total billed charges,90% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,604.08,97,,,percent of total billed charges,97% of total billed charges,579.17,93,,,percent of total billed charges,93% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,604.08,97,,,percent of total billed charges,97% of total billed charges,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,435.93,622.76,
33641- ASD repair/CP bypass w w/o patch,3430670,CDM,510,RC,33641,HCPCS,Outpatient,,,4401.08,2200.54,,3960.97,90,,,percent of total billed charges,90% of total Billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3520.86,80,,,Percent of total Billed charges,80% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3960.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4269.05,97,,,Percent of total billed charges,97% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4048.99,92,,,Percent of total billed charges,92% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3960.97,90,,,percent of total billed charges,90% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3080.76,70,,,percent of total billed charges,70% of total billed charges,3960.97,90,,,percent of total billed charges,90% of total billed charges,4181.03,95,,,percent of total billed charges,95% of total billed charges,4181.03,95,,,percent of total billed charges,95% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3784.93,86,,,percent of total billed charges,86% of total billed charges,3520.86,80,,,percent of total billed charges,80% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4269.05,97,,,percent of total billed charges,97% of total billed charges,3960.97,90,,,percent of total billed charges,90% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4269.05,97,,,percent of total billed charges,97% of total billed charges,4093,93,,,percent of total billed charges,93% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4269.05,97,,,percent of total billed charges,97% of total billed charges,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4401.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3080.76,4401.08,
33735 - (PF) Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation),3634899,CDM,510,RC,33735,HCPCS,Outpatient,,,3466.59,1733.30,,3119.93,90,,,percent of total billed charges,90% of total Billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2773.27,80,,,Percent of total Billed charges,80% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3119.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3362.59,97,,,Percent of total billed charges,97% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3189.26,92,,,Percent of total billed charges,92% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3119.93,90,,,percent of total billed charges,90% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2426.61,70,,,percent of total billed charges,70% of total billed charges,3119.93,90,,,percent of total billed charges,90% of total billed charges,3293.26,95,,,percent of total billed charges,95% of total billed charges,3293.26,95,,,percent of total billed charges,95% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2981.27,86,,,percent of total billed charges,86% of total billed charges,2773.27,80,,,percent of total billed charges,80% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3362.59,97,,,percent of total billed charges,97% of total billed charges,3119.93,90,,,percent of total billed charges,90% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3362.59,97,,,percent of total billed charges,97% of total billed charges,3223.93,93,,,percent of total billed charges,93% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3362.59,97,,,percent of total billed charges,97% of total billed charges,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3466.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2426.61,3466.59,
33858 - ASCEND AORTIC GRFT W/CARIOPUL BYPASS,3429669,CDM,960,RC,33858,HCPCS,Outpatient,,,9150.6,4575.30,,8235.54,90,,,percent of total billed charges,90% of total Billed charges,6838.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3397.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5265.82,155,,,Fee Schedule,155% of CMS OPPS Rate,3397.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5037.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3397.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5665.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5665.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5368.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5368.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3057.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3397.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6794.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6334.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,4640.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,5265.82,155,,,Fee Schedule,155% of CMS OPPS Rate,3397.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,10599.26,155,,,Fee Schedule,155% of CMS OPPS Rate,10599.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,3397.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3837.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3397.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3057.14,10599.26,
ASCEND AORTIC GRFT W/ CARDIOPUL BYP,3527865,CDM,481,RC,33858,HCPCS,Outpatient,,,9150.6,4575.30,,8235.54,90,,,percent of total billed charges,90% of total Billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7320.48,80,,,Percent of total Billed charges,80% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8235.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8876.08,97,,,Percent of total billed charges,97% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8418.55,92,,,Percent of total billed charges,92% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8235.54,90,,,percent of total billed charges,90% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6405.42,70,,,percent of total billed charges,70% of total billed charges,8235.54,90,,,percent of total billed charges,90% of total billed charges,8693.07,95,,,percent of total billed charges,95% of total billed charges,8693.07,95,,,percent of total billed charges,95% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7869.52,86,,,percent of total billed charges,86% of total billed charges,7320.48,80,,,percent of total billed charges,80% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8876.08,97,,,percent of total billed charges,97% of total billed charges,8235.54,90,,,percent of total billed charges,90% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8876.08,97,,,percent of total billed charges,97% of total billed charges,8510.06,93,,,percent of total billed charges,93% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8876.08,97,,,percent of total billed charges,97% of total billed charges,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,9150.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6405.42,9150.6,
33859 - ASCEND AORTIC GRFT W/ CARDIOPULBYPASS,3429672,CDM,960,RC,33859,HCPCS,Outpatient,,,6568.41,3284.21,,5911.57,90,,,percent of total billed charges,90% of total Billed charges,4906.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2436.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.33,155,,,Fee Schedule,155% of CMS OPPS Rate,2436.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3616.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2436.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4067.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4067.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3847.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3847.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2194.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2436.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4872.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4540.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3317.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3776.33,155,,,Fee Schedule,155% of CMS OPPS Rate,2436.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,7604.75,155,,,Fee Schedule,155% of CMS OPPS Rate,7604.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2436.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2753.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2436.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2194.61,7604.75,
ASCEND AORTIC GRFT W/CARDIOPUL BYP,3527866,CDM,481,RC,33859,HCPCS,Outpatient,,,6568.41,3284.21,,5911.57,90,,,percent of total billed charges,90% of total Billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.73,80,,,Percent of total Billed charges,80% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5911.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6371.36,97,,,Percent of total billed charges,97% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6042.94,92,,,Percent of total billed charges,92% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5911.57,90,,,percent of total billed charges,90% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4597.89,70,,,percent of total billed charges,70% of total billed charges,5911.57,90,,,percent of total billed charges,90% of total billed charges,6239.99,95,,,percent of total billed charges,95% of total billed charges,6239.99,95,,,percent of total billed charges,95% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5648.83,86,,,percent of total billed charges,86% of total billed charges,5254.73,80,,,percent of total billed charges,80% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6371.36,97,,,percent of total billed charges,97% of total billed charges,5911.57,90,,,percent of total billed charges,90% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6371.36,97,,,percent of total billed charges,97% of total billed charges,6108.62,93,,,percent of total billed charges,93% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6371.36,97,,,percent of total billed charges,97% of total billed charges,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6568.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4597.89,6568.41,
33863- AA graft w/BP/aortic root replace,3430671,CDM,510,RC,33863,HCPCS,Outpatient,,,8482.33,4241.17,,7634.1,90,,,percent of total billed charges,90% of total Billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6785.86,80,,,Percent of total Billed charges,80% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7634.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8227.86,97,,,Percent of total billed charges,97% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7803.74,92,,,Percent of total billed charges,92% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7634.1,90,,,percent of total billed charges,90% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5937.63,70,,,percent of total billed charges,70% of total billed charges,7634.1,90,,,percent of total billed charges,90% of total billed charges,8058.21,95,,,percent of total billed charges,95% of total billed charges,8058.21,95,,,percent of total billed charges,95% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7294.8,86,,,percent of total billed charges,86% of total billed charges,6785.86,80,,,percent of total billed charges,80% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8227.86,97,,,percent of total billed charges,97% of total billed charges,7634.1,90,,,percent of total billed charges,90% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8227.86,97,,,percent of total billed charges,97% of total billed charges,7888.57,93,,,percent of total billed charges,93% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8227.86,97,,,percent of total billed charges,97% of total billed charges,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8482.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5937.63,8482.33,
33864- Asc aort gft/CP/root rem/cor recon,3430866,CDM,510,RC,33864,HCPCS,Outpatient,,,8680.04,4340.02,,7812.04,90,,,percent of total billed charges,90% of total Billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6944.03,80,,,Percent of total Billed charges,80% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7812.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8419.64,97,,,Percent of total billed charges,97% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7985.64,92,,,Percent of total billed charges,92% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7812.04,90,,,percent of total billed charges,90% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6076.03,70,,,percent of total billed charges,70% of total billed charges,7812.04,90,,,percent of total billed charges,90% of total billed charges,8246.04,95,,,percent of total billed charges,95% of total billed charges,8246.04,95,,,percent of total billed charges,95% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7464.83,86,,,percent of total billed charges,86% of total billed charges,6944.03,80,,,percent of total billed charges,80% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8419.64,97,,,percent of total billed charges,97% of total billed charges,7812.04,90,,,percent of total billed charges,90% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8419.64,97,,,percent of total billed charges,97% of total billed charges,8072.44,93,,,percent of total billed charges,93% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8419.64,97,,,percent of total billed charges,97% of total billed charges,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8680.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6076.03,8680.04,
33880- Descend thora aorta rpr/lt sub art,3430867,CDM,510,RC,33880,HCPCS,Outpatient,,,4850.93,2425.47,,4365.84,90,,,percent of total billed charges,90% of total Billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3880.74,80,,,Percent of total Billed charges,80% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4365.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4705.4,97,,,Percent of total billed charges,97% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4462.86,92,,,Percent of total billed charges,92% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4365.84,90,,,percent of total billed charges,90% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3395.65,70,,,percent of total billed charges,70% of total billed charges,4365.84,90,,,percent of total billed charges,90% of total billed charges,4608.38,95,,,percent of total billed charges,95% of total billed charges,4608.38,95,,,percent of total billed charges,95% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4171.8,86,,,percent of total billed charges,86% of total billed charges,3880.74,80,,,percent of total billed charges,80% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4705.4,97,,,percent of total billed charges,97% of total billed charges,4365.84,90,,,percent of total billed charges,90% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4705.4,97,,,percent of total billed charges,97% of total billed charges,4511.36,93,,,percent of total billed charges,93% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4705.4,97,,,percent of total billed charges,97% of total billed charges,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4850.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3395.65,4850.93,
33880-PF TEVAR - Endovasc TAA Repair INCL Subcl,4213467,CDM,960,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,3430.96,90,,,percent of total billed charges,90% of total Billed charges,3622.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1798.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2787.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1798.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2661.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1798.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2993.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2993.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2849.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2849.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1459.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1798.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3361.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2476.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2787.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1798.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,5614.58,155,,,Fee Schedule,155% of CMS OPPS Rate,5614.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1798.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1798.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,3800.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3800.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5614.58,
33880-TEVAR - Endovasc TAA Repair INCL Subcl,4213466,CDM,481,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,3430.96,90,,,percent of total billed charges,90% of total Billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3049.74,80,,,Percent of total Billed charges,80% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3430.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3697.81,97,,,Percent of total billed charges,97% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3507.21,92,,,Percent of total billed charges,92% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3430.96,90,,,percent of total billed charges,90% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.53,70,,,percent of total billed charges,70% of total billed charges,3430.96,90,,,percent of total billed charges,90% of total billed charges,3621.57,95,,,percent of total billed charges,95% of total billed charges,3621.57,95,,,percent of total billed charges,95% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3278.47,86,,,percent of total billed charges,86% of total billed charges,3049.74,80,,,percent of total billed charges,80% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3697.81,97,,,percent of total billed charges,97% of total billed charges,3430.96,90,,,percent of total billed charges,90% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3697.81,97,,,percent of total billed charges,97% of total billed charges,3545.33,93,,,percent of total billed charges,93% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3697.81,97,,,percent of total billed charges,97% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.53,3812.18,
TEVAR - Endovasc TAA Repair INCL Subcl,,,761,RC,33880,HCPCS,Outpatient,,,3812.18,1906.09,,3430.96,90,,,percent of total billed charges,90% of total Billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3049.74,80,,,Percent of total Billed charges,80% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3430.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3697.81,97,,,Percent of total billed charges,97% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3507.21,92,,,Percent of total billed charges,92% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3430.96,90,,,percent of total billed charges,90% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.53,70,,,percent of total billed charges,70% of total billed charges,3430.96,90,,,percent of total billed charges,90% of total billed charges,3621.57,95,,,percent of total billed charges,95% of total billed charges,3621.57,95,,,percent of total billed charges,95% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3278.47,86,,,percent of total billed charges,86% of total billed charges,3049.74,80,,,percent of total billed charges,80% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3697.81,97,,,percent of total billed charges,97% of total billed charges,3430.96,90,,,percent of total billed charges,90% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3697.81,97,,,percent of total billed charges,97% of total billed charges,3545.33,93,,,percent of total billed charges,93% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3697.81,97,,,percent of total billed charges,97% of total billed charges,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.53,3812.18,
33881- Des thora aorta rpr w/o lt sub art,3430868,CDM,510,RC,33881,HCPCS,Outpatient,,,4156.29,2078.15,,3740.66,90,,,percent of total billed charges,90% of total Billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3325.03,80,,,Percent of total Billed charges,80% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3740.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4031.6,97,,,Percent of total billed charges,97% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3823.79,92,,,Percent of total billed charges,92% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3740.66,90,,,percent of total billed charges,90% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2909.4,70,,,percent of total billed charges,70% of total billed charges,3740.66,90,,,percent of total billed charges,90% of total billed charges,3948.48,95,,,percent of total billed charges,95% of total billed charges,3948.48,95,,,percent of total billed charges,95% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3574.41,86,,,percent of total billed charges,86% of total billed charges,3325.03,80,,,percent of total billed charges,80% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4031.6,97,,,percent of total billed charges,97% of total billed charges,3740.66,90,,,percent of total billed charges,90% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4031.6,97,,,percent of total billed charges,97% of total billed charges,3865.35,93,,,percent of total billed charges,93% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4031.6,97,,,percent of total billed charges,97% of total billed charges,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4156.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2909.4,4156.29,
33881-PF TEVAR - Endovasc TAA Repair WO Subcl,4213464,CDM,960,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,2938.01,90,,,percent of total billed charges,90% of total Billed charges,3102.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1539.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2386.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1539.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2284.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1539.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2569.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2569.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2445.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2445.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1253.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1539.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3079.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2885.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2126.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2386.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1539.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,4809.26,155,,,Fee Schedule,155% of CMS OPPS Rate,4809.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1539.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1485.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1539.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3273.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4809.26,
33881-TEVAR - Endovasc TAA Repair WO Subcl,4213463,CDM,481,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,2938.01,90,,,percent of total billed charges,90% of total Billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2611.57,80,,,Percent of total Billed charges,80% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2938.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3166.53,97,,,Percent of total billed charges,97% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3003.3,92,,,Percent of total billed charges,92% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2938.01,90,,,percent of total billed charges,90% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2285.12,70,,,percent of total billed charges,70% of total billed charges,2938.01,90,,,percent of total billed charges,90% of total billed charges,3101.24,95,,,percent of total billed charges,95% of total billed charges,3101.24,95,,,percent of total billed charges,95% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2807.44,86,,,percent of total billed charges,86% of total billed charges,2611.57,80,,,percent of total billed charges,80% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.53,97,,,percent of total billed charges,97% of total billed charges,2938.01,90,,,percent of total billed charges,90% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.53,97,,,percent of total billed charges,97% of total billed charges,3035.95,93,,,percent of total billed charges,93% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3166.53,97,,,percent of total billed charges,97% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2285.12,3264.46,
TEVAR - Endovasc TAA Repair WO Subcl,,,761,RC,33881,HCPCS,Outpatient,,,3264.46,1632.23,,2938.01,90,,,percent of total billed charges,90% of total Billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2611.57,80,,,Percent of total Billed charges,80% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2938.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3166.53,97,,,Percent of total billed charges,97% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3003.3,92,,,Percent of total billed charges,92% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2938.01,90,,,percent of total billed charges,90% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2285.12,70,,,percent of total billed charges,70% of total billed charges,2938.01,90,,,percent of total billed charges,90% of total billed charges,3101.24,95,,,percent of total billed charges,95% of total billed charges,3101.24,95,,,percent of total billed charges,95% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2807.44,86,,,percent of total billed charges,86% of total billed charges,2611.57,80,,,percent of total billed charges,80% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.53,97,,,percent of total billed charges,97% of total billed charges,2938.01,90,,,percent of total billed charges,90% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.53,97,,,percent of total billed charges,97% of total billed charges,3035.95,93,,,percent of total billed charges,93% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3166.53,97,,,percent of total billed charges,97% of total billed charges,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2285.12,3264.46,
33883- Prox ext prosth/rpr descend thorac aorta/initial,3430869,CDM,510,RC,33883,HCPCS,Outpatient,,,3002.73,1501.37,,2702.46,90,,,percent of total billed charges,90% of total Billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2402.18,80,,,Percent of total Billed charges,80% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2702.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2912.65,97,,,Percent of total billed charges,97% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2762.51,92,,,Percent of total billed charges,92% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2702.46,90,,,percent of total billed charges,90% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.91,70,,,percent of total billed charges,70% of total billed charges,2702.46,90,,,percent of total billed charges,90% of total billed charges,2852.59,95,,,percent of total billed charges,95% of total billed charges,2852.59,95,,,percent of total billed charges,95% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2582.35,86,,,percent of total billed charges,86% of total billed charges,2402.18,80,,,percent of total billed charges,80% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2912.65,97,,,percent of total billed charges,97% of total billed charges,2702.46,90,,,percent of total billed charges,90% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2912.65,97,,,percent of total billed charges,97% of total billed charges,2792.54,93,,,percent of total billed charges,93% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2912.65,97,,,percent of total billed charges,97% of total billed charges,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2101.91,3002.73,
33883-PF Placement of prox ext. prosthesis for endovasc repair of descend  thoracic aorta,4271128,CDM,960,RC,33883,HCPCS,Outpatient,,,2359.64,1179.82,,2123.68,90,,,percent of total billed charges,90% of total Billed charges,2242.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1113.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,727.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1725.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1113.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1113.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1859.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1764.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1764.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,910.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2081.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1523.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1725.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1113.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,3475.35,155,,,Fee Schedule,155% of CMS OPPS Rate,3475.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1113.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,727.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1108.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1113.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,2373.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2373.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,727.08,3475.35,
33883-Placement of prox ext prosthesis for endovasc repair of descend  thoracic aorta,4271127,CDM,481,RC,33883,HCPCS,Outpatient,,,2359.64,1179.82,,2123.68,90,,,percent of total billed charges,90% of total Billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.71,80,,,Percent of total Billed charges,80% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2123.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2288.85,97,,,Percent of total billed charges,97% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2170.87,92,,,Percent of total billed charges,92% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2123.68,90,,,percent of total billed charges,90% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1651.75,70,,,percent of total billed charges,70% of total billed charges,2123.68,90,,,percent of total billed charges,90% of total billed charges,2241.66,95,,,percent of total billed charges,95% of total billed charges,2241.66,95,,,percent of total billed charges,95% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2029.29,86,,,percent of total billed charges,86% of total billed charges,1887.71,80,,,percent of total billed charges,80% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2288.85,97,,,percent of total billed charges,97% of total billed charges,2123.68,90,,,percent of total billed charges,90% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2288.85,97,,,percent of total billed charges,97% of total billed charges,2194.47,93,,,percent of total billed charges,93% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2288.85,97,,,percent of total billed charges,97% of total billed charges,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1651.75,2359.64,
33884- Prox ext prosth/rpr descend thorac aorta/ea add prox ext,3430870,CDM,510,RC,33884,HCPCS,Outpatient,,,1082.99,541.50,,974.69,90,,,percent of total billed charges,90% of total Billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,866.39,80,,,Percent of total Billed charges,80% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,974.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1050.5,97,,,Percent of total billed charges,97% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,996.35,92,,,Percent of total billed charges,92% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,974.69,90,,,percent of total billed charges,90% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.09,70,,,percent of total billed charges,70% of total billed charges,974.69,90,,,percent of total billed charges,90% of total billed charges,1028.84,95,,,percent of total billed charges,95% of total billed charges,1028.84,95,,,percent of total billed charges,95% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,931.37,86,,,percent of total billed charges,86% of total billed charges,866.39,80,,,percent of total billed charges,80% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1050.5,97,,,percent of total billed charges,97% of total billed charges,974.69,90,,,percent of total billed charges,90% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1050.5,97,,,percent of total billed charges,97% of total billed charges,1007.18,93,,,percent of total billed charges,93% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1050.5,97,,,percent of total billed charges,97% of total billed charges,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.09,1082.99,
33884-PF Placement of prox ext. prosthesis for endovasc repair of descend thoracic aorta- each add't,4271130,CDM,960,RC,33884,HCPCS,Outpatient,,,849.78,424.89,,764.8,90,,,percent of total billed charges,90% of total Billed charges,808.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,261.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,621.3,155,,,Fee Schedule,155% of CMS OPPS Rate,400.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,400.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,661.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,661.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,638.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,638.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,334.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,801.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,570.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,621.3,155,,,Fee Schedule,155% of CMS OPPS Rate,400.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1252.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1252.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,400.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,400.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,870.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,870.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,261.15,1252.52,
33884-Placement of prox ext. prosthesis for endovasc repair of descend thoracic aorta- each add't,4271129,CDM,481,RC,33884,HCPCS,Outpatient,,,849.78,424.89,,764.8,90,,,percent of total billed charges,90% of total Billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,679.82,80,,,Percent of total Billed charges,80% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,764.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.29,97,,,Percent of total billed charges,97% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,781.8,92,,,Percent of total billed charges,92% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,764.8,90,,,percent of total billed charges,90% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,594.85,70,,,percent of total billed charges,70% of total billed charges,764.8,90,,,percent of total billed charges,90% of total billed charges,807.29,95,,,percent of total billed charges,95% of total billed charges,807.29,95,,,percent of total billed charges,95% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,730.81,86,,,percent of total billed charges,86% of total billed charges,679.82,80,,,percent of total billed charges,80% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,824.29,97,,,percent of total billed charges,97% of total billed charges,764.8,90,,,percent of total billed charges,90% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,824.29,97,,,percent of total billed charges,97% of total billed charges,790.3,93,,,percent of total billed charges,93% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,824.29,97,,,percent of total billed charges,97% of total billed charges,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,594.85,849.78,
33895 - Evasc St Rpr Coarcj Thrc/AA XCRSG Maj Side Brnch,4201241,CDM,983,RC,33895,HCPCS,Outpatient,,,1649.95,824.98,,1484.96,90,,,percent of total billed charges,90% of total Billed charges,1555.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.2,155,,,Fee Schedule,155% of CMS OPPS Rate,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1555.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.2,155,,,Fee Schedule,155% of CMS OPPS Rate,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2411.52,155,,,Fee Schedule,155% of CMS OPPS Rate,2411.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.99,2411.52,
33915-Percutaneous Pulmonary Embolectomy,3431822,CDM,360,RC,33915,HCPCS,Outpatient,,,3703.25,1851.63,,3332.93,90,,,percent of total billed charges,90% of total Billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2962.6,80,,,Percent of total Billed charges,80% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3332.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3592.15,97,,,Percent of total billed charges,97% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3406.99,92,,,Percent of total billed charges,92% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3332.93,90,,,percent of total billed charges,90% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.28,70,,,percent of total billed charges,70% of total billed charges,3332.93,90,,,percent of total billed charges,90% of total billed charges,3518.09,95,,,percent of total billed charges,95% of total billed charges,3518.09,95,,,percent of total billed charges,95% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3184.8,86,,,percent of total billed charges,86% of total billed charges,2962.6,80,,,percent of total billed charges,80% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3592.15,97,,,percent of total billed charges,97% of total billed charges,3332.93,90,,,percent of total billed charges,90% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3592.15,97,,,percent of total billed charges,97% of total billed charges,3444.02,93,,,percent of total billed charges,93% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3592.15,97,,,percent of total billed charges,97% of total billed charges,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3703.25,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.28,3703.25,
Percutaneous Pulmonary Embolectomy,3427261,CDM,960,RC,33915,HCPCS,Outpatient,,,3703.25,1851.63,,3332.93,90,,,percent of total billed charges,90% of total Billed charges,2762.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1370.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2123.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1370.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1370.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2161.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2161.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1025.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1370.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2740.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2550.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1849.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2123.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1370.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,4282.4,155,,,Fee Schedule,155% of CMS OPPS Rate,4282.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1370.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1400.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1370.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2821.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2821.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4282.4,
33947-Ecmo/ecls initiation artery.,3754893,CDM,481,RC,33947,HCPCS,Outpatient,,,923.54,461.77,,831.19,90,,,percent of total billed charges,90% of total Billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,738.83,80,,,Percent of total Billed charges,80% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,831.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,895.83,97,,,Percent of total billed charges,97% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,849.66,92,,,Percent of total billed charges,92% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,831.19,90,,,percent of total billed charges,90% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,646.48,70,,,percent of total billed charges,70% of total billed charges,831.19,90,,,percent of total billed charges,90% of total billed charges,877.36,95,,,percent of total billed charges,95% of total billed charges,877.36,95,,,percent of total billed charges,95% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,794.24,86,,,percent of total billed charges,86% of total billed charges,738.83,80,,,percent of total billed charges,80% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,895.83,97,,,percent of total billed charges,97% of total billed charges,831.19,90,,,percent of total billed charges,90% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,895.83,97,,,percent of total billed charges,97% of total billed charges,858.89,93,,,percent of total billed charges,93% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,895.83,97,,,percent of total billed charges,97% of total billed charges,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,923.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,646.48,923.54,
33947-PF Ecmo/ecls initiation artery,3754894,CDM,960,RC,33947,HCPCS,Outpatient,,,923.54,461.77,,831.19,90,,,percent of total billed charges,90% of total Billed charges,689.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,279.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,530.55,155,,,Fee Schedule,155% of CMS OPPS Rate,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,572.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,572.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,542.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,542.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,639.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,462.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.55,155,,,Fee Schedule,155% of CMS OPPS Rate,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1068.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.41,1068.82,
33948- ECMO/ECLS/daily mgmt/venous,3430672,CDM,510,RC,33948,HCPCS,Outpatient,,,637.04,318.52,,573.34,90,,,percent of total billed charges,90% of total Billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,509.63,80,,,Percent of total Billed charges,80% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,573.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,617.93,97,,,Percent of total billed charges,97% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,586.08,92,,,Percent of total billed charges,92% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,573.34,90,,,percent of total billed charges,90% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.93,70,,,percent of total billed charges,70% of total billed charges,573.34,90,,,percent of total billed charges,90% of total billed charges,605.19,95,,,percent of total billed charges,95% of total billed charges,605.19,95,,,percent of total billed charges,95% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,547.85,86,,,percent of total billed charges,86% of total billed charges,509.63,80,,,percent of total billed charges,80% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,617.93,97,,,percent of total billed charges,97% of total billed charges,573.34,90,,,percent of total billed charges,90% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,617.93,97,,,percent of total billed charges,97% of total billed charges,592.45,93,,,percent of total billed charges,93% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,617.93,97,,,percent of total billed charges,97% of total billed charges,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637.04,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.93,637.04,
33952- Extracorporeal membrane oxygenation (ECMO)/extracorpo,3566782,CDM,510,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,1037.27,90,,,percent of total billed charges,90% of total Billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,922.02,80,,,Percent of total Billed charges,80% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1037.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1117.94,97,,,Percent of total billed charges,97% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1060.32,92,,,Percent of total billed charges,92% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1037.27,90,,,percent of total billed charges,90% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,806.76,70,,,percent of total billed charges,70% of total billed charges,1037.27,90,,,percent of total billed charges,90% of total billed charges,1094.89,95,,,percent of total billed charges,95% of total billed charges,1094.89,95,,,percent of total billed charges,95% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,991.17,86,,,percent of total billed charges,86% of total billed charges,922.02,80,,,percent of total billed charges,80% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1117.94,97,,,percent of total billed charges,97% of total billed charges,1037.27,90,,,percent of total billed charges,90% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1117.94,97,,,percent of total billed charges,97% of total billed charges,1071.84,93,,,percent of total billed charges,93% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1117.94,97,,,percent of total billed charges,97% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,806.76,1152.52,
33952-Ecmo/ecls insj prph cannula,3754895,CDM,481,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,1037.27,90,,,percent of total billed charges,90% of total Billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,922.02,80,,,Percent of total Billed charges,80% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1037.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1117.94,97,,,Percent of total billed charges,97% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1060.32,92,,,Percent of total billed charges,92% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1037.27,90,,,percent of total billed charges,90% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,806.76,70,,,percent of total billed charges,70% of total billed charges,1037.27,90,,,percent of total billed charges,90% of total billed charges,1094.89,95,,,percent of total billed charges,95% of total billed charges,1094.89,95,,,percent of total billed charges,95% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,991.17,86,,,percent of total billed charges,86% of total billed charges,922.02,80,,,percent of total billed charges,80% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1117.94,97,,,percent of total billed charges,97% of total billed charges,1037.27,90,,,percent of total billed charges,90% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1117.94,97,,,percent of total billed charges,97% of total billed charges,1071.84,93,,,percent of total billed charges,93% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1117.94,97,,,percent of total billed charges,97% of total billed charges,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1152.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,806.76,1152.52,
33952-PF Ecmo/ecls insj prph cannula,3754896,CDM,960,RC,33952,HCPCS,Outpatient,,,1152.52,576.26,,1037.27,90,,,percent of total billed charges,90% of total Billed charges,860.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,426.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,352.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,661.83,155,,,Fee Schedule,155% of CMS OPPS Rate,426.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,426.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,714.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,714.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,676.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,676.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,346.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,426.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,853.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,798.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,580.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,661.83,155,,,Fee Schedule,155% of CMS OPPS Rate,426.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1333.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1333.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,426.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,485.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,426.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.37,1333.57,
"33967- Insert IABP, percutaneous",3430674,CDM,481,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,627.28,90,,,percent of total billed charges,90% of total Billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,557.58,80,,,Percent of total Billed charges,80% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,627.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,676.07,97,,,Percent of total billed charges,97% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,641.22,92,,,Percent of total billed charges,92% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,627.28,90,,,percent of total billed charges,90% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.89,70,,,percent of total billed charges,70% of total billed charges,627.28,90,,,percent of total billed charges,90% of total billed charges,662.13,95,,,percent of total billed charges,95% of total billed charges,662.13,95,,,percent of total billed charges,95% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,599.4,86,,,percent of total billed charges,86% of total billed charges,557.58,80,,,percent of total billed charges,80% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.07,97,,,percent of total billed charges,97% of total billed charges,627.28,90,,,percent of total billed charges,90% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.07,97,,,percent of total billed charges,97% of total billed charges,648.19,93,,,percent of total billed charges,93% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,676.07,97,,,percent of total billed charges,97% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.89,696.98,
33967-INSERTION INTRA AORTIC BALLOON PUMP,3431823,CDM,481,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,627.28,90,,,percent of total billed charges,90% of total Billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,557.58,80,,,Percent of total Billed charges,80% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,627.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,676.07,97,,,Percent of total billed charges,97% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,641.22,92,,,Percent of total billed charges,92% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,627.28,90,,,percent of total billed charges,90% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.89,70,,,percent of total billed charges,70% of total billed charges,627.28,90,,,percent of total billed charges,90% of total billed charges,662.13,95,,,percent of total billed charges,95% of total billed charges,662.13,95,,,percent of total billed charges,95% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,599.4,86,,,percent of total billed charges,86% of total billed charges,557.58,80,,,percent of total billed charges,80% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.07,97,,,percent of total billed charges,97% of total billed charges,627.28,90,,,percent of total billed charges,90% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.07,97,,,percent of total billed charges,97% of total billed charges,648.19,93,,,percent of total billed charges,93% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,676.07,97,,,percent of total billed charges,97% of total billed charges,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,696.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,487.89,696.98,
33967-PF INSERTION INTRA AORTIC BALLOON PUMP,3580875,CDM,960,RC,33967,HCPCS,Outpatient,,,696.98,348.49,,627.28,90,,,percent of total billed charges,90% of total Billed charges,519.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,398.33,155,,,Fee Schedule,155% of CMS OPPS Rate,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,431.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,408.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,408.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,210.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,348.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,398.33,155,,,Fee Schedule,155% of CMS OPPS Rate,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.57,155,,,Fee Schedule,155% of CMS OPPS Rate,804.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.34,804.57,
33967-PF INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ,4321419,CDM,981,RC,33967,HCPCS,Outpatient,,,513.98,256.99,,462.58,90,,,percent of total billed charges,90% of total Billed charges,519.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,398.33,155,,,Fee Schedule,155% of CMS OPPS Rate,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,431.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,431.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,408.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,408.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,210.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,348.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,398.33,155,,,Fee Schedule,155% of CMS OPPS Rate,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.57,155,,,Fee Schedule,155% of CMS OPPS Rate,804.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,256.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,529.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.34,804.57,
Intra Aortic Balloon Pump Insertion,634101,CDM,481,RC,33967,HCPCS,Outpatient,,,681.03,340.52,,612.93,90,,,percent of total billed charges,90% of total Billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.82,80,,,Percent of total Billed charges,80% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,612.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,660.6,97,,,Percent of total billed charges,97% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,626.55,92,,,Percent of total billed charges,92% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,612.93,90,,,percent of total billed charges,90% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476.72,70,,,percent of total billed charges,70% of total billed charges,612.93,90,,,percent of total billed charges,90% of total billed charges,646.98,95,,,percent of total billed charges,95% of total billed charges,646.98,95,,,percent of total billed charges,95% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,585.69,86,,,percent of total billed charges,86% of total billed charges,544.82,80,,,percent of total billed charges,80% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,660.6,97,,,percent of total billed charges,97% of total billed charges,612.93,90,,,percent of total billed charges,90% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,660.6,97,,,percent of total billed charges,97% of total billed charges,633.36,93,,,percent of total billed charges,93% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,660.6,97,,,percent of total billed charges,97% of total billed charges,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,476.72,681.03,
33968- Remove IABP/percutaneous,3430873,CDM,510,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,79.85,90,,,percent of total billed charges,90% of total Billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,70.98,80,,,Percent of total Billed charges,80% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,79.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,86.06,97,,,Percent of total billed charges,97% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,81.62,92,,,Percent of total billed charges,92% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,79.85,90,,,percent of total billed charges,90% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.1,70,,,percent of total billed charges,70% of total billed charges,79.85,90,,,percent of total billed charges,90% of total billed charges,84.28,95,,,percent of total billed charges,95% of total billed charges,84.28,95,,,percent of total billed charges,95% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,76.3,86,,,percent of total billed charges,86% of total billed charges,70.98,80,,,percent of total billed charges,80% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,86.06,97,,,percent of total billed charges,97% of total billed charges,79.85,90,,,percent of total billed charges,90% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,86.06,97,,,percent of total billed charges,97% of total billed charges,82.51,93,,,percent of total billed charges,93% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,86.06,97,,,percent of total billed charges,97% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.1,88.72,
33968-PF Removal of Intra-aortic balloon pump,4271132,CDM,960,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,79.85,90,,,percent of total billed charges,90% of total Billed charges,67.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,52.41,155,,,Fee Schedule,155% of CMS OPPS Rate,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,44.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,52.41,155,,,Fee Schedule,155% of CMS OPPS Rate,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.1,155,,,Fee Schedule,155% of CMS OPPS Rate,104.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.19,104.1,
33968-Removal of Intra-aortic balloon pump,4271131,CDM,481,RC,33968,HCPCS,Outpatient,,,88.72,44.36,,79.85,90,,,percent of total billed charges,90% of total Billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,70.98,80,,,Percent of total Billed charges,80% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,79.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,86.06,97,,,Percent of total billed charges,97% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,81.62,92,,,Percent of total billed charges,92% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,79.85,90,,,percent of total billed charges,90% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.1,70,,,percent of total billed charges,70% of total billed charges,79.85,90,,,percent of total billed charges,90% of total billed charges,84.28,95,,,percent of total billed charges,95% of total billed charges,84.28,95,,,percent of total billed charges,95% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,76.3,86,,,percent of total billed charges,86% of total billed charges,70.98,80,,,percent of total billed charges,80% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,86.06,97,,,percent of total billed charges,97% of total billed charges,79.85,90,,,percent of total billed charges,90% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,86.06,97,,,percent of total billed charges,97% of total billed charges,82.51,93,,,percent of total billed charges,93% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,86.06,97,,,percent of total billed charges,97% of total billed charges,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,88.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,62.1,88.72,
Removal of Balloon Pump,,,960,RC,33968,HCPCS,Outpatient,,,89.6,44.80,,80.64,90,,,percent of total billed charges,90% of total Billed charges,67.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,52.41,155,,,Fee Schedule,155% of CMS OPPS Rate,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,44.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,52.41,155,,,Fee Schedule,155% of CMS OPPS Rate,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.1,155,,,Fee Schedule,155% of CMS OPPS Rate,104.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.19,104.1,
33970 - Insj Intra-Aort Balo Assist Dev Via Fem Art Open,4107503,CDM,960,RC,33970,HCPCS,Outpatient,,,853.48,426.74,,768.13,90,,,percent of total billed charges,90% of total Billed charges,713.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,354.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,334.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,549.04,155,,,Fee Schedule,155% of CMS OPPS Rate,354.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,590.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,590.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,560.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,560.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,287.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,661.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,483.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,549.04,155,,,Fee Schedule,155% of CMS OPPS Rate,354.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1106.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1106.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,354.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,468.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,354.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,734.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,287.56,1106.17,
Insert Balloon Pump,,,960,RC,33973,HCPCS,Outpatient,,,1332.66,666.33,,1199.39,90,,,percent of total billed charges,90% of total Billed charges,1014.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,502.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,488.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,779.46,155,,,Fee Schedule,155% of CMS OPPS Rate,502.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,502.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,810.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,810.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,417.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,955.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,695.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,779.46,155,,,Fee Schedule,155% of CMS OPPS Rate,502.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1572.3,155,,,Fee Schedule,155% of CMS OPPS Rate,1572.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,502.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,729.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,502.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1064.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1064.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,417.17,1572.3,
33975 - PF Insert Ventric Assist Device Xtrcorp Sngl Ventricle,4361838,CDM,960,RC,33975,HCPCS,Outpatient,,,2608.36,1304.18,,2347.52,90,,,percent of total billed charges,90% of total Billed charges,2623.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1300.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2015.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1300.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1936.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1300.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2177.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2177.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2068.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2068.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1060.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2601.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2440.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1787.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2015.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1300.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,4066.15,155,,,Fee Schedule,155% of CMS OPPS Rate,4066.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1300.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1190.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1300.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2283.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2283.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4066.15,
33977 - PF Remove Ventric Assist Device Xtrcorp Sngl Ventricle,4361839,CDM,960,RC,33977,HCPCS,Outpatient,,,2233.88,1116.94,,2010.49,90,,,percent of total billed charges,90% of total Billed charges,2252.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1120.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1736.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1120.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1667.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1120.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1875.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1774.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1774.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,913.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2240.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2094.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1529.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1736.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1120.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,3490.86,155,,,Fee Schedule,155% of CMS OPPS Rate,3490.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1120.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1232.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1120.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,2480.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2480.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,913.08,3490.86,
33979- Insert VAD/intracorporeal/sgn vent,3430675,CDM,510,RC,33979,HCPCS,Outpatient,,,5260.02,2630.01,,4734.02,90,,,percent of total billed charges,90% of total Billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4208.02,80,,,Percent of total Billed charges,80% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4734.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5102.22,97,,,Percent of total billed charges,97% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4839.22,92,,,Percent of total billed charges,92% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4734.02,90,,,percent of total billed charges,90% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3682.01,70,,,percent of total billed charges,70% of total billed charges,4734.02,90,,,percent of total billed charges,90% of total billed charges,4997.02,95,,,percent of total billed charges,95% of total billed charges,4997.02,95,,,percent of total billed charges,95% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4523.62,86,,,percent of total billed charges,86% of total billed charges,4208.02,80,,,percent of total billed charges,80% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5102.22,97,,,percent of total billed charges,97% of total billed charges,4734.02,90,,,percent of total billed charges,90% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5102.22,97,,,percent of total billed charges,97% of total billed charges,4891.82,93,,,percent of total billed charges,93% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5102.22,97,,,percent of total billed charges,97% of total billed charges,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5260.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3682.01,5260.02,
33990- VAD insert/perc/arterial/S&I Left Heart,3430676,CDM,481,RC,33990,HCPCS,Outpatient,,,973.4,486.70,,876.06,90,,,percent of total billed charges,90% of total Billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,778.72,80,,,Percent of total Billed charges,80% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,876.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,944.2,97,,,Percent of total billed charges,97% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,895.53,92,,,Percent of total billed charges,92% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,876.06,90,,,percent of total billed charges,90% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.38,70,,,percent of total billed charges,70% of total billed charges,876.06,90,,,percent of total billed charges,90% of total billed charges,924.73,95,,,percent of total billed charges,95% of total billed charges,924.73,95,,,percent of total billed charges,95% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,837.12,86,,,percent of total billed charges,86% of total billed charges,778.72,80,,,percent of total billed charges,80% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,944.2,97,,,percent of total billed charges,97% of total billed charges,876.06,90,,,percent of total billed charges,90% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,944.2,97,,,percent of total billed charges,97% of total billed charges,905.26,93,,,percent of total billed charges,93% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,944.2,97,,,percent of total billed charges,97% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.38,973.4,
33990-IMPELLA(INSERT PERCUTANEOUS VENTRIC) LEFT HEART,3431824,CDM,481,RC,33990,HCPCS,Outpatient,,,973.4,486.70,,876.06,90,,,percent of total billed charges,90% of total Billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,778.72,80,,,Percent of total Billed charges,80% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,876.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,944.2,97,,,Percent of total billed charges,97% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,895.53,92,,,Percent of total billed charges,92% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,876.06,90,,,percent of total billed charges,90% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.38,70,,,percent of total billed charges,70% of total billed charges,876.06,90,,,percent of total billed charges,90% of total billed charges,924.73,95,,,percent of total billed charges,95% of total billed charges,924.73,95,,,percent of total billed charges,95% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,837.12,86,,,percent of total billed charges,86% of total billed charges,778.72,80,,,percent of total billed charges,80% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,944.2,97,,,percent of total billed charges,97% of total billed charges,876.06,90,,,percent of total billed charges,90% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,944.2,97,,,percent of total billed charges,97% of total billed charges,905.26,93,,,percent of total billed charges,93% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,944.2,97,,,percent of total billed charges,97% of total billed charges,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,973.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,681.38,973.4,
33990-PF IMPELLA(INSERT PERCUTANEOUS VENTRIC,3580876,CDM,960,RC,33990,HCPCS,Outpatient,,,973.4,486.70,,876.06,90,,,percent of total billed charges,90% of total Billed charges,725.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.94,155,,,Fee Schedule,155% of CMS OPPS Rate,359.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,359.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,708.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,708.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,669.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,669.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,789.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,572.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,557.94,155,,,Fee Schedule,155% of CMS OPPS Rate,359.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1125.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1125.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,359.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,408.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,359.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.39,1125.27,
33992-Impella Removal Left Heart,3560671,CDM,481,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,917.68,90,,,percent of total billed charges,90% of total Billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,815.71,80,,,Percent of total Billed charges,80% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,917.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,989.05,97,,,Percent of total billed charges,97% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,938.07,92,,,Percent of total billed charges,92% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,917.68,90,,,percent of total billed charges,90% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.75,70,,,percent of total billed charges,70% of total billed charges,917.68,90,,,percent of total billed charges,90% of total billed charges,968.66,95,,,percent of total billed charges,95% of total billed charges,968.66,95,,,percent of total billed charges,95% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,876.89,86,,,percent of total billed charges,86% of total billed charges,815.71,80,,,percent of total billed charges,80% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,989.05,97,,,percent of total billed charges,97% of total billed charges,917.68,90,,,percent of total billed charges,90% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,989.05,97,,,percent of total billed charges,97% of total billed charges,948.27,93,,,percent of total billed charges,93% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,989.05,97,,,percent of total billed charges,97% of total billed charges,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1019.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.75,1019.64,
33992-PF Impella Removal (In CCL),3580877,CDM,960,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,917.68,90,,,percent of total billed charges,90% of total Billed charges,378.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.04,155,,,Fee Schedule,155% of CMS OPPS Rate,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,269.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,290.04,155,,,Fee Schedule,155% of CMS OPPS Rate,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.17,155,,,Fee Schedule,155% of CMS OPPS Rate,587.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.47,917.68,
"33992-Removal percutaneous LHV device, arterial or A&V cannu",4197203,CDM,480,RC,33992,HCPCS,Outpatient,,,445.7,222.85,,401.13,90,,,percent of total billed charges,90% of total Billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,356.56,80,,,Percent of total Billed charges,80% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,401.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,432.33,97,,,Percent of total billed charges,97% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,410.04,92,,,Percent of total billed charges,92% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,401.13,90,,,percent of total billed charges,90% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,311.99,70,,,percent of total billed charges,70% of total billed charges,401.13,90,,,percent of total billed charges,90% of total billed charges,423.42,95,,,percent of total billed charges,95% of total billed charges,423.42,95,,,percent of total billed charges,95% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.3,86,,,percent of total billed charges,86% of total billed charges,356.56,80,,,percent of total billed charges,80% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,432.33,97,,,percent of total billed charges,97% of total billed charges,401.13,90,,,percent of total billed charges,90% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,432.33,97,,,percent of total billed charges,97% of total billed charges,414.5,93,,,percent of total billed charges,93% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,432.33,97,,,percent of total billed charges,97% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,311.99,445.7,
Impella Removal (In  CCL),,,960,RC,33992,HCPCS,Outpatient,,,1019.64,509.82,,917.68,90,,,percent of total billed charges,90% of total Billed charges,378.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.04,155,,,Fee Schedule,155% of CMS OPPS Rate,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,374.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,269.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,290.04,155,,,Fee Schedule,155% of CMS OPPS Rate,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.17,155,,,Fee Schedule,155% of CMS OPPS Rate,587.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,187.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.47,917.68,
33993-Impella Reposition (in CCL),4181457,CDM,481,RC,33993,HCPCS,Outpatient,,,891.4,445.70,,802.26,90,,,percent of total billed charges,90% of total Billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.12,80,,,Percent of total Billed charges,80% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,802.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,864.66,97,,,Percent of total billed charges,97% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,820.09,92,,,Percent of total billed charges,92% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,802.26,90,,,percent of total billed charges,90% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.98,70,,,percent of total billed charges,70% of total billed charges,802.26,90,,,percent of total billed charges,90% of total billed charges,846.83,95,,,percent of total billed charges,95% of total billed charges,846.83,95,,,percent of total billed charges,95% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,766.6,86,,,percent of total billed charges,86% of total billed charges,713.12,80,,,percent of total billed charges,80% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,864.66,97,,,percent of total billed charges,97% of total billed charges,802.26,90,,,percent of total billed charges,90% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,864.66,97,,,percent of total billed charges,97% of total billed charges,829,93,,,percent of total billed charges,93% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,864.66,97,,,percent of total billed charges,97% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.98,891.4,
33993-PF Impella Reposition ( In  CCL),4181472,CDM,960,RC,33993,HCPCS,Outpatient,,,891.4,445.70,,802.26,90,,,percent of total billed charges,90% of total Billed charges,332.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.73,155,,,Fee Schedule,155% of CMS OPPS Rate,164.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,289.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,141.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,230.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,255.73,155,,,Fee Schedule,155% of CMS OPPS Rate,164.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.5,155,,,Fee Schedule,155% of CMS OPPS Rate,515.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,164.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,170.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,164.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.86,802.26,
33993-Repositioning percutaneous Left or Right HV device w/,4197204,CDM,480,RC,33993,HCPCS,Outpatient,,,445.7,222.85,,401.13,90,,,percent of total billed charges,90% of total Billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,356.56,80,,,Percent of total Billed charges,80% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,401.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,432.33,97,,,Percent of total billed charges,97% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,410.04,92,,,Percent of total billed charges,92% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,401.13,90,,,percent of total billed charges,90% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,311.99,70,,,percent of total billed charges,70% of total billed charges,401.13,90,,,percent of total billed charges,90% of total billed charges,423.42,95,,,percent of total billed charges,95% of total billed charges,423.42,95,,,percent of total billed charges,95% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.3,86,,,percent of total billed charges,86% of total billed charges,356.56,80,,,percent of total billed charges,80% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,432.33,97,,,percent of total billed charges,97% of total billed charges,401.13,90,,,percent of total billed charges,90% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,432.33,97,,,percent of total billed charges,97% of total billed charges,414.5,93,,,percent of total billed charges,93% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,432.33,97,,,percent of total billed charges,97% of total billed charges,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,445.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,311.99,445.7,
Impella Reposition (in CCL),,,761,RC,33993,HCPCS,Outpatient,,,891.4,445.70,,802.26,90,,,percent of total billed charges,90% of total Billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.12,80,,,Percent of total Billed charges,80% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,802.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,864.66,97,,,Percent of total billed charges,97% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,820.09,92,,,Percent of total billed charges,92% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,802.26,90,,,percent of total billed charges,90% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.98,70,,,percent of total billed charges,70% of total billed charges,802.26,90,,,percent of total billed charges,90% of total billed charges,846.83,95,,,percent of total billed charges,95% of total billed charges,846.83,95,,,percent of total billed charges,95% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,766.6,86,,,percent of total billed charges,86% of total billed charges,713.12,80,,,percent of total billed charges,80% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,864.66,97,,,percent of total billed charges,97% of total billed charges,802.26,90,,,percent of total billed charges,90% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,864.66,97,,,percent of total billed charges,97% of total billed charges,829,93,,,percent of total billed charges,93% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,864.66,97,,,percent of total billed charges,97% of total billed charges,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,891.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,623.98,891.4,
"33999 - Unlisted procedure, cardiac surgery",4169575,CDM,983,RC,33999,HCPCS,Outpatient,,,4748.8,2374.40,,4273.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1424.64,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1424.64,4273.92,
33999-PF TAVR Other,4249295,CDM,960,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,3178.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.58,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.58,3178.73,
33999-RV Impella Placement,3670897,CDM,481,RC,33999,HCPCS,Outpatient,,,1068.24,534.12,,961.42,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,854.59,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,961.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1036.19,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,982.78,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,961.42,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,747.77,70,,,percent of total billed charges,70% of total billed charges,961.42,90,,,percent of total billed charges,90% of total billed charges,1014.83,95,,,percent of total billed charges,95% of total billed charges,1014.83,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,918.69,86,,,percent of total billed charges,86% of total billed charges,854.59,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1036.19,97,,,percent of total billed charges,97% of total billed charges,961.42,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1036.19,97,,,percent of total billed charges,97% of total billed charges,993.46,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1036.19,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
33999-TAVR-Other,4249294,CDM,481,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,3178.73,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2825.54,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3178.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3425.96,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3249.37,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3178.73,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2472.34,70,,,percent of total billed charges,70% of total billed charges,3178.73,90,,,percent of total billed charges,90% of total billed charges,3355.32,95,,,percent of total billed charges,95% of total billed charges,3355.32,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3037.45,86,,,percent of total billed charges,86% of total billed charges,2825.54,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3425.96,97,,,percent of total billed charges,97% of total billed charges,3178.73,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3425.96,97,,,percent of total billed charges,97% of total billed charges,3284.69,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3425.96,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,3425.96,
SURG AST OTHER CARDIAC PROCEDURE,3527879,CDM,960,RC,33999,HCPCS,Outpatient,,,148.92,74.46,,134.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.68,134.03,
TAVR-Other,,,761,RC,33999,HCPCS,Outpatient,,,3531.92,1765.96,,3178.73,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2825.54,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3178.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3425.96,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3249.37,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3178.73,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2472.34,70,,,percent of total billed charges,70% of total billed charges,3178.73,90,,,percent of total billed charges,90% of total billed charges,3355.32,95,,,percent of total billed charges,95% of total billed charges,3355.32,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3037.45,86,,,percent of total billed charges,86% of total billed charges,2825.54,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3425.96,97,,,percent of total billed charges,97% of total billed charges,3178.73,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3425.96,97,,,percent of total billed charges,97% of total billed charges,3284.69,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3425.96,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,3425.96,
"34101-Arterial Embolectomy or thrombectomy by arm incision (axillary, brachial, innominate, subclavi",4271133,CDM,481,RC,34101,HCPCS,Outpatient,,,1267.8,633.90,,1141.02,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.24,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1141.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1229.77,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.38,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1141.02,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,887.46,70,,,percent of total billed charges,70% of total billed charges,1141.02,90,,,percent of total billed charges,90% of total billed charges,1204.41,95,,,percent of total billed charges,95% of total billed charges,1204.41,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1090.31,86,,,percent of total billed charges,86% of total billed charges,1014.24,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1229.77,97,,,percent of total billed charges,97% of total billed charges,1141.02,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1229.77,97,,,percent of total billed charges,97% of total billed charges,1179.05,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1229.77,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,887.46,25056.97,
"34101-PF Arterial Embolectomy or thrombectomy by arm incision (axillary, brachial, innominate, subcl",4271134,CDM,960,RC,34101,HCPCS,Outpatient,,,1267.8,633.90,,1141.02,90,,,percent of total billed charges,90% of total Billed charges,1204.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,598.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,582.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,926.93,155,,,Fee Schedule,155% of CMS OPPS Rate,598.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,888.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,598.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,999.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,999.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,945.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,945.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,488.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1196.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1116.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,821.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,926.93,155,,,Fee Schedule,155% of CMS OPPS Rate,598.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1866.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1866.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,598.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,752.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,598.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1294.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1294.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,488.72,1866.65,
34111-Arterial Embolectomy or thrombectomy by arm incision (radial or ulnar),4271135,CDM,481,RC,34111,HCPCS,Outpatient,,,1270.94,635.47,,1143.85,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.75,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1143.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1232.81,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1169.26,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1143.85,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,889.66,70,,,percent of total billed charges,70% of total billed charges,1143.85,90,,,percent of total billed charges,90% of total billed charges,1207.39,95,,,percent of total billed charges,95% of total billed charges,1207.39,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1093.01,86,,,percent of total billed charges,86% of total billed charges,1016.75,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1232.81,97,,,percent of total billed charges,97% of total billed charges,1143.85,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1232.81,97,,,percent of total billed charges,97% of total billed charges,1181.97,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1232.81,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,889.66,25056.97,
34111-PF Arterial Embolectomy or thrombectomy by arm incision (radial or ulnar),4271136,CDM,960,RC,34111,HCPCS,Outpatient,,,1270.94,635.47,,1143.85,90,,,percent of total billed charges,90% of total Billed charges,1208.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,599.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,581.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,929.21,155,,,Fee Schedule,155% of CMS OPPS Rate,599.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,599.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1004.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1004.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,949.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,949.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,488.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1198.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1119.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,820.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,929.21,155,,,Fee Schedule,155% of CMS OPPS Rate,599.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1872.9,155,,,Fee Schedule,155% of CMS OPPS Rate,1872.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,599.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,657.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,599.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1294.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1294.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,488.36,1872.9,
34201- Emb/throm/fempop/aor/ilia/leg inc,3430678,CDM,510,RC,34201,HCPCS,Outpatient,,,2774.53,1387.27,,2497.08,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2219.62,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2497.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2691.29,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.57,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2497.08,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1942.17,70,,,percent of total billed charges,70% of total billed charges,2497.08,90,,,percent of total billed charges,90% of total billed charges,2635.8,95,,,percent of total billed charges,95% of total billed charges,2635.8,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2386.1,86,,,percent of total billed charges,86% of total billed charges,2219.62,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2691.29,97,,,percent of total billed charges,97% of total billed charges,2497.08,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2691.29,97,,,percent of total billed charges,97% of total billed charges,2580.31,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2691.29,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1942.17,25056.97,
34201-Arterial Embolectomy or thrombectomy by leg incision (fempop or aortoiliac),4271137,CDM,481,RC,34201,HCPCS,Outpatient,,,2176.29,1088.15,,1958.66,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1741.03,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1958.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2111,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2002.19,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1958.66,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1523.4,70,,,percent of total billed charges,70% of total billed charges,1958.66,90,,,percent of total billed charges,90% of total billed charges,2067.48,95,,,percent of total billed charges,95% of total billed charges,2067.48,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1871.61,86,,,percent of total billed charges,86% of total billed charges,1741.03,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2111,97,,,percent of total billed charges,97% of total billed charges,1958.66,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2111,97,,,percent of total billed charges,97% of total billed charges,2023.95,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2111,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1523.4,25056.97,
34201-PF Arterial Embolectomy or thrombectomy by leg incision (fempop or aortoiliac),4271138,CDM,960,RC,34201,HCPCS,Outpatient,,,2176.29,1088.15,,1958.66,90,,,percent of total billed charges,90% of total Billed charges,2069.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1026.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,609.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1591.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1026.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1524.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1026.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1714.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1714.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1632,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1632,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,840.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1026.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2053.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1925.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1428.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1591.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1026.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,3208.3,155,,,Fee Schedule,155% of CMS OPPS Rate,3208.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1026.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,609.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1020.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1026.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2225.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2225.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,609.26,3208.3,
34203- Emb/throm/pop-tib-pero art/leg inc,3430679,CDM,510,RC,34203,HCPCS,Outpatient,,,2570.61,1285.31,,2313.55,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.49,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2313.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2493.49,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2364.96,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2313.55,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1799.43,70,,,percent of total billed charges,70% of total billed charges,2313.55,90,,,percent of total billed charges,90% of total billed charges,2442.08,95,,,percent of total billed charges,95% of total billed charges,2442.08,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2210.72,86,,,percent of total billed charges,86% of total billed charges,2056.49,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2493.49,97,,,percent of total billed charges,97% of total billed charges,2313.55,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2493.49,97,,,percent of total billed charges,97% of total billed charges,2390.67,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2493.49,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1799.43,25056.97,
34203-Arterial Embolectomy or thrombectomy by leg incision (popliteal-tibio-peroneal),4271139,CDM,481,RC,34203,HCPCS,Outpatient,,,2016.42,1008.21,,1814.78,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1613.14,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1814.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1955.93,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1855.11,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1814.78,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.49,70,,,percent of total billed charges,70% of total billed charges,1814.78,90,,,percent of total billed charges,90% of total billed charges,1915.6,95,,,percent of total billed charges,95% of total billed charges,1915.6,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1734.12,86,,,percent of total billed charges,86% of total billed charges,1613.14,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1955.93,97,,,percent of total billed charges,97% of total billed charges,1814.78,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1955.93,97,,,percent of total billed charges,97% of total billed charges,1875.27,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1955.93,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1411.49,25056.97,
34203-PF Arterial Embolectomy or thrombectomy by leg incision (popliteal-tibio-peroneal),4271140,CDM,960,RC,34203,HCPCS,Outpatient,,,2016.42,1008.21,,1814.78,90,,,percent of total billed charges,90% of total Billed charges,1917.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,951.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,693,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1474.25,155,,,Fee Schedule,155% of CMS OPPS Rate,951.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1411.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,951.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1587.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1587.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1509.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1509.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,778.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1902.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1781.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1318.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1474.25,155,,,Fee Schedule,155% of CMS OPPS Rate,951.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2972.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2972.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,951.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,693,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1014.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,951.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2067.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2067.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,693,2972.53,
34421 - THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC,4037488,CDM,983,RC,34421,HCPCS,Outpatient,,,1889.56,944.78,,1700.6,90,,,percent of total billed charges,90% of total Billed charges,1410.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,699.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,541,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1084.38,155,,,Fee Schedule,155% of CMS OPPS Rate,699.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,699.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1169.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1169.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,590.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1399.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1379.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1006.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1084.38,155,,,Fee Schedule,155% of CMS OPPS Rate,699.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2185.72,155,,,Fee Schedule,155% of CMS OPPS Rate,2185.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,699.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,541,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,755.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,699.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1575.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1575.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,541,2185.72,
34701 - EVASC RPR DPLMNT AORTO-AORTIC NDGFT,4037491,CDM,983,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,3021.18,90,,,percent of total billed charges,90% of total Billed charges,2502.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1020.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1848.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2078.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1098.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2331.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1717.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3878.39,155,,,Fee Schedule,155% of CMS OPPS Rate,3878.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1393.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.3,3878.39,
34701- EVASC RPR A-AO NDGFT,3556815,CDM,481,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,3021.18,90,,,percent of total billed charges,90% of total Billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2685.5,80,,,Percent of total Billed charges,80% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3021.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3256.16,97,,,Percent of total billed charges,97% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3088.32,92,,,Percent of total billed charges,92% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3021.18,90,,,percent of total billed charges,90% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2349.81,70,,,percent of total billed charges,70% of total billed charges,3021.18,90,,,percent of total billed charges,90% of total billed charges,3189.03,95,,,percent of total billed charges,95% of total billed charges,3189.03,95,,,percent of total billed charges,95% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2886.91,86,,,percent of total billed charges,86% of total billed charges,2685.5,80,,,percent of total billed charges,80% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3256.16,97,,,percent of total billed charges,97% of total billed charges,3021.18,90,,,percent of total billed charges,90% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3256.16,97,,,percent of total billed charges,97% of total billed charges,3121.89,93,,,percent of total billed charges,93% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3256.16,97,,,percent of total billed charges,97% of total billed charges,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2349.81,3356.87,
34701-EVASC RPR A-AO NDGFT,,,960,RC,34701,HCPCS,Outpatient,,,3285.77,1642.89,,2957.19,90,,,percent of total billed charges,90% of total Billed charges,2502.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1020.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1848.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2078.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1098.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2331.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1717.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3878.39,155,,,Fee Schedule,155% of CMS OPPS Rate,3878.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1393.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.3,3878.39,
EVASC RPR A-AO NDGFT,3527868,CDM,960,RC,34701,HCPCS,Outpatient,,,3356.87,1678.44,,3021.18,90,,,percent of total billed charges,90% of total Billed charges,2502.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1020.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1848.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2078.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2078.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1976.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1098.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2331.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1717.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1921.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3878.39,155,,,Fee Schedule,155% of CMS OPPS Rate,3878.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1393.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1239.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1020.3,3878.39,
34702 - Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft incl,3783518,CDM,510,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,4517.7,90,,,percent of total billed charges,90% of total Billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4015.74,80,,,Percent of total Billed charges,80% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4869.08,97,,,Percent of total billed charges,97% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4618.1,92,,,Percent of total billed charges,92% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.7,90,,,percent of total billed charges,90% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3513.77,70,,,percent of total billed charges,70% of total billed charges,4517.7,90,,,percent of total billed charges,90% of total billed charges,4768.69,95,,,percent of total billed charges,95% of total billed charges,4768.69,95,,,percent of total billed charges,95% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4316.92,86,,,percent of total billed charges,86% of total billed charges,4015.74,80,,,percent of total billed charges,80% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4869.08,97,,,percent of total billed charges,97% of total billed charges,4517.7,90,,,percent of total billed charges,90% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4869.08,97,,,percent of total billed charges,97% of total billed charges,4668.29,93,,,percent of total billed charges,93% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4869.08,97,,,percent of total billed charges,97% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3513.77,5019.67,
34702- EVASC RPR A-AO NDGFT RPT,3556816,CDM,481,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,4517.7,90,,,percent of total billed charges,90% of total Billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4015.74,80,,,Percent of total Billed charges,80% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4869.08,97,,,Percent of total billed charges,97% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4618.1,92,,,Percent of total billed charges,92% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.7,90,,,percent of total billed charges,90% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3513.77,70,,,percent of total billed charges,70% of total billed charges,4517.7,90,,,percent of total billed charges,90% of total billed charges,4768.69,95,,,percent of total billed charges,95% of total billed charges,4768.69,95,,,percent of total billed charges,95% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4316.92,86,,,percent of total billed charges,86% of total billed charges,4015.74,80,,,percent of total billed charges,80% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4869.08,97,,,percent of total billed charges,97% of total billed charges,4517.7,90,,,percent of total billed charges,90% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4869.08,97,,,percent of total billed charges,97% of total billed charges,4668.29,93,,,percent of total billed charges,93% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4869.08,97,,,percent of total billed charges,97% of total billed charges,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5019.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3513.77,5019.67,
34702-EVASC RPR A-AO NDGFT RPT,,,960,RC,34702,HCPCS,Outpatient,,,4920.1,2460.05,,4428.09,90,,,percent of total billed charges,90% of total Billed charges,3744.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1525.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2877.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2758.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1856.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3102.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2958.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2958.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1639.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3713.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3490.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2583.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2877.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,5803.53,155,,,Fee Schedule,155% of CMS OPPS Rate,5803.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1525.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2082.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1525.01,5803.53,
EVASC RPR A-AO NDGFT RPT,3527869,CDM,960,RC,34702,HCPCS,Outpatient,,,5019.67,2509.84,,4517.7,90,,,percent of total billed charges,90% of total Billed charges,3744.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1525.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2877.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2758.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1856.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3102.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2958.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2958.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1639.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3713.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3490.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2583.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2877.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,5803.53,155,,,Fee Schedule,155% of CMS OPPS Rate,5803.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1525.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2082.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1856.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1525.01,5803.53,
34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni,3623200,CDM,510,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,3353.65,90,,,percent of total billed charges,90% of total Billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2981.02,80,,,Percent of total Billed charges,80% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3353.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3614.49,97,,,Percent of total billed charges,97% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3428.18,92,,,Percent of total billed charges,92% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3353.65,90,,,percent of total billed charges,90% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.4,70,,,percent of total billed charges,70% of total billed charges,3353.65,90,,,percent of total billed charges,90% of total billed charges,3539.97,95,,,percent of total billed charges,95% of total billed charges,3539.97,95,,,percent of total billed charges,95% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3204.6,86,,,percent of total billed charges,86% of total billed charges,2981.02,80,,,percent of total billed charges,80% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3614.49,97,,,percent of total billed charges,97% of total billed charges,3353.65,90,,,percent of total billed charges,90% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3614.49,97,,,percent of total billed charges,97% of total billed charges,3465.44,93,,,percent of total billed charges,93% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3614.49,97,,,percent of total billed charges,97% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.4,3726.28,
34703- EVASC RPR A-UNILAC NDGFT,3556817,CDM,481,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,3353.65,90,,,percent of total billed charges,90% of total Billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2981.02,80,,,Percent of total Billed charges,80% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3353.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3614.49,97,,,Percent of total billed charges,97% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3428.18,92,,,Percent of total billed charges,92% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3353.65,90,,,percent of total billed charges,90% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.4,70,,,percent of total billed charges,70% of total billed charges,3353.65,90,,,percent of total billed charges,90% of total billed charges,3539.97,95,,,percent of total billed charges,95% of total billed charges,3539.97,95,,,percent of total billed charges,95% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3204.6,86,,,percent of total billed charges,86% of total billed charges,2981.02,80,,,percent of total billed charges,80% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3614.49,97,,,percent of total billed charges,97% of total billed charges,3353.65,90,,,percent of total billed charges,90% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3614.49,97,,,percent of total billed charges,97% of total billed charges,3465.44,93,,,percent of total billed charges,93% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3614.49,97,,,percent of total billed charges,97% of total billed charges,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3726.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.4,3726.28,
34703-EVASC RPR A-UNILAC NDGFT,,,960,RC,34703,HCPCS,Outpatient,,,3661.54,1830.77,,3295.39,90,,,percent of total billed charges,90% of total Billed charges,2782.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1240.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2577.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1903.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,4313.5,155,,,Fee Schedule,155% of CMS OPPS Rate,4313.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1571.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.5,4313.5,
EVASC RPR A-UNILAC NDGFT,3527870,CDM,960,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,3353.65,90,,,percent of total billed charges,90% of total Billed charges,2782.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1240.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2577.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1903.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,4313.5,155,,,Fee Schedule,155% of CMS OPPS Rate,4313.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1571.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.5,4313.5,
34704- EVASC RPR A-UNILAC NDGFT RPT,3556818,CDM,481,RC,34704,HCPCS,Outpatient,,,6216.64,3108.32,,5594.98,90,,,percent of total billed charges,90% of total Billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4973.31,80,,,Percent of total Billed charges,80% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5594.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6030.14,97,,,Percent of total billed charges,97% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5719.31,92,,,Percent of total billed charges,92% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5594.98,90,,,percent of total billed charges,90% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.65,70,,,percent of total billed charges,70% of total billed charges,5594.98,90,,,percent of total billed charges,90% of total billed charges,5905.81,95,,,percent of total billed charges,95% of total billed charges,5905.81,95,,,percent of total billed charges,95% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5346.31,86,,,percent of total billed charges,86% of total billed charges,4973.31,80,,,percent of total billed charges,80% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6030.14,97,,,percent of total billed charges,97% of total billed charges,5594.98,90,,,percent of total billed charges,90% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6030.14,97,,,percent of total billed charges,97% of total billed charges,5781.48,93,,,percent of total billed charges,93% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6030.14,97,,,percent of total billed charges,97% of total billed charges,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6216.64,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.65,6216.64,
34704-EVASC RPR A-UNILAC  NDGFT RPT,,,960,RC,34704,HCPCS,Outpatient,,,6107.24,3053.62,,5496.52,90,,,percent of total billed charges,90% of total Billed charges,4642.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1914.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3572.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3396.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2304.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3819.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3819.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3650.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3650.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2061.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4609.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4307.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3198.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3572.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,7195.53,155,,,Fee Schedule,155% of CMS OPPS Rate,7195.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1914.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2615.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914.83,7195.53,
EVASC RPR A-UNILAC NDGFT RPT,3527871,CDM,960,RC,34704,HCPCS,Outpatient,,,6216.64,3108.32,,5594.98,90,,,percent of total billed charges,90% of total Billed charges,4642.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1914.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3572.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3396.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2304.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3819.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3819.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3650.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3650.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2061.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4609.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4307.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3198.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3572.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,7195.53,155,,,Fee Schedule,155% of CMS OPPS Rate,7195.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1914.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2615.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2304.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914.83,7195.53,
34705- EVAC RPR A-BIILIAC NDGFT,3556819,CDM,481,RC,34705,HCPCS,Outpatient,,,4141.43,2070.72,,3727.29,90,,,percent of total billed charges,90% of total Billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3313.14,80,,,Percent of total Billed charges,80% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3727.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4017.19,97,,,Percent of total billed charges,97% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3810.12,92,,,Percent of total billed charges,92% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3727.29,90,,,percent of total billed charges,90% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2899,70,,,percent of total billed charges,70% of total billed charges,3727.29,90,,,percent of total billed charges,90% of total billed charges,3934.36,95,,,percent of total billed charges,95% of total billed charges,3934.36,95,,,percent of total billed charges,95% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3561.63,86,,,percent of total billed charges,86% of total billed charges,3313.14,80,,,percent of total billed charges,80% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017.19,97,,,percent of total billed charges,97% of total billed charges,3727.29,90,,,percent of total billed charges,90% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017.19,97,,,percent of total billed charges,97% of total billed charges,3851.53,93,,,percent of total billed charges,93% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4017.19,97,,,percent of total billed charges,97% of total billed charges,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4141.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2899,4141.43,
34705-EVAC RPR A-BIILIAC NDGFT,3430882,CDM,960,RC,34705,HCPCS,Outpatient,,,4141.43,2070.72,,3727.29,90,,,percent of total billed charges,90% of total Billed charges,3090.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1532.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1267.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2375.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2276.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1532.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2560.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2560.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2438.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2438.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1364.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3065.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2876.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2122.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2375.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,4789.7,155,,,Fee Schedule,155% of CMS OPPS Rate,4789.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1532.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1267.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1730.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1532.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1267.1,4789.7,
34706- EVASC RPR A-BIILIAC RPT,3556820,CDM,481,RC,34706,HCPCS,Outpatient,,,6206.71,3103.36,,5586.04,90,,,percent of total billed charges,90% of total Billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4965.37,80,,,Percent of total Billed charges,80% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6020.51,97,,,Percent of total billed charges,97% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5710.17,92,,,Percent of total billed charges,92% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.04,90,,,percent of total billed charges,90% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4344.7,70,,,percent of total billed charges,70% of total billed charges,5586.04,90,,,percent of total billed charges,90% of total billed charges,5896.37,95,,,percent of total billed charges,95% of total billed charges,5896.37,95,,,percent of total billed charges,95% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5337.77,86,,,percent of total billed charges,86% of total billed charges,4965.37,80,,,percent of total billed charges,80% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6020.51,97,,,percent of total billed charges,97% of total billed charges,5586.04,90,,,percent of total billed charges,90% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6020.51,97,,,percent of total billed charges,97% of total billed charges,5772.24,93,,,percent of total billed charges,93% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6020.51,97,,,percent of total billed charges,97% of total billed charges,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6206.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4344.7,6206.71,
34706-EVASC RPR A-BIILIAC RPT,,,960,RC,34706,HCPCS,Outpatient,,,6076.13,3038.07,,5468.52,90,,,percent of total billed charges,90% of total Billed charges,4626.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1908.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3553.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3860.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3860.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3681.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3681.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2052.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4585.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4344.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3214.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3553.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,7171.56,155,,,Fee Schedule,155% of CMS OPPS Rate,7171.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1908.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2606.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1908.28,7171.56,
EVASC RPR A-BIILIAC RPT,3527872,CDM,960,RC,34706,HCPCS,Outpatient,,,6206.71,3103.36,,5586.04,90,,,percent of total billed charges,90% of total Billed charges,4626.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1908.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3553.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3432.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3860.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3860.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3681.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3681.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2052.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4585.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4344.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3214.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3553.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,7171.56,155,,,Fee Schedule,155% of CMS OPPS Rate,7171.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1908.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2606.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2292.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1908.28,7171.56,
34707- EVASC RPR ILIO-ILIAC NDGFT,3556821,CDM,481,RC,34707,HCPCS,Outpatient,,,3133.14,1566.57,,2819.83,90,,,percent of total billed charges,90% of total Billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2506.51,80,,,Percent of total Billed charges,80% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2819.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3039.15,97,,,Percent of total billed charges,97% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.49,92,,,Percent of total billed charges,92% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2819.83,90,,,percent of total billed charges,90% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2193.2,70,,,percent of total billed charges,70% of total billed charges,2819.83,90,,,percent of total billed charges,90% of total billed charges,2976.48,95,,,percent of total billed charges,95% of total billed charges,2976.48,95,,,percent of total billed charges,95% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2694.5,86,,,percent of total billed charges,86% of total billed charges,2506.51,80,,,percent of total billed charges,80% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3039.15,97,,,percent of total billed charges,97% of total billed charges,2819.83,90,,,percent of total billed charges,90% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3039.15,97,,,percent of total billed charges,97% of total billed charges,2913.82,93,,,percent of total billed charges,93% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3039.15,97,,,percent of total billed charges,97% of total billed charges,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3133.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2193.2,3133.14,
34707-EVASC RPR ILIO-ILIAC NDGFT,,,960,RC,34707,HCPCS,Outpatient,,,3097.4,1548.70,,2787.66,90,,,percent of total billed charges,90% of total Billed charges,2346.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1811.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1168.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1940.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1940.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1845.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1845.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1024.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2177.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1600.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1811.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3637.83,155,,,Fee Schedule,155% of CMS OPPS Rate,3637.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1299.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1024.37,3637.83,
EVASC RPR ILIO-ILIAC NDGFT,3527873,CDM,960,RC,34707,HCPCS,Outpatient,,,3133.14,1566.57,,2819.83,90,,,percent of total billed charges,90% of total Billed charges,2346.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1811.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1168.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1940.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1940.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1845.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1845.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1024.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2177.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1600.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1811.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3637.83,155,,,Fee Schedule,155% of CMS OPPS Rate,3637.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1299.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1168.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1024.37,3637.83,
34708- EVASC RPR ILIO-ILIAC RPT,3556822,CDM,481,RC,34708,HCPCS,Outpatient,,,5017.12,2508.56,,4515.41,90,,,percent of total billed charges,90% of total Billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4013.7,80,,,Percent of total Billed charges,80% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4515.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4866.61,97,,,Percent of total billed charges,97% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4615.75,92,,,Percent of total billed charges,92% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4515.41,90,,,percent of total billed charges,90% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3511.98,70,,,percent of total billed charges,70% of total billed charges,4515.41,90,,,percent of total billed charges,90% of total billed charges,4766.26,95,,,percent of total billed charges,95% of total billed charges,4766.26,95,,,percent of total billed charges,95% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4314.72,86,,,percent of total billed charges,86% of total billed charges,4013.7,80,,,percent of total billed charges,80% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4866.61,97,,,percent of total billed charges,97% of total billed charges,4515.41,90,,,percent of total billed charges,90% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4866.61,97,,,percent of total billed charges,97% of total billed charges,4665.92,93,,,percent of total billed charges,93% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4866.61,97,,,percent of total billed charges,97% of total billed charges,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5017.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3511.98,5017.12,
34708-EVASC RPR ILIO-ILIAC RPT,,,960,RC,34708,HCPCS,Outpatient,,,4871.18,2435.59,,4384.06,90,,,percent of total billed charges,90% of total Billed charges,3724.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2849.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2753.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1838.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3097.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3097.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2954.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2954.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1647.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3676.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3485.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2567.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2849.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,5773.41,155,,,Fee Schedule,155% of CMS OPPS Rate,5773.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2093.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.32,5773.41,
EVASC RPR ILIO-ILIAC RPT,3527874,CDM,960,RC,34708,HCPCS,Outpatient,,,5017.12,2508.56,,4515.41,90,,,percent of total billed charges,90% of total Billed charges,3724.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2849.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2753.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1838.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3097.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3097.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2954.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2954.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1647.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3676.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3485.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2567.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2849.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,5773.41,155,,,Fee Schedule,155% of CMS OPPS Rate,5773.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2093.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1838.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.32,5773.41,
34709 - Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to,3783521,CDM,510,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,790.25,90,,,percent of total billed charges,90% of total Billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,702.44,80,,,Percent of total Billed charges,80% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,790.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.71,97,,,Percent of total billed charges,97% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,807.81,92,,,Percent of total billed charges,92% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,790.25,90,,,percent of total billed charges,90% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,614.64,70,,,percent of total billed charges,70% of total billed charges,790.25,90,,,percent of total billed charges,90% of total billed charges,834.15,95,,,percent of total billed charges,95% of total billed charges,834.15,95,,,percent of total billed charges,95% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,755.12,86,,,percent of total billed charges,86% of total billed charges,702.44,80,,,percent of total billed charges,80% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,851.71,97,,,percent of total billed charges,97% of total billed charges,790.25,90,,,percent of total billed charges,90% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,851.71,97,,,percent of total billed charges,97% of total billed charges,816.59,93,,,percent of total billed charges,93% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,851.71,97,,,percent of total billed charges,97% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,614.64,878.05,
34709- PLMT XTN PROSTH EVASC RPR,3556823,CDM,481,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,790.25,90,,,percent of total billed charges,90% of total Billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,702.44,80,,,Percent of total Billed charges,80% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,790.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.71,97,,,Percent of total billed charges,97% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,807.81,92,,,Percent of total billed charges,92% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,790.25,90,,,percent of total billed charges,90% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,614.64,70,,,percent of total billed charges,70% of total billed charges,790.25,90,,,percent of total billed charges,90% of total billed charges,834.15,95,,,percent of total billed charges,95% of total billed charges,834.15,95,,,percent of total billed charges,95% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,755.12,86,,,percent of total billed charges,86% of total billed charges,702.44,80,,,percent of total billed charges,80% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,851.71,97,,,percent of total billed charges,97% of total billed charges,790.25,90,,,percent of total billed charges,90% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,851.71,97,,,percent of total billed charges,97% of total billed charges,816.59,93,,,percent of total billed charges,93% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,851.71,97,,,percent of total billed charges,97% of total billed charges,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,614.64,878.05,
34709-PLMT XTN PROSTH EVASC RPR,,,960,RC,34709,HCPCS,Outpatient,,,863.05,431.53,,776.75,90,,,percent of total billed charges,90% of total Billed charges,655.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,504.79,155,,,Fee Schedule,155% of CMS OPPS Rate,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,519.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,519.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,288.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,504.79,155,,,Fee Schedule,155% of CMS OPPS Rate,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1016.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1016.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.71,1016.55,
PLMT XTN PROSTH EVASC RPR,3527875,CDM,960,RC,34709,HCPCS,Outpatient,,,878.05,439.03,,790.25,90,,,percent of total billed charges,90% of total Billed charges,655.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,504.79,155,,,Fee Schedule,155% of CMS OPPS Rate,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,519.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,519.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,288.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,504.79,155,,,Fee Schedule,155% of CMS OPPS Rate,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1016.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1016.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,325.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.71,1016.55,
34710- DLYD PLMT XTN PROSTH 1ST VSL,3556824,CDM,481,RC,34710,HCPCS,Outpatient,,,2148.47,1074.24,,1933.62,90,,,percent of total billed charges,90% of total Billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.78,80,,,Percent of total Billed charges,80% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2084.02,97,,,Percent of total billed charges,97% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1976.59,92,,,Percent of total billed charges,92% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.62,90,,,percent of total billed charges,90% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.93,70,,,percent of total billed charges,70% of total billed charges,1933.62,90,,,percent of total billed charges,90% of total billed charges,2041.05,95,,,percent of total billed charges,95% of total billed charges,2041.05,95,,,percent of total billed charges,95% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1847.68,86,,,percent of total billed charges,86% of total billed charges,1718.78,80,,,percent of total billed charges,80% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2084.02,97,,,percent of total billed charges,97% of total billed charges,1933.62,90,,,percent of total billed charges,90% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2084.02,97,,,percent of total billed charges,97% of total billed charges,1998.08,93,,,percent of total billed charges,93% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2084.02,97,,,percent of total billed charges,97% of total billed charges,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.93,2148.47,
34710-DLYD PLMT XTN PROSTH 1ST VSL,,,960,RC,34710,HCPCS,Outpatient,,,2107.49,1053.75,,1896.74,90,,,percent of total billed charges,90% of total Billed charges,1603.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,663.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1232.68,155,,,Fee Schedule,155% of CMS OPPS Rate,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1191.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,795.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1340.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1269.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1269.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,715.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1590.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1497.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1095.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1232.68,155,,,Fee Schedule,155% of CMS OPPS Rate,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2484.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,663.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,906.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.24,2484.91,
DLYD PLMT XTN PROSTH 1ST VSL,3527876,CDM,960,RC,34710,HCPCS,Outpatient,,,2148.47,1074.24,,1933.62,90,,,percent of total billed charges,90% of total Billed charges,1603.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,663.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1232.68,155,,,Fee Schedule,155% of CMS OPPS Rate,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1191.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,795.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1340.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1340.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1269.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1269.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,715.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1590.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1497.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1095.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1232.68,155,,,Fee Schedule,155% of CMS OPPS Rate,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2484.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,663.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,906.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,795.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.24,2484.91,
34711- DLYD PLMT XTN PROSTH EA ADDL,3556825,CDM,481,RC,34711,HCPCS,Outpatient,,,803.81,401.91,,723.43,90,,,percent of total billed charges,90% of total Billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,643.05,80,,,Percent of total Billed charges,80% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,779.7,97,,,Percent of total billed charges,97% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,739.51,92,,,Percent of total billed charges,92% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.43,90,,,percent of total billed charges,90% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,562.67,70,,,percent of total billed charges,70% of total billed charges,723.43,90,,,percent of total billed charges,90% of total billed charges,763.62,95,,,percent of total billed charges,95% of total billed charges,763.62,95,,,percent of total billed charges,95% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,691.28,86,,,percent of total billed charges,86% of total billed charges,643.05,80,,,percent of total billed charges,80% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,779.7,97,,,percent of total billed charges,97% of total billed charges,723.43,90,,,percent of total billed charges,90% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,779.7,97,,,percent of total billed charges,97% of total billed charges,747.54,93,,,percent of total billed charges,93% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,779.7,97,,,percent of total billed charges,97% of total billed charges,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.81,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,562.67,803.81,
34711-DLYD PLMT XTN PROSTH EA ADDL,,,960,RC,34711,HCPCS,Outpatient,,,787.56,393.78,,708.8,90,,,percent of total billed charges,90% of total Billed charges,599.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,460.64,155,,,Fee Schedule,155% of CMS OPPS Rate,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,499.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,478.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,478.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,420.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.64,155,,,Fee Schedule,155% of CMS OPPS Rate,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.13,155,,,Fee Schedule,155% of CMS OPPS Rate,929.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,338.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.1,929.13,
DLYD PLMT XTN PROSTH EA ADDL,3527877,CDM,960,RC,34711,HCPCS,Outpatient,,,803.81,401.91,,723.43,90,,,percent of total billed charges,90% of total Billed charges,599.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,460.64,155,,,Fee Schedule,155% of CMS OPPS Rate,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,499.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,478.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,478.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,420.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.64,155,,,Fee Schedule,155% of CMS OPPS Rate,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.13,155,,,Fee Schedule,155% of CMS OPPS Rate,929.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,338.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.1,929.13,
"34712 - Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, t",3572786,CDM,960,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,1248.06,90,,,percent of total billed charges,90% of total Billed charges,1315.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,654.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,564.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1013.89,155,,,Fee Schedule,155% of CMS OPPS Rate,654.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,654.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1103.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1040.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1040.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,611.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1228.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,892.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1013.89,155,,,Fee Schedule,155% of CMS OPPS Rate,654.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,2039.78,155,,,Fee Schedule,155% of CMS OPPS Rate,2039.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,654.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,771.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,654.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.39,2039.78,
"34712-PF Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw,",4271142,CDM,481,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,1248.06,90,,,percent of total billed charges,90% of total Billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1109.38,80,,,Percent of total Billed charges,80% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1345.13,97,,,Percent of total billed charges,97% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1275.79,92,,,Percent of total billed charges,92% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248.06,90,,,percent of total billed charges,90% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,970.71,70,,,percent of total billed charges,70% of total billed charges,1248.06,90,,,percent of total billed charges,90% of total billed charges,1317.39,95,,,percent of total billed charges,95% of total billed charges,1317.39,95,,,percent of total billed charges,95% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.59,86,,,percent of total billed charges,86% of total billed charges,1109.38,80,,,percent of total billed charges,80% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1345.13,97,,,percent of total billed charges,97% of total billed charges,1248.06,90,,,percent of total billed charges,90% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1345.13,97,,,percent of total billed charges,97% of total billed charges,1289.66,93,,,percent of total billed charges,93% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1345.13,97,,,percent of total billed charges,97% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,970.71,1386.73,
"34712-Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tac",4271141,CDM,481,RC,34712,HCPCS,Outpatient,,,1386.73,693.37,,1248.06,90,,,percent of total billed charges,90% of total Billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1109.38,80,,,Percent of total Billed charges,80% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1345.13,97,,,Percent of total billed charges,97% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1275.79,92,,,Percent of total billed charges,92% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248.06,90,,,percent of total billed charges,90% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,970.71,70,,,percent of total billed charges,70% of total billed charges,1248.06,90,,,percent of total billed charges,90% of total billed charges,1317.39,95,,,percent of total billed charges,95% of total billed charges,1317.39,95,,,percent of total billed charges,95% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.59,86,,,percent of total billed charges,86% of total billed charges,1109.38,80,,,percent of total billed charges,80% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1345.13,97,,,percent of total billed charges,97% of total billed charges,1248.06,90,,,percent of total billed charges,90% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1345.13,97,,,percent of total billed charges,97% of total billed charges,1289.66,93,,,percent of total billed charges,93% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1345.13,97,,,percent of total billed charges,97% of total billed charges,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1386.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,970.71,1386.73,
34713-Add On Code: Unilateral perc access and closure of fem. art for delivery of endograft through,4271143,CDM,481,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,302.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,269.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,302.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,309.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,214.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,264.66,78.65,,,percent of total billed charges,78.65% of total billed charges,300.59,89.33,,,percent of total billed charges,89.33% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,235.54,70,,,percent of total billed charges,70% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,319.67,95,,,percent of total billed charges,95% of total billed charges,319.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.38,86,,,percent of total billed charges,86% of total billed charges,269.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,312.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.89,326.4,
34713-PERCUTANEOUS ACCESS & CLOSURE,3430890,CDM,510,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,302.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,269.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,302.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,309.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,214.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,264.66,78.65,,,percent of total billed charges,78.65% of total billed charges,300.59,89.33,,,percent of total billed charges,89.33% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,235.54,70,,,percent of total billed charges,70% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,319.67,95,,,percent of total billed charges,95% of total billed charges,319.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.38,86,,,percent of total billed charges,86% of total billed charges,269.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,302.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,312.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.89,326.4,
34713-PF Add On Code: Unilateral perc access and closure of fem. art for delivery of endograft throu,4271144,CDM,960,RC,34713,HCPCS,Outpatient,,,336.49,168.25,,302.84,90,,,percent of total billed charges,90% of total Billed charges,251.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,193.13,155,,,Fee Schedule,155% of CMS OPPS Rate,124.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,235.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,173.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,193.13,155,,,Fee Schedule,155% of CMS OPPS Rate,124.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.25,155,,,Fee Schedule,155% of CMS OPPS Rate,389.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,124.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,124.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.85,389.25,
34716 - PF Opn Ax/Subcla Art Expos w/ Cndt Crt,4363204,CDM,960,RC,34716,HCPCS,Outpatient,,,743.8,371.90,,669.42,90,,,percent of total billed charges,90% of total Billed charges,750.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,373.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,310.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,578.58,155,,,Fee Schedule,155% of CMS OPPS Rate,373.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,552.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,373.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,620.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,620.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,591.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,591.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,334.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,746.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,697.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,513.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,578.58,155,,,Fee Schedule,155% of CMS OPPS Rate,373.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1163.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1163.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,373.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,424.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,373.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.72,1163.79,
34717-Add On Code: Repair of iliac art. at time of aorto-iliac graft placement of an iliac branched,4271145,CDM,481,RC,34717,HCPCS,Outpatient,,,947.53,473.77,,852.78,90,,,percent of total billed charges,90% of total Billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.02,80,,,Percent of total Billed charges,80% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,852.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,919.1,97,,,Percent of total billed charges,97% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,871.73,92,,,Percent of total billed charges,92% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,852.78,90,,,percent of total billed charges,90% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,663.27,70,,,percent of total billed charges,70% of total billed charges,852.78,90,,,percent of total billed charges,90% of total billed charges,900.15,95,,,percent of total billed charges,95% of total billed charges,900.15,95,,,percent of total billed charges,95% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,814.88,86,,,percent of total billed charges,86% of total billed charges,758.02,80,,,percent of total billed charges,80% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,919.1,97,,,percent of total billed charges,97% of total billed charges,852.78,90,,,percent of total billed charges,90% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,919.1,97,,,percent of total billed charges,97% of total billed charges,881.2,93,,,percent of total billed charges,93% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,919.1,97,,,percent of total billed charges,97% of total billed charges,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,663.27,947.53,
34717-PF Add On Code: Repair of iliac art. at time of aorto-iliac graft placement of an iliac branch,4271146,CDM,960,RC,34717,HCPCS,Outpatient,,,947.53,473.77,,852.78,90,,,percent of total billed charges,90% of total Billed charges,903.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.77,155,,,Fee Schedule,155% of CMS OPPS Rate,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,446.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,713.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,713.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,401.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,893.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,842.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,628.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,692.77,155,,,Fee Schedule,155% of CMS OPPS Rate,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1400.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1400.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,505.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,446.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.19,1400.12,
34718-PF Repair of iliac art not at time of aorto-iliac graft placement of an iliac branched endogra,4271148,CDM,960,RC,34718,HCPCS,Outpatient,,,2629.18,1314.59,,2366.26,90,,,percent of total billed charges,90% of total Billed charges,2500.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1240.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1240.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1844.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1240.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2074.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2074.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1977.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1977.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1119.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1240.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2480.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2333.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1726.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1922.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1240.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3875.12,155,,,Fee Schedule,155% of CMS OPPS Rate,3875.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1240.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1407.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1240.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1119.41,3875.12,
34718-Repair of iliac art not at time of aorto-iliac graft placement of an iliac branched endograft,4271147,CDM,481,RC,34718,HCPCS,Outpatient,,,2629.18,1314.59,,2366.26,90,,,percent of total billed charges,90% of total Billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2103.34,80,,,Percent of total Billed charges,80% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2366.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2550.3,97,,,Percent of total billed charges,97% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2418.85,92,,,Percent of total billed charges,92% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2366.26,90,,,percent of total billed charges,90% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1840.43,70,,,percent of total billed charges,70% of total billed charges,2366.26,90,,,percent of total billed charges,90% of total billed charges,2497.72,95,,,percent of total billed charges,95% of total billed charges,2497.72,95,,,percent of total billed charges,95% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2261.09,86,,,percent of total billed charges,86% of total billed charges,2103.34,80,,,percent of total billed charges,80% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2550.3,97,,,percent of total billed charges,97% of total billed charges,2366.26,90,,,percent of total billed charges,90% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2550.3,97,,,percent of total billed charges,97% of total billed charges,2445.14,93,,,percent of total billed charges,93% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2550.3,97,,,percent of total billed charges,97% of total billed charges,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2629.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1840.43,2629.18,
34808-Add on code: Endovascular placement of iliac artery occlusion device,4271252,CDM,481,RC,34808,HCPCS,Outpatient,,,433.92,216.96,,390.53,90,,,percent of total billed charges,90% of total Billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,347.14,80,,,Percent of total Billed charges,80% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,390.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,420.9,97,,,Percent of total billed charges,97% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,399.21,92,,,Percent of total billed charges,92% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,390.53,90,,,percent of total billed charges,90% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,303.74,70,,,percent of total billed charges,70% of total billed charges,390.53,90,,,percent of total billed charges,90% of total billed charges,412.22,95,,,percent of total billed charges,95% of total billed charges,412.22,95,,,percent of total billed charges,95% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,373.17,86,,,percent of total billed charges,86% of total billed charges,347.14,80,,,percent of total billed charges,80% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,420.9,97,,,percent of total billed charges,97% of total billed charges,390.53,90,,,percent of total billed charges,90% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,420.9,97,,,percent of total billed charges,97% of total billed charges,403.55,93,,,percent of total billed charges,93% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,420.9,97,,,percent of total billed charges,97% of total billed charges,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,433.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,303.74,433.92,
34808-PF Add on code: Endovascular placement of iliac artery occlusion device,4271253,CDM,960,RC,34808,HCPCS,Outpatient,,,433.92,216.96,,390.53,90,,,percent of total billed charges,90% of total Billed charges,409.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,195.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,317.25,155,,,Fee Schedule,155% of CMS OPPS Rate,204.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,322.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,322.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,169.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,317.25,155,,,Fee Schedule,155% of CMS OPPS Rate,204.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.62,155,,,Fee Schedule,155% of CMS OPPS Rate,634.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,204.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,229.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,437.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,169.05,634.62,
34812- Open fem art/endovas prosthes/uni,3430681,CDM,481,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,505.28,90,,,percent of total billed charges,90% of total Billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,449.14,80,,,Percent of total Billed charges,80% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,544.58,97,,,Percent of total billed charges,97% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.51,92,,,Percent of total billed charges,92% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.28,90,,,percent of total billed charges,90% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,392.99,70,,,percent of total billed charges,70% of total billed charges,505.28,90,,,percent of total billed charges,90% of total billed charges,533.35,95,,,percent of total billed charges,95% of total billed charges,533.35,95,,,percent of total billed charges,95% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,482.82,86,,,percent of total billed charges,86% of total billed charges,449.14,80,,,percent of total billed charges,80% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.58,97,,,percent of total billed charges,97% of total billed charges,505.28,90,,,percent of total billed charges,90% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.58,97,,,percent of total billed charges,97% of total billed charges,522.12,93,,,percent of total billed charges,93% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,544.58,97,,,percent of total billed charges,97% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,392.99,561.42,
34812-FEM CUTDOWN AAA STENT,3431825,CDM,481,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,505.28,90,,,percent of total billed charges,90% of total Billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,449.14,80,,,Percent of total Billed charges,80% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,544.58,97,,,Percent of total billed charges,97% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,516.51,92,,,Percent of total billed charges,92% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.28,90,,,percent of total billed charges,90% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,392.99,70,,,percent of total billed charges,70% of total billed charges,505.28,90,,,percent of total billed charges,90% of total billed charges,533.35,95,,,percent of total billed charges,95% of total billed charges,533.35,95,,,percent of total billed charges,95% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,482.82,86,,,percent of total billed charges,86% of total billed charges,449.14,80,,,percent of total billed charges,80% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.58,97,,,percent of total billed charges,97% of total billed charges,505.28,90,,,percent of total billed charges,90% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.58,97,,,percent of total billed charges,97% of total billed charges,522.12,93,,,percent of total billed charges,93% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,544.58,97,,,percent of total billed charges,97% of total billed charges,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,561.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,392.99,561.42,
34812-PF FEM CUTDOWN AAA STENT,3580879,CDM,960,RC,34812,HCPCS,Outpatient,,,561.42,280.71,,505.28,90,,,percent of total billed charges,90% of total Billed charges,418.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,321.84,155,,,Fee Schedule,155% of CMS OPPS Rate,207.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,331.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,331.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,234.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,390.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,291.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,321.84,155,,,Fee Schedule,155% of CMS OPPS Rate,207.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.05,155,,,Fee Schedule,155% of CMS OPPS Rate,649.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,207.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,378.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,207.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,722.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,722.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,207.64,722.16,
34813 - Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (Li,3572794,CDM,960,RC,34813,HCPCS,Outpatient,,,645.15,322.58,,580.64,90,,,percent of total billed charges,90% of total Billed charges,480.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,227.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,369.41,155,,,Fee Schedule,155% of CMS OPPS Rate,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,381.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,381.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,449.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,369.41,155,,,Fee Schedule,155% of CMS OPPS Rate,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,745.43,155,,,Fee Schedule,155% of CMS OPPS Rate,745.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,268.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,510,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,510,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,192.16,745.43,
34813-Add On Code: Placement fem/fem graft during EVAR,4271149,CDM,481,RC,34813,HCPCS,Outpatient,,,505.26,252.63,,454.73,90,,,percent of total billed charges,90% of total Billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,404.21,80,,,Percent of total Billed charges,80% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,454.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.1,97,,,Percent of total billed charges,97% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,464.84,92,,,Percent of total billed charges,92% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,454.73,90,,,percent of total billed charges,90% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.68,70,,,percent of total billed charges,70% of total billed charges,454.73,90,,,percent of total billed charges,90% of total billed charges,480,95,,,percent of total billed charges,95% of total billed charges,480,95,,,percent of total billed charges,95% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,434.52,86,,,percent of total billed charges,86% of total billed charges,404.21,80,,,percent of total billed charges,80% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,490.1,97,,,percent of total billed charges,97% of total billed charges,454.73,90,,,percent of total billed charges,90% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,490.1,97,,,percent of total billed charges,97% of total billed charges,469.89,93,,,percent of total billed charges,93% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,490.1,97,,,percent of total billed charges,97% of total billed charges,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,353.68,505.26,
34813-PF Add On Code: Placement fem/fem graft during EVAR,4271150,CDM,960,RC,34813,HCPCS,Outpatient,,,505.26,252.63,,454.73,90,,,percent of total billed charges,90% of total Billed charges,480.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,227.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,369.41,155,,,Fee Schedule,155% of CMS OPPS Rate,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,381.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,381.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,449.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,369.41,155,,,Fee Schedule,155% of CMS OPPS Rate,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,745.43,155,,,Fee Schedule,155% of CMS OPPS Rate,745.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,268.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,238.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,510,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,510,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,192.16,745.43,
34841-EVAR by deployment of a fenestrated visceral aortic endograft with 1 artery prostheses,4271151,CDM,481,RC,34841,HCPCS,Outpatient,,,3690.92,1845.46,,3321.83,90,,,percent of total billed charges,90% of total Billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2952.74,80,,,Percent of total Billed charges,80% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3321.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3580.19,97,,,Percent of total billed charges,97% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3395.65,92,,,Percent of total billed charges,92% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3321.83,90,,,percent of total billed charges,90% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2583.64,70,,,percent of total billed charges,70% of total billed charges,3321.83,90,,,percent of total billed charges,90% of total billed charges,3506.37,95,,,percent of total billed charges,95% of total billed charges,3506.37,95,,,percent of total billed charges,95% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3174.19,86,,,percent of total billed charges,86% of total billed charges,2952.74,80,,,percent of total billed charges,80% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3580.19,97,,,percent of total billed charges,97% of total billed charges,3321.83,90,,,percent of total billed charges,90% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3580.19,97,,,percent of total billed charges,97% of total billed charges,3432.56,93,,,percent of total billed charges,93% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3580.19,97,,,percent of total billed charges,97% of total billed charges,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3690.92,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2583.64,3690.92,
34841-PF EVAR by deployment of a fenestrated visceral aortic endograft with 1 artery prostheses,4271152,CDM,960,RC,34841,HCPCS,Outpatient,,,3690.92,1845.46,,3321.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2198.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,2472.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2472.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1642.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1642.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1562.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2157.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1562.88,3321.83,
34842-EVAR by deployment of a fenestrated visceral aortic endograft with 2 artery prostheses,4271153,CDM,481,RC,34842,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4245.94,80,,,Percent of total Billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5148.2,97,,,Percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4882.83,92,,,Percent of total billed charges,92% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,70,,,percent of total billed charges,70% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4564.38,86,,,percent of total billed charges,86% of total billed charges,4245.94,80,,,percent of total billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4935.9,93,,,percent of total billed charges,93% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5148.2,97,,,percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,5307.42,
34842-PF EVAR by deployment of a fenestrated visceral aortic endograft with 2 artery prostheses,4271154,CDM,960,RC,34842,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2411.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,2712.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2712.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1987.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1987.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1719.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.55,4776.68,
34843-EVAR by deployment of a fenestrated visceral aortic endograft with 3 artery prostheses,4271155,CDM,481,RC,34843,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4245.94,80,,,Percent of total Billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5148.2,97,,,Percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4882.83,92,,,Percent of total billed charges,92% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,70,,,percent of total billed charges,70% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4564.38,86,,,percent of total billed charges,86% of total billed charges,4245.94,80,,,percent of total billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4935.9,93,,,percent of total billed charges,93% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5148.2,97,,,percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,5307.42,
34843-PF EVAR by deployment of a fenestrated visceral aortic endograft with 3 artery prostheses,4271156,CDM,960,RC,34843,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2646.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,2977.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2977.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1944.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1944.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1876.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1876.21,4776.68,
34844-EVAR by deployment of a fenestrated visceral aortic endograft with 4 or more artery prostheses,4271157,CDM,481,RC,34844,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4245.94,80,,,Percent of total Billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5148.2,97,,,Percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4882.83,92,,,Percent of total billed charges,92% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,70,,,percent of total billed charges,70% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5042.05,95,,,percent of total billed charges,95% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4564.38,86,,,percent of total billed charges,86% of total billed charges,4245.94,80,,,percent of total billed charges,80% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4776.68,90,,,percent of total billed charges,90% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5148.2,97,,,percent of total billed charges,97% of total billed charges,4935.9,93,,,percent of total billed charges,93% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5148.2,97,,,percent of total billed charges,97% of total billed charges,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5307.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.19,5307.42,
34844-PF EVAR by deployment of a fenestrated visceral aortic endograft with 4 or more artery prosthe,4271158,CDM,960,RC,34844,HCPCS,Outpatient,,,5307.42,2653.71,,4776.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2929.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,3294.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3294.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2008.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2008.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2032.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2860.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2008.89,4776.68,
34846-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 2 arter,4271159,CDM,481,RC,34846,HCPCS,Outpatient,,,5099.66,2549.83,,4589.69,90,,,percent of total billed charges,90% of total Billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4079.73,80,,,Percent of total Billed charges,80% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4589.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4946.67,97,,,Percent of total billed charges,97% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4691.69,92,,,Percent of total billed charges,92% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4589.69,90,,,percent of total billed charges,90% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3569.76,70,,,percent of total billed charges,70% of total billed charges,4589.69,90,,,percent of total billed charges,90% of total billed charges,4844.68,95,,,percent of total billed charges,95% of total billed charges,4844.68,95,,,percent of total billed charges,95% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4385.71,86,,,percent of total billed charges,86% of total billed charges,4079.73,80,,,percent of total billed charges,80% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.67,97,,,percent of total billed charges,97% of total billed charges,4589.69,90,,,percent of total billed charges,90% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.67,97,,,percent of total billed charges,97% of total billed charges,4742.68,93,,,percent of total billed charges,93% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4946.67,97,,,percent of total billed charges,97% of total billed charges,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5099.66,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3569.76,5099.66,
34846-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 2 ar,4271160,CDM,960,RC,34846,HCPCS,Outpatient,,,5099.66,2549.83,,4589.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2750.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,3093.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3093.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2140.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2140.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1719.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2391.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1719.55,4589.69,
34847-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 3 arter,4271161,CDM,481,RC,34847,HCPCS,Outpatient,,,4996.84,2498.42,,4497.16,90,,,percent of total billed charges,90% of total Billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3997.47,80,,,Percent of total Billed charges,80% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4497.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4846.93,97,,,Percent of total billed charges,97% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4597.09,92,,,Percent of total billed charges,92% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4497.16,90,,,percent of total billed charges,90% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3497.79,70,,,percent of total billed charges,70% of total billed charges,4497.16,90,,,percent of total billed charges,90% of total billed charges,4747,95,,,percent of total billed charges,95% of total billed charges,4747,95,,,percent of total billed charges,95% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4297.28,86,,,percent of total billed charges,86% of total billed charges,3997.47,80,,,percent of total billed charges,80% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4846.93,97,,,percent of total billed charges,97% of total billed charges,4497.16,90,,,percent of total billed charges,90% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4846.93,97,,,percent of total billed charges,97% of total billed charges,4647.06,93,,,percent of total billed charges,93% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4846.93,97,,,percent of total billed charges,97% of total billed charges,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4996.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3497.79,4996.84,
34847-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 3 ar,4271162,CDM,960,RC,34847,HCPCS,Outpatient,,,4996.84,2498.42,,4497.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2918.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,3282.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3282.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2097.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2097.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1876.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2625.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1876.21,4497.16,
34848-EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 4 or mo,4271163,CDM,481,RC,34848,HCPCS,Outpatient,,,4860.1,2430.05,,4374.09,90,,,percent of total billed charges,90% of total Billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3888.08,80,,,Percent of total Billed charges,80% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4374.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4714.3,97,,,Percent of total billed charges,97% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4471.29,92,,,Percent of total billed charges,92% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4374.09,90,,,percent of total billed charges,90% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3402.07,70,,,percent of total billed charges,70% of total billed charges,4374.09,90,,,percent of total billed charges,90% of total billed charges,4617.1,95,,,percent of total billed charges,95% of total billed charges,4617.1,95,,,percent of total billed charges,95% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4179.69,86,,,percent of total billed charges,86% of total billed charges,3888.08,80,,,percent of total billed charges,80% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4714.3,97,,,percent of total billed charges,97% of total billed charges,4374.09,90,,,percent of total billed charges,90% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4714.3,97,,,percent of total billed charges,97% of total billed charges,4519.89,93,,,percent of total billed charges,93% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4714.3,97,,,percent of total billed charges,97% of total billed charges,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4860.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3402.07,4860.1,
34848-PF EVAR and infrarenal abd aorta repair with a fenestrated visceral aortic endograft with 4 or,4271164,CDM,960,RC,34848,HCPCS,Outpatient,,,4860.1,2430.05,,4374.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3127.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,3518.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3518.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2162.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2162.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2032.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2860.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2032.88,4374.09,
35011 - Rpr Defect of Artery-Dir Rpr Aneurysm Axil-Brachial Arm Incision,3899025,CDM,983,RC,35011,HCPCS,Outpatient,,,2729.35,1364.68,,2456.42,90,,,percent of total billed charges,90% of total Billed charges,2038.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,797.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1569.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1012.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1489.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1012.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1675.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1675.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1589.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1589.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,820.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2024.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1875.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1384.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1569.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1012.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,3159.97,155,,,Fee Schedule,155% of CMS OPPS Rate,3159.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1012.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1078,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1012.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2139.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2139.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,797.5,3159.97,
"35045 - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertio",3783530,CDM,510,RC,35045,HCPCS,Outpatient,,,2630.85,1315.43,,2367.77,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2104.68,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2367.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2551.92,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2420.38,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2367.77,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1841.6,70,,,percent of total billed charges,70% of total billed charges,2367.77,90,,,percent of total billed charges,90% of total billed charges,2499.31,95,,,percent of total billed charges,95% of total billed charges,2499.31,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2262.53,86,,,percent of total billed charges,86% of total billed charges,2104.68,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2551.92,97,,,percent of total billed charges,97% of total billed charges,2367.77,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2551.92,97,,,percent of total billed charges,97% of total billed charges,2446.69,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2551.92,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1841.6,25056.97,
35141 - DIR RPR Aneurysm & Graft Common Femoral Artery,4169578,CDM,983,RC,35141,HCPCS,Outpatient,,,2656.43,1328.22,,2390.79,90,,,percent of total billed charges,90% of total Billed charges,2217.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1099.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1703.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1099.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1637.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1099.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1842.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1752.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1752.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,902.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1099.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2198.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2068.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1531.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1703.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1099.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,3437.65,155,,,Fee Schedule,155% of CMS OPPS Rate,3437.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1099.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1248.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1099.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2382.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2382.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,902.01,3437.65,
35151 - PF Dir Rpr Aneurysm & Graft Popliteal Artery,4309236,CDM,960,RC,35151,HCPCS,Outpatient,,,2640.97,1320.49,,2376.87,90,,,percent of total billed charges,90% of total Billed charges,2508.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1245.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,957,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1930.9,155,,,Fee Schedule,155% of CMS OPPS Rate,1245.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1838.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1245.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2068.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2068.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1971.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1971.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1012.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2491.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2326.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1728.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1930.9,155,,,Fee Schedule,155% of CMS OPPS Rate,1245.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3888.41,155,,,Fee Schedule,155% of CMS OPPS Rate,3888.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1245.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,957,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1364.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1245.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2688.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2688.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,957,3888.41,
"35201- Repair blood ves, direct neck",3430683,CDM,510,RC,35201,HCPCS,Outpatient,,,2532.04,1266.02,,2278.84,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2025.63,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2278.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2456.08,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2329.48,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2278.84,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1772.43,70,,,percent of total billed charges,70% of total billed charges,2278.84,90,,,percent of total billed charges,90% of total billed charges,2405.44,95,,,percent of total billed charges,95% of total billed charges,2405.44,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2177.55,86,,,percent of total billed charges,86% of total billed charges,2025.63,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2456.08,97,,,percent of total billed charges,97% of total billed charges,2278.84,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2456.08,97,,,percent of total billed charges,97% of total billed charges,2354.8,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2456.08,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1772.43,25056.97,
35206- Repair blood vessel direct/up ext,3430684,CDM,510,RC,35206,HCPCS,Outpatient,,,2104.04,1052.02,,1893.64,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1683.23,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1893.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2040.92,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1935.72,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1893.64,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1472.83,70,,,percent of total billed charges,70% of total billed charges,1893.64,90,,,percent of total billed charges,90% of total billed charges,1998.84,95,,,percent of total billed charges,95% of total billed charges,1998.84,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1809.47,86,,,percent of total billed charges,86% of total billed charges,1683.23,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2040.92,97,,,percent of total billed charges,97% of total billed charges,1893.64,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2040.92,97,,,percent of total billed charges,97% of total billed charges,1956.76,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2040.92,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1472.83,14522.85,
35206-PF REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY,4321672,CDM,981,RC,35206,HCPCS,Outpatient,,,1565.82,782.91,,1409.24,90,,,percent of total billed charges,90% of total Billed charges,1574.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,782.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,352,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1213.5,155,,,Fee Schedule,155% of CMS OPPS Rate,782.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,782.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1303.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1225.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1225.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,633.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1565.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1445.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1045.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1213.5,155,,,Fee Schedule,155% of CMS OPPS Rate,782.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,2439.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2439.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,782.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,352,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,838.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,782.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1650.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,352,2439.82,
35207- Repair blood vess/direct/hand/fing,3430685,CDM,510,RC,35207,HCPCS,Outpatient,,,1971.57,985.79,,1774.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1577.26,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1774.41,90,,,Percent of total Billed charges,90% of total billed charges,726.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1912.42,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1813.84,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1774.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.1,70,,,percent of total billed charges,70% of total billed charges,1774.41,90,,,percent of total billed charges,90% of total billed charges,1872.99,95,,,percent of total billed charges,95% of total billed charges,1872.99,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1695.55,86,,,percent of total billed charges,86% of total billed charges,1577.26,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1912.42,97,,,percent of total billed charges,97% of total billed charges,1774.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1912.42,97,,,percent of total billed charges,97% of total billed charges,1833.56,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1912.42,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,660.29,14522.85,
35207-PF REPAIR BLOOD VESSEL DIRECT HAND FINGER,4321671,CDM,981,RC,35207,HCPCS,Outpatient,,,1483.06,741.53,,1334.75,90,,,percent of total billed charges,90% of total Billed charges,1482.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,741.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,660.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1149.37,155,,,Fee Schedule,155% of CMS OPPS Rate,741.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1251.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1251.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1135.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1135.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,608.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,741.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1483.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1339.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,899,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1149.37,155,,,Fee Schedule,155% of CMS OPPS Rate,741.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2298.51,155,,,Fee Schedule,155% of CMS OPPS Rate,2298.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,741.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,879.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,741.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1544.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,608.01,2298.51,
35221- Repair blood vess/direct/intra/abd,3430686,CDM,510,RC,35221,HCPCS,Outpatient,,,3980.09,1990.05,,3582.08,90,,,percent of total billed charges,90% of total Billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3184.07,80,,,Percent of total Billed charges,80% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3582.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3860.69,97,,,Percent of total billed charges,97% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3661.68,92,,,Percent of total billed charges,92% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3582.08,90,,,percent of total billed charges,90% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2786.06,70,,,percent of total billed charges,70% of total billed charges,3582.08,90,,,percent of total billed charges,90% of total billed charges,3781.09,95,,,percent of total billed charges,95% of total billed charges,3781.09,95,,,percent of total billed charges,95% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3422.88,86,,,percent of total billed charges,86% of total billed charges,3184.07,80,,,percent of total billed charges,80% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3860.69,97,,,percent of total billed charges,97% of total billed charges,3582.08,90,,,percent of total billed charges,90% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3860.69,97,,,percent of total billed charges,97% of total billed charges,3701.48,93,,,percent of total billed charges,93% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3860.69,97,,,percent of total billed charges,97% of total billed charges,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3980.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2786.06,3980.09,
35226- Repair blood vessel direct/low ext,3430687,CDM,510,RC,35226,HCPCS,Outpatient,,,2248.04,1124.02,,2023.24,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.43,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2023.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2180.6,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2068.2,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2023.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1573.63,70,,,percent of total billed charges,70% of total billed charges,2023.24,90,,,percent of total billed charges,90% of total billed charges,2135.64,95,,,percent of total billed charges,95% of total billed charges,2135.64,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1933.31,86,,,percent of total billed charges,86% of total billed charges,1798.43,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2180.6,97,,,percent of total billed charges,97% of total billed charges,2023.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2180.6,97,,,percent of total billed charges,97% of total billed charges,2090.68,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2180.6,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.01,3163.8,
35226-PF RPR BLOOD VESSEL DIRECT LOWER EXTREMITY,4321670,CDM,981,RC,35226,HCPCS,Outpatient,,,1666.04,833.02,,1499.44,90,,,percent of total billed charges,90% of total Billed charges,1678.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,833.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1291.17,155,,,Fee Schedule,155% of CMS OPPS Rate,833.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,833.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1389.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1389.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1314.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1314.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,679.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,833.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1666.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1551.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1137.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1291.17,155,,,Fee Schedule,155% of CMS OPPS Rate,833.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2601.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2601.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,833.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,854.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,833.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1780.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1780.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,589.5,2601.44,
35236- Rpr blood ves w/vein graft/up ext,3430688,CDM,510,RC,35236,HCPCS,Outpatient,,,2690.1,1345.05,,2421.09,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2152.08,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2421.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2609.4,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2474.89,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2421.09,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1883.07,70,,,percent of total billed charges,70% of total billed charges,2421.09,90,,,percent of total billed charges,90% of total billed charges,2555.6,95,,,percent of total billed charges,95% of total billed charges,2555.6,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2313.49,86,,,percent of total billed charges,86% of total billed charges,2152.08,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2609.4,97,,,percent of total billed charges,97% of total billed charges,2421.09,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2609.4,97,,,percent of total billed charges,97% of total billed charges,2501.79,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2609.4,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1883.07,25056.97,
35256 - (50) Repair blood vessel with vein graft; lower extremity,3698997,CDM,510,RC,35256,HCPCS,Outpatient,,,2752.35,1376.18,,2477.12,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.88,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2477.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2669.78,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2532.16,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2477.12,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.65,70,,,percent of total billed charges,70% of total billed charges,2477.12,90,,,percent of total billed charges,90% of total billed charges,2614.73,95,,,percent of total billed charges,95% of total billed charges,2614.73,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2367.02,86,,,percent of total billed charges,86% of total billed charges,2201.88,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2669.78,97,,,percent of total billed charges,97% of total billed charges,2477.12,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2669.78,97,,,percent of total billed charges,97% of total billed charges,2559.69,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2669.78,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1926.65,25056.97,
35256 - PF Repair blood vessel with vein graft; lower extremity,3698994,CDM,510,RC,35256,HCPCS,Outpatient,,,2752.35,1376.18,,2477.12,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.88,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2477.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2669.78,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2532.16,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2477.12,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.65,70,,,percent of total billed charges,70% of total billed charges,2477.12,90,,,percent of total billed charges,90% of total billed charges,2614.73,95,,,percent of total billed charges,95% of total billed charges,2614.73,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2367.02,86,,,percent of total billed charges,86% of total billed charges,2201.88,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2669.78,97,,,percent of total billed charges,97% of total billed charges,2477.12,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2669.78,97,,,percent of total billed charges,97% of total billed charges,2559.69,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2669.78,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1926.65,25056.97,
35266 - (50) Repair blood vessel with graft other than vein; upper extremity,3713007,CDM,510,RC,35266,HCPCS,Outpatient,,,2330.26,1165.13,,2097.23,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1864.21,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2097.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2260.35,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2143.84,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2097.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1631.18,70,,,percent of total billed charges,70% of total billed charges,2097.23,90,,,percent of total billed charges,90% of total billed charges,2213.75,95,,,percent of total billed charges,95% of total billed charges,2213.75,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2004.02,86,,,percent of total billed charges,86% of total billed charges,1864.21,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2260.35,97,,,percent of total billed charges,97% of total billed charges,2097.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2260.35,97,,,percent of total billed charges,97% of total billed charges,2167.14,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2260.35,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1631.18,25056.97,
35266 - PF Repair blood vessel with graft other than vein; upper extremity,3713004,CDM,510,RC,35266,HCPCS,Outpatient,,,2330.26,1165.13,,2097.23,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1864.21,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2097.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2260.35,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2143.84,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2097.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1631.18,70,,,percent of total billed charges,70% of total billed charges,2097.23,90,,,percent of total billed charges,90% of total billed charges,2213.75,95,,,percent of total billed charges,95% of total billed charges,2213.75,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2004.02,86,,,percent of total billed charges,86% of total billed charges,1864.21,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2260.35,97,,,percent of total billed charges,97% of total billed charges,2097.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2260.35,97,,,percent of total billed charges,97% of total billed charges,2167.14,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2260.35,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1631.18,25056.97,
35271- Rpr bld ves/gft no vn/intrathor/BP,3430689,CDM,510,RC,35271,HCPCS,Outpatient,,,3711.36,1855.68,,3340.22,90,,,percent of total billed charges,90% of total Billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2969.09,80,,,Percent of total Billed charges,80% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3340.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3600.02,97,,,Percent of total billed charges,97% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3414.45,92,,,Percent of total billed charges,92% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3340.22,90,,,percent of total billed charges,90% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2597.95,70,,,percent of total billed charges,70% of total billed charges,3340.22,90,,,percent of total billed charges,90% of total billed charges,3525.79,95,,,percent of total billed charges,95% of total billed charges,3525.79,95,,,percent of total billed charges,95% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3191.77,86,,,percent of total billed charges,86% of total billed charges,2969.09,80,,,percent of total billed charges,80% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3600.02,97,,,percent of total billed charges,97% of total billed charges,3340.22,90,,,percent of total billed charges,90% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3600.02,97,,,percent of total billed charges,97% of total billed charges,3451.56,93,,,percent of total billed charges,93% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3600.02,97,,,percent of total billed charges,97% of total billed charges,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2597.95,3711.36,
35301- Thromb/endar/neck inc/car/vert/sub,3430690,CDM,510,RC,35301,HCPCS,Outpatient,,,3059.61,1529.81,,2753.65,90,,,percent of total billed charges,90% of total Billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2447.69,80,,,Percent of total Billed charges,80% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2753.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2967.82,97,,,Percent of total billed charges,97% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2814.84,92,,,Percent of total billed charges,92% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2753.65,90,,,percent of total billed charges,90% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.73,70,,,percent of total billed charges,70% of total billed charges,2753.65,90,,,percent of total billed charges,90% of total billed charges,2906.63,95,,,percent of total billed charges,95% of total billed charges,2906.63,95,,,percent of total billed charges,95% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2631.26,86,,,percent of total billed charges,86% of total billed charges,2447.69,80,,,percent of total billed charges,80% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.82,97,,,percent of total billed charges,97% of total billed charges,2753.65,90,,,percent of total billed charges,90% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.82,97,,,percent of total billed charges,97% of total billed charges,2845.44,93,,,percent of total billed charges,93% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2967.82,97,,,percent of total billed charges,97% of total billed charges,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3059.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.73,3059.61,
35302- Thromboendarterectomy SF femoral art,3569391,CDM,510,RC,35302,HCPCS,Outpatient,,,3040.46,1520.23,,2736.41,90,,,percent of total billed charges,90% of total Billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2432.37,80,,,Percent of total Billed charges,80% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2736.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2949.25,97,,,Percent of total billed charges,97% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2797.22,92,,,Percent of total billed charges,92% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2736.41,90,,,percent of total billed charges,90% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2128.32,70,,,percent of total billed charges,70% of total billed charges,2736.41,90,,,percent of total billed charges,90% of total billed charges,2888.44,95,,,percent of total billed charges,95% of total billed charges,2888.44,95,,,percent of total billed charges,95% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2614.8,86,,,percent of total billed charges,86% of total billed charges,2432.37,80,,,percent of total billed charges,80% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.25,97,,,percent of total billed charges,97% of total billed charges,2736.41,90,,,percent of total billed charges,90% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.25,97,,,percent of total billed charges,97% of total billed charges,2827.63,93,,,percent of total billed charges,93% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2949.25,97,,,percent of total billed charges,97% of total billed charges,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3040.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2128.32,3040.46,
"35303 - Thromboendarterectomy, including patch graft, if performed; popliteal artery",3783512,CDM,975,RC,35303,HCPCS,Outpatient,,,3346.84,1673.42,,3012.16,90,,,percent of total billed charges,90% of total Billed charges,2501.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1243.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1927.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1243.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1243.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2069.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2069.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1970.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1970.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1011.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1243.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2486.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2325.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1723.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1927.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1243.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,3877.84,155,,,Fee Schedule,155% of CMS OPPS Rate,3877.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1243.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1182.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1243.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2681.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2681.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1011.77,3877.84,
"35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial",3622973,CDM,510,RC,35305,HCPCS,Outpatient,,,3328.55,1664.28,,2995.7,90,,,percent of total billed charges,90% of total Billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2662.84,80,,,Percent of total Billed charges,80% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2995.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3228.69,97,,,Percent of total billed charges,97% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3062.27,92,,,Percent of total billed charges,92% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2995.7,90,,,percent of total billed charges,90% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2329.99,70,,,percent of total billed charges,70% of total billed charges,2995.7,90,,,percent of total billed charges,90% of total billed charges,3162.12,95,,,percent of total billed charges,95% of total billed charges,3162.12,95,,,percent of total billed charges,95% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2862.55,86,,,percent of total billed charges,86% of total billed charges,2662.84,80,,,percent of total billed charges,80% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3228.69,97,,,percent of total billed charges,97% of total billed charges,2995.7,90,,,percent of total billed charges,90% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3228.69,97,,,percent of total billed charges,97% of total billed charges,3095.55,93,,,percent of total billed charges,93% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3228.69,97,,,percent of total billed charges,97% of total billed charges,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.55,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2329.99,3328.55,
35341- Thromboendarterectomy;mesen/celiac/renal,3569380,CDM,510,RC,35341,HCPCS,Outpatient,,,3748.58,1874.29,,3373.72,90,,,percent of total billed charges,90% of total Billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2998.86,80,,,Percent of total Billed charges,80% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3373.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3636.12,97,,,Percent of total billed charges,97% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3448.69,92,,,Percent of total billed charges,92% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3373.72,90,,,percent of total billed charges,90% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2624.01,70,,,percent of total billed charges,70% of total billed charges,3373.72,90,,,percent of total billed charges,90% of total billed charges,3561.15,95,,,percent of total billed charges,95% of total billed charges,3561.15,95,,,percent of total billed charges,95% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3223.78,86,,,percent of total billed charges,86% of total billed charges,2998.86,80,,,percent of total billed charges,80% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3636.12,97,,,percent of total billed charges,97% of total billed charges,3373.72,90,,,percent of total billed charges,90% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3636.12,97,,,percent of total billed charges,97% of total billed charges,3486.18,93,,,percent of total billed charges,93% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3636.12,97,,,percent of total billed charges,97% of total billed charges,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3748.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2624.01,3748.58,
"35351 - (50)  Thromboendarterectomy, including patch graft, if performed; iliac",3699122,CDM,510,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,3144.92,90,,,percent of total billed charges,90% of total Billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2795.48,80,,,Percent of total Billed charges,80% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3144.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3389.52,97,,,Percent of total billed charges,97% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3214.8,92,,,Percent of total billed charges,92% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3144.92,90,,,percent of total billed charges,90% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.05,70,,,percent of total billed charges,70% of total billed charges,3144.92,90,,,percent of total billed charges,90% of total billed charges,3319.63,95,,,percent of total billed charges,95% of total billed charges,3319.63,95,,,percent of total billed charges,95% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3005.14,86,,,percent of total billed charges,86% of total billed charges,2795.48,80,,,percent of total billed charges,80% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.52,97,,,percent of total billed charges,97% of total billed charges,3144.92,90,,,percent of total billed charges,90% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.52,97,,,percent of total billed charges,97% of total billed charges,3249.75,93,,,percent of total billed charges,93% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3389.52,97,,,percent of total billed charges,97% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.05,3494.35,
"35351 - (PF) Thromboendarterectomy, including patch graft, if performed; iliac",3634901,CDM,510,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,3144.92,90,,,percent of total billed charges,90% of total Billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2795.48,80,,,Percent of total Billed charges,80% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3144.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3389.52,97,,,Percent of total billed charges,97% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3214.8,92,,,Percent of total billed charges,92% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3144.92,90,,,percent of total billed charges,90% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.05,70,,,percent of total billed charges,70% of total billed charges,3144.92,90,,,percent of total billed charges,90% of total billed charges,3319.63,95,,,percent of total billed charges,95% of total billed charges,3319.63,95,,,percent of total billed charges,95% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3005.14,86,,,percent of total billed charges,86% of total billed charges,2795.48,80,,,percent of total billed charges,80% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.52,97,,,percent of total billed charges,97% of total billed charges,3144.92,90,,,percent of total billed charges,90% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.52,97,,,percent of total billed charges,97% of total billed charges,3249.75,93,,,percent of total billed charges,93% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3389.52,97,,,percent of total billed charges,97% of total billed charges,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3494.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2446.05,3494.35,
35371- Thromboendarterectomy/com femoral,3430691,CDM,510,RC,35371,HCPCS,Outpatient,,,2207.4,1103.70,,1986.66,90,,,percent of total billed charges,90% of total Billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1765.92,80,,,Percent of total Billed charges,80% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1986.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2141.18,97,,,Percent of total billed charges,97% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2030.81,92,,,Percent of total billed charges,92% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1986.66,90,,,percent of total billed charges,90% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1545.18,70,,,percent of total billed charges,70% of total billed charges,1986.66,90,,,percent of total billed charges,90% of total billed charges,2097.03,95,,,percent of total billed charges,95% of total billed charges,2097.03,95,,,percent of total billed charges,95% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1898.36,86,,,percent of total billed charges,86% of total billed charges,1765.92,80,,,percent of total billed charges,80% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.18,97,,,percent of total billed charges,97% of total billed charges,1986.66,90,,,percent of total billed charges,90% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.18,97,,,percent of total billed charges,97% of total billed charges,2052.88,93,,,percent of total billed charges,93% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2141.18,97,,,percent of total billed charges,97% of total billed charges,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1545.18,2207.4,
"35372 - Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral",3572787,CDM,960,RC,35372,HCPCS,Outpatient,,,2641.89,1320.95,,2377.7,90,,,percent of total billed charges,90% of total Billed charges,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,980.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1519.53,155,,,Fee Schedule,155% of CMS OPPS Rate,980.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1454.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,980.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1635.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1635.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1557.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1557.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,800.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1960.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1837.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1362.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1519.53,155,,,Fee Schedule,155% of CMS OPPS Rate,980.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,3059.34,155,,,Fee Schedule,155% of CMS OPPS Rate,3059.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,980.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1032.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,980.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,2114.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2114.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,3059.34,
35509 - Bypass W/ Vein Carotid-Contraleteral Carotid,4113111,CDM,975,RC,35509,HCPCS,Outpatient,,,3439.09,1719.55,,3095.18,90,,,percent of total billed charges,90% of total Billed charges,2874.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1425.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,899,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2209.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1425.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2098.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1425.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2360.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2360.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2264.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2264.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1149.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1425.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2851.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2672.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2006.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2209.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1425.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,4454.95,155,,,Fee Schedule,155% of CMS OPPS Rate,4454.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1425.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,899,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1428.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1425.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,3178.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3178.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,899,4454.95,
"35521 - Bypass graft, with vein; axillary-femoral",3899028,CDM,983,RC,35521,HCPCS,Outpatient,,,3345.03,1672.52,,3010.53,90,,,percent of total billed charges,90% of total Billed charges,2496.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1239.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,899,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1920.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2047.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1961.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1961.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,997.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2478.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2314.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1732.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1920.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1239.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,3870.33,155,,,Fee Schedule,155% of CMS OPPS Rate,3870.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1239.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,899,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1508.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1239.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2958.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2958.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,899,3870.33,
35526- Vein BG/aorto/subclav/innom/caroti,3430694,CDM,510,RC,35526,HCPCS,Outpatient,,,4657.12,2328.56,,4191.41,90,,,percent of total billed charges,90% of total Billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3725.7,80,,,Percent of total Billed charges,80% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4191.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4517.41,97,,,Percent of total billed charges,97% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4284.55,92,,,Percent of total billed charges,92% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4191.41,90,,,percent of total billed charges,90% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3259.98,70,,,percent of total billed charges,70% of total billed charges,4191.41,90,,,percent of total billed charges,90% of total billed charges,4424.26,95,,,percent of total billed charges,95% of total billed charges,4424.26,95,,,percent of total billed charges,95% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4005.12,86,,,percent of total billed charges,86% of total billed charges,3725.7,80,,,percent of total billed charges,80% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.41,97,,,percent of total billed charges,97% of total billed charges,4191.41,90,,,percent of total billed charges,90% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.41,97,,,percent of total billed charges,97% of total billed charges,4331.12,93,,,percent of total billed charges,93% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4517.41,97,,,percent of total billed charges,97% of total billed charges,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4657.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3259.98,4657.12,
35531 Bypass graft with vein aortoceliac or aortomesenteri,3623346,CDM,510,RC,35531,HCPCS,Outpatient,,,5325.01,2662.51,,4792.51,90,,,percent of total billed charges,90% of total Billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4260.01,80,,,Percent of total Billed charges,80% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4792.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5165.26,97,,,Percent of total billed charges,97% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4899.01,92,,,Percent of total billed charges,92% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4792.51,90,,,percent of total billed charges,90% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3727.51,70,,,percent of total billed charges,70% of total billed charges,4792.51,90,,,percent of total billed charges,90% of total billed charges,5058.76,95,,,percent of total billed charges,95% of total billed charges,5058.76,95,,,percent of total billed charges,95% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4579.51,86,,,percent of total billed charges,86% of total billed charges,4260.01,80,,,percent of total billed charges,80% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5165.26,97,,,percent of total billed charges,97% of total billed charges,4792.51,90,,,percent of total billed charges,90% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5165.26,97,,,percent of total billed charges,97% of total billed charges,4952.26,93,,,percent of total billed charges,93% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5165.26,97,,,percent of total billed charges,97% of total billed charges,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5325.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3727.51,5325.01,
"35540 - (50) Bypass graft, with vein; aortobifemoral",3696902,CDM,510,RC,35540,HCPCS,Outpatient,,,6675.88,3337.94,,6008.29,90,,,percent of total billed charges,90% of total Billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5340.7,80,,,Percent of total Billed charges,80% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6008.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6475.6,97,,,Percent of total billed charges,97% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6141.81,92,,,Percent of total billed charges,92% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6008.29,90,,,percent of total billed charges,90% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4673.12,70,,,percent of total billed charges,70% of total billed charges,6008.29,90,,,percent of total billed charges,90% of total billed charges,6342.09,95,,,percent of total billed charges,95% of total billed charges,6342.09,95,,,percent of total billed charges,95% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5741.26,86,,,percent of total billed charges,86% of total billed charges,5340.7,80,,,percent of total billed charges,80% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6475.6,97,,,percent of total billed charges,97% of total billed charges,6008.29,90,,,percent of total billed charges,90% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6475.6,97,,,percent of total billed charges,97% of total billed charges,6208.57,93,,,percent of total billed charges,93% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6475.6,97,,,percent of total billed charges,97% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4673.12,6675.88,
"35540 - PF Bypass graft, with vein; aortobifemoral",3696899,CDM,510,RC,35540,HCPCS,Outpatient,,,6675.88,3337.94,,6008.29,90,,,percent of total billed charges,90% of total Billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5340.7,80,,,Percent of total Billed charges,80% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6008.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6475.6,97,,,Percent of total billed charges,97% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6141.81,92,,,Percent of total billed charges,92% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6008.29,90,,,percent of total billed charges,90% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4673.12,70,,,percent of total billed charges,70% of total billed charges,6008.29,90,,,percent of total billed charges,90% of total billed charges,6342.09,95,,,percent of total billed charges,95% of total billed charges,6342.09,95,,,percent of total billed charges,95% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5741.26,86,,,percent of total billed charges,86% of total billed charges,5340.7,80,,,percent of total billed charges,80% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6475.6,97,,,percent of total billed charges,97% of total billed charges,6008.29,90,,,percent of total billed charges,90% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6475.6,97,,,percent of total billed charges,97% of total billed charges,6208.57,93,,,percent of total billed charges,93% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6475.6,97,,,percent of total billed charges,97% of total billed charges,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6675.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4673.12,6675.88,
Bypass w/Vein Femoral - Popliteal PF,4223274,CDM,983,RC,35556,HCPCS,Outpatient,,,3021.51,1510.76,,2719.36,90,,,percent of total billed charges,90% of total Billed charges,2825.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1400.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2170.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1400.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2082.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1400.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2341.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2341.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2230.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2230.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1142.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1400.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2801.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2632.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1953.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2170.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1400.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,4380.04,155,,,Fee Schedule,155% of CMS OPPS Rate,4380.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1400.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1602.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1400.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3027.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4380.04,
"35558 - Bypass Graft, with vein femoral-femoral",3800922,CDM,983,RC,35558,HCPCS,Outpatient,,,3333.94,1666.97,,3000.55,90,,,percent of total billed charges,90% of total Billed charges,2490,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1236.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,775.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1916.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1236.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1827.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1236.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2055.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1952.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1952.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1005.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1236.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2472.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2304.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1702,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1916.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1236.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3859.5,155,,,Fee Schedule,155% of CMS OPPS Rate,3859.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1236.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1319.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1236.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,2670.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2670.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,775.5,3859.5,
35566- Vein gft fem A/P tib/pero/dis art,3430695,CDM,510,RC,35566,HCPCS,Outpatient,,,4530.78,2265.39,,4077.7,90,,,percent of total billed charges,90% of total Billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3624.62,80,,,Percent of total Billed charges,80% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4077.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4394.86,97,,,Percent of total billed charges,97% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4168.32,92,,,Percent of total billed charges,92% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4077.7,90,,,percent of total billed charges,90% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3171.55,70,,,percent of total billed charges,70% of total billed charges,4077.7,90,,,percent of total billed charges,90% of total billed charges,4304.24,95,,,percent of total billed charges,95% of total billed charges,4304.24,95,,,percent of total billed charges,95% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3896.47,86,,,percent of total billed charges,86% of total billed charges,3624.62,80,,,percent of total billed charges,80% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4394.86,97,,,percent of total billed charges,97% of total billed charges,4077.7,90,,,percent of total billed charges,90% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4394.86,97,,,percent of total billed charges,97% of total billed charges,4213.63,93,,,percent of total billed charges,93% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4394.86,97,,,percent of total billed charges,97% of total billed charges,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4530.78,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3171.55,4530.78,
"35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial",3623374,CDM,510,RC,35570,HCPCS,Outpatient,,,4017,2008.50,,3615.3,90,,,percent of total billed charges,90% of total Billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3213.6,80,,,Percent of total Billed charges,80% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3615.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3896.49,97,,,Percent of total billed charges,97% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3695.64,92,,,Percent of total billed charges,92% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3615.3,90,,,percent of total billed charges,90% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2811.9,70,,,percent of total billed charges,70% of total billed charges,3615.3,90,,,percent of total billed charges,90% of total billed charges,3816.15,95,,,percent of total billed charges,95% of total billed charges,3816.15,95,,,percent of total billed charges,95% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3454.62,86,,,percent of total billed charges,86% of total billed charges,3213.6,80,,,percent of total billed charges,80% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3896.49,97,,,percent of total billed charges,97% of total billed charges,3615.3,90,,,percent of total billed charges,90% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3896.49,97,,,percent of total billed charges,97% of total billed charges,3735.81,93,,,percent of total billed charges,93% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3896.49,97,,,percent of total billed charges,97% of total billed charges,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4017,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2811.9,4017,
"35571 - (50) Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels",3714919,CDM,510,RC,35571,HCPCS,Outpatient,,,3599.51,1799.76,,3239.56,90,,,percent of total billed charges,90% of total Billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2879.61,80,,,Percent of total Billed charges,80% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3239.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3491.52,97,,,Percent of total billed charges,97% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3311.55,92,,,Percent of total billed charges,92% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3239.56,90,,,percent of total billed charges,90% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.66,70,,,percent of total billed charges,70% of total billed charges,3239.56,90,,,percent of total billed charges,90% of total billed charges,3419.53,95,,,percent of total billed charges,95% of total billed charges,3419.53,95,,,percent of total billed charges,95% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3095.58,86,,,percent of total billed charges,86% of total billed charges,2879.61,80,,,percent of total billed charges,80% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3491.52,97,,,percent of total billed charges,97% of total billed charges,3239.56,90,,,percent of total billed charges,90% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3491.52,97,,,percent of total billed charges,97% of total billed charges,3347.54,93,,,percent of total billed charges,93% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3491.52,97,,,percent of total billed charges,97% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.66,3599.51,
"35571 - PF Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels",3714916,CDM,510,RC,35571,HCPCS,Outpatient,,,3599.51,1799.76,,3239.56,90,,,percent of total billed charges,90% of total Billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2879.61,80,,,Percent of total Billed charges,80% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3239.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3491.52,97,,,Percent of total billed charges,97% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3311.55,92,,,Percent of total billed charges,92% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3239.56,90,,,percent of total billed charges,90% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.66,70,,,percent of total billed charges,70% of total billed charges,3239.56,90,,,percent of total billed charges,90% of total billed charges,3419.53,95,,,percent of total billed charges,95% of total billed charges,3419.53,95,,,percent of total billed charges,95% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3095.58,86,,,percent of total billed charges,86% of total billed charges,2879.61,80,,,percent of total billed charges,80% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3491.52,97,,,percent of total billed charges,97% of total billed charges,3239.56,90,,,percent of total billed charges,90% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3491.52,97,,,percent of total billed charges,97% of total billed charges,3347.54,93,,,percent of total billed charges,93% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3491.52,97,,,percent of total billed charges,97% of total billed charges,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3599.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.66,3599.51,
"35600- Upper ext harvest for CABG,1 seg",3430696,CDM,510,RC,35600,HCPCS,Outpatient,,,505.75,252.88,,455.18,90,,,percent of total billed charges,90% of total Billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,404.6,80,,,Percent of total Billed charges,80% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,455.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.58,97,,,Percent of total billed charges,97% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,465.29,92,,,Percent of total billed charges,92% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,455.18,90,,,percent of total billed charges,90% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,354.03,70,,,percent of total billed charges,70% of total billed charges,455.18,90,,,percent of total billed charges,90% of total billed charges,480.46,95,,,percent of total billed charges,95% of total billed charges,480.46,95,,,percent of total billed charges,95% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,434.95,86,,,percent of total billed charges,86% of total billed charges,404.6,80,,,percent of total billed charges,80% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,490.58,97,,,percent of total billed charges,97% of total billed charges,455.18,90,,,percent of total billed charges,90% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,490.58,97,,,percent of total billed charges,97% of total billed charges,470.35,93,,,percent of total billed charges,93% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,490.58,97,,,percent of total billed charges,97% of total billed charges,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,354.03,505.75,
"35606 - (50) Bypass graft, with other than vein; carotid-subclavian",3696913,CDM,510,RC,35606,HCPCS,Outpatient,,,3177.45,1588.73,,2859.71,90,,,percent of total billed charges,90% of total Billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2541.96,80,,,Percent of total Billed charges,80% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2859.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.13,97,,,Percent of total billed charges,97% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2923.25,92,,,Percent of total billed charges,92% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2859.71,90,,,percent of total billed charges,90% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.22,70,,,percent of total billed charges,70% of total billed charges,2859.71,90,,,percent of total billed charges,90% of total billed charges,3018.58,95,,,percent of total billed charges,95% of total billed charges,3018.58,95,,,percent of total billed charges,95% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.61,86,,,percent of total billed charges,86% of total billed charges,2541.96,80,,,percent of total billed charges,80% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.13,97,,,percent of total billed charges,97% of total billed charges,2859.71,90,,,percent of total billed charges,90% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.13,97,,,percent of total billed charges,97% of total billed charges,2955.03,93,,,percent of total billed charges,93% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3082.13,97,,,percent of total billed charges,97% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.22,3177.45,
"35606 - PF Bypass graft, with other than vein; carotid-subclavian",3696910,CDM,510,RC,35606,HCPCS,Outpatient,,,3177.45,1588.73,,2859.71,90,,,percent of total billed charges,90% of total Billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2541.96,80,,,Percent of total Billed charges,80% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2859.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.13,97,,,Percent of total billed charges,97% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2923.25,92,,,Percent of total billed charges,92% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2859.71,90,,,percent of total billed charges,90% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.22,70,,,percent of total billed charges,70% of total billed charges,2859.71,90,,,percent of total billed charges,90% of total billed charges,3018.58,95,,,percent of total billed charges,95% of total billed charges,3018.58,95,,,percent of total billed charges,95% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.61,86,,,percent of total billed charges,86% of total billed charges,2541.96,80,,,percent of total billed charges,80% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.13,97,,,percent of total billed charges,97% of total billed charges,2859.71,90,,,percent of total billed charges,90% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.13,97,,,percent of total billed charges,97% of total billed charges,2955.03,93,,,percent of total billed charges,93% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3082.13,97,,,percent of total billed charges,97% of total billed charges,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.22,3177.45,
"35621 - Bypass graft, with other than vein; axillary-femoral",3760898,CDM,983,RC,35621,HCPCS,Outpatient,,,2978.81,1489.41,,2680.93,90,,,percent of total billed charges,90% of total Billed charges,2223.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1103.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,899,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1710.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1103.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1103.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1833.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1833.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1747.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1747.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,897.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2206.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2062.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1532.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1710.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1103.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.22,155,,,Fee Schedule,155% of CMS OPPS Rate,3446.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1103.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,899,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1384.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1103.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2377.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2377.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,897.33,3446.22,
"35636 - PF Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis",3696914,CDM,510,RC,35636,HCPCS,Outpatient,,,4351.62,2175.81,,3916.46,90,,,percent of total billed charges,90% of total Billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3481.3,80,,,Percent of total Billed charges,80% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3916.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4221.07,97,,,Percent of total billed charges,97% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4003.49,92,,,Percent of total billed charges,92% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3916.46,90,,,percent of total billed charges,90% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3046.13,70,,,percent of total billed charges,70% of total billed charges,3916.46,90,,,percent of total billed charges,90% of total billed charges,4134.04,95,,,percent of total billed charges,95% of total billed charges,4134.04,95,,,percent of total billed charges,95% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3742.39,86,,,percent of total billed charges,86% of total billed charges,3481.3,80,,,percent of total billed charges,80% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4221.07,97,,,percent of total billed charges,97% of total billed charges,3916.46,90,,,percent of total billed charges,90% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4221.07,97,,,percent of total billed charges,97% of total billed charges,4047.01,93,,,percent of total billed charges,93% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4221.07,97,,,percent of total billed charges,97% of total billed charges,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4351.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3046.13,4351.62,
"35646 - (PF) Bypass graft, with other than vein; aortobifemoral",3634902,CDM,510,RC,35646,HCPCS,Outpatient,,,4635.95,2317.98,,4172.36,90,,,percent of total billed charges,90% of total Billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3708.76,80,,,Percent of total Billed charges,80% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4172.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4496.87,97,,,Percent of total billed charges,97% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4265.07,92,,,Percent of total billed charges,92% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4172.36,90,,,percent of total billed charges,90% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3245.17,70,,,percent of total billed charges,70% of total billed charges,4172.36,90,,,percent of total billed charges,90% of total billed charges,4404.15,95,,,percent of total billed charges,95% of total billed charges,4404.15,95,,,percent of total billed charges,95% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3986.92,86,,,percent of total billed charges,86% of total billed charges,3708.76,80,,,percent of total billed charges,80% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4496.87,97,,,percent of total billed charges,97% of total billed charges,4172.36,90,,,percent of total billed charges,90% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4496.87,97,,,percent of total billed charges,97% of total billed charges,4311.43,93,,,percent of total billed charges,93% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4496.87,97,,,percent of total billed charges,97% of total billed charges,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4635.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3245.17,4635.95,
"35647 - (50) Bypass graft, with other than vein; aortofemoral",3714920,CDM,510,RC,35647,HCPCS,Outpatient,,,4204.14,2102.07,,3783.73,90,,,percent of total billed charges,90% of total Billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3363.31,80,,,Percent of total Billed charges,80% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3783.73,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4078.02,97,,,Percent of total billed charges,97% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3867.81,92,,,Percent of total billed charges,92% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3783.73,90,,,percent of total billed charges,90% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2942.9,70,,,percent of total billed charges,70% of total billed charges,3783.73,90,,,percent of total billed charges,90% of total billed charges,3993.93,95,,,percent of total billed charges,95% of total billed charges,3993.93,95,,,percent of total billed charges,95% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3615.56,86,,,percent of total billed charges,86% of total billed charges,3363.31,80,,,percent of total billed charges,80% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,3783.73,90,,,percent of total billed charges,90% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,3909.85,93,,,percent of total billed charges,93% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,4204.14,
"35647 - PF Bypass graft, with other than vein; aortofemoral",3699125,CDM,510,RC,35647,HCPCS,Outpatient,,,4204.14,2102.07,,3783.73,90,,,percent of total billed charges,90% of total Billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3363.31,80,,,Percent of total Billed charges,80% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3783.73,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4078.02,97,,,Percent of total billed charges,97% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3867.81,92,,,Percent of total billed charges,92% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3783.73,90,,,percent of total billed charges,90% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2942.9,70,,,percent of total billed charges,70% of total billed charges,3783.73,90,,,percent of total billed charges,90% of total billed charges,3993.93,95,,,percent of total billed charges,95% of total billed charges,3993.93,95,,,percent of total billed charges,95% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3615.56,86,,,percent of total billed charges,86% of total billed charges,3363.31,80,,,percent of total billed charges,80% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,3783.73,90,,,percent of total billed charges,90% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,3909.85,93,,,percent of total billed charges,93% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4078.02,97,,,percent of total billed charges,97% of total billed charges,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,4204.14,
35656 - PF Bypass Graft w/Other Than Vein Femoral-Popliteal,4315551,CDM,960,RC,35656,HCPCS,Outpatient,,,2287.48,1143.74,,2058.73,90,,,percent of total billed charges,90% of total Billed charges,2175.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1079,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1672.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1079,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1605.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1079,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1805.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1805.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1717.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1717.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,885.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1079,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2158,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2027.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1500.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1672.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1079,100,,,Fee Schedule,100% of CMS OPPS Rate ,3372.66,155,,,Fee Schedule,155% of CMS OPPS Rate,3372.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1079,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1480.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1079,100,,,Fee Schedule,100% of CMS OPPS Rate ,2339.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2339.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,885.34,3372.66,
"35661 - (50) Bypass graft, with other than vein; femoral-femoral",3699131,CDM,510,RC,35661,HCPCS,Outpatient,,,2933.5,1466.75,,2640.15,90,,,percent of total billed charges,90% of total Billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.8,80,,,Percent of total Billed charges,80% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2640.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2845.5,97,,,Percent of total billed charges,97% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2698.82,92,,,Percent of total billed charges,92% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2640.15,90,,,percent of total billed charges,90% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2053.45,70,,,percent of total billed charges,70% of total billed charges,2640.15,90,,,percent of total billed charges,90% of total billed charges,2786.83,95,,,percent of total billed charges,95% of total billed charges,2786.83,95,,,percent of total billed charges,95% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2522.81,86,,,percent of total billed charges,86% of total billed charges,2346.8,80,,,percent of total billed charges,80% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2845.5,97,,,percent of total billed charges,97% of total billed charges,2640.15,90,,,percent of total billed charges,90% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2845.5,97,,,percent of total billed charges,97% of total billed charges,2728.16,93,,,percent of total billed charges,93% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2845.5,97,,,percent of total billed charges,97% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2053.45,2933.5,
"35661 - PF Bypass graft, with other than vein; femoral-femoral",3699128,CDM,510,RC,35661,HCPCS,Outpatient,,,2933.5,1466.75,,2640.15,90,,,percent of total billed charges,90% of total Billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.8,80,,,Percent of total Billed charges,80% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2640.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2845.5,97,,,Percent of total billed charges,97% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2698.82,92,,,Percent of total billed charges,92% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2640.15,90,,,percent of total billed charges,90% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2053.45,70,,,percent of total billed charges,70% of total billed charges,2640.15,90,,,percent of total billed charges,90% of total billed charges,2786.83,95,,,percent of total billed charges,95% of total billed charges,2786.83,95,,,percent of total billed charges,95% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2522.81,86,,,percent of total billed charges,86% of total billed charges,2346.8,80,,,percent of total billed charges,80% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2845.5,97,,,percent of total billed charges,97% of total billed charges,2640.15,90,,,percent of total billed charges,90% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2845.5,97,,,percent of total billed charges,97% of total billed charges,2728.16,93,,,percent of total billed charges,93% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2845.5,97,,,percent of total billed charges,97% of total billed charges,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2933.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2053.45,2933.5,
35665 - BYP Oth/Thn Vein Iliofemoral,4113114,CDM,975,RC,35665,HCPCS,Outpatient,,,2834.04,1417.02,,2550.64,90,,,percent of total billed charges,90% of total Billed charges,2370.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1177.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1824.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1177.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1744.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1177.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1962.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1962.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1868.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1868.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,957.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1177.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2354.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2204.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1634.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1824.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1177.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,3674.94,155,,,Fee Schedule,155% of CMS OPPS Rate,3674.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1177.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1439.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1177.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2535.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2535.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,957.24,3674.94,
35666- Fem-Pop Bypass Graft. Oth Than Vein,3569382,CDM,510,RC,35666,HCPCS,Outpatient,,,3480.74,1740.37,,3132.67,90,,,percent of total billed charges,90% of total Billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2784.59,80,,,Percent of total Billed charges,80% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3132.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3376.32,97,,,Percent of total billed charges,97% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3202.28,92,,,Percent of total billed charges,92% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3132.67,90,,,percent of total billed charges,90% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2436.52,70,,,percent of total billed charges,70% of total billed charges,3132.67,90,,,percent of total billed charges,90% of total billed charges,3306.7,95,,,percent of total billed charges,95% of total billed charges,3306.7,95,,,percent of total billed charges,95% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2993.44,86,,,percent of total billed charges,86% of total billed charges,2784.59,80,,,percent of total billed charges,80% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3376.32,97,,,percent of total billed charges,97% of total billed charges,3132.67,90,,,percent of total billed charges,90% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3376.32,97,,,percent of total billed charges,97% of total billed charges,3237.09,93,,,percent of total billed charges,93% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3376.32,97,,,percent of total billed charges,97% of total billed charges,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2436.52,3480.74,
"35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal artery",3622963,CDM,510,RC,35671,HCPCS,Outpatient,,,3068.12,1534.06,,2761.31,90,,,percent of total billed charges,90% of total Billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2454.5,80,,,Percent of total Billed charges,80% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2761.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2976.08,97,,,Percent of total billed charges,97% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2822.67,92,,,Percent of total billed charges,92% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2761.31,90,,,percent of total billed charges,90% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2147.68,70,,,percent of total billed charges,70% of total billed charges,2761.31,90,,,percent of total billed charges,90% of total billed charges,2914.71,95,,,percent of total billed charges,95% of total billed charges,2914.71,95,,,percent of total billed charges,95% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2638.58,86,,,percent of total billed charges,86% of total billed charges,2454.5,80,,,percent of total billed charges,80% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2976.08,97,,,percent of total billed charges,97% of total billed charges,2761.31,90,,,percent of total billed charges,90% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2976.08,97,,,percent of total billed charges,97% of total billed charges,2853.35,93,,,percent of total billed charges,93% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2976.08,97,,,percent of total billed charges,97% of total billed charges,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2147.68,3068.12,
"35697 - (PF) Bypass graft, with other than vein; aortofemoral",3634903,CDM,510,RC,35697,HCPCS,Outpatient,,,400.79,200.40,,360.71,90,,,percent of total billed charges,90% of total Billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,320.63,80,,,Percent of total Billed charges,80% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,360.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388.77,97,,,Percent of total billed charges,97% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,368.73,92,,,Percent of total billed charges,92% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,360.71,90,,,percent of total billed charges,90% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,280.55,70,,,percent of total billed charges,70% of total billed charges,360.71,90,,,percent of total billed charges,90% of total billed charges,380.75,95,,,percent of total billed charges,95% of total billed charges,380.75,95,,,percent of total billed charges,95% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,344.68,86,,,percent of total billed charges,86% of total billed charges,320.63,80,,,percent of total billed charges,80% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,388.77,97,,,percent of total billed charges,97% of total billed charges,360.71,90,,,percent of total billed charges,90% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,388.77,97,,,percent of total billed charges,97% of total billed charges,372.73,93,,,percent of total billed charges,93% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,388.77,97,,,percent of total billed charges,97% of total billed charges,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,400.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,280.55,400.79,
"35701 Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)",3621969,CDM,510,RC,35701,HCPCS,Outpatient,,,1155.4,577.70,,1039.86,90,,,percent of total billed charges,90% of total Billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,924.32,80,,,Percent of total Billed charges,80% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1039.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1120.74,97,,,Percent of total billed charges,97% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1062.97,92,,,Percent of total billed charges,92% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1039.86,90,,,percent of total billed charges,90% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,808.78,70,,,percent of total billed charges,70% of total billed charges,1039.86,90,,,percent of total billed charges,90% of total billed charges,1097.63,95,,,percent of total billed charges,95% of total billed charges,1097.63,95,,,percent of total billed charges,95% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,993.64,86,,,percent of total billed charges,86% of total billed charges,924.32,80,,,percent of total billed charges,80% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1120.74,97,,,percent of total billed charges,97% of total billed charges,1039.86,90,,,percent of total billed charges,90% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1120.74,97,,,percent of total billed charges,97% of total billed charges,1074.52,93,,,percent of total billed charges,93% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1120.74,97,,,percent of total billed charges,97% of total billed charges,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1155.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,808.78,1155.4,
"35702 - Exploration not followed by surgical repair, artery; upper extremity (eg, axillary, brachial",3783515,CDM,975,RC,35702,HCPCS,Outpatient,,,1090.94,545.47,,981.85,90,,,percent of total billed charges,90% of total Billed charges,819.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.95,155,,,Fee Schedule,155% of CMS OPPS Rate,409,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,684.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,639.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,639.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,755.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,539.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,633.95,155,,,Fee Schedule,155% of CMS OPPS Rate,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1269.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,461.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.06,1269.81,
35702PF Exploration Not Followed By Surgical Repair Artery U,4273264,CDM,960,RC,35702,HCPCS,Outpatient,,,971.13,485.57,,874.02,90,,,percent of total billed charges,90% of total Billed charges,819.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,633.95,155,,,Fee Schedule,155% of CMS OPPS Rate,409,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,684.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,639.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,639.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,755.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,539.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,633.95,155,,,Fee Schedule,155% of CMS OPPS Rate,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1269.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,461.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.06,1269.81,
"35703 Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep",3621877,CDM,960,RC,35703,HCPCS,Outpatient,,,1126.53,563.27,,1013.88,90,,,percent of total billed charges,90% of total Billed charges,839.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,416.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.16,155,,,Fee Schedule,155% of CMS OPPS Rate,416.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,617.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,416.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,694.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,654.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,654.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,374.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,832.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,772.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,560.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,645.16,155,,,Fee Schedule,155% of CMS OPPS Rate,416.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1301.74,155,,,Fee Schedule,155% of CMS OPPS Rate,1301.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,416.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,469.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,416.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.87,1301.74,
35800 - EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK,4249118,CDM,983,RC,35800,HCPCS,Outpatient,,,1914.41,957.21,,1722.97,90,,,percent of total billed charges,90% of total Billed charges,1448.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,722.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,304,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1119.74,155,,,Fee Schedule,155% of CMS OPPS Rate,722.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,722.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1197.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1108.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1108.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,580.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1444.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1308.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,911.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1119.74,155,,,Fee Schedule,155% of CMS OPPS Rate,722.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2244.48,155,,,Fee Schedule,155% of CMS OPPS Rate,2244.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,722.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,304,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,489.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,722.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1043.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,304,2244.48,
35820PF Exploration Post Operative Hemorrhage Thrombosis/Inf,4273265,CDM,960,RC,35820,HCPCS,Outpatient,,,4778.5,2389.25,,4300.65,90,,,percent of total billed charges,90% of total Billed charges,4048.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2012.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,704,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3119.39,155,,,Fee Schedule,155% of CMS OPPS Rate,2012.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2979.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2012.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3350.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3350.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3165.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3165.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1627.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2012.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4025.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3734.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2720.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3119.39,155,,,Fee Schedule,155% of CMS OPPS Rate,2012.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,6275.13,155,,,Fee Schedule,155% of CMS OPPS Rate,6275.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2012.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,704,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1901.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2012.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,4194.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4194.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,704,6275.13,
35840PF Exploration Postoperative Hemorrhage Thrombosis or I,4273266,CDM,960,RC,35840,HCPCS,Outpatient,,,2882.5,1441.25,,2594.25,90,,,percent of total billed charges,90% of total Billed charges,2435.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1213.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,480,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1881.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1213.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1781.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1213.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2004.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2004.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1877.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1877.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,966.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2427.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2215.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1598.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1881.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1213.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3774.95,155,,,Fee Schedule,155% of CMS OPPS Rate,3774.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1213.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,480,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,717.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1213.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1364.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1364.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,480,3774.95,
35860-PF EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR,4321669,CDM,981,RC,35860,HCPCS,Outpatient,,,1681.3,840.65,,1513.17,90,,,percent of total billed charges,90% of total Billed charges,1692.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.88,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1302.99,155,,,Fee Schedule,155% of CMS OPPS Rate,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1242.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,840.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1397.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1397.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1321.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1321.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1559.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1144.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1302.99,155,,,Fee Schedule,155% of CMS OPPS Rate,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2622.72,155,,,Fee Schedule,155% of CMS OPPS Rate,2622.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.88,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,869.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,869.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,371.88,2622.72,
35860PF Exploration Postoperative Hemorrhage Thrombosis or I,4273267,CDM,960,RC,35860,HCPCS,Outpatient,,,1996.04,998.02,,1796.44,90,,,percent of total billed charges,90% of total Billed charges,1692.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.88,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1302.99,155,,,Fee Schedule,155% of CMS OPPS Rate,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1242.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,840.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1397.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1397.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1321.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1321.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1559.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1144.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1302.99,155,,,Fee Schedule,155% of CMS OPPS Rate,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2622.72,155,,,Fee Schedule,155% of CMS OPPS Rate,2622.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.88,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,840.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,869.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,869.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,371.88,2622.72,
35876 - Thrmbc Artl/Ven GRF XCP HEMO GRF/FSTL W/REVJ GRF,4169581,CDM,983,RC,35876,HCPCS,Outpatient,,,2281.34,1140.67,,2053.21,90,,,percent of total billed charges,90% of total Billed charges,1905.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,945.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,809.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1464.78,155,,,Fee Schedule,155% of CMS OPPS Rate,945.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1406.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,945.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1582.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1582.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1503.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1503.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,772.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1890.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1773.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1309.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1464.78,155,,,Fee Schedule,155% of CMS OPPS Rate,945.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.02,155,,,Fee Schedule,155% of CMS OPPS Rate,2954.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,945.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,809.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,998.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,945.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2040,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2040,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,772.86,2954.02,
35879 - Revise Grft w/ Vein - lower extremity arterial bypass,3899033,CDM,983,RC,35879,HCPCS,Outpatient,,,2498.28,1249.14,,2248.45,90,,,percent of total billed charges,90% of total Billed charges,1864.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,925.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.48,155,,,Fee Schedule,155% of CMS OPPS Rate,925.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1375.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,925.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1546.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1546.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1470.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1470.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,752.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1850.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1735.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1286.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1434.48,155,,,Fee Schedule,155% of CMS OPPS Rate,925.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2890.6,155,,,Fee Schedule,155% of CMS OPPS Rate,2890.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,925.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1015.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,925.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2003.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2003.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,752.46,2890.6,
"35881 - PF Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vei",3715392,CDM,510,RC,35881,HCPCS,Outpatient,,,2770.46,1385.23,,2493.41,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2216.37,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2493.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2687.35,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2548.82,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2493.41,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1939.32,70,,,percent of total billed charges,70% of total billed charges,2493.41,90,,,percent of total billed charges,90% of total billed charges,2631.94,95,,,percent of total billed charges,95% of total billed charges,2631.94,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2382.6,86,,,percent of total billed charges,86% of total billed charges,2216.37,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2687.35,97,,,percent of total billed charges,97% of total billed charges,2493.41,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.35,97,,,percent of total billed charges,97% of total billed charges,2576.53,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2687.35,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1939.32,25056.97,
35903- Excision of infected graft; extremity,3569423,CDM,510,RC,35903,HCPCS,Outpatient,,,1515.45,757.73,,1363.91,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1212.36,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1363.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1469.99,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1394.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1363.91,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1060.82,70,,,percent of total billed charges,70% of total billed charges,1363.91,90,,,percent of total billed charges,90% of total billed charges,1439.68,95,,,percent of total billed charges,95% of total billed charges,1439.68,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1303.29,86,,,percent of total billed charges,86% of total billed charges,1212.36,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1469.99,97,,,percent of total billed charges,97% of total billed charges,1363.91,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1469.99,97,,,percent of total billed charges,97% of total billed charges,1409.37,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1469.99,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1060.82,14522.85,
36002- Extremity pseudoaneurysm injection,3430899,CDM,320,RC,36002,HCPCS,Outpatient,,,386.85,193.43,,348.17,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,309.48,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.17,90,,,Percent of total Billed charges,90% of total billed charges,113.66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,375.24,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,355.9,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,348.17,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,270.8,70,,,percent of total billed charges,70% of total billed charges,348.17,90,,,percent of total billed charges,90% of total billed charges,367.51,95,,,percent of total billed charges,95% of total billed charges,367.51,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,332.69,86,,,percent of total billed charges,86% of total billed charges,309.48,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,375.24,97,,,percent of total billed charges,97% of total billed charges,348.17,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.24,97,,,percent of total billed charges,97% of total billed charges,359.77,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.24,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.33,2820.25,
36002-PF Thrombin injection treatment of extremity pseudoaneurysm,4271166,CDM,960,RC,36002,HCPCS,Outpatient,,,308.33,154.17,,277.5,90,,,percent of total billed charges,90% of total Billed charges,248.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,103.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.03,155,,,Fee Schedule,155% of CMS OPPS Rate,102.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.03,155,,,Fee Schedule,155% of CMS OPPS Rate,102.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.51,155,,,Fee Schedule,155% of CMS OPPS Rate,384.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,102.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,102.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,319.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.6,384.51,
36002-Thrombin injection treatment of extremity pseudoaneurysm,4271165,CDM,481,RC,36002,HCPCS,Outpatient,,,308.33,154.17,,277.5,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,246.66,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,90,,,Percent of total Billed charges,90% of total billed charges,113.66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.08,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,283.66,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.5,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,215.83,70,,,percent of total billed charges,70% of total billed charges,277.5,90,,,percent of total billed charges,90% of total billed charges,292.91,95,,,percent of total billed charges,95% of total billed charges,292.91,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.16,86,,,percent of total billed charges,86% of total billed charges,246.66,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.08,97,,,percent of total billed charges,97% of total billed charges,277.5,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.08,97,,,percent of total billed charges,97% of total billed charges,286.75,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.08,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.33,2820.25,
US Thrombin Injection,1879101,CDM,320,RC,36002,HCPCS,Outpatient,,,385.42,192.71,,346.88,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,308.34,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.88,90,,,Percent of total Billed charges,90% of total billed charges,113.66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,373.86,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,354.59,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,346.88,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,269.79,70,,,percent of total billed charges,70% of total billed charges,346.88,90,,,percent of total billed charges,90% of total billed charges,366.15,95,,,percent of total billed charges,95% of total billed charges,366.15,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,331.46,86,,,percent of total billed charges,86% of total billed charges,308.34,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,373.86,97,,,percent of total billed charges,97% of total billed charges,346.88,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.86,97,,,percent of total billed charges,97% of total billed charges,358.44,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.86,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.33,2820.25,
36005- Injection for extremity venography,3430698,CDM,510,RC,36005,HCPCS,Outpatient,,,643.75,321.88,,579.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,515,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,579.38,90,,,Percent of total Billed charges,90% of total billed charges,48.02,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,624.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,592.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,411.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,506.32,78.65,,,percent of total billed charges,78.65% of total billed charges,575.07,89.33,,,percent of total billed charges,89.33% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,450.63,70,,,percent of total billed charges,70% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,611.56,95,,,percent of total billed charges,95% of total billed charges,611.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.63,86,,,percent of total billed charges,86% of total billed charges,515,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,624.44,97,,,percent of total billed charges,97% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,624.44,97,,,percent of total billed charges,97% of total billed charges,598.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,624.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,624.44,
36005-Injection Proced for Extrem Venography,3431826,CDM,481,RC,36005,HCPCS,Outpatient,,,643.75,321.88,,579.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,515,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,579.38,90,,,Percent of total Billed charges,90% of total billed charges,48.02,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,624.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,592.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,411.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,506.32,78.65,,,percent of total billed charges,78.65% of total billed charges,575.07,89.33,,,percent of total billed charges,89.33% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,450.63,70,,,percent of total billed charges,70% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,611.56,95,,,percent of total billed charges,95% of total billed charges,611.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.63,86,,,percent of total billed charges,86% of total billed charges,515,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,624.44,97,,,percent of total billed charges,97% of total billed charges,579.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,624.44,97,,,percent of total billed charges,97% of total billed charges,598.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,624.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,624.44,
Injection Proced for Extrem Venography,3427271,CDM,960,RC,36005,HCPCS,Outpatient,,,613.58,306.79,,552.22,90,,,percent of total billed charges,90% of total Billed charges,290,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.29,155,,,Fee Schedule,155% of CMS OPPS Rate,47.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,74.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.29,155,,,Fee Schedule,155% of CMS OPPS Rate,47.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.5,155,,,Fee Schedule,155% of CMS OPPS Rate,449.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1169.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,654.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.65,1169.27,
"36010 - (50)  Introduction of catheter, superior or inferior vena cava",3699136,CDM,510,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1236.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1099.47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1236.91,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1333.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1264.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,877.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1080.95,78.65,,,percent of total billed charges,78.65% of total billed charges,1227.72,89.33,,,percent of total billed charges,89.33% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,962.04,70,,,percent of total billed charges,70% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.93,86,,,percent of total billed charges,86% of total billed charges,1099.47,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1278.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1333.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1333.11,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,510,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1236.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1099.47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1236.91,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1333.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1264.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,877.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1080.95,78.65,,,percent of total billed charges,78.65% of total billed charges,1227.72,89.33,,,percent of total billed charges,89.33% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,962.04,70,,,percent of total billed charges,70% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.93,86,,,percent of total billed charges,86% of total billed charges,1099.47,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1278.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1333.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1333.11,
36010-Introduction of Catheter SVC or IVC,3431827,CDM,481,RC,36010,HCPCS,Outpatient,,,1374.34,687.17,,1236.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1099.47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1236.91,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1333.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1264.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,877.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1080.95,78.65,,,percent of total billed charges,78.65% of total billed charges,1227.72,89.33,,,percent of total billed charges,89.33% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,962.04,70,,,percent of total billed charges,70% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,1305.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1181.93,86,,,percent of total billed charges,86% of total billed charges,1099.47,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1236.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1333.11,97,,,percent of total billed charges,97% of total billed charges,1278.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1333.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1333.11,
Introduction of Catheter SVC or IVC,,,761,RC,36010,HCPCS,Outpatient,,,1299.33,649.67,,1169.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1039.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1169.4,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1260.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1195.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,829.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1021.95,78.65,,,percent of total billed charges,78.65% of total billed charges,1160.71,89.33,,,percent of total billed charges,89.33% of total billed charges,1169.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,909.53,70,,,percent of total billed charges,70% of total billed charges,1169.4,90,,,percent of total billed charges,90% of total billed charges,1234.36,95,,,percent of total billed charges,95% of total billed charges,1234.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1117.42,86,,,percent of total billed charges,86% of total billed charges,1039.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1260.35,97,,,percent of total billed charges,97% of total billed charges,1169.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1260.35,97,,,percent of total billed charges,97% of total billed charges,1208.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1260.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1260.35,
36011- Cath placement/venous/1st order,3430900,CDM,510,RC,36011,HCPCS,Outpatient,,,2051.09,1025.55,,1845.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1640.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1845.98,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1989.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1887,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1309.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1613.23,78.65,,,percent of total billed charges,78.65% of total billed charges,1832.27,89.33,,,percent of total billed charges,89.33% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1435.76,70,,,percent of total billed charges,70% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,1948.54,95,,,percent of total billed charges,95% of total billed charges,1948.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.94,86,,,percent of total billed charges,86% of total billed charges,1640.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1989.56,97,,,percent of total billed charges,97% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1989.56,97,,,percent of total billed charges,97% of total billed charges,1907.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1989.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1989.56,
36011-Cath Placement venous 1st order branch,3431828,CDM,481,RC,36011,HCPCS,Outpatient,,,2051.09,1025.55,,1845.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1640.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1845.98,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1989.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1887,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1309.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1613.23,78.65,,,percent of total billed charges,78.65% of total billed charges,1832.27,89.33,,,percent of total billed charges,89.33% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1435.76,70,,,percent of total billed charges,70% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,1948.54,95,,,percent of total billed charges,95% of total billed charges,1948.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1763.94,86,,,percent of total billed charges,86% of total billed charges,1640.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1989.56,97,,,percent of total billed charges,97% of total billed charges,1845.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1989.56,97,,,percent of total billed charges,97% of total billed charges,1907.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1989.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1989.56,
Cath Placement venous 1st order branch,,,761,RC,36011,HCPCS,Outpatient,,,1930.87,965.44,,1737.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1544.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1737.78,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1872.94,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1776.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1233.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1518.67,78.65,,,percent of total billed charges,78.65% of total billed charges,1724.88,89.33,,,percent of total billed charges,89.33% of total billed charges,1737.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1351.61,70,,,percent of total billed charges,70% of total billed charges,1737.78,90,,,percent of total billed charges,90% of total billed charges,1834.33,95,,,percent of total billed charges,95% of total billed charges,1834.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1660.55,86,,,percent of total billed charges,86% of total billed charges,1544.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1872.94,97,,,percent of total billed charges,97% of total billed charges,1737.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1872.94,97,,,percent of total billed charges,97% of total billed charges,1795.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1872.94,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1872.94,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,510,RC,36012,HCPCS,Outpatient,,,2103.26,1051.63,,1892.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1682.61,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1892.93,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2040.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1935,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1343.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1654.26,78.65,,,percent of total billed charges,78.65% of total billed charges,1878.88,89.33,,,percent of total billed charges,89.33% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1472.28,70,,,percent of total billed charges,70% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,1998.1,95,,,percent of total billed charges,95% of total billed charges,1998.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.8,86,,,percent of total billed charges,86% of total billed charges,1682.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2040.16,97,,,percent of total billed charges,97% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2040.16,97,,,percent of total billed charges,97% of total billed charges,1956.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2040.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,2040.16,
36012-Catheter 2nd order or more selective,3431829,CDM,481,RC,36012,HCPCS,Outpatient,,,2103.26,1051.63,,1892.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1682.61,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1892.93,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2040.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1935,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1343.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1654.26,78.65,,,percent of total billed charges,78.65% of total billed charges,1878.88,89.33,,,percent of total billed charges,89.33% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1472.28,70,,,percent of total billed charges,70% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,1998.1,95,,,percent of total billed charges,95% of total billed charges,1998.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.8,86,,,percent of total billed charges,86% of total billed charges,1682.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2040.16,97,,,percent of total billed charges,97% of total billed charges,1892.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2040.16,97,,,percent of total billed charges,97% of total billed charges,1956.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2040.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,2040.16,
Catheter 2nd order or more selective,,,761,RC,36012,HCPCS,Outpatient,,,2004.17,1002.09,,1803.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1603.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1803.75,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1944.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1843.84,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1279.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1576.32,78.65,,,percent of total billed charges,78.65% of total billed charges,1790.36,89.33,,,percent of total billed charges,89.33% of total billed charges,1803.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1402.92,70,,,percent of total billed charges,70% of total billed charges,1803.75,90,,,percent of total billed charges,90% of total billed charges,1903.96,95,,,percent of total billed charges,95% of total billed charges,1903.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1723.59,86,,,percent of total billed charges,86% of total billed charges,1603.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1944.04,97,,,percent of total billed charges,97% of total billed charges,1803.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1944.04,97,,,percent of total billed charges,97% of total billed charges,1863.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1944.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1944.04,
36013-Cath Placement Main PA,3431830,CDM,481,RC,36013,HCPCS,Outpatient,,,1951.76,975.88,,1756.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1561.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1756.58,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1893.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1795.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1246.44,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1535.1,78.65,,,percent of total billed charges,78.65% of total billed charges,1743.54,89.33,,,percent of total billed charges,89.33% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1366.23,70,,,percent of total billed charges,70% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,1854.17,95,,,percent of total billed charges,95% of total billed charges,1854.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.51,86,,,percent of total billed charges,86% of total billed charges,1561.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1893.21,97,,,percent of total billed charges,97% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1893.21,97,,,percent of total billed charges,97% of total billed charges,1815.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1893.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1893.21,
36013-Right Heart Cath,3431831,CDM,481,RC,36013,HCPCS,Outpatient,,,1951.76,975.88,,1756.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1561.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1756.58,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1893.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1795.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1246.44,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1535.1,78.65,,,percent of total billed charges,78.65% of total billed charges,1743.54,89.33,,,percent of total billed charges,89.33% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1366.23,70,,,percent of total billed charges,70% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,1854.17,95,,,percent of total billed charges,95% of total billed charges,1854.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1678.51,86,,,percent of total billed charges,86% of total billed charges,1561.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1893.21,97,,,percent of total billed charges,97% of total billed charges,1756.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1893.21,97,,,percent of total billed charges,97% of total billed charges,1815.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1893.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1893.21,
Cath Placement Main PA,,,761,RC,36013,HCPCS,Outpatient,,,1873.63,936.82,,1686.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1498.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1686.27,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1817.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1723.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1196.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1473.65,78.65,,,percent of total billed charges,78.65% of total billed charges,1673.74,89.33,,,percent of total billed charges,89.33% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1311.54,70,,,percent of total billed charges,70% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,1779.95,95,,,percent of total billed charges,95% of total billed charges,1779.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.32,86,,,percent of total billed charges,86% of total billed charges,1498.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1817.42,97,,,percent of total billed charges,97% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1817.42,97,,,percent of total billed charges,97% of total billed charges,1742.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1817.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1817.42,
Right Heart Cath,604623,CDM,481,RC,36013,HCPCS,Outpatient,,,1873.63,936.82,,1686.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1498.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1686.27,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1817.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1723.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1196.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1473.65,78.65,,,percent of total billed charges,78.65% of total billed charges,1673.74,89.33,,,percent of total billed charges,89.33% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1311.54,70,,,percent of total billed charges,70% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,1779.95,95,,,percent of total billed charges,95% of total billed charges,1779.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1611.32,86,,,percent of total billed charges,86% of total billed charges,1498.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1817.42,97,,,percent of total billed charges,97% of total billed charges,1686.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1817.42,97,,,percent of total billed charges,97% of total billed charges,1742.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1817.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1817.42,
"36014 - Selective catheter placement, left or right pulmonary artery",3760896,CDM,983,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,1788.58,90,,,percent of total billed charges,90% of total Billed charges,896.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,231.88,155,,,Fee Schedule,155% of CMS OPPS Rate,149.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,189.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,231.88,155,,,Fee Schedule,155% of CMS OPPS Rate,149.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1621.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1621.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.5,1788.58,
36014-Cath Placement Pulm Artery,3431832,CDM,481,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,1788.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1589.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1788.58,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1927.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1828.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1269.14,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1563.06,78.65,,,percent of total billed charges,78.65% of total billed charges,1775.3,89.33,,,percent of total billed charges,89.33% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1391.12,70,,,percent of total billed charges,70% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,1887.94,95,,,percent of total billed charges,95% of total billed charges,1887.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.09,86,,,percent of total billed charges,86% of total billed charges,1589.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1927.69,97,,,percent of total billed charges,97% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1927.69,97,,,percent of total billed charges,97% of total billed charges,1848.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1927.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1927.69,
36014-Cath Placement Pulm Artery RT,3431833,CDM,481,RC,36014,HCPCS,Outpatient,,,1987.31,993.66,,1788.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1589.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1788.58,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1927.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1828.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1269.14,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1563.06,78.65,,,percent of total billed charges,78.65% of total billed charges,1775.3,89.33,,,percent of total billed charges,89.33% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1391.12,70,,,percent of total billed charges,70% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,1887.94,95,,,percent of total billed charges,95% of total billed charges,1887.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1709.09,86,,,percent of total billed charges,86% of total billed charges,1589.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1927.69,97,,,percent of total billed charges,97% of total billed charges,1788.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1927.69,97,,,percent of total billed charges,97% of total billed charges,1848.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1927.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1927.69,
Cath Placement Pulm Artery LT,,,761,RC,36014,HCPCS,Outpatient,,,1883.12,941.56,,1694.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1506.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1694.81,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1826.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1732.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1202.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1481.12,78.65,,,percent of total billed charges,78.65% of total billed charges,1682.22,89.33,,,percent of total billed charges,89.33% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1318.18,70,,,percent of total billed charges,70% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,1788.96,95,,,percent of total billed charges,95% of total billed charges,1788.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.48,86,,,percent of total billed charges,86% of total billed charges,1506.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1826.63,97,,,percent of total billed charges,97% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1826.63,97,,,percent of total billed charges,97% of total billed charges,1751.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1826.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1826.63,
Cath Placement Pulm Artery RT,,,761,RC,36014,HCPCS,Outpatient,,,1883.12,941.56,,1694.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1506.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1694.81,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1826.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1732.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1202.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1481.12,78.65,,,percent of total billed charges,78.65% of total billed charges,1682.22,89.33,,,percent of total billed charges,89.33% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1318.18,70,,,percent of total billed charges,70% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,1788.96,95,,,percent of total billed charges,95% of total billed charges,1788.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1619.48,86,,,percent of total billed charges,86% of total billed charges,1506.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1826.63,97,,,percent of total billed charges,97% of total billed charges,1694.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1826.63,97,,,percent of total billed charges,97% of total billed charges,1751.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1826.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1826.63,
36015-Cath Placement Segmen Subseg Pulm Artery,3431834,CDM,320,RC,36015,HCPCS,Outpatient,,,2146.89,1073.45,,1932.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1717.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1932.2,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2082.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1975.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1371.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1688.58,78.65,,,percent of total billed charges,78.65% of total billed charges,1917.85,89.33,,,percent of total billed charges,89.33% of total billed charges,1932.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1502.82,70,,,percent of total billed charges,70% of total billed charges,1932.2,90,,,percent of total billed charges,90% of total billed charges,2039.55,95,,,percent of total billed charges,95% of total billed charges,2039.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1846.33,86,,,percent of total billed charges,86% of total billed charges,1717.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2082.48,97,,,percent of total billed charges,97% of total billed charges,1932.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2082.48,97,,,percent of total billed charges,97% of total billed charges,1996.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2082.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,2082.48,
Cath Placement Segmen Subseg Pulm Artery,,,761,RC,36015,HCPCS,Outpatient,,,2039.18,1019.59,,1835.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1631.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1835.26,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1978,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1876.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1302.27,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1603.86,78.65,,,percent of total billed charges,78.65% of total billed charges,1821.63,89.33,,,percent of total billed charges,89.33% of total billed charges,1835.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1427.43,70,,,percent of total billed charges,70% of total billed charges,1835.26,90,,,percent of total billed charges,90% of total billed charges,1937.22,95,,,percent of total billed charges,95% of total billed charges,1937.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1753.69,86,,,percent of total billed charges,86% of total billed charges,1631.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1978,97,,,percent of total billed charges,97% of total billed charges,1835.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1978,97,,,percent of total billed charges,97% of total billed charges,1896.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1978,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1978,
36140- Intro of needle/intracath/ext art,3430901,CDM,510,RC,36140,HCPCS,Outpatient,,,1288.66,644.33,,1159.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1030.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1159.79,90,,,Percent of total Billed charges,90% of total billed charges,105.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1250,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1185.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,822.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1013.56,78.65,,,percent of total billed charges,78.65% of total billed charges,1151.18,89.33,,,percent of total billed charges,89.33% of total billed charges,1159.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,902.06,70,,,percent of total billed charges,70% of total billed charges,1159.79,90,,,percent of total billed charges,90% of total billed charges,1224.23,95,,,percent of total billed charges,95% of total billed charges,1224.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.25,86,,,percent of total billed charges,86% of total billed charges,1030.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1250,97,,,percent of total billed charges,97% of total billed charges,1159.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1250,97,,,percent of total billed charges,97% of total billed charges,1198.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1250,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,1250,
"36140-Arterial Vascular Cathterization Extremity Artery, Nee",4217141,CDM,481,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,780.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,878.1,90,,,Percent of total Billed charges,90% of total billed charges,105.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,897.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,623.08,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,767.39,78.65,,,percent of total billed charges,78.65% of total billed charges,871.58,89.33,,,percent of total billed charges,89.33% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,682.97,70,,,percent of total billed charges,70% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.08,86,,,percent of total billed charges,86% of total billed charges,780.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,907.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,946.4,
"36140-Arterial Vascular Cathterization Extremity Artery, Nee",4217144,CDM,481,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,780.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,878.1,90,,,Percent of total Billed charges,90% of total billed charges,105.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,897.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,623.08,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,767.39,78.65,,,percent of total billed charges,78.65% of total billed charges,871.58,89.33,,,percent of total billed charges,89.33% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,682.97,70,,,percent of total billed charges,70% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.08,86,,,percent of total billed charges,86% of total billed charges,780.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,907.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,946.4,
"36140-PF Arterial Vascular Cathterization Extremity Artery,",4217142,CDM,960,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,573.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.93,155,,,Fee Schedule,155% of CMS OPPS Rate,888.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,884,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.42,888.93,
"36140-PF Arterial Vascular Cathterization Extremity Artery,",4217145,CDM,960,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,573.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.93,155,,,Fee Schedule,155% of CMS OPPS Rate,888.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,884,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.42,888.93,
Art Line Placement,3428391,CDM,981,RC,36140,HCPCS,Outpatient,,,1288.66,644.33,,1159.79,90,,,percent of total billed charges,90% of total Billed charges,573.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.84,155,,,Fee Schedule,155% of CMS OPPS Rate,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.93,155,,,Fee Schedule,155% of CMS OPPS Rate,888.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,884,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.42,1159.79,
"Arterial Vascular Cathterization Extremity Artery, Needle, (Lt)",,,761,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,780.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,878.1,90,,,Percent of total Billed charges,90% of total billed charges,105.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,897.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,623.08,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,767.39,78.65,,,percent of total billed charges,78.65% of total billed charges,871.58,89.33,,,percent of total billed charges,89.33% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,682.97,70,,,percent of total billed charges,70% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.08,86,,,percent of total billed charges,86% of total billed charges,780.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,907.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,946.4,
"Arterial Vascular Cathterization Extremity Artery, Needle, (Rt)",,,761,RC,36140,HCPCS,Outpatient,,,975.67,487.84,,878.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,780.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,878.1,90,,,Percent of total Billed charges,90% of total billed charges,105.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,897.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,623.08,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,767.39,78.65,,,percent of total billed charges,78.65% of total billed charges,871.58,89.33,,,percent of total billed charges,89.33% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,682.97,70,,,percent of total billed charges,70% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,926.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.08,86,,,percent of total billed charges,86% of total billed charges,780.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,878.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,946.4,97,,,percent of total billed charges,97% of total billed charges,907.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.67,946.4,
36200- Intro of cath/aorta,3430700,CDM,510,RC,36200,HCPCS,Outpatient,,,1510.24,755.12,,1359.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1208.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1359.22,90,,,Percent of total Billed charges,90% of total billed charges,122.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1464.93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1389.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,964.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1187.84,78.65,,,percent of total billed charges,78.65% of total billed charges,1349.12,89.33,,,percent of total billed charges,89.33% of total billed charges,1359.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1057.17,70,,,percent of total billed charges,70% of total billed charges,1359.22,90,,,percent of total billed charges,90% of total billed charges,1434.73,95,,,percent of total billed charges,95% of total billed charges,1434.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.81,86,,,percent of total billed charges,86% of total billed charges,1208.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1464.93,97,,,percent of total billed charges,97% of total billed charges,1359.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1464.93,97,,,percent of total billed charges,97% of total billed charges,1404.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1464.93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,1464.93,
"36200-Introduction of catheter, aorta",4271167,CDM,481,RC,36200,HCPCS,Outpatient,,,1146.05,573.03,,1031.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,916.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1031.45,90,,,Percent of total Billed charges,90% of total billed charges,122.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1111.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1054.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,731.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,901.39,78.65,,,percent of total billed charges,78.65% of total billed charges,1023.78,89.33,,,percent of total billed charges,89.33% of total billed charges,1031.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,802.24,70,,,percent of total billed charges,70% of total billed charges,1031.45,90,,,percent of total billed charges,90% of total billed charges,1088.75,95,,,percent of total billed charges,95% of total billed charges,1088.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.6,86,,,percent of total billed charges,86% of total billed charges,916.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1111.67,97,,,percent of total billed charges,97% of total billed charges,1031.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1111.67,97,,,percent of total billed charges,97% of total billed charges,1065.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1111.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,1111.67,
"36200-PF Introduction of catheter, aorta",4271168,CDM,960,RC,36200,HCPCS,Outpatient,,,1146.05,573.03,,1031.45,90,,,percent of total billed charges,90% of total Billed charges,707.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,215.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,222.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,222.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,116.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,215.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1096.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1215.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1215.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111,1215.16,
36215- Selec place/art 1st ord/thor/brach,3430701,CDM,510,RC,36215,HCPCS,Outpatient,,,2594.36,1297.18,,2334.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2075.49,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2334.92,90,,,Percent of total Billed charges,90% of total billed charges,189.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2516.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2386.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1656.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2040.52,78.65,,,percent of total billed charges,78.65% of total billed charges,2317.58,89.33,,,percent of total billed charges,89.33% of total billed charges,2334.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1816.05,70,,,percent of total billed charges,70% of total billed charges,2334.92,90,,,percent of total billed charges,90% of total billed charges,2464.64,95,,,percent of total billed charges,95% of total billed charges,2464.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2231.15,86,,,percent of total billed charges,86% of total billed charges,2075.49,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2516.53,97,,,percent of total billed charges,97% of total billed charges,2334.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2516.53,97,,,percent of total billed charges,97% of total billed charges,2412.75,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2516.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172,2516.53,
"36215-Catheter placement, arterial system; first order thoracic or brachiocephalic branch",4271254,CDM,481,RC,36215,HCPCS,Outpatient,,,1980.31,990.16,,1782.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1584.25,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1782.28,90,,,Percent of total Billed charges,90% of total billed charges,189.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1920.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1821.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1264.67,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1557.56,78.65,,,percent of total billed charges,78.65% of total billed charges,1769.04,89.33,,,percent of total billed charges,89.33% of total billed charges,1782.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1386.22,70,,,percent of total billed charges,70% of total billed charges,1782.28,90,,,percent of total billed charges,90% of total billed charges,1881.29,95,,,percent of total billed charges,95% of total billed charges,1881.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1703.07,86,,,percent of total billed charges,86% of total billed charges,1584.25,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1920.9,97,,,percent of total billed charges,97% of total billed charges,1782.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1920.9,97,,,percent of total billed charges,97% of total billed charges,1841.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1920.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172,1920.9,
"36215-PF Catheter placement, arterial system; first order thoracic or brachiocephalic branch",4271255,CDM,960,RC,36215,HCPCS,Outpatient,,,1980.31,990.16,,1782.28,90,,,percent of total billed charges,90% of total Billed charges,1184,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,208.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,172,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,323.08,155,,,Fee Schedule,155% of CMS OPPS Rate,208.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,328.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,328.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,416.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,387.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,256.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,323.08,155,,,Fee Schedule,155% of CMS OPPS Rate,208.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1835.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1835.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,208.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,172,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,208.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2176,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2176,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,172,2176,
36216- Selec place/art 2nd ord/thor/brach,3430702,CDM,510,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,2423.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2154.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2423.35,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2611.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2477.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1719.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2117.8,78.65,,,percent of total billed charges,78.65% of total billed charges,2405.35,89.33,,,percent of total billed charges,89.33% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1884.83,70,,,percent of total billed charges,70% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,2557.98,95,,,percent of total billed charges,95% of total billed charges,2557.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.64,86,,,percent of total billed charges,86% of total billed charges,2154.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2611.83,97,,,percent of total billed charges,97% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2611.83,97,,,percent of total billed charges,97% of total billed charges,2504.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2611.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,2611.83,
"36216-Catheter placement, arterial system; initial second order thoracic or brachiocephalic branch",4271225,CDM,481,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,2423.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2154.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2423.35,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2611.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2477.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1719.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2117.8,78.65,,,percent of total billed charges,78.65% of total billed charges,2405.35,89.33,,,percent of total billed charges,89.33% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1884.83,70,,,percent of total billed charges,70% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,2557.98,95,,,percent of total billed charges,95% of total billed charges,2557.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2315.64,86,,,percent of total billed charges,86% of total billed charges,2154.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2611.83,97,,,percent of total billed charges,97% of total billed charges,2423.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2611.83,97,,,percent of total billed charges,97% of total billed charges,2504.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2611.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,2611.83,
"36216-PF Catheter placement, arterial system; initial second order thoracic or brachiocephalic branc",4271226,CDM,960,RC,36216,HCPCS,Outpatient,,,2692.61,1346.31,,2423.35,90,,,percent of total billed charges,90% of total Billed charges,1281.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,417.14,155,,,Fee Schedule,155% of CMS OPPS Rate,269.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,269.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,343.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,427.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,427.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,218.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,353.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,417.14,155,,,Fee Schedule,155% of CMS OPPS Rate,269.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,1986.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1986.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,269.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,269.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,2413.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2413.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.5,2423.35,
"36217- Selective catheter placement, arterial system; initial third order or more selective thoracic",3569386,CDM,510,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,3974.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3533.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3974.69,90,,,Percent of total Billed charges,90% of total billed charges,332.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4283.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4063.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2820.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3473.53,78.65,,,percent of total billed charges,78.65% of total billed charges,3945.17,89.33,,,percent of total billed charges,89.33% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3091.42,70,,,percent of total billed charges,70% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,4195.5,95,,,percent of total billed charges,95% of total billed charges,4195.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3798.04,86,,,percent of total billed charges,86% of total billed charges,3533.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4283.83,97,,,percent of total billed charges,97% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4283.83,97,,,percent of total billed charges,97% of total billed charges,4107.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4283.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.07,4283.83,
"36217-Catheter placement, arterial system; initial third order or more selective thoracic or brachio",4271227,CDM,481,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,3974.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3533.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3974.69,90,,,Percent of total Billed charges,90% of total billed charges,332.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4283.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4063.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2820.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3473.53,78.65,,,percent of total billed charges,78.65% of total billed charges,3945.17,89.33,,,percent of total billed charges,89.33% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3091.42,70,,,percent of total billed charges,70% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,4195.5,95,,,percent of total billed charges,95% of total billed charges,4195.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3798.04,86,,,percent of total billed charges,86% of total billed charges,3533.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4283.83,97,,,percent of total billed charges,97% of total billed charges,3974.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4283.83,97,,,percent of total billed charges,97% of total billed charges,4107.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4283.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.07,4283.83,
"36217-PF Catheter placement, arterial system; initial third order or more selective thoracic or brac",4271228,CDM,960,RC,36217,HCPCS,Outpatient,,,4416.32,2208.16,,3974.69,90,,,percent of total billed charges,90% of total Billed charges,1990.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,330.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,302.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,511.83,155,,,Fee Schedule,155% of CMS OPPS Rate,330.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,515.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,515.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,260.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,608.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,432,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,511.83,155,,,Fee Schedule,155% of CMS OPPS Rate,330.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3085.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3085.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,330.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,330.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3941.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3941.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,260.26,3974.69,
"36218-Cath placement, art system; additional second order, third order, and beyond, thoracic or brac",4271229,CDM,481,RC,36218,HCPCS,Outpatient,,,401.23,200.62,,361.11,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,320.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,361.11,90,,,Percent of total Billed charges,90% of total billed charges,53.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,389.19,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,369.13,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,256.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,315.58,78.65,,,percent of total billed charges,78.65% of total billed charges,358.43,89.33,,,percent of total billed charges,89.33% of total billed charges,361.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,280.86,70,,,percent of total billed charges,70% of total billed charges,361.11,90,,,percent of total billed charges,90% of total billed charges,381.17,95,,,percent of total billed charges,95% of total billed charges,381.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.06,86,,,percent of total billed charges,86% of total billed charges,320.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,389.19,97,,,percent of total billed charges,97% of total billed charges,361.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,389.19,97,,,percent of total billed charges,97% of total billed charges,373.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,389.19,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.24,389.19,
"36218-PF Cath placement, art system; additional second order, third order, and beyond, thoracic or b",4271230,CDM,960,RC,36218,HCPCS,Outpatient,,,401.23,200.62,,361.11,90,,,percent of total billed charges,90% of total Billed charges,241.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,80.14,155,,,Fee Schedule,155% of CMS OPPS Rate,51.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,67.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.14,155,,,Fee Schedule,155% of CMS OPPS Rate,51.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.6,155,,,Fee Schedule,155% of CMS OPPS Rate,374.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,362.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,362.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41.79,374.6,
36221- Non-select cath/thoracic aorta,3430703,CDM,510,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,2252.86,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2002.54,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2252.86,90,,,Percent of total Billed charges,90% of total billed charges,190.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2428.08,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.93,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2252.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1752.23,70,,,percent of total billed charges,70% of total billed charges,2252.86,90,,,percent of total billed charges,90% of total billed charges,2378.02,95,,,percent of total billed charges,95% of total billed charges,2378.02,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2152.73,86,,,percent of total billed charges,86% of total billed charges,2002.54,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2428.08,97,,,percent of total billed charges,97% of total billed charges,2252.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2428.08,97,,,percent of total billed charges,97% of total billed charges,2327.96,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2428.08,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.42,14522.85,
36221-PF Thoracic Angiogram,3580880,CDM,960,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,2252.86,90,,,percent of total billed charges,90% of total Billed charges,1141.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,199.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,173.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,309.63,155,,,Fee Schedule,155% of CMS OPPS Rate,199.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,419.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,318.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,318.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,184.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,375.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,309.63,155,,,Fee Schedule,155% of CMS OPPS Rate,199.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1768.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1768.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,199.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1007,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,199.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.42,2252.86,
36221-Thoracic Angiogram,3560673,CDM,481,RC,36221,HCPCS,Outpatient,,,2503.18,1251.59,,2252.86,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2002.54,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2252.86,90,,,Percent of total Billed charges,90% of total billed charges,190.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2428.08,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.93,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2252.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1752.23,70,,,percent of total billed charges,70% of total billed charges,2252.86,90,,,percent of total billed charges,90% of total billed charges,2378.02,95,,,percent of total billed charges,95% of total billed charges,2378.02,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2152.73,86,,,percent of total billed charges,86% of total billed charges,2002.54,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2428.08,97,,,percent of total billed charges,97% of total billed charges,2252.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2428.08,97,,,percent of total billed charges,97% of total billed charges,2327.96,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2428.08,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.42,14522.85,
Arch Study (Cardiology),,,761,RC,36221,HCPCS,Outpatient,,,2375.94,1187.97,,2138.35,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1900.75,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2138.35,90,,,Percent of total Billed charges,90% of total billed charges,190.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2304.66,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2185.86,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2138.35,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1663.16,70,,,percent of total billed charges,70% of total billed charges,2138.35,90,,,percent of total billed charges,90% of total billed charges,2257.14,95,,,percent of total billed charges,95% of total billed charges,2257.14,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2043.31,86,,,percent of total billed charges,86% of total billed charges,1900.75,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2304.66,97,,,percent of total billed charges,97% of total billed charges,2138.35,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2304.66,97,,,percent of total billed charges,97% of total billed charges,2209.62,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2304.66,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.42,14522.85,
36222- Cath place/com carotid/innom art,3430704,CDM,510,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2731.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2427.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2731.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2943.68,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2791.94,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2124.3,70,,,percent of total billed charges,70% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2609.86,86,,,percent of total billed charges,86% of total billed charges,2427.78,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2943.68,97,,,percent of total billed charges,97% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2943.68,97,,,percent of total billed charges,97% of total billed charges,2822.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2943.68,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2124.3,14522.85,
36222-Carotid Angiography Selective,3431836,CDM,481,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2731.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2427.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2731.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2943.68,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2791.94,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2124.3,70,,,percent of total billed charges,70% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2609.86,86,,,percent of total billed charges,86% of total billed charges,2427.78,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2943.68,97,,,percent of total billed charges,97% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2943.68,97,,,percent of total billed charges,97% of total billed charges,2822.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2943.68,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2124.3,14522.85,
36222-Carotid Angiography Selective BILAT,3431835,CDM,320,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2731.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2427.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2731.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2943.68,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2791.94,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2124.3,70,,,percent of total billed charges,70% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2609.86,86,,,percent of total billed charges,86% of total billed charges,2427.78,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2943.68,97,,,percent of total billed charges,97% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2943.68,97,,,percent of total billed charges,97% of total billed charges,2822.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2943.68,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2124.3,14522.85,
36222-Carotid Angiography Selective RT,3431837,CDM,320,RC,36222,HCPCS,Outpatient,,,3034.72,1517.36,,2731.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2427.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2731.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2943.68,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2791.94,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2124.3,70,,,percent of total billed charges,70% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2882.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2609.86,86,,,percent of total billed charges,86% of total billed charges,2427.78,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2943.68,97,,,percent of total billed charges,97% of total billed charges,2731.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2943.68,97,,,percent of total billed charges,97% of total billed charges,2822.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2943.68,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2124.3,14522.85,
Carotid Angio BILAT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2643.63,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2349.9,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2643.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2849.25,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2702.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.16,70,,,percent of total billed charges,70% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2526.14,86,,,percent of total billed charges,86% of total billed charges,2349.9,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2849.25,97,,,percent of total billed charges,97% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2849.25,97,,,percent of total billed charges,97% of total billed charges,2731.75,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2849.25,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2056.16,14522.85,
Carotid Angio LT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2643.63,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2349.9,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2643.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2849.25,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2702.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.16,70,,,percent of total billed charges,70% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2526.14,86,,,percent of total billed charges,86% of total billed charges,2349.9,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2849.25,97,,,percent of total billed charges,97% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2849.25,97,,,percent of total billed charges,97% of total billed charges,2731.75,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2849.25,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2056.16,14522.85,
Carotid Angio RT,,,761,RC,36222,HCPCS,Outpatient,,,2937.37,1468.69,,2643.63,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2349.9,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2643.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2849.25,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2702.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.16,70,,,percent of total billed charges,70% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2790.5,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2526.14,86,,,percent of total billed charges,86% of total billed charges,2349.9,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2849.25,97,,,percent of total billed charges,97% of total billed charges,2643.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2849.25,97,,,percent of total billed charges,97% of total billed charges,2731.75,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2849.25,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2056.16,14522.85,
36223- Cath place/com carotid/innom art,3430705,CDM,510,RC,36223,HCPCS,Outpatient,,,3993.24,1996.62,,3593.92,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3194.59,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3593.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3873.44,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3673.78,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3593.92,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,2795.27,70,,,percent of total billed charges,70% of total billed charges,3593.92,90,,,percent of total billed charges,90% of total billed charges,3793.58,95,,,percent of total billed charges,95% of total billed charges,3793.58,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3434.19,86,,,percent of total billed charges,86% of total billed charges,3194.59,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3873.44,97,,,percent of total billed charges,97% of total billed charges,3593.92,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3873.44,97,,,percent of total billed charges,97% of total billed charges,3713.71,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3873.44,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2795.27,25056.98,
36224-Carotid Angio,3431838,CDM,481,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3994.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4494.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4843.7,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4594.02,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.45,70,,,percent of total billed charges,70% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4294.41,86,,,percent of total billed charges,86% of total billed charges,3994.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4843.7,97,,,percent of total billed charges,97% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4843.7,97,,,percent of total billed charges,97% of total billed charges,4643.96,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4843.7,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3495.45,25056.98,
36224-Carotid Angiography Selective BILAT,3533611,CDM,360,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3994.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4494.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4843.7,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4594.02,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.45,70,,,percent of total billed charges,70% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4294.41,86,,,percent of total billed charges,86% of total billed charges,3994.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4843.7,97,,,percent of total billed charges,97% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4843.7,97,,,percent of total billed charges,97% of total billed charges,4643.96,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4843.7,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3495.45,25056.98,
36224-Carotid Angiography Selective LT,3533612,CDM,320,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3994.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4494.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4843.7,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4594.02,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.45,70,,,percent of total billed charges,70% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4294.41,86,,,percent of total billed charges,86% of total billed charges,3994.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4843.7,97,,,percent of total billed charges,97% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4843.7,97,,,percent of total billed charges,97% of total billed charges,4643.96,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4843.7,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3495.45,25056.98,
36224-Carotid Angiography Selective RT,3533613,CDM,320,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3994.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4494.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4843.7,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4594.02,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.45,70,,,percent of total billed charges,70% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4743.83,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4294.41,86,,,percent of total billed charges,86% of total billed charges,3994.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4843.7,97,,,percent of total billed charges,97% of total billed charges,4494.15,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4843.7,97,,,percent of total billed charges,97% of total billed charges,4643.96,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4843.7,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3495.45,25056.98,
36224-PF Carotid Angio,3580881,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,2248.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,667.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,492.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,3484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3484.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1482.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.18,4494.15,
36224-PF Carotid Angiography Selective BILAT,3580882,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,2248.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,667.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,492.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,3484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3484.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1482.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.18,4494.15,
36224-PF Carotid Angiography Selective LT,3580883,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,2248.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,667.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,492.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,3484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3484.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1482.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.18,4494.15,
36224-PF Carotid Angiography Selective RT,3580884,CDM,960,RC,36224,HCPCS,Outpatient,,,4993.5,2496.75,,4494.15,90,,,percent of total billed charges,90% of total Billed charges,2248.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,565.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,667.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,492.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,574.4,155,,,Fee Schedule,155% of CMS OPPS Rate,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,3484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3484.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1482.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,370.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.18,4494.15,
36225- Cath place/subclavian artery,3430706,CDM,320,RC,36225,HCPCS,Outpatient,,,3797.57,1898.79,,3417.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3038.06,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3683.64,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3493.76,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3417.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.3,70,,,percent of total billed charges,70% of total billed charges,3417.81,90,,,percent of total billed charges,90% of total billed charges,3607.69,95,,,percent of total billed charges,95% of total billed charges,3607.69,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3265.91,86,,,percent of total billed charges,86% of total billed charges,3038.06,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3683.64,97,,,percent of total billed charges,97% of total billed charges,3417.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3683.64,97,,,percent of total billed charges,97% of total billed charges,3531.74,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3683.64,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
36225-Subclavian Angiography,3431839,CDM,481,RC,36225,HCPCS,Outpatient,,,3797.57,1898.79,,3417.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3038.06,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3683.64,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3493.76,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3417.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2658.3,70,,,percent of total billed charges,70% of total billed charges,3417.81,90,,,percent of total billed charges,90% of total billed charges,3607.69,95,,,percent of total billed charges,95% of total billed charges,3607.69,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3265.91,86,,,percent of total billed charges,86% of total billed charges,3038.06,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3683.64,97,,,percent of total billed charges,97% of total billed charges,3417.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3683.64,97,,,percent of total billed charges,97% of total billed charges,3531.74,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3683.64,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
Subclavian Angiography,3427226,CDM,960,RC,36225,HCPCS,Outpatient,,,3726.91,1863.46,,3354.22,90,,,percent of total billed charges,90% of total Billed charges,1754.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.81,155,,,Fee Schedule,155% of CMS OPPS Rate,326.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,497.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,497.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,262.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,586.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,429.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,505.81,155,,,Fee Schedule,155% of CMS OPPS Rate,326.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,2719.23,155,,,Fee Schedule,155% of CMS OPPS Rate,2719.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1354.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.89,3354.22,
36226- Cath place/vertebral artery,3430707,CDM,510,RC,36226,HCPCS,Outpatient,,,4819.17,2409.59,,4337.25,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3855.34,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4337.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4674.59,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4433.64,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4337.25,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3373.42,70,,,percent of total billed charges,70% of total billed charges,4337.25,90,,,percent of total billed charges,90% of total billed charges,4578.21,95,,,percent of total billed charges,95% of total billed charges,4578.21,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4144.49,86,,,percent of total billed charges,86% of total billed charges,3855.34,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4674.59,97,,,percent of total billed charges,97% of total billed charges,4337.25,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4674.59,97,,,percent of total billed charges,97% of total billed charges,4481.83,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4674.59,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3373.42,25056.98,
36245- Selec place/art 1st ord/abd/pel/LE,3430708,CDM,481,RC,36245,HCPCS,Outpatient,,,3121.54,1560.77,,2809.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2497.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2809.39,90,,,Percent of total Billed charges,90% of total billed charges,147.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3027.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2871.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1993.48,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2455.16,78.65,,,percent of total billed charges,78.65% of total billed charges,2788.52,89.33,,,percent of total billed charges,89.33% of total billed charges,2809.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2185.08,70,,,percent of total billed charges,70% of total billed charges,2809.39,90,,,percent of total billed charges,90% of total billed charges,2965.46,95,,,percent of total billed charges,95% of total billed charges,2965.46,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2684.52,86,,,percent of total billed charges,86% of total billed charges,2497.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3027.89,97,,,percent of total billed charges,97% of total billed charges,2809.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3027.89,97,,,percent of total billed charges,97% of total billed charges,2903.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3027.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,3027.89,
"36245-Lower extremity cath, first order",4271169,CDM,481,RC,36245,HCPCS,Outpatient,,,2381.42,1190.71,,2143.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1905.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2143.28,90,,,Percent of total Billed charges,90% of total billed charges,147.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2309.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2190.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1520.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1873.04,78.65,,,percent of total billed charges,78.65% of total billed charges,2127.36,89.33,,,percent of total billed charges,89.33% of total billed charges,2143.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1666.99,70,,,percent of total billed charges,70% of total billed charges,2143.28,90,,,percent of total billed charges,90% of total billed charges,2262.35,95,,,percent of total billed charges,95% of total billed charges,2262.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2048.02,86,,,percent of total billed charges,86% of total billed charges,1905.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2309.98,97,,,percent of total billed charges,97% of total billed charges,2143.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2309.98,97,,,percent of total billed charges,97% of total billed charges,2214.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2309.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,2309.98,
"36245-PF Lower extremity cath, first order",4271170,CDM,960,RC,36245,HCPCS,Outpatient,,,2381.42,1190.71,,2143.28,90,,,percent of total billed charges,90% of total Billed charges,1407.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,361.57,155,,,Fee Schedule,155% of CMS OPPS Rate,233.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,299.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,372.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,372.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,466.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,439.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,304.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,361.57,155,,,Fee Schedule,155% of CMS OPPS Rate,233.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,2180.96,155,,,Fee Schedule,155% of CMS OPPS Rate,2180.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,233.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,288.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,233.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,2173.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2173.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,134.5,2180.96,
IR Sel Cath Placement Abdominal,603468,CDM,481,RC,36245,HCPCS,Outpatient,,,2976.78,1488.39,,2679.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2381.42,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2679.1,90,,,Percent of total Billed charges,90% of total billed charges,147.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2887.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2738.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1901.04,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2341.3,78.65,,,percent of total billed charges,78.65% of total billed charges,2659.21,89.33,,,percent of total billed charges,89.33% of total billed charges,2679.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2083.75,70,,,percent of total billed charges,70% of total billed charges,2679.1,90,,,percent of total billed charges,90% of total billed charges,2827.94,95,,,percent of total billed charges,95% of total billed charges,2827.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2560.03,86,,,percent of total billed charges,86% of total billed charges,2381.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2887.48,97,,,percent of total billed charges,97% of total billed charges,2679.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2887.48,97,,,percent of total billed charges,97% of total billed charges,2768.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2887.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.5,2887.48,
36246- Selec place/art 2nd ord/abd/pel/LE,3430709,CDM,510,RC,36246,HCPCS,Outpatient,,,2132.83,1066.42,,1919.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1706.26,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1919.55,90,,,Percent of total Billed charges,90% of total billed charges,279.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2068.85,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1962.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1362.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1677.52,78.65,,,percent of total billed charges,78.65% of total billed charges,1905.29,89.33,,,percent of total billed charges,89.33% of total billed charges,1919.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1492.98,70,,,percent of total billed charges,70% of total billed charges,1919.55,90,,,percent of total billed charges,90% of total billed charges,2026.19,95,,,percent of total billed charges,95% of total billed charges,2026.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1834.23,86,,,percent of total billed charges,86% of total billed charges,1706.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2068.85,97,,,percent of total billed charges,97% of total billed charges,1919.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2068.85,97,,,percent of total billed charges,97% of total billed charges,1983.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2068.85,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.09,2068.85,
"36246-Lower extremity cath, second order",4271171,CDM,481,RC,36246,HCPCS,Outpatient,,,1626.74,813.37,,1464.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1301.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1464.07,90,,,Percent of total Billed charges,90% of total billed charges,279.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1577.94,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1496.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1038.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1279.47,78.65,,,percent of total billed charges,78.65% of total billed charges,1453.19,89.33,,,percent of total billed charges,89.33% of total billed charges,1464.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1138.72,70,,,percent of total billed charges,70% of total billed charges,1464.07,90,,,percent of total billed charges,90% of total billed charges,1545.4,95,,,percent of total billed charges,95% of total billed charges,1545.4,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1399,86,,,percent of total billed charges,86% of total billed charges,1301.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1577.94,97,,,percent of total billed charges,97% of total billed charges,1464.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1577.94,97,,,percent of total billed charges,97% of total billed charges,1512.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1577.94,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.09,1577.94,
"36246-PF Lower extremity cath, second order",4271172,CDM,960,RC,36246,HCPCS,Outpatient,,,1626.74,813.37,,1464.07,90,,,percent of total billed charges,90% of total Billed charges,1052.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,250.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,254.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,388.91,155,,,Fee Schedule,155% of CMS OPPS Rate,250.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,319.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,400.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,400.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,206.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,472.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,336.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,388.91,155,,,Fee Schedule,155% of CMS OPPS Rate,250.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1632.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,250.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,250.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2276.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2276.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,206.68,2276.64,
36247- Selec place/art 3rd ord/abd/pel/LE,3430710,CDM,510,RC,36247,HCPCS,Outpatient,,,3592.24,1796.12,,3233.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2873.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3233.02,90,,,Percent of total Billed charges,90% of total billed charges,325.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3484.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3304.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2294.08,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2825.38,78.65,,,percent of total billed charges,78.65% of total billed charges,3209.01,89.33,,,percent of total billed charges,89.33% of total billed charges,3233.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2514.57,70,,,percent of total billed charges,70% of total billed charges,3233.02,90,,,percent of total billed charges,90% of total billed charges,3412.63,95,,,percent of total billed charges,95% of total billed charges,3412.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3089.33,86,,,percent of total billed charges,86% of total billed charges,2873.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3484.47,97,,,percent of total billed charges,97% of total billed charges,3233.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3484.47,97,,,percent of total billed charges,97% of total billed charges,3340.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3484.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296,3484.47,
"36247-Lower extremity cath, third order",4271173,CDM,481,RC,36247,HCPCS,Outpatient,,,2732.96,1366.48,,2459.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2186.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2459.66,90,,,Percent of total Billed charges,90% of total billed charges,325.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2650.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2514.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1745.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2149.53,78.65,,,percent of total billed charges,78.65% of total billed charges,2441.4,89.33,,,percent of total billed charges,89.33% of total billed charges,2459.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1913.07,70,,,percent of total billed charges,70% of total billed charges,2459.66,90,,,percent of total billed charges,90% of total billed charges,2596.31,95,,,percent of total billed charges,95% of total billed charges,2596.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2350.35,86,,,percent of total billed charges,86% of total billed charges,2186.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2650.97,97,,,percent of total billed charges,97% of total billed charges,2459.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2650.97,97,,,percent of total billed charges,97% of total billed charges,2541.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2650.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296,2650.97,
"36247-PF Lower extremity cath, third order",4271174,CDM,960,RC,36247,HCPCS,Outpatient,,,2732.96,1366.48,,2459.66,90,,,percent of total billed charges,90% of total Billed charges,1647.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,296.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,296,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,459.16,155,,,Fee Schedule,155% of CMS OPPS Rate,296.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,474.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,474.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,246.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,389.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,459.16,155,,,Fee Schedule,155% of CMS OPPS Rate,296.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,2552.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2552.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,296.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,296,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,296.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3572.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3572.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,246.16,3572.72,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,510,RC,36248,HCPCS,Outpatient,,,296.97,148.49,,267.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,237.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.27,90,,,Percent of total Billed charges,90% of total billed charges,53.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,288.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,273.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,189.65,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,233.57,78.65,,,percent of total billed charges,78.65% of total billed charges,265.29,89.33,,,percent of total billed charges,89.33% of total billed charges,267.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,207.88,70,,,percent of total billed charges,70% of total billed charges,267.27,90,,,percent of total billed charges,90% of total billed charges,282.12,95,,,percent of total billed charges,95% of total billed charges,282.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.39,86,,,percent of total billed charges,86% of total billed charges,237.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,288.06,97,,,percent of total billed charges,97% of total billed charges,267.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,288.06,97,,,percent of total billed charges,97% of total billed charges,276.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,288.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,288.06,
"36248-Lower extremity cath, each additional order",4271175,CDM,481,RC,36248,HCPCS,Outpatient,,,230.51,115.26,,207.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.46,90,,,Percent of total Billed charges,90% of total billed charges,53.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,212.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,147.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,181.3,78.65,,,percent of total billed charges,78.65% of total billed charges,205.92,89.33,,,percent of total billed charges,89.33% of total billed charges,207.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.36,70,,,percent of total billed charges,70% of total billed charges,207.46,90,,,percent of total billed charges,90% of total billed charges,218.98,95,,,percent of total billed charges,95% of total billed charges,218.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.24,86,,,percent of total billed charges,86% of total billed charges,184.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.59,97,,,percent of total billed charges,97% of total billed charges,207.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.59,97,,,percent of total billed charges,97% of total billed charges,214.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,223.59,
"36248-PF Lower extremity cath, each additional order",4271176,CDM,960,RC,36248,HCPCS,Outpatient,,,230.51,115.26,,207.46,90,,,percent of total billed charges,90% of total Billed charges,159.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.67,155,,,Fee Schedule,155% of CMS OPPS Rate,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.67,155,,,Fee Schedule,155% of CMS OPPS Rate,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.74,155,,,Fee Schedule,155% of CMS OPPS Rate,246.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,297.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.35,297.16,
36251-Renal Angio Ulilateral (Right),3560672,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2918.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.14,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.41,90,,,Percent of total Billed charges,90% of total billed charges,247.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3145.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2983.27,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.88,70,,,percent of total billed charges,70% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2788.7,86,,,percent of total billed charges,86% of total billed charges,2594.14,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3145.4,97,,,percent of total billed charges,97% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3145.4,97,,,percent of total billed charges,97% of total billed charges,3015.69,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3145.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224.74,14522.85,
36251-Renal Angiography LT,3431840,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2918.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.14,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.41,90,,,Percent of total Billed charges,90% of total billed charges,247.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3145.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2983.27,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.88,70,,,percent of total billed charges,70% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2788.7,86,,,percent of total billed charges,86% of total billed charges,2594.14,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3145.4,97,,,percent of total billed charges,97% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3145.4,97,,,percent of total billed charges,97% of total billed charges,3015.69,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3145.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224.74,14522.85,
36251-Renal Angiography RT,3431841,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2918.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.14,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.41,90,,,Percent of total Billed charges,90% of total billed charges,247.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3145.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2983.27,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.88,70,,,percent of total billed charges,70% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2788.7,86,,,percent of total billed charges,86% of total billed charges,2594.14,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3145.4,97,,,percent of total billed charges,97% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3145.4,97,,,percent of total billed charges,97% of total billed charges,3015.69,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3145.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224.74,14522.85,
36251-SELECT/FLUSH RENAL ANGIO UNILAT LT,3431842,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2918.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.14,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.41,90,,,Percent of total Billed charges,90% of total billed charges,247.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3145.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2983.27,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.88,70,,,percent of total billed charges,70% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2788.7,86,,,percent of total billed charges,86% of total billed charges,2594.14,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3145.4,97,,,percent of total billed charges,97% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3145.4,97,,,percent of total billed charges,97% of total billed charges,3015.69,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3145.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224.74,14522.85,
36251-SELECT/FLUSH RENAL ANGIO UNILAT RT,3431843,CDM,481,RC,36251,HCPCS,Outpatient,,,3242.68,1621.34,,2918.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.14,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.41,90,,,Percent of total Billed charges,90% of total billed charges,247.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3145.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2983.27,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2269.88,70,,,percent of total billed charges,70% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,3080.55,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2788.7,86,,,percent of total billed charges,86% of total billed charges,2594.14,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3145.4,97,,,percent of total billed charges,97% of total billed charges,2918.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3145.4,97,,,percent of total billed charges,97% of total billed charges,3015.69,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3145.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224.74,14522.85,
Renal Angiography LT,3427235,CDM,960,RC,36251,HCPCS,Outpatient,,,3091.1,1545.55,,2781.99,90,,,percent of total billed charges,90% of total Billed charges,1473.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,394.57,155,,,Fee Schedule,155% of CMS OPPS Rate,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,539.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,406.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,406.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,239.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,394.57,155,,,Fee Schedule,155% of CMS OPPS Rate,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2284.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2284.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1269.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.74,2781.99,
Renal Angiography RT,3427236,CDM,960,RC,36251,HCPCS,Outpatient,,,3091.1,1545.55,,2781.99,90,,,percent of total billed charges,90% of total Billed charges,1473.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,394.57,155,,,Fee Schedule,155% of CMS OPPS Rate,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,479.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,539.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,539.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,406.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,406.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,239.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,509.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,479.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,394.57,155,,,Fee Schedule,155% of CMS OPPS Rate,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2284.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2284.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1269.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,254.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.74,2781.99,
36252- Sel cath place/renal/1st ord/bilat,3430902,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,3175.33,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2822.51,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3175.33,90,,,Percent of total Billed charges,90% of total billed charges,322.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3422.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2469.7,70,,,percent of total billed charges,70% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3034.2,86,,,percent of total billed charges,86% of total billed charges,2822.51,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3422.3,97,,,percent of total billed charges,97% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3422.3,97,,,percent of total billed charges,97% of total billed charges,3281.17,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3422.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292.74,14522.85,
36252-Renal Angio Bilateral,3560641,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,3175.33,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2822.51,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3175.33,90,,,Percent of total Billed charges,90% of total billed charges,322.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3422.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2469.7,70,,,percent of total billed charges,70% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3034.2,86,,,percent of total billed charges,86% of total billed charges,2822.51,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3422.3,97,,,percent of total billed charges,97% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3422.3,97,,,percent of total billed charges,97% of total billed charges,3281.17,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3422.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292.74,14522.85,
36252-Renal Angiography BILAT,3431844,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,3175.33,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2822.51,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3175.33,90,,,Percent of total Billed charges,90% of total billed charges,322.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3422.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2469.7,70,,,percent of total billed charges,70% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3034.2,86,,,percent of total billed charges,86% of total billed charges,2822.51,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3422.3,97,,,percent of total billed charges,97% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3422.3,97,,,percent of total billed charges,97% of total billed charges,3281.17,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3422.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292.74,14522.85,
36252-SELECT/FLUSH ANGIO RENAL BILATERAL,3431845,CDM,481,RC,36252,HCPCS,Outpatient,,,3528.14,1764.07,,3175.33,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2822.51,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3175.33,90,,,Percent of total Billed charges,90% of total billed charges,322.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3422.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3245.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2469.7,70,,,percent of total billed charges,70% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,3351.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3034.2,86,,,percent of total billed charges,86% of total billed charges,2822.51,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3422.3,97,,,percent of total billed charges,97% of total billed charges,3175.33,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3422.3,97,,,percent of total billed charges,97% of total billed charges,3281.17,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3422.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292.74,14522.85,
Read,630458,CDM,972,RC,36252,HCPCS,Outpatient,,,1344.14,672.07,,1209.73,90,,,percent of total billed charges,90% of total Billed charges,1681.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,355.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,292.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,550.27,155,,,Fee Schedule,155% of CMS OPPS Rate,355.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,749.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,566.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,566.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,311.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,667.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,481.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,550.27,155,,,Fee Schedule,155% of CMS OPPS Rate,355.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2606.65,155,,,Fee Schedule,155% of CMS OPPS Rate,2606.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,355.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1398.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,355.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.74,2606.65,
Renal Angiography BILAT,,,761,RC,36252,HCPCS,Outpatient,,,3360.36,1680.18,,3024.32,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.29,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3024.32,90,,,Percent of total Billed charges,90% of total billed charges,322.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3259.55,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3091.53,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3024.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2352.25,70,,,percent of total billed charges,70% of total billed charges,3024.32,90,,,percent of total billed charges,90% of total billed charges,3192.34,95,,,percent of total billed charges,95% of total billed charges,3192.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2889.91,86,,,percent of total billed charges,86% of total billed charges,2688.29,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3259.55,97,,,percent of total billed charges,97% of total billed charges,3024.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3259.55,97,,,percent of total billed charges,97% of total billed charges,3125.13,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3259.55,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292.74,14522.85,
36253 - Supslctv Cath 3nd+Ord Renal & Accessory Artery/S&I,3899034,CDM,975,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,4537.85,90,,,percent of total billed charges,90% of total Billed charges,2242.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,346.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,313.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,536.83,155,,,Fee Schedule,155% of CMS OPPS Rate,346.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,553.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,553.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,692.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,652.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,424.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,536.83,155,,,Fee Schedule,155% of CMS OPPS Rate,346.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,3475.6,155,,,Fee Schedule,155% of CMS OPPS Rate,3475.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,346.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1940.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,346.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.1,4537.85,
36253-Renal Angiography Supraselect  LT,3431846,CDM,481,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,4537.85,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4033.65,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4537.85,90,,,Percent of total Billed charges,90% of total billed charges,344.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4890.8,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4638.7,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4537.85,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3529.44,70,,,percent of total billed charges,70% of total billed charges,4537.85,90,,,percent of total billed charges,90% of total billed charges,4789.96,95,,,percent of total billed charges,95% of total billed charges,4789.96,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4336.17,86,,,percent of total billed charges,86% of total billed charges,4033.65,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4890.8,97,,,percent of total billed charges,97% of total billed charges,4537.85,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4890.8,97,,,percent of total billed charges,97% of total billed charges,4689.12,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4890.8,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,313.1,25056.98,
36253-Renal Angiography Supraselect RT,3431847,CDM,481,RC,36253,HCPCS,Outpatient,,,5042.06,2521.03,,4537.85,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4033.65,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4537.85,90,,,Percent of total Billed charges,90% of total billed charges,344.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4890.8,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4638.7,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4537.85,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3529.44,70,,,percent of total billed charges,70% of total billed charges,4537.85,90,,,percent of total billed charges,90% of total billed charges,4789.96,95,,,percent of total billed charges,95% of total billed charges,4789.96,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4336.17,86,,,percent of total billed charges,86% of total billed charges,4033.65,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4890.8,97,,,percent of total billed charges,97% of total billed charges,4537.85,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4890.8,97,,,percent of total billed charges,97% of total billed charges,4689.12,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4890.8,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,313.1,25056.98,
Renal Angiography Supraselect  LT,,,761,RC,36253,HCPCS,Outpatient,,,4804.75,2402.38,,4324.28,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4324.28,90,,,Percent of total Billed charges,90% of total billed charges,344.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4660.61,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4420.37,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4324.28,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3363.33,70,,,percent of total billed charges,70% of total billed charges,4324.28,90,,,percent of total billed charges,90% of total billed charges,4564.51,95,,,percent of total billed charges,95% of total billed charges,4564.51,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4132.09,86,,,percent of total billed charges,86% of total billed charges,3843.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4660.61,97,,,percent of total billed charges,97% of total billed charges,4324.28,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4660.61,97,,,percent of total billed charges,97% of total billed charges,4468.42,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4660.61,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,313.1,25056.98,
Renal Angiography Supraselect RT,,,761,RC,36253,HCPCS,Outpatient,,,4804.75,2402.38,,4324.28,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.8,80,,,Percent of total Billed charges,80% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4324.28,90,,,Percent of total Billed charges,90% of total billed charges,344.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4660.61,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4420.37,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4324.28,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,3363.33,70,,,percent of total billed charges,70% of total billed charges,4324.28,90,,,percent of total billed charges,90% of total billed charges,4564.51,95,,,percent of total billed charges,95% of total billed charges,4564.51,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4132.09,86,,,percent of total billed charges,86% of total billed charges,3843.8,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4660.61,97,,,percent of total billed charges,97% of total billed charges,4324.28,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4660.61,97,,,percent of total billed charges,97% of total billed charges,4468.42,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4660.61,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,313.1,25056.98,
36254-Renal Angiography Supraselect BILAT,3431848,CDM,481,RC,36254,HCPCS,Outpatient,,,5020.79,2510.40,,4518.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4016.63,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,4518.71,90,,,Percent of total Billed charges,90% of total billed charges,371.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4870.17,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4619.13,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4518.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3514.55,70,,,percent of total billed charges,70% of total billed charges,4518.71,90,,,percent of total billed charges,90% of total billed charges,4769.75,95,,,percent of total billed charges,95% of total billed charges,4769.75,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4317.88,86,,,percent of total billed charges,86% of total billed charges,4016.63,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4870.17,97,,,percent of total billed charges,97% of total billed charges,4518.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,4870.17,97,,,percent of total billed charges,97% of total billed charges,4669.33,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4870.17,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,337.77,14522.85,
Renal Angiography Supraselect BILAT,,,761,RC,36254,HCPCS,Outpatient,,,4760.78,2380.39,,4284.7,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3808.62,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,4284.7,90,,,Percent of total Billed charges,90% of total billed charges,371.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4617.96,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4379.92,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4284.7,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3332.55,70,,,percent of total billed charges,70% of total billed charges,4284.7,90,,,percent of total billed charges,90% of total billed charges,4522.74,95,,,percent of total billed charges,95% of total billed charges,4522.74,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4094.27,86,,,percent of total billed charges,86% of total billed charges,3808.62,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4617.96,97,,,percent of total billed charges,97% of total billed charges,4284.7,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,4617.96,97,,,percent of total billed charges,97% of total billed charges,4427.53,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4617.96,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,337.77,14522.85,
36406- Venipunc/<3yrs/MD/PA/APRN/oth vein,3430712,CDM,510,RC,36406,HCPCS,Outpatient,,,42.95,21.48,,38.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,34.36,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,38.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,39.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,27.43,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,33.78,78.65,,,percent of total billed charges,78.65% of total billed charges,38.37,89.33,,,percent of total billed charges,89.33% of total billed charges,38.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.07,70,,,percent of total billed charges,70% of total billed charges,38.66,90,,,percent of total billed charges,90% of total billed charges,40.8,95,,,percent of total billed charges,95% of total billed charges,40.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.94,86,,,percent of total billed charges,86% of total billed charges,34.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.66,97,,,percent of total billed charges,97% of total billed charges,38.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.66,97,,,percent of total billed charges,97% of total billed charges,39.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.43,41.66,
36410 - PF Non-Routine BL Draw 3/ > Yrs,4311494,CDM,960,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,16.68,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,10.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.59,155,,,Fee Schedule,155% of CMS OPPS Rate,39.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.43,39.59,
36410-PF NON-ROUTINE BL DRAW 3/> YRS,4321424,CDM,981,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,16.68,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,10.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.59,155,,,Fee Schedule,155% of CMS OPPS Rate,39.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.43,39.59,
Midline Insertion,605007,CDM,940,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,16.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,16.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,17.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,14.57,78.65,,,percent of total billed charges,78.65% of total billed charges,16.55,89.33,,,percent of total billed charges,89.33% of total billed charges,16.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.97,70,,,percent of total billed charges,70% of total billed charges,16.68,90,,,percent of total billed charges,90% of total billed charges,17.6,95,,,percent of total billed charges,95% of total billed charges,17.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.94,86,,,percent of total billed charges,86% of total billed charges,14.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.97,97,,,percent of total billed charges,97% of total billed charges,16.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.97,97,,,percent of total billed charges,97% of total billed charges,17.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,17.97,
Venipuncture,3549915,CDM,960,RC,36415,HCPCS,Outpatient,,,14.63,7.32,,13.17,90,,,percent of total billed charges,90% of total Billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,155,,,Fee Schedule,155% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.75,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.57,155,,,Fee Schedule,155% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.57,155,,,Fee Schedule,155% of CMS OPPS Rate,11.57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.39,17.14,
36425-PF VENIPUNCTURE CUTDOWN AGE 1 YR/>,4321426,CDM,981,RC,36425,HCPCS,Outpatient,,,78.16,39.08,,70.34,90,,,percent of total billed charges,90% of total Billed charges,79.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.56,155,,,Fee Schedule,155% of CMS OPPS Rate,39.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,61.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,61.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.56,155,,,Fee Schedule,155% of CMS OPPS Rate,39.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.47,155,,,Fee Schedule,155% of CMS OPPS Rate,122.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14,150.04,
36430-PF  TRANSFUSION BLOOD/BLOOD COMPONENTS,4321667,CDM,981,RC,36430,HCPCS,Outpatient,,,68.74,34.37,,61.87,90,,,percent of total billed charges,90% of total Billed charges,68.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.27,155,,,Fee Schedule,155% of CMS OPPS Rate,34.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.27,155,,,Fee Schedule,155% of CMS OPPS Rate,34.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.63,155,,,Fee Schedule,155% of CMS OPPS Rate,105.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.84,105.63,
36471- Inj sclero solu/mult vein/same leg,3430715,CDM,960,RC,36471,HCPCS,Outpatient,,,157.62,78.81,,141.86,90,,,percent of total billed charges,90% of total Billed charges,233.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.94,155,,,Fee Schedule,155% of CMS OPPS Rate,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,100.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.94,155,,,Fee Schedule,155% of CMS OPPS Rate,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,362.25,155,,,Fee Schedule,155% of CMS OPPS Rate,362.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.09,362.25,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,518.45,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,460.84,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,558.77,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,529.97,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,518.45,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,403.24,70,,,percent of total billed charges,70% of total billed charges,518.45,90,,,percent of total billed charges,90% of total billed charges,547.25,95,,,percent of total billed charges,95% of total billed charges,547.25,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,495.4,86,,,percent of total billed charges,86% of total billed charges,460.84,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,558.77,97,,,percent of total billed charges,97% of total billed charges,518.45,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.77,97,,,percent of total billed charges,97% of total billed charges,535.73,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,558.77,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,403.24,14522.85,
36475 Endovenous rf 1st vein,3428319,CDM,510,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,518.45,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,460.84,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,558.77,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,529.97,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,518.45,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,403.24,70,,,percent of total billed charges,70% of total billed charges,518.45,90,,,percent of total billed charges,90% of total billed charges,547.25,95,,,percent of total billed charges,95% of total billed charges,547.25,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,495.4,86,,,percent of total billed charges,86% of total billed charges,460.84,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,558.77,97,,,percent of total billed charges,97% of total billed charges,518.45,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.77,97,,,percent of total billed charges,97% of total billed charges,535.73,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,558.77,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,403.24,14522.85,
36476- RF abla/sec & subs vein/single ext,3430903,CDM,761,RC,36476,HCPCS,Outpatient,,,738.63,369.32,,664.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,590.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,664.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,716.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,679.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,471.71,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,580.95,78.65,,,percent of total billed charges,78.65% of total billed charges,659.83,89.33,,,percent of total billed charges,89.33% of total billed charges,664.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,517.04,70,,,percent of total billed charges,70% of total billed charges,664.77,90,,,percent of total billed charges,90% of total billed charges,701.7,95,,,percent of total billed charges,95% of total billed charges,701.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.22,86,,,percent of total billed charges,86% of total billed charges,590.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,716.47,97,,,percent of total billed charges,97% of total billed charges,664.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,716.47,97,,,percent of total billed charges,97% of total billed charges,686.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.71,716.47,
36513- Apheresis/platelets,3430717,CDM,510,RC,36513,HCPCS,Outpatient,,,278.27,139.14,,250.44,90,,,percent of total billed charges,90% of total Billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,222.62,80,,,Percent of total Billed charges,80% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.44,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,269.92,97,,,Percent of total billed charges,97% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,256.01,92,,,Percent of total billed charges,92% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,984.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1569.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1987.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,250.44,90,,,percent of total billed charges,90% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,194.79,70,,,percent of total billed charges,70% of total billed charges,250.44,90,,,percent of total billed charges,90% of total billed charges,264.36,95,,,percent of total billed charges,95% of total billed charges,264.36,95,,,percent of total billed charges,95% of total billed charges,370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,239.31,86,,,percent of total billed charges,86% of total billed charges,222.62,80,,,percent of total billed charges,80% of total billed charges,401.18,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,269.92,97,,,percent of total billed charges,97% of total billed charges,250.44,90,,,percent of total billed charges,90% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.92,97,,,percent of total billed charges,97% of total billed charges,258.79,93,,,percent of total billed charges,93% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.92,97,,,percent of total billed charges,97% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.34,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,314.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,1987.82,
36513-PF THERAPEUTIC APHERESIS PLATELETS,4321666,CDM,981,RC,36513,HCPCS,Outpatient,,,206.06,103.03,,185.45,90,,,percent of total billed charges,90% of total Billed charges,207.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.87,155,,,Fee Schedule,155% of CMS OPPS Rate,321.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,208.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.42,321.87,
36514- Apheresis/plasma pheresis,3430718,CDM,510,RC,36514,HCPCS,Outpatient,,,1383,691.50,,1244.7,90,,,percent of total billed charges,90% of total Billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1106.4,80,,,Percent of total Billed charges,80% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1244.7,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1341.51,97,,,Percent of total billed charges,97% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.36,92,,,Percent of total billed charges,92% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3283,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1235.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5233.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6629.38,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1244.7,90,,,percent of total billed charges,90% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,968.1,70,,,percent of total billed charges,70% of total billed charges,1244.7,90,,,percent of total billed charges,90% of total billed charges,1313.85,95,,,percent of total billed charges,95% of total billed charges,1313.85,95,,,percent of total billed charges,95% of total billed charges,1235.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2470.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1189.38,86,,,percent of total billed charges,86% of total billed charges,1106.4,80,,,percent of total billed charges,80% of total billed charges,1368.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1341.51,97,,,percent of total billed charges,97% of total billed charges,1244.7,90,,,percent of total billed charges,90% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1341.51,97,,,percent of total billed charges,97% of total billed charges,1286.19,93,,,percent of total billed charges,93% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1341.51,97,,,percent of total billed charges,97% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1049.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,6629.38,
36555- Insert central venous cath/<5yrs,3430719,CDM,510,RC,36555,HCPCS,Outpatient,,,483.78,241.89,,435.4,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,387.02,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,435.4,90,,,Percent of total Billed charges,90% of total billed charges,129.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,469.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,445.08,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,435.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,338.65,70,,,percent of total billed charges,70% of total billed charges,435.4,90,,,percent of total billed charges,90% of total billed charges,459.59,95,,,percent of total billed charges,95% of total billed charges,459.59,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,416.05,86,,,percent of total billed charges,86% of total billed charges,387.02,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,469.27,97,,,percent of total billed charges,97% of total billed charges,435.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.27,97,,,percent of total billed charges,97% of total billed charges,449.92,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,469.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.84,14522.85,
36555-PF INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y,4321665,CDM,981,RC,36555,HCPCS,Outpatient,,,168.12,84.06,,151.31,90,,,percent of total billed charges,90% of total Billed charges,252.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.29,155,,,Fee Schedule,155% of CMS OPPS Rate,84.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.29,155,,,Fee Schedule,155% of CMS OPPS Rate,84.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.88,155,,,Fee Schedule,155% of CMS OPPS Rate,390.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,514.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,514.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,84.06,514.26,
36556 - PF Ins Non-Tunneled CV Cath Age 5 yr/ >,4311495,CDM,960,RC,36556,HCPCS,Outpatient,,,198.5,99.25,,178.65,90,,,percent of total billed charges,90% of total Billed charges,282.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.26,155,,,Fee Schedule,155% of CMS OPPS Rate,437.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,457.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83.6,457.64,
36556- Insert CVC 5 yrs or >,3430720,CDM,510,RC,36556,HCPCS,Outpatient,,,543.02,271.51,,488.72,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,434.42,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.72,90,,,Percent of total Billed charges,90% of total billed charges,124.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,526.73,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,499.58,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,488.72,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,380.11,70,,,percent of total billed charges,70% of total billed charges,488.72,90,,,percent of total billed charges,90% of total billed charges,515.87,95,,,percent of total billed charges,95% of total billed charges,515.87,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,467,86,,,percent of total billed charges,86% of total billed charges,434.42,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,526.73,97,,,percent of total billed charges,97% of total billed charges,488.72,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.73,97,,,percent of total billed charges,97% of total billed charges,505.01,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.73,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.21,14522.85,
36556-Insert non-tunnel CV catheter AGE 5 YR/>,4271231,CDM,481,RC,36556,HCPCS,Outpatient,,,542.99,271.50,,488.69,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,434.39,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.69,90,,,Percent of total Billed charges,90% of total billed charges,124.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,526.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,499.55,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,488.69,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,380.09,70,,,percent of total billed charges,70% of total billed charges,488.69,90,,,percent of total billed charges,90% of total billed charges,515.84,95,,,percent of total billed charges,95% of total billed charges,515.84,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,466.97,86,,,percent of total billed charges,86% of total billed charges,434.39,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,526.7,97,,,percent of total billed charges,97% of total billed charges,488.69,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.7,97,,,percent of total billed charges,97% of total billed charges,504.98,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.21,14522.85,
36556-PF Insert non-tunnel CV catheter AGE 5 YR/>,4271232,CDM,960,RC,36556,HCPCS,Outpatient,,,542.99,271.50,,488.69,90,,,percent of total billed charges,90% of total Billed charges,287.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,446.06,155,,,Fee Schedule,155% of CMS OPPS Rate,446.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,457.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83.6,488.69,
36556-PF INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/>,4321664,CDM,981,RC,36556,HCPCS,Outpatient,,,167.2,83.60,,150.48,90,,,percent of total billed charges,90% of total Billed charges,250.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.58,155,,,Fee Schedule,155% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,388.74,155,,,Fee Schedule,155% of CMS OPPS Rate,388.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,457.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83.6,457.64,
Insert non-tunnel CV catheter AGE 5 YR/>,4271233,CDM,761,RC,36556,HCPCS,Outpatient,,,542.99,271.50,,488.69,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,434.39,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.69,90,,,Percent of total Billed charges,90% of total billed charges,124.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,526.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,499.55,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,488.69,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,380.09,70,,,percent of total billed charges,70% of total billed charges,488.69,90,,,percent of total billed charges,90% of total billed charges,515.84,95,,,percent of total billed charges,95% of total billed charges,515.84,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,466.97,86,,,percent of total billed charges,86% of total billed charges,434.39,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,526.7,97,,,percent of total billed charges,97% of total billed charges,488.69,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.7,97,,,percent of total billed charges,97% of total billed charges,504.98,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.21,14522.85,
"36557- Insertion of tunneled  venous cath, upto 5 yrs",3569417,CDM,510,RC,36557,HCPCS,Outpatient,,,2971.37,1485.69,,2674.23,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2377.1,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2674.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2882.23,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2733.66,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2674.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2079.96,70,,,percent of total billed charges,70% of total billed charges,2674.23,90,,,percent of total billed charges,90% of total billed charges,2822.8,95,,,percent of total billed charges,95% of total billed charges,2822.8,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2555.38,86,,,percent of total billed charges,86% of total billed charges,2377.1,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2882.23,97,,,percent of total billed charges,97% of total billed charges,2674.23,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2882.23,97,,,percent of total billed charges,97% of total billed charges,2763.37,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2882.23,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2079.96,25056.97,
36558 - PF In Tunneled CV Cath w/ o Subq Port/ Pmp Age 5 yr/ >,4311496,CDM,960,RC,36558,HCPCS,Outpatient,,,602.29,301.15,,542.06,90,,,percent of total billed charges,90% of total Billed charges,855.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,434.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,470.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1326.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1326.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,217.44,1521.84,
36558- Insert tunn CVC w/o sub-q port 5yr,3430721,CDM,510,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1906.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1694.27,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1906.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2054.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1948.41,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1482.49,70,,,percent of total billed charges,70% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1821.34,86,,,percent of total billed charges,86% of total billed charges,1694.27,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2054.3,97,,,percent of total billed charges,97% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2054.3,97,,,percent of total billed charges,97% of total billed charges,1969.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2054.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1482.49,14522.85,
"36558-Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or",3554657,CDM,481,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1906.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1694.27,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1906.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2054.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1948.41,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1482.49,70,,,percent of total billed charges,70% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1821.34,86,,,percent of total billed charges,86% of total billed charges,1694.27,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2054.3,97,,,percent of total billed charges,97% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2054.3,97,,,percent of total billed charges,97% of total billed charges,1969.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2054.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1482.49,14522.85,
36558-PF INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/>,4321663,CDM,981,RC,36558,HCPCS,Outpatient,,,507.32,253.66,,456.59,90,,,percent of total billed charges,90% of total Billed charges,760.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,434.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,470.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1179.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,217.44,1521.84,
36558-TCC Placement,3431849,CDM,481,RC,36558,HCPCS,Outpatient,,,2117.84,1058.92,,1906.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1694.27,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1906.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2054.3,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1948.41,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1482.49,70,,,percent of total billed charges,70% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2011.95,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1821.34,86,,,percent of total billed charges,86% of total billed charges,1694.27,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2054.3,97,,,percent of total billed charges,97% of total billed charges,1906.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2054.3,97,,,percent of total billed charges,97% of total billed charges,1969.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2054.3,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1482.49,14522.85,
Hickman Placement,,,761,RC,36558,HCPCS,Outpatient,,,2016.76,1008.38,,1815.08,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1613.41,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1815.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1956.26,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1855.42,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1815.08,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.73,70,,,percent of total billed charges,70% of total billed charges,1815.08,90,,,percent of total billed charges,90% of total billed charges,1915.92,95,,,percent of total billed charges,95% of total billed charges,1915.92,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1734.41,86,,,percent of total billed charges,86% of total billed charges,1613.41,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1956.26,97,,,percent of total billed charges,97% of total billed charges,1815.08,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1956.26,97,,,percent of total billed charges,97% of total billed charges,1875.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1956.26,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1411.73,14522.85,
TCC Placement,3427243,CDM,960,RC,36558,HCPCS,Outpatient,,,2016.76,1008.38,,1815.08,90,,,percent of total billed charges,90% of total Billed charges,1050.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,434.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,470.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1627.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1627.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,217.44,1815.08,
36561 - PF Ins Tunneled CV Cath VAD w/ Subq Port Age 5 yr/ >,4311497,CDM,960,RC,36561,HCPCS,Outpatient,,,774.74,387.37,,697.27,90,,,percent of total billed charges,90% of total Billed charges,1101.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,273.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,609.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,411.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1706.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1706.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1468.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,2303.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2303.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,273.41,2303.16,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,510,RC,36561,HCPCS,Outpatient,,,2525.55,1262.78,,2273,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2020.44,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2273,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2449.78,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.51,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2273,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1767.89,70,,,percent of total billed charges,70% of total billed charges,2273,90,,,percent of total billed charges,90% of total billed charges,2399.27,95,,,percent of total billed charges,95% of total billed charges,2399.27,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2171.97,86,,,percent of total billed charges,86% of total billed charges,2020.44,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2449.78,97,,,percent of total billed charges,97% of total billed charges,2273,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2449.78,97,,,percent of total billed charges,97% of total billed charges,2348.76,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2449.78,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1767.89,14522.85,
"36561-Insertion of tunneled centrally inserted central venous access device, with subcut port,age 5",3554656,CDM,481,RC,36561,HCPCS,Outpatient,,,2525.55,1262.78,,2273,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2020.44,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2273,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2449.78,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.51,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2273,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1767.89,70,,,percent of total billed charges,70% of total billed charges,2273,90,,,percent of total billed charges,90% of total billed charges,2399.27,95,,,percent of total billed charges,95% of total billed charges,2399.27,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2171.97,86,,,percent of total billed charges,86% of total billed charges,2020.44,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2449.78,97,,,percent of total billed charges,97% of total billed charges,2273,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2449.78,97,,,percent of total billed charges,97% of total billed charges,2348.76,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2449.78,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1767.89,14522.85,
36561-PF INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/>,4321435,CDM,981,RC,36561,HCPCS,Outpatient,,,652.58,326.29,,587.32,90,,,percent of total billed charges,90% of total Billed charges,978.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,273.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,609.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,411.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.25,155,,,Fee Schedule,155% of CMS OPPS Rate,1517.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1468.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,2303.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2303.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,273.41,2303.16,
36563-Insertion of tunneled centrally inserted central venous access device w/ subcutanoues pump,3554655,CDM,481,RC,36563,HCPCS,Outpatient,,,2877.05,1438.53,,2589.35,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2301.64,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2589.35,90,,,Percent of total Billed charges,90% of total billed charges,369.02,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2790.74,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2646.89,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2589.35,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2013.94,70,,,percent of total billed charges,70% of total billed charges,2589.35,90,,,percent of total billed charges,90% of total billed charges,2733.2,95,,,percent of total billed charges,95% of total billed charges,2733.2,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2474.26,86,,,percent of total billed charges,86% of total billed charges,2301.64,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2790.74,97,,,percent of total billed charges,97% of total billed charges,2589.35,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2790.74,97,,,percent of total billed charges,97% of total billed charges,2675.66,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2790.74,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,335.47,25056.97,
36563-PF Insertion of tunneled centrally inserted central venous access device w/ subcutanoues pump,3580885,CDM,960,RC,36563,HCPCS,Outpatient,,,2877.05,1438.53,,2589.35,90,,,percent of total billed charges,90% of total Billed charges,1442.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,360.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,335.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,559.16,155,,,Fee Schedule,155% of CMS OPPS Rate,360.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,360.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,609.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,567.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,567.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,721.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,669.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,478.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,559.16,155,,,Fee Schedule,155% of CMS OPPS Rate,360.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2236.05,155,,,Fee Schedule,155% of CMS OPPS Rate,2236.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,360.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1224.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,360.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2577.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2577.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298.33,2589.35,
"36565 - Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters",3783246,CDM,510,RC,36565,HCPCS,Outpatient,,,2131.3,1065.65,,1918.17,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1705.04,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1918.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2067.36,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1960.8,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1918.17,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1491.91,70,,,percent of total billed charges,70% of total billed charges,1918.17,90,,,percent of total billed charges,90% of total billed charges,2024.74,95,,,percent of total billed charges,95% of total billed charges,2024.74,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1832.92,86,,,percent of total billed charges,86% of total billed charges,1705.04,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2067.36,97,,,percent of total billed charges,97% of total billed charges,1918.17,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2067.36,97,,,percent of total billed charges,97% of total billed charges,1982.11,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2067.36,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1491.91,14522.85,
36566-INSERT TUNNELED CV CATH,3430904,CDM,510,RC,36566,HCPCS,Outpatient,,,10675.26,5337.63,,9607.73,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8540.21,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,9607.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10355,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,9821.24,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9607.73,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,7472.68,70,,,percent of total billed charges,70% of total billed charges,9607.73,90,,,percent of total billed charges,90% of total billed charges,10141.5,95,,,percent of total billed charges,95% of total billed charges,10141.5,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9180.72,86,,,percent of total billed charges,86% of total billed charges,8540.21,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10355,97,,,percent of total billed charges,97% of total billed charges,9607.73,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,10355,97,,,percent of total billed charges,97% of total billed charges,9927.99,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10355,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3967.99,25056.97,
36568-PF INSERTION PICC W/O IMG GDN < 5 YR,4321436,CDM,981,RC,36568,HCPCS,Outpatient,,,184.86,92.43,,166.37,90,,,percent of total billed charges,90% of total Billed charges,184.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,143.25,155,,,Fee Schedule,155% of CMS OPPS Rate,92.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,143.25,155,,,Fee Schedule,155% of CMS OPPS Rate,92.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.02,155,,,Fee Schedule,155% of CMS OPPS Rate,286.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,895.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,540.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,540.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71.12,895.01,
36569 PF Insertion PICC w/o Img Gdn 5 yrs/>,4279417,CDM,960,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,198.16,90,,,percent of total billed charges,90% of total Billed charges,186.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,143.73,155,,,Fee Schedule,155% of CMS OPPS Rate,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,109.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,143.73,155,,,Fee Schedule,155% of CMS OPPS Rate,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.67,155,,,Fee Schedule,155% of CMS OPPS Rate,288.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,361.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,472.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.67,472.6,
36569-PF INSERTION PICC W/O IMG GDN 5 YR/>,4321662,CDM,981,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,198.16,90,,,percent of total billed charges,90% of total Billed charges,186.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,143.73,155,,,Fee Schedule,155% of CMS OPPS Rate,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,109.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,143.73,155,,,Fee Schedule,155% of CMS OPPS Rate,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.67,155,,,Fee Schedule,155% of CMS OPPS Rate,288.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,361.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,472.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.67,472.6,
PICC Insertion with ECG Confirmation,3310602,CDM,940,RC,36569,HCPCS,Outpatient,,,220.18,110.09,,198.16,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,176.14,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.16,90,,,Percent of total Billed charges,90% of total billed charges,96.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,213.57,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,202.57,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,198.16,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,154.13,70,,,percent of total billed charges,70% of total billed charges,198.16,90,,,percent of total billed charges,90% of total billed charges,209.17,95,,,percent of total billed charges,95% of total billed charges,209.17,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,189.35,86,,,percent of total billed charges,86% of total billed charges,176.14,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,213.57,97,,,percent of total billed charges,97% of total billed charges,198.16,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.57,97,,,percent of total billed charges,97% of total billed charges,204.77,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.57,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87.39,7253.45,
36570-PF INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR,4321661,CDM,981,RC,36570,HCPCS,Outpatient,,,660.16,330.08,,594.14,90,,,percent of total billed charges,90% of total Billed charges,990.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,330.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,511.61,155,,,Fee Schedule,155% of CMS OPPS Rate,330.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,552.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,511.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,511.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,254.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,660.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,603.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,433.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,511.61,155,,,Fee Schedule,155% of CMS OPPS Rate,330.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1534.86,155,,,Fee Schedule,155% of CMS OPPS Rate,1534.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,330.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1691.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,330.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2041.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2041.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,254.88,2041.36,
RI INF Ins Non-Tunnel CVC -> Insert Non-Tunnel CVC <5 Yrs,3438251,CDM,360,RC,36570,HCPCS,Outpatient,,,3512.84,1756.42,,3161.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2810.27,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3161.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3407.45,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3231.81,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3161.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2458.99,70,,,percent of total billed charges,70% of total billed charges,3161.56,90,,,percent of total billed charges,90% of total billed charges,3337.2,95,,,percent of total billed charges,95% of total billed charges,3337.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3021.04,86,,,percent of total billed charges,86% of total billed charges,2810.27,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3407.45,97,,,percent of total billed charges,97% of total billed charges,3161.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3407.45,97,,,percent of total billed charges,97% of total billed charges,3266.94,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3407.45,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
"36571 - (50)  Insertion of peripherally inserted central venous access device, with subcutaneous por",3699142,CDM,510,RC,36571,HCPCS,Outpatient,,,3244.72,1622.36,,2920.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2595.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2920.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3147.38,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.14,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2920.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.3,70,,,percent of total billed charges,70% of total billed charges,2920.25,90,,,percent of total billed charges,90% of total billed charges,3082.48,95,,,percent of total billed charges,95% of total billed charges,3082.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2790.46,86,,,percent of total billed charges,86% of total billed charges,2595.78,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3147.38,97,,,percent of total billed charges,97% of total billed charges,2920.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3147.38,97,,,percent of total billed charges,97% of total billed charges,3017.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3147.38,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2271.3,14522.85,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,510,RC,36571,HCPCS,Outpatient,,,3244.72,1622.36,,2920.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2595.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2920.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3147.38,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.14,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2920.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.3,70,,,percent of total billed charges,70% of total billed charges,2920.25,90,,,percent of total billed charges,90% of total billed charges,3082.48,95,,,percent of total billed charges,95% of total billed charges,3082.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2790.46,86,,,percent of total billed charges,86% of total billed charges,2595.78,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3147.38,97,,,percent of total billed charges,97% of total billed charges,2920.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3147.38,97,,,percent of total billed charges,97% of total billed charges,3017.59,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3147.38,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2271.3,14522.85,
36571 - PF Ins Prph Ctr Vad w/ Subq Port Age 5 yr/ >,4311498,CDM,960,RC,36571,HCPCS,Outpatient,,,730.03,365.02,,657.03,90,,,percent of total billed charges,90% of total Billed charges,1037.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.56,155,,,Fee Schedule,155% of CMS OPPS Rate,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,519.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,478.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,478.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,249.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,389.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,476.56,155,,,Fee Schedule,155% of CMS OPPS Rate,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1608.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1608.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4188.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2491.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2491.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,249.82,4188.55,
RI INF Ins Non-Tunnel CVC -> Insert Non-Tunnel CVC >=5 yrs,3438250,CDM,360,RC,36571,HCPCS,Outpatient,,,3042.07,1521.04,,2737.86,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2433.66,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2737.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2950.81,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2798.7,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2737.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2129.45,70,,,percent of total billed charges,70% of total billed charges,2737.86,90,,,percent of total billed charges,90% of total billed charges,2889.97,95,,,percent of total billed charges,95% of total billed charges,2889.97,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2616.18,86,,,percent of total billed charges,86% of total billed charges,2433.66,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2950.81,97,,,percent of total billed charges,97% of total billed charges,2737.86,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2950.81,97,,,percent of total billed charges,97% of total billed charges,2829.13,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2950.81,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2129.45,14522.85,
36573-PF INSERTION PICC W/RS&I 5 YR/>,4321437,CDM,981,RC,36573,HCPCS,Outpatient,,,165.04,82.52,,148.54,90,,,percent of total billed charges,90% of total Billed charges,247.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.91,155,,,Fee Schedule,155% of CMS OPPS Rate,82.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,100.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.91,155,,,Fee Schedule,155% of CMS OPPS Rate,82.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,383.72,155,,,Fee Schedule,155% of CMS OPPS Rate,383.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,420.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.76,420.6,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,510,RC,36575,HCPCS,Outpatient,,,370.52,185.26,,333.47,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,296.42,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.47,90,,,Percent of total Billed charges,90% of total billed charges,41.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,359.4,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,340.88,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,333.47,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,259.36,70,,,percent of total billed charges,70% of total billed charges,333.47,90,,,percent of total billed charges,90% of total billed charges,351.99,95,,,percent of total billed charges,95% of total billed charges,351.99,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,318.65,86,,,percent of total billed charges,86% of total billed charges,296.42,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,359.4,97,,,percent of total billed charges,97% of total billed charges,333.47,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.4,97,,,percent of total billed charges,97% of total billed charges,344.58,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,359.4,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.31,2820.25,
36575-PF RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP,4321442,CDM,981,RC,36575,HCPCS,Outpatient,,,65.4,32.70,,58.86,90,,,percent of total billed charges,90% of total Billed charges,98.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.69,155,,,Fee Schedule,155% of CMS OPPS Rate,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.69,155,,,Fee Schedule,155% of CMS OPPS Rate,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.06,155,,,Fee Schedule,155% of CMS OPPS Rate,152.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,165.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,314.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.93,314.16,
RI INF Repair CVAD w/o Port/Pump,3402965,CDM,360,RC,36575,HCPCS,Outpatient,,,346.92,173.46,,312.23,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,277.54,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.23,90,,,Percent of total Billed charges,90% of total billed charges,41.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,336.51,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,319.17,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,312.23,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,242.84,70,,,percent of total billed charges,70% of total billed charges,312.23,90,,,percent of total billed charges,90% of total billed charges,329.57,95,,,percent of total billed charges,95% of total billed charges,329.57,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,298.35,86,,,percent of total billed charges,86% of total billed charges,277.54,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,336.51,97,,,percent of total billed charges,97% of total billed charges,312.23,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,336.51,97,,,percent of total billed charges,97% of total billed charges,322.64,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,336.51,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.31,2820.25,
36576- Rpr cent ven access dev/port/pump,3430905,CDM,510,RC,36576,HCPCS,Outpatient,,,895.48,447.74,,805.93,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,716.38,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,805.93,90,,,Percent of total Billed charges,90% of total billed charges,191.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,868.62,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,823.84,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,805.93,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,626.84,70,,,percent of total billed charges,70% of total billed charges,805.93,90,,,percent of total billed charges,90% of total billed charges,850.71,95,,,percent of total billed charges,95% of total billed charges,850.71,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,770.11,86,,,percent of total billed charges,86% of total billed charges,716.38,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,868.62,97,,,percent of total billed charges,97% of total billed charges,805.93,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,868.62,97,,,percent of total billed charges,97% of total billed charges,832.8,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,868.62,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,174.1,7253.45,
36578- Rep cath only/cen ven acc/por/pump,3430906,CDM,510,RC,36578,HCPCS,Outpatient,,,1121.72,560.86,,1009.55,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,897.38,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1009.55,90,,,Percent of total Billed charges,90% of total billed charges,219.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1088.07,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.98,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1009.55,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,785.2,70,,,percent of total billed charges,70% of total billed charges,1009.55,90,,,percent of total billed charges,90% of total billed charges,1065.63,95,,,percent of total billed charges,95% of total billed charges,1065.63,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,964.68,86,,,percent of total billed charges,86% of total billed charges,897.38,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1088.07,97,,,percent of total billed charges,97% of total billed charges,1009.55,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1088.07,97,,,percent of total billed charges,97% of total billed charges,1043.2,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1088.07,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,199.32,14522.85,
36580-PF RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP,4321660,CDM,981,RC,36580,HCPCS,Outpatient,,,129.88,64.94,,116.89,90,,,percent of total billed charges,90% of total Billed charges,194.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,100.64,155,,,Fee Schedule,155% of CMS OPPS Rate,64.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.64,155,,,Fee Schedule,155% of CMS OPPS Rate,64.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.96,155,,,Fee Schedule,155% of CMS OPPS Rate,301.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,64.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,410.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.48,686.67,
36581-TCC Replacement,3431850,CDM,481,RC,36581,HCPCS,Outpatient,,,1971.9,985.95,,1774.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1577.52,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1774.71,90,,,Percent of total Billed charges,90% of total billed charges,204.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1912.74,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1814.15,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1774.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.33,70,,,percent of total billed charges,70% of total billed charges,1774.71,90,,,percent of total billed charges,90% of total billed charges,1873.31,95,,,percent of total billed charges,95% of total billed charges,1873.31,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1695.83,86,,,percent of total billed charges,86% of total billed charges,1577.52,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1912.74,97,,,percent of total billed charges,97% of total billed charges,1774.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1912.74,97,,,percent of total billed charges,97% of total billed charges,1833.87,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1912.74,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,185.89,14522.85,
TCC Replacement,3427244,CDM,960,RC,36581,HCPCS,Outpatient,,,1867.35,933.68,,1680.62,90,,,percent of total billed charges,90% of total Billed charges,919.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.51,155,,,Fee Schedule,155% of CMS OPPS Rate,177.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,279.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,279.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,329.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,213.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.51,155,,,Fee Schedule,155% of CMS OPPS Rate,177.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1424.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1424.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1680.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1457.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1457.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.58,1680.62,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,510,RC,36582,HCPCS,Outpatient,,,2260.41,1130.21,,2034.37,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1808.33,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2034.37,90,,,Percent of total Billed charges,90% of total billed charges,301.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2192.6,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2079.58,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2034.37,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1582.29,70,,,percent of total billed charges,70% of total billed charges,2034.37,90,,,percent of total billed charges,90% of total billed charges,2147.39,95,,,percent of total billed charges,95% of total billed charges,2147.39,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1943.95,86,,,percent of total billed charges,86% of total billed charges,1808.33,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2192.6,97,,,percent of total billed charges,97% of total billed charges,2034.37,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2192.6,97,,,percent of total billed charges,97% of total billed charges,2102.18,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2192.6,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,274.21,14522.85,
36584-PF COMPLETE REPLACEMENT PICC RS&I,4321659,CDM,981,RC,36584,HCPCS,Outpatient,,,114.94,57.47,,103.45,90,,,percent of total billed charges,90% of total Billed charges,172.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.06,155,,,Fee Schedule,155% of CMS OPPS Rate,57.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.06,155,,,Fee Schedule,155% of CMS OPPS Rate,57.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.22,155,,,Fee Schedule,155% of CMS OPPS Rate,267.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,57.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.68,699.09,
36585- Replace PICC/same venous access,3430907,CDM,510,RC,36585,HCPCS,Outpatient,,,2947.04,1473.52,,2652.34,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2357.63,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2652.34,90,,,Percent of total Billed charges,90% of total billed charges,283.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2858.63,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2711.28,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2652.34,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2062.93,70,,,percent of total billed charges,70% of total billed charges,2652.34,90,,,percent of total billed charges,90% of total billed charges,2799.69,95,,,percent of total billed charges,95% of total billed charges,2799.69,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2534.45,86,,,percent of total billed charges,86% of total billed charges,2357.63,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2858.63,97,,,percent of total billed charges,97% of total billed charges,2652.34,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2858.63,97,,,percent of total billed charges,97% of total billed charges,2740.75,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2858.63,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,258.09,14522.85,
36589 - PF Rmvl Tun CVC w/ o Subq Port/ Pmp,4311499,CDM,960,RC,36589,HCPCS,Outpatient,,,316.35,158.18,,284.72,90,,,percent of total billed charges,90% of total Billed charges,295.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.51,155,,,Fee Schedule,155% of CMS OPPS Rate,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,246.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,206.51,155,,,Fee Schedule,155% of CMS OPPS Rate,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.7,155,,,Fee Schedule,155% of CMS OPPS Rate,457.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,172.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,334.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,110,457.7,
36589- Rmv tunnel cent ven access cath,3430724,CDM,361,RC,36589,HCPCS,Outpatient,,,430.96,215.48,,387.86,90,,,percent of total billed charges,90% of total Billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,344.77,80,,,Percent of total Billed charges,80% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,418.03,97,,,Percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,396.48,92,,,Percent of total billed charges,92% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.26,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,387.86,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,301.67,70,,,percent of total billed charges,70% of total billed charges,387.86,90,,,percent of total billed charges,90% of total billed charges,409.41,95,,,percent of total billed charges,95% of total billed charges,409.41,95,,,percent of total billed charges,95% of total billed charges,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,370.63,86,,,percent of total billed charges,86% of total billed charges,344.77,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,418.03,97,,,percent of total billed charges,97% of total billed charges,387.86,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.03,97,,,percent of total billed charges,97% of total billed charges,400.79,93,,,percent of total billed charges,93% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,418.03,97,,,percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.67,2820.26,
36589-TCC Removal,3431851,CDM,481,RC,36589,HCPCS,Outpatient,,,430.96,215.48,,387.86,90,,,percent of total billed charges,90% of total Billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,344.77,80,,,Percent of total Billed charges,80% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,418.03,97,,,Percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,396.48,92,,,Percent of total billed charges,92% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.26,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,387.86,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,301.67,70,,,percent of total billed charges,70% of total billed charges,387.86,90,,,percent of total billed charges,90% of total billed charges,409.41,95,,,percent of total billed charges,95% of total billed charges,409.41,95,,,percent of total billed charges,95% of total billed charges,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,370.63,86,,,percent of total billed charges,86% of total billed charges,344.77,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,418.03,97,,,percent of total billed charges,97% of total billed charges,387.86,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.03,97,,,percent of total billed charges,97% of total billed charges,400.79,93,,,percent of total billed charges,93% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,418.03,97,,,percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.67,2820.26,
TCC Removal,,,761,RC,36589,HCPCS,Outpatient,,,421.81,210.91,,379.63,90,,,percent of total billed charges,90% of total Billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,337.45,80,,,Percent of total Billed charges,80% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,379.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,409.16,97,,,Percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,388.07,92,,,Percent of total billed charges,92% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.26,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,379.63,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,295.27,70,,,percent of total billed charges,70% of total billed charges,379.63,90,,,percent of total billed charges,90% of total billed charges,400.72,95,,,percent of total billed charges,95% of total billed charges,400.72,95,,,percent of total billed charges,95% of total billed charges,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,362.76,86,,,percent of total billed charges,86% of total billed charges,337.45,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,409.16,97,,,percent of total billed charges,97% of total billed charges,379.63,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.16,97,,,percent of total billed charges,97% of total billed charges,392.28,93,,,percent of total billed charges,93% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,409.16,97,,,percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,295.27,2820.26,
36590 - PF Rmvl Tun Ctr Vad W/ Subq Port/ Pmp Ctr/ Prph Ins,4311500,CDM,960,RC,36590,HCPCS,Outpatient,,,441.45,220.73,,397.31,90,,,percent of total billed charges,90% of total Billed charges,406.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,343.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.62,155,,,Fee Schedule,155% of CMS OPPS Rate,630.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,586.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.8,630.62,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,361,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,528.8,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.8,90,,,Percent of total Billed charges,90% of total billed charges,202.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,569.93,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,540.56,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,528.8,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,411.29,70,,,percent of total billed charges,70% of total billed charges,528.8,90,,,percent of total billed charges,90% of total billed charges,558.18,95,,,percent of total billed charges,95% of total billed charges,558.18,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,505.3,86,,,percent of total billed charges,86% of total billed charges,470.05,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,569.93,97,,,percent of total billed charges,97% of total billed charges,528.8,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.93,97,,,percent of total billed charges,97% of total billed charges,546.43,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.93,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,184.09,7253.45,
36590-PF Removal of Tunneled CV Access Device,3872931,CDM,960,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,528.8,90,,,percent of total billed charges,90% of total Billed charges,406.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,343.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.62,155,,,Fee Schedule,155% of CMS OPPS Rate,630.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,586.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.8,630.62,
36590-PF RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ,4321443,CDM,981,RC,36590,HCPCS,Outpatient,,,371.84,185.92,,334.66,90,,,percent of total billed charges,90% of total Billed charges,406.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,343.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.62,155,,,Fee Schedule,155% of CMS OPPS Rate,630.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,586.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.8,630.62,
36590-Removal of Tunneled CV Access Device,3872929,CDM,481,RC,36590,HCPCS,Outpatient,,,587.56,293.78,,528.8,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,470.05,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.8,90,,,Percent of total Billed charges,90% of total billed charges,202.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,569.93,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,540.56,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,528.8,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,411.29,70,,,percent of total billed charges,70% of total billed charges,528.8,90,,,percent of total billed charges,90% of total billed charges,558.18,95,,,percent of total billed charges,95% of total billed charges,558.18,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,505.3,86,,,percent of total billed charges,86% of total billed charges,470.05,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,569.93,97,,,percent of total billed charges,97% of total billed charges,528.8,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.93,97,,,percent of total billed charges,97% of total billed charges,546.43,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.93,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,184.09,7253.45,
Removal of Tunneled CV Access Device,,,761,RC,36590,HCPCS,Outpatient,,,573.78,286.89,,516.4,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,459.02,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,516.4,90,,,Percent of total Billed charges,90% of total billed charges,202.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,556.57,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,527.88,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,516.4,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,401.65,70,,,percent of total billed charges,70% of total billed charges,516.4,90,,,percent of total billed charges,90% of total billed charges,545.09,95,,,percent of total billed charges,95% of total billed charges,545.09,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,493.45,86,,,percent of total billed charges,86% of total billed charges,459.02,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,556.57,97,,,percent of total billed charges,97% of total billed charges,516.4,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.57,97,,,percent of total billed charges,97% of total billed charges,533.62,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,556.57,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,184.09,7253.45,
36591-PF COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE,4321658,CDM,981,RC,36591,HCPCS,Outpatient,,,46.9,23.45,,42.21,90,,,percent of total billed charges,90% of total Billed charges,47.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,155,,,Fee Schedule,155% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,32.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,32.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,155,,,Fee Schedule,155% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.88,155,,,Fee Schedule,155% of CMS OPPS Rate,72.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.13,72.88,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,510,RC,36595,HCPCS,Outpatient,,,1510.73,755.37,,1359.66,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1208.58,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1359.66,90,,,Percent of total Billed charges,90% of total billed charges,193.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1465.41,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1389.87,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1359.66,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.51,70,,,percent of total billed charges,70% of total billed charges,1359.66,90,,,percent of total billed charges,90% of total billed charges,1435.19,95,,,percent of total billed charges,95% of total billed charges,1435.19,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1299.23,86,,,percent of total billed charges,86% of total billed charges,1208.58,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1465.41,97,,,percent of total billed charges,97% of total billed charges,1359.66,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1465.41,97,,,percent of total billed charges,97% of total billed charges,1404.98,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1465.41,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,176.34,14522.85,
36597-TCC Reposition,3431852,CDM,481,RC,36597,HCPCS,Outpatient,,,281.74,140.87,,253.57,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,225.39,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,253.57,90,,,Percent of total Billed charges,90% of total billed charges,63.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,273.29,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,259.2,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,253.57,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,197.22,70,,,percent of total billed charges,70% of total billed charges,253.57,90,,,percent of total billed charges,90% of total billed charges,267.65,95,,,percent of total billed charges,95% of total billed charges,267.65,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,242.3,86,,,percent of total billed charges,86% of total billed charges,225.39,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,273.29,97,,,percent of total billed charges,97% of total billed charges,253.57,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.29,97,,,percent of total billed charges,97% of total billed charges,262.02,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.29,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.14,7253.45,
TCC Reposition,,,761,RC,36597,HCPCS,Outpatient,,,280.14,140.07,,252.13,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,224.11,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.13,90,,,Percent of total Billed charges,90% of total billed charges,63.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,271.74,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,257.73,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,252.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,196.1,70,,,percent of total billed charges,70% of total billed charges,252.13,90,,,percent of total billed charges,90% of total billed charges,266.13,95,,,percent of total billed charges,95% of total billed charges,266.13,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,240.92,86,,,percent of total billed charges,86% of total billed charges,224.11,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,271.74,97,,,percent of total billed charges,97% of total billed charges,252.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.74,97,,,percent of total billed charges,97% of total billed charges,260.53,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.74,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.14,7253.45,
DR Existing Central Venous Injection,659958,CDM,320,RC,36598,HCPCS,Outpatient,,,292.19,146.10,,262.97,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,233.75,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,283.42,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,268.81,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,262.97,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,204.53,70,,,percent of total billed charges,70% of total billed charges,262.97,90,,,percent of total billed charges,90% of total billed charges,277.58,95,,,percent of total billed charges,95% of total billed charges,277.58,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,251.28,86,,,percent of total billed charges,86% of total billed charges,233.75,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,283.42,97,,,percent of total billed charges,97% of total billed charges,262.97,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.42,97,,,percent of total billed charges,97% of total billed charges,271.74,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,283.42,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.47,1007.05,
Read,3348400,CDM,972,RC,36598,HCPCS,Outpatient,,,116.88,58.44,,105.19,90,,,percent of total billed charges,90% of total Billed charges,149.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.36,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,54.36,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.28,155,,,Fee Schedule,155% of CMS OPPS Rate,231.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,153.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.07,231.28,
36600 - PF Arterial Puncture Withdrawal Blood Dx,4311501,CDM,960,RC,36600,HCPCS,Outpatient,,,34.72,17.36,,31.25,90,,,percent of total billed charges,90% of total Billed charges,41.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.65,155,,,Fee Schedule,155% of CMS OPPS Rate,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,23.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,18.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,22.65,155,,,Fee Schedule,155% of CMS OPPS Rate,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.93,155,,,Fee Schedule,155% of CMS OPPS Rate,64.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.01,64.93,
36600-PF ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX,4321444,CDM,981,RC,36600,HCPCS,Outpatient,,,29.24,14.62,,26.32,90,,,percent of total billed charges,90% of total Billed charges,41.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.65,155,,,Fee Schedule,155% of CMS OPPS Rate,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,23.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,18.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,22.65,155,,,Fee Schedule,155% of CMS OPPS Rate,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.93,155,,,Fee Schedule,155% of CMS OPPS Rate,64.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.01,64.93,
36620 - PF Artl Cath/ Cannul Mntr/ Transfusion Spx Prq,4311502,CDM,960,RC,36620,HCPCS,Outpatient,,,105.18,52.59,,94.66,90,,,percent of total billed charges,90% of total Billed charges,88.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.27,155,,,Fee Schedule,155% of CMS OPPS Rate,137.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.08,137.27,
36620- Arterial Blood Draw/Perc,3430728,CDM,510,RC,36620,HCPCS,Outpatient,,,117.76,58.88,,105.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,94.21,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,105.98,90,,,Percent of total Billed charges,90% of total billed charges,52.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,114.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,108.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,75.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,92.62,78.65,,,percent of total billed charges,78.65% of total billed charges,105.2,89.33,,,percent of total billed charges,89.33% of total billed charges,105.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.43,70,,,percent of total billed charges,70% of total billed charges,105.98,90,,,percent of total billed charges,90% of total billed charges,111.87,95,,,percent of total billed charges,95% of total billed charges,111.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.27,86,,,percent of total billed charges,86% of total billed charges,94.21,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,114.23,97,,,percent of total billed charges,97% of total billed charges,105.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,114.23,97,,,percent of total billed charges,97% of total billed charges,109.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.58,114.23,
"36620-Arterial cannulation for sampling, monitoring or transfusion",4271177,CDM,481,RC,36620,HCPCS,Outpatient,,,93.92,46.96,,84.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,75.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,84.53,90,,,Percent of total Billed charges,90% of total billed charges,52.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,91.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,86.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,59.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,73.87,78.65,,,percent of total billed charges,78.65% of total billed charges,83.9,89.33,,,percent of total billed charges,89.33% of total billed charges,84.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.74,70,,,percent of total billed charges,70% of total billed charges,84.53,90,,,percent of total billed charges,90% of total billed charges,89.22,95,,,percent of total billed charges,95% of total billed charges,89.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.77,86,,,percent of total billed charges,86% of total billed charges,75.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,91.1,97,,,percent of total billed charges,97% of total billed charges,84.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,91.1,97,,,percent of total billed charges,97% of total billed charges,87.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.58,91.1,
"36620-PF Arterial cannulation for sampling, monitoring or transfusion",4271178,CDM,960,RC,36620,HCPCS,Outpatient,,,93.92,46.96,,84.53,90,,,percent of total billed charges,90% of total Billed charges,88.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.27,155,,,Fee Schedule,155% of CMS OPPS Rate,137.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.08,137.27,
36620-PF ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ,4321445,CDM,981,RC,36620,HCPCS,Outpatient,,,88.6,44.30,,79.74,90,,,percent of total billed charges,90% of total Billed charges,88.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.65,155,,,Fee Schedule,155% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.27,155,,,Fee Schedule,155% of CMS OPPS Rate,137.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.08,137.27,
36680-PF PLACEMENT NEEDLE INTRAOSSEOUS INFUSION,4321657,CDM,981,RC,36680,HCPCS,Outpatient,,,120.02,60.01,,108.02,90,,,percent of total billed charges,90% of total Billed charges,120.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.02,155,,,Fee Schedule,155% of CMS OPPS Rate,60.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,94.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,94.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.02,155,,,Fee Schedule,155% of CMS OPPS Rate,60.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.23,155,,,Fee Schedule,155% of CMS OPPS Rate,186.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,60.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,119.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.56,186.23,
36800- Insert hemodial cannula/vein/vein,3430730,CDM,510,RC,36800,HCPCS,Outpatient,,,322.71,161.36,,290.44,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,258.17,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.44,90,,,Percent of total Billed charges,90% of total billed charges,163.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.03,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,296.89,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,290.44,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,225.9,70,,,percent of total billed charges,70% of total billed charges,290.44,90,,,percent of total billed charges,90% of total billed charges,306.57,95,,,percent of total billed charges,95% of total billed charges,306.57,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,277.53,86,,,percent of total billed charges,86% of total billed charges,258.17,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,313.03,97,,,percent of total billed charges,97% of total billed charges,290.44,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.03,97,,,percent of total billed charges,97% of total billed charges,300.12,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.03,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.57,25056.97,
"36818- Arteriovenous anastomosis, open; by upper arm cephalic vein transposition",3566783,CDM,510,RC,36818,HCPCS,Outpatient,,,1856.79,928.40,,1671.11,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.43,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1671.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1801.09,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1708.25,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1671.11,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1299.75,70,,,percent of total billed charges,70% of total billed charges,1671.11,90,,,percent of total billed charges,90% of total billed charges,1763.95,95,,,percent of total billed charges,95% of total billed charges,1763.95,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1596.84,86,,,percent of total billed charges,86% of total billed charges,1485.43,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1801.09,97,,,percent of total billed charges,97% of total billed charges,1671.11,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1801.09,97,,,percent of total billed charges,97% of total billed charges,1726.81,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1801.09,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1299.75,25056.97,
"36821- Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure",3566784,CDM,510,RC,36821,HCPCS,Outpatient,,,1784.88,892.44,,1606.39,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1427.9,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1606.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1731.33,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.09,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1606.39,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1249.42,70,,,percent of total billed charges,70% of total billed charges,1606.39,90,,,percent of total billed charges,90% of total billed charges,1695.64,95,,,percent of total billed charges,95% of total billed charges,1695.64,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1535,86,,,percent of total billed charges,86% of total billed charges,1427.9,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1731.33,97,,,percent of total billed charges,97% of total billed charges,1606.39,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1731.33,97,,,percent of total billed charges,97% of total billed charges,1659.94,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1731.33,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1249.42,14522.85,
36825 - Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate p,3783259,CDM,510,RC,36825,HCPCS,Outpatient,,,2138.57,1069.29,,1924.71,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.86,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1924.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2074.41,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1967.48,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1924.71,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1497,70,,,percent of total billed charges,70% of total billed charges,1924.71,90,,,percent of total billed charges,90% of total billed charges,2031.64,95,,,percent of total billed charges,95% of total billed charges,2031.64,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1839.17,86,,,percent of total billed charges,86% of total billed charges,1710.86,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2074.41,97,,,percent of total billed charges,97% of total billed charges,1924.71,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2074.41,97,,,percent of total billed charges,97% of total billed charges,1988.87,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2074.41,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1497,25056.97,
36830 - Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate p,3572801,CDM,960,RC,36830,HCPCS,Outpatient,,,1797.79,898.90,,1618.01,90,,,percent of total billed charges,90% of total Billed charges,1341.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,624.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1031.39,155,,,Fee Schedule,155% of CMS OPPS Rate,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1115.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1054.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1054.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,544.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1243.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,913.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1031.39,155,,,Fee Schedule,155% of CMS OPPS Rate,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2079.22,155,,,Fee Schedule,155% of CMS OPPS Rate,2079.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,903.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1395.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544.88,2079.22,
36830-Hero Graft Placement,4233157,CDM,481,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,1269.6,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.54,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.6,90,,,Percent of total Billed charges,90% of total billed charges,687.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1368.35,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1297.82,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1269.6,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,987.47,70,,,percent of total billed charges,70% of total billed charges,1269.6,90,,,percent of total billed charges,90% of total billed charges,1340.14,95,,,percent of total billed charges,95% of total billed charges,1340.14,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1213.18,86,,,percent of total billed charges,86% of total billed charges,1128.54,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1368.35,97,,,percent of total billed charges,97% of total billed charges,1269.6,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368.35,97,,,percent of total billed charges,97% of total billed charges,1311.92,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1368.35,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,624.8,25056.97,
36830-PF Hero Graft Placement,4233158,CDM,960,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,1269.6,90,,,percent of total billed charges,90% of total Billed charges,1341.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,624.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1031.39,155,,,Fee Schedule,155% of CMS OPPS Rate,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1115.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1054.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1054.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,544.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1243.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,913.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1031.39,155,,,Fee Schedule,155% of CMS OPPS Rate,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2079.22,155,,,Fee Schedule,155% of CMS OPPS Rate,2079.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,903.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,665.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1395.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544.88,2079.22,
Hero Graft Placement,,,761,RC,36830,HCPCS,Outpatient,,,1410.67,705.34,,1269.6,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.54,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.6,90,,,Percent of total Billed charges,90% of total billed charges,687.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1368.35,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1297.82,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1269.6,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,987.47,70,,,percent of total billed charges,70% of total billed charges,1269.6,90,,,percent of total billed charges,90% of total billed charges,1340.14,95,,,percent of total billed charges,95% of total billed charges,1340.14,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1213.18,86,,,percent of total billed charges,86% of total billed charges,1128.54,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1368.35,97,,,percent of total billed charges,97% of total billed charges,1269.6,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368.35,97,,,percent of total billed charges,97% of total billed charges,1311.92,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1368.35,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,624.8,25056.97,
36831- Open Thrombectomy of AV Fistula w/o Revision,3430908,CDM,510,RC,36831,HCPCS,Outpatient,,,1656.18,828.09,,1490.56,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1324.94,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1490.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1606.49,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1523.69,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1490.56,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1159.33,70,,,percent of total billed charges,70% of total billed charges,1490.56,90,,,percent of total billed charges,90% of total billed charges,1573.37,95,,,percent of total billed charges,95% of total billed charges,1573.37,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1424.31,86,,,percent of total billed charges,86% of total billed charges,1324.94,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1606.49,97,,,percent of total billed charges,97% of total billed charges,1490.56,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1606.49,97,,,percent of total billed charges,97% of total billed charges,1540.25,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1606.49,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1159.33,25056.97,
36832- Revise/open/AV fist w/o thrombect,3430731,CDM,510,RC,36832,HCPCS,Outpatient,,,2035.14,1017.57,,1831.63,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1628.11,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1831.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1974.09,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1872.33,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1831.63,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1424.6,70,,,percent of total billed charges,70% of total billed charges,1831.63,90,,,percent of total billed charges,90% of total billed charges,1933.38,95,,,percent of total billed charges,95% of total billed charges,1933.38,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1750.22,86,,,percent of total billed charges,86% of total billed charges,1628.11,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1974.09,97,,,percent of total billed charges,97% of total billed charges,1831.63,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1974.09,97,,,percent of total billed charges,97% of total billed charges,1892.68,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1974.09,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1424.6,25056.97,
36833- AV fis revis/open throm/dial gft,3430909,CDM,510,RC,36833,HCPCS,Outpatient,,,2178.25,1089.13,,1960.43,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.6,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2112.9,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.99,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1960.43,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.78,70,,,percent of total billed charges,70% of total billed charges,1960.43,90,,,percent of total billed charges,90% of total billed charges,2069.34,95,,,percent of total billed charges,95% of total billed charges,2069.34,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1873.3,86,,,percent of total billed charges,86% of total billed charges,1742.6,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2112.9,97,,,percent of total billed charges,97% of total billed charges,1960.43,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.9,97,,,percent of total billed charges,97% of total billed charges,2025.77,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2112.9,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1524.78,25056.97,
36861-Insert balloon catheter for declot from dialysis cannula,4271234,CDM,481,RC,36861,HCPCS,Outpatient,,,298.24,149.12,,268.42,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,238.59,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.29,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,274.38,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,268.42,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,208.77,70,,,percent of total billed charges,70% of total billed charges,268.42,90,,,percent of total billed charges,90% of total billed charges,283.33,95,,,percent of total billed charges,95% of total billed charges,283.33,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,256.49,86,,,percent of total billed charges,86% of total billed charges,238.59,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,289.29,97,,,percent of total billed charges,97% of total billed charges,268.42,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.29,97,,,percent of total billed charges,97% of total billed charges,277.36,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,289.29,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,208.77,25056.97,
36861-PF Insert balloon catheter for declot from dialysis cannula,4271235,CDM,960,RC,36861,HCPCS,Outpatient,,,298.24,149.12,,268.42,90,,,percent of total billed charges,90% of total Billed charges,282.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,218.04,155,,,Fee Schedule,155% of CMS OPPS Rate,140.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,220.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,220.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,260.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,218.04,155,,,Fee Schedule,155% of CMS OPPS Rate,140.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.6,155,,,Fee Schedule,155% of CMS OPPS Rate,437.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,140.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,285.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,140.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,313.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,110.38,437.6,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,510,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1600.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.82,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1725.17,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.25,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.97,70,,,percent of total billed charges,70% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.54,86,,,percent of total billed charges,86% of total billed charges,1422.82,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.17,97,,,percent of total billed charges,97% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.17,97,,,percent of total billed charges,97% of total billed charges,1654.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.17,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
36901-Fistulogram Angiography,3431853,CDM,360,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1600.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.82,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1725.17,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.25,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.97,70,,,percent of total billed charges,70% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.54,86,,,percent of total billed charges,86% of total billed charges,1422.82,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.17,97,,,percent of total billed charges,97% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.17,97,,,percent of total billed charges,97% of total billed charges,1654.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.17,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
36901-Fistulogram- Angiography,3560663,CDM,481,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1600.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.82,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1725.17,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.25,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.97,70,,,percent of total billed charges,70% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.54,86,,,percent of total billed charges,86% of total billed charges,1422.82,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.17,97,,,percent of total billed charges,97% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.17,97,,,percent of total billed charges,97% of total billed charges,1654.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.17,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
36901-Fistulogram LT,3431854,CDM,481,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1600.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.82,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1725.17,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.25,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.97,70,,,percent of total billed charges,70% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.54,86,,,percent of total billed charges,86% of total billed charges,1422.82,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.17,97,,,percent of total billed charges,97% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.17,97,,,percent of total billed charges,97% of total billed charges,1654.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.17,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
36901-Fistulogram RT,3431855,CDM,360,RC,36901,HCPCS,Outpatient,,,1778.53,889.27,,1600.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.82,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1725.17,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.25,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.97,70,,,percent of total billed charges,70% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1689.6,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.54,86,,,percent of total billed charges,86% of total billed charges,1422.82,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.17,97,,,percent of total billed charges,97% of total billed charges,1600.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.17,97,,,percent of total billed charges,97% of total billed charges,1654.03,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.17,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
Fistulogram LT,,,761,RC,36901,HCPCS,Outpatient,,,1699.64,849.82,,1529.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1648.65,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.67,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.75,70,,,percent of total billed charges,70% of total billed charges,1529.68,90,,,percent of total billed charges,90% of total billed charges,1614.66,95,,,percent of total billed charges,95% of total billed charges,1614.66,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.69,86,,,percent of total billed charges,86% of total billed charges,1359.71,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.65,97,,,percent of total billed charges,97% of total billed charges,1529.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.65,97,,,percent of total billed charges,97% of total billed charges,1580.67,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1648.65,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
Fistulogram RT,,,761,RC,36901,HCPCS,Outpatient,,,1699.64,849.82,,1529.68,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.71,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.68,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1648.65,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.67,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.75,70,,,percent of total billed charges,70% of total billed charges,1529.68,90,,,percent of total billed charges,90% of total billed charges,1614.66,95,,,percent of total billed charges,95% of total billed charges,1614.66,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.69,86,,,percent of total billed charges,86% of total billed charges,1359.71,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.65,97,,,percent of total billed charges,97% of total billed charges,1529.68,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.65,97,,,percent of total billed charges,97% of total billed charges,1580.67,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1648.65,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,510,RC,36902,HCPCS,Outpatient,,,3038.33,1519.17,,2734.5,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2430.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2734.5,90,,,Percent of total Billed charges,90% of total billed charges,195.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2947.18,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2795.26,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2734.5,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.83,70,,,percent of total billed charges,70% of total billed charges,2734.5,90,,,percent of total billed charges,90% of total billed charges,2886.41,95,,,percent of total billed charges,95% of total billed charges,2886.41,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2612.96,86,,,percent of total billed charges,86% of total billed charges,2430.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2947.18,97,,,percent of total billed charges,97% of total billed charges,2734.5,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2947.18,97,,,percent of total billed charges,97% of total billed charges,2825.65,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2947.18,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.66,25425.73,
36902-Fistulogram PTA,3431856,CDM,481,RC,36902,HCPCS,Outpatient,,,3038.33,1519.17,,2734.5,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2430.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2734.5,90,,,Percent of total Billed charges,90% of total billed charges,195.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2947.18,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2795.26,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2734.5,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.83,70,,,percent of total billed charges,70% of total billed charges,2734.5,90,,,percent of total billed charges,90% of total billed charges,2886.41,95,,,percent of total billed charges,95% of total billed charges,2886.41,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2612.96,86,,,percent of total billed charges,86% of total billed charges,2430.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2947.18,97,,,percent of total billed charges,97% of total billed charges,2734.5,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2947.18,97,,,percent of total billed charges,97% of total billed charges,2825.65,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2947.18,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.66,25425.73,
Fistulogram PTA,,,761,RC,36902,HCPCS,Outpatient,,,2890.83,1445.42,,2601.75,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2312.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2601.75,90,,,Percent of total Billed charges,90% of total billed charges,195.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2804.11,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2659.56,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2601.75,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2023.58,70,,,percent of total billed charges,70% of total billed charges,2601.75,90,,,percent of total billed charges,90% of total billed charges,2746.29,95,,,percent of total billed charges,95% of total billed charges,2746.29,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2486.11,86,,,percent of total billed charges,86% of total billed charges,2312.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2804.11,97,,,percent of total billed charges,97% of total billed charges,2601.75,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2804.11,97,,,percent of total billed charges,97% of total billed charges,2688.47,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2804.11,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.66,25425.73,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,510,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,9674.06,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8599.16,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9674.06,90,,,Percent of total Billed charges,90% of total billed charges,267.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10426.48,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9889.03,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7524.27,70,,,percent of total billed charges,70% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9244.1,86,,,percent of total billed charges,86% of total billed charges,8599.16,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10426.48,97,,,percent of total billed charges,97% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10426.48,97,,,percent of total billed charges,97% of total billed charges,9996.52,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10426.48,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243.21,51750.98,
36903-Fistulogram Stent w PTA,3431857,CDM,481,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,9674.06,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8599.16,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9674.06,90,,,Percent of total Billed charges,90% of total billed charges,267.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10426.48,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9889.03,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7524.27,70,,,percent of total billed charges,70% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9244.1,86,,,percent of total billed charges,86% of total billed charges,8599.16,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10426.48,97,,,percent of total billed charges,97% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10426.48,97,,,percent of total billed charges,97% of total billed charges,9996.52,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10426.48,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243.21,51750.98,
36903-Tib/Peroneal PTA Unilateral,3560661,CDM,481,RC,36903,HCPCS,Outpatient,,,10748.95,5374.48,,9674.06,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8599.16,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9674.06,90,,,Percent of total Billed charges,90% of total billed charges,267.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10426.48,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9889.03,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7524.27,70,,,percent of total billed charges,70% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,10211.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9244.1,86,,,percent of total billed charges,86% of total billed charges,8599.16,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10426.48,97,,,percent of total billed charges,97% of total billed charges,9674.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10426.48,97,,,percent of total billed charges,97% of total billed charges,9996.52,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10426.48,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243.21,51750.98,
Fistulogram Stent w PTA,,,761,RC,36903,HCPCS,Outpatient,,,10078.59,5039.30,,9070.73,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8062.87,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9070.73,90,,,Percent of total Billed charges,90% of total billed charges,267.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9776.23,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9272.3,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9070.73,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7055.01,70,,,percent of total billed charges,70% of total billed charges,9070.73,90,,,percent of total billed charges,90% of total billed charges,9574.66,95,,,percent of total billed charges,95% of total billed charges,9574.66,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8667.59,86,,,percent of total billed charges,86% of total billed charges,8062.87,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9776.23,97,,,percent of total billed charges,97% of total billed charges,9070.73,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9776.23,97,,,percent of total billed charges,97% of total billed charges,9373.09,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9776.23,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243.21,51750.98,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,4541.32,2270.66,,4087.19,90,,,percent of total billed charges,90% of total Billed charges,2070.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,280.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,617.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,299.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,681.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3209.79,155,,,Fee Schedule,155% of CMS OPPS Rate,3209.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1869.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.06,4087.19,
36904-Fistulogram Thrombectomy,3431858,CDM,481,RC,36904,HCPCS,Outpatient,,,4541.32,2270.66,,4087.19,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3633.06,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4087.19,90,,,Percent of total Billed charges,90% of total billed charges,308.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4405.08,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4178.01,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4087.19,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3178.92,70,,,percent of total billed charges,70% of total billed charges,4087.19,90,,,percent of total billed charges,90% of total billed charges,4314.25,95,,,percent of total billed charges,95% of total billed charges,4314.25,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3905.54,86,,,percent of total billed charges,86% of total billed charges,3633.06,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4405.08,97,,,percent of total billed charges,97% of total billed charges,4087.19,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4405.08,97,,,percent of total billed charges,97% of total billed charges,4223.43,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4405.08,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,280.06,25425.73,
Fistulogram Thrombectomy,,,761,RC,36904,HCPCS,Outpatient,,,4342.64,2171.32,,3908.38,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3474.11,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3908.38,90,,,Percent of total Billed charges,90% of total billed charges,308.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4212.36,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3995.23,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3908.38,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3039.85,70,,,percent of total billed charges,70% of total billed charges,3908.38,90,,,percent of total billed charges,90% of total billed charges,4125.51,95,,,percent of total billed charges,95% of total billed charges,4125.51,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3734.67,86,,,percent of total billed charges,86% of total billed charges,3474.11,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4212.36,97,,,percent of total billed charges,97% of total billed charges,3908.38,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4212.36,97,,,percent of total billed charges,97% of total billed charges,4038.66,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4212.36,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,280.06,25425.73,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,510,RC,36905,HCPCS,Outpatient,,,5747.99,2874.00,,5173.19,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4598.39,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5173.19,90,,,Percent of total Billed charges,90% of total billed charges,386.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5575.55,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5288.15,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5173.19,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4023.59,70,,,percent of total billed charges,70% of total billed charges,5173.19,90,,,percent of total billed charges,90% of total billed charges,5460.59,95,,,percent of total billed charges,95% of total billed charges,5460.59,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4943.27,86,,,percent of total billed charges,86% of total billed charges,4598.39,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5575.55,97,,,percent of total billed charges,97% of total billed charges,5173.19,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5575.55,97,,,percent of total billed charges,97% of total billed charges,5345.63,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5575.55,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,351.53,51750.98,
36905-Fistulogram with Balloon PTA,3431859,CDM,481,RC,36905,HCPCS,Outpatient,,,5747.99,2874.00,,5173.19,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4598.39,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5173.19,90,,,Percent of total Billed charges,90% of total billed charges,386.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5575.55,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5288.15,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5173.19,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4023.59,70,,,percent of total billed charges,70% of total billed charges,5173.19,90,,,percent of total billed charges,90% of total billed charges,5460.59,95,,,percent of total billed charges,95% of total billed charges,5460.59,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4943.27,86,,,percent of total billed charges,86% of total billed charges,4598.39,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5575.55,97,,,percent of total billed charges,97% of total billed charges,5173.19,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5575.55,97,,,percent of total billed charges,97% of total billed charges,5345.63,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5575.55,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,351.53,51750.98,
Fistulogram with Balloon PTA,,,761,RC,36905,HCPCS,Outpatient,,,5457.49,2728.75,,4911.74,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4365.99,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4911.74,90,,,Percent of total Billed charges,90% of total billed charges,386.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5293.77,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5020.89,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4911.74,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3820.24,70,,,percent of total billed charges,70% of total billed charges,4911.74,90,,,percent of total billed charges,90% of total billed charges,5184.62,95,,,percent of total billed charges,95% of total billed charges,5184.62,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4693.44,86,,,percent of total billed charges,86% of total billed charges,4365.99,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5293.77,97,,,percent of total billed charges,97% of total billed charges,4911.74,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5293.77,97,,,percent of total billed charges,97% of total billed charges,5075.47,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5293.77,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,351.53,51750.98,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,13628.47,6814.24,,12265.62,90,,,percent of total billed charges,90% of total Billed charges,5627.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,410.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,438.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,631.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,8723.28,155,,,Fee Schedule,155% of CMS OPPS Rate,8723.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7079.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.24,12265.62,
36906-Fistulogram with Intravascular Stent,3431860,CDM,481,RC,36906,HCPCS,Outpatient,,,13628.47,6814.24,,12265.62,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10902.78,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,12265.62,90,,,Percent of total Billed charges,90% of total billed charges,451.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13219.62,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,12538.19,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12265.62,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9539.93,70,,,percent of total billed charges,70% of total billed charges,12265.62,90,,,percent of total billed charges,90% of total billed charges,12947.05,95,,,percent of total billed charges,95% of total billed charges,12947.05,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11720.48,86,,,percent of total billed charges,86% of total billed charges,10902.78,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13219.62,97,,,percent of total billed charges,97% of total billed charges,12265.62,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,13219.62,97,,,percent of total billed charges,97% of total billed charges,12674.48,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13219.62,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,410.24,83742.97,
Fistulogram with Intravascular Stent,,,761,RC,36906,HCPCS,Outpatient,,,12816.51,6408.26,,11534.86,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,10253.21,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,11534.86,90,,,Percent of total Billed charges,90% of total billed charges,451.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12432.01,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,11791.19,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11534.86,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8971.56,70,,,percent of total billed charges,70% of total billed charges,11534.86,90,,,percent of total billed charges,90% of total billed charges,12175.68,95,,,percent of total billed charges,95% of total billed charges,12175.68,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11022.2,86,,,percent of total billed charges,86% of total billed charges,10253.21,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12432.01,97,,,percent of total billed charges,97% of total billed charges,11534.86,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,12432.01,97,,,percent of total billed charges,97% of total billed charges,11919.35,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12432.01,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,410.24,83742.97,
36907-Add On Code: Dialysis Circuit PTA In Central Segment,4271179,CDM,481,RC,36907,HCPCS,Outpatient,,,1140.28,570.14,,1026.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,912.22,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1026.25,90,,,Percent of total Billed charges,90% of total billed charges,112.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1106.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1049.06,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,728.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,896.86,78.65,,,percent of total billed charges,78.65% of total billed charges,1018.63,89.33,,,percent of total billed charges,89.33% of total billed charges,1026.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,798.2,70,,,percent of total billed charges,70% of total billed charges,1026.25,90,,,percent of total billed charges,90% of total billed charges,1083.27,95,,,percent of total billed charges,95% of total billed charges,1083.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,980.64,86,,,percent of total billed charges,86% of total billed charges,912.22,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1106.07,97,,,percent of total billed charges,97% of total billed charges,1026.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1106.07,97,,,percent of total billed charges,97% of total billed charges,1060.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1106.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,1106.07,
36907-PF Add On Code: Dialysis Circuit PTA In Central Segment,4271180,CDM,960,RC,36907,HCPCS,Outpatient,,,1140.28,570.14,,1026.25,90,,,percent of total billed charges,90% of total Billed charges,705.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,223.87,155,,,Fee Schedule,155% of CMS OPPS Rate,144.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,181.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,223.87,155,,,Fee Schedule,155% of CMS OPPS Rate,144.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1094.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,144.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,766.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,144.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,1094.28,
"z36907- TBA, central dialysis seg, perf thru dialysis circ",3569473,CDM,510,RC,36907,HCPCS,Outpatient,,,1493.4,746.70,,1344.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1194.72,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1344.06,90,,,Percent of total Billed charges,90% of total billed charges,112.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1448.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1373.93,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,953.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1174.59,78.65,,,percent of total billed charges,78.65% of total billed charges,1334.08,89.33,,,percent of total billed charges,89.33% of total billed charges,1344.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1045.38,70,,,percent of total billed charges,70% of total billed charges,1344.06,90,,,percent of total billed charges,90% of total billed charges,1418.73,95,,,percent of total billed charges,95% of total billed charges,1418.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1284.32,86,,,percent of total billed charges,86% of total billed charges,1194.72,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1448.6,97,,,percent of total billed charges,97% of total billed charges,1344.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1448.6,97,,,percent of total billed charges,97% of total billed charges,1388.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1448.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.38,1448.6,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,510,RC,36908,HCPCS,Outpatient,,,3568.15,1784.08,,3211.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2854.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3211.34,90,,,Percent of total Billed charges,90% of total billed charges,168.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3461.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3282.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2278.7,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2806.43,78.65,,,percent of total billed charges,78.65% of total billed charges,3187.49,89.33,,,percent of total billed charges,89.33% of total billed charges,3211.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2497.71,70,,,percent of total billed charges,70% of total billed charges,3211.34,90,,,percent of total billed charges,90% of total billed charges,3389.74,95,,,percent of total billed charges,95% of total billed charges,3389.74,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3068.61,86,,,percent of total billed charges,86% of total billed charges,2854.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3461.11,97,,,percent of total billed charges,97% of total billed charges,3211.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3461.11,97,,,percent of total billed charges,97% of total billed charges,3318.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3461.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,3461.11,
36908-Add On Code: Dialysis Circuit Stent In Central Segment,4271181,CDM,481,RC,36908,HCPCS,Outpatient,,,2698.57,1349.29,,2428.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2158.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2428.71,90,,,Percent of total Billed charges,90% of total billed charges,168.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2617.61,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2482.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1723.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2122.48,78.65,,,percent of total billed charges,78.65% of total billed charges,2410.68,89.33,,,percent of total billed charges,89.33% of total billed charges,2428.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1889,70,,,percent of total billed charges,70% of total billed charges,2428.71,90,,,percent of total billed charges,90% of total billed charges,2563.64,95,,,percent of total billed charges,95% of total billed charges,2563.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2320.77,86,,,percent of total billed charges,86% of total billed charges,2158.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2617.61,97,,,percent of total billed charges,97% of total billed charges,2428.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2617.61,97,,,percent of total billed charges,97% of total billed charges,2509.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2617.61,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,2617.61,
36908-PF Add On Code: Dialysis Circuit Stent In Central Segment,4271182,CDM,960,RC,36908,HCPCS,Outpatient,,,2698.57,1349.29,,2428.71,90,,,percent of total billed charges,90% of total Billed charges,1546.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,153.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,317.02,155,,,Fee Schedule,155% of CMS OPPS Rate,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,325.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,325.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,164.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,384.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,262.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,317.02,155,,,Fee Schedule,155% of CMS OPPS Rate,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2396.73,155,,,Fee Schedule,155% of CMS OPPS Rate,2396.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2805.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,2805.13,
36909-Dialysis Circuit- Embolization,4217147,CDM,481,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,3261.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2898.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3261.1,90,,,Percent of total Billed charges,90% of total billed charges,160.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3514.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3333.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2314.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2849.92,78.65,,,percent of total billed charges,78.65% of total billed charges,3236.88,89.33,,,percent of total billed charges,89.33% of total billed charges,3261.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2536.41,70,,,percent of total billed charges,70% of total billed charges,3261.1,90,,,percent of total billed charges,90% of total billed charges,3442.27,95,,,percent of total billed charges,95% of total billed charges,3442.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3116.16,86,,,percent of total billed charges,86% of total billed charges,2898.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3514.74,97,,,percent of total billed charges,97% of total billed charges,3261.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3514.74,97,,,percent of total billed charges,97% of total billed charges,3369.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3514.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.66,3514.74,
36909-PF Dialysis Circuit- Embolization,4217148,CDM,960,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,3261.1,90,,,percent of total billed charges,90% of total Billed charges,2019.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,308.85,155,,,Fee Schedule,155% of CMS OPPS Rate,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,335.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,315.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,315.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.85,155,,,Fee Schedule,155% of CMS OPPS Rate,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3130.75,155,,,Fee Schedule,155% of CMS OPPS Rate,3130.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2048.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.66,3261.1,
Dialysis Circuit- Embolization,4217149,CDM,960,RC,36909,HCPCS,Outpatient,,,3623.44,1811.72,,3261.1,90,,,percent of total billed charges,90% of total Billed charges,2019.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,308.85,155,,,Fee Schedule,155% of CMS OPPS Rate,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,335.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,335.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,315.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,315.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.85,155,,,Fee Schedule,155% of CMS OPPS Rate,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3130.75,155,,,Fee Schedule,155% of CMS OPPS Rate,3130.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2048.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,199.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.66,3261.1,
37184- Thromb/perc/translu/thromb inj/ini,3430910,CDM,510,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3932.85,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.86,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3932.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4238.74,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4020.24,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3058.88,70,,,percent of total billed charges,70% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3758.05,86,,,percent of total billed charges,86% of total billed charges,3495.86,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4238.74,97,,,percent of total billed charges,97% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4238.74,97,,,percent of total billed charges,97% of total billed charges,4063.94,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4238.74,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3058.88,51750.98,
37184-Peripheral Thrombectomy,3560669,CDM,481,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3932.85,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.86,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3932.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4238.74,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4020.24,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3058.88,70,,,percent of total billed charges,70% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3758.05,86,,,percent of total billed charges,86% of total billed charges,3495.86,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4238.74,97,,,percent of total billed charges,97% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4238.74,97,,,percent of total billed charges,97% of total billed charges,4063.94,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4238.74,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3058.88,51750.98,
37184-Peripheral Thrombectomy Arterial,3431861,CDM,360,RC,37184,HCPCS,Outpatient,,,4369.83,2184.92,,3932.85,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3495.86,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3932.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4238.74,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4020.24,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3058.88,70,,,percent of total billed charges,70% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,4151.34,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3758.05,86,,,percent of total billed charges,86% of total billed charges,3495.86,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4238.74,97,,,percent of total billed charges,97% of total billed charges,3932.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4238.74,97,,,percent of total billed charges,97% of total billed charges,4063.94,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4238.74,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3058.88,51750.98,
Peripheral Thrombectomy Arterial,,,761,RC,37184,HCPCS,Outpatient,,,4141,2070.50,,3726.9,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3312.8,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3726.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4016.77,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3809.72,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3726.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2898.7,70,,,percent of total billed charges,70% of total billed charges,3726.9,90,,,percent of total billed charges,90% of total billed charges,3933.95,95,,,percent of total billed charges,95% of total billed charges,3933.95,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3561.26,86,,,percent of total billed charges,86% of total billed charges,3312.8,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4016.77,97,,,percent of total billed charges,97% of total billed charges,3726.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4016.77,97,,,percent of total billed charges,97% of total billed charges,3851.13,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4016.77,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2898.7,51750.98,
"37185 - Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, ar",3800923,CDM,983,RC,37185,HCPCS,Outpatient,,,1213.19,606.60,,1091.87,90,,,percent of total billed charges,90% of total Billed charges,619.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,252.54,155,,,Fee Schedule,155% of CMS OPPS Rate,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,274.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,260.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,260.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,252.54,155,,,Fee Schedule,155% of CMS OPPS Rate,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,959.65,155,,,Fee Schedule,155% of CMS OPPS Rate,959.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1078.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1449.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,134.93,1449.08,
37185-Periph Thrombectomy Art same add vessel,3431862,CDM,481,RC,37185,HCPCS,Outpatient,,,1213.19,606.60,,1091.87,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,970.55,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1091.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.79,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1116.13,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,774.77,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,954.2,78.65,,,percent of total billed charges,78.65% of total billed charges,1083.76,89.33,,,percent of total billed charges,89.33% of total billed charges,1091.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,849.23,70,,,percent of total billed charges,70% of total billed charges,1091.87,90,,,percent of total billed charges,90% of total billed charges,1152.53,95,,,percent of total billed charges,95% of total billed charges,1152.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1043.34,86,,,percent of total billed charges,86% of total billed charges,970.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1176.79,97,,,percent of total billed charges,97% of total billed charges,1091.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.79,97,,,percent of total billed charges,97% of total billed charges,1128.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.79,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.77,1176.79,
Periph Thrombectomy Art same add vessel,3427279,CDM,960,RC,37185,HCPCS,Outpatient,,,1160.81,580.41,,1044.73,90,,,percent of total billed charges,90% of total Billed charges,619.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,252.54,155,,,Fee Schedule,155% of CMS OPPS Rate,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,274.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,260.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,260.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,252.54,155,,,Fee Schedule,155% of CMS OPPS Rate,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,959.65,155,,,Fee Schedule,155% of CMS OPPS Rate,959.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1078.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1449.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,134.93,1449.08,
37186-Periph Thrombectomy Art second vessel,3431863,CDM,481,RC,37186,HCPCS,Outpatient,,,3014.93,1507.47,,2713.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2411.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2713.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2924.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2773.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1925.4,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2371.31,78.65,,,percent of total billed charges,78.65% of total billed charges,2693.29,89.33,,,percent of total billed charges,89.33% of total billed charges,2713.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2110.45,70,,,percent of total billed charges,70% of total billed charges,2713.44,90,,,percent of total billed charges,90% of total billed charges,2864.18,95,,,percent of total billed charges,95% of total billed charges,2864.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2592.84,86,,,percent of total billed charges,86% of total billed charges,2411.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2924.48,97,,,percent of total billed charges,97% of total billed charges,2713.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2924.48,97,,,percent of total billed charges,97% of total billed charges,2803.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2924.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1925.4,2924.48,
37186-PF Periph Thrombectomy Art second vessel,3580886,CDM,960,RC,37186,HCPCS,Outpatient,,,3014.93,1507.47,,2713.44,90,,,percent of total billed charges,90% of total Billed charges,1376.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,202.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,376.01,155,,,Fee Schedule,155% of CMS OPPS Rate,242.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,242.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,407.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,386.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,386.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,200.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,456.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,325.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,376.01,155,,,Fee Schedule,155% of CMS OPPS Rate,242.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,2133.28,155,,,Fee Schedule,155% of CMS OPPS Rate,2133.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,242.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2075.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,242.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,2726.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2726.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,200.02,2726.12,
37187- Thrombectomy/mechanical/venous,3430911,CDM,360,RC,37187,HCPCS,Outpatient,,,4355.74,2177.87,,3920.17,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3484.59,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3920.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4225.07,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4007.28,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3920.17,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3049.02,70,,,percent of total billed charges,70% of total billed charges,3920.17,90,,,percent of total billed charges,90% of total billed charges,4137.95,95,,,percent of total billed charges,95% of total billed charges,4137.95,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3745.94,86,,,percent of total billed charges,86% of total billed charges,3484.59,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4225.07,97,,,percent of total billed charges,97% of total billed charges,3920.17,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4225.07,97,,,percent of total billed charges,97% of total billed charges,4050.84,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4225.07,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3049.02,51750.98,
37187-Thrombectomy Venous,3431864,CDM,481,RC,37187,HCPCS,Outpatient,,,4355.74,2177.87,,3920.17,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3484.59,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3920.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4225.07,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4007.28,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3920.17,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3049.02,70,,,percent of total billed charges,70% of total billed charges,3920.17,90,,,percent of total billed charges,90% of total billed charges,4137.95,95,,,percent of total billed charges,95% of total billed charges,4137.95,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3745.94,86,,,percent of total billed charges,86% of total billed charges,3484.59,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4225.07,97,,,percent of total billed charges,97% of total billed charges,3920.17,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4225.07,97,,,percent of total billed charges,97% of total billed charges,4050.84,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4225.07,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3049.02,51750.98,
Thrombectomy Venous,,,761,RC,37187,HCPCS,Outpatient,,,4104.53,2052.27,,3694.08,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3283.62,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3694.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3981.39,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3776.17,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3694.08,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2873.17,70,,,percent of total billed charges,70% of total billed charges,3694.08,90,,,percent of total billed charges,90% of total billed charges,3899.3,95,,,percent of total billed charges,95% of total billed charges,3899.3,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3529.9,86,,,percent of total billed charges,86% of total billed charges,3283.62,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3981.39,97,,,percent of total billed charges,97% of total billed charges,3694.08,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3981.39,97,,,percent of total billed charges,97% of total billed charges,3817.21,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3981.39,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2873.17,51750.98,
37188-Thombectomy Venous repeat tx,3431865,CDM,481,RC,37188,HCPCS,Outpatient,,,3700.78,1850.39,,3330.7,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2960.62,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3330.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3589.76,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3404.72,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3330.7,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2590.55,70,,,percent of total billed charges,70% of total billed charges,3330.7,90,,,percent of total billed charges,90% of total billed charges,3515.74,95,,,percent of total billed charges,95% of total billed charges,3515.74,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3182.67,86,,,percent of total billed charges,86% of total billed charges,2960.62,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3589.76,97,,,percent of total billed charges,97% of total billed charges,3330.7,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3589.76,97,,,percent of total billed charges,97% of total billed charges,3441.73,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3589.76,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
Thombectomy Venous repeat tx,,,761,RC,37188,HCPCS,Outpatient,,,3523.84,1761.92,,3171.46,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2819.07,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3171.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3418.12,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3241.93,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3171.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2466.69,70,,,percent of total billed charges,70% of total billed charges,3171.46,90,,,percent of total billed charges,90% of total billed charges,3347.65,95,,,percent of total billed charges,95% of total billed charges,3347.65,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3030.5,86,,,percent of total billed charges,86% of total billed charges,2819.07,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3418.12,97,,,percent of total billed charges,97% of total billed charges,3171.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3418.12,97,,,percent of total billed charges,97% of total billed charges,3277.17,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3418.12,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
"37191- Insert IVC filter, endovascular",3430732,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,4585.82,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4076.29,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4585.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4942.5,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.73,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3566.75,70,,,percent of total billed charges,70% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4382.01,86,,,percent of total billed charges,86% of total billed charges,4076.29,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4942.5,97,,,percent of total billed charges,97% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4942.5,97,,,percent of total billed charges,97% of total billed charges,4738.68,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4942.5,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3566.75,25056.97,
37191-IVC Filter Insertion,3431866,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,4585.82,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4076.29,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4585.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4942.5,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.73,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3566.75,70,,,percent of total billed charges,70% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4382.01,86,,,percent of total billed charges,86% of total billed charges,4076.29,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4942.5,97,,,percent of total billed charges,97% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4942.5,97,,,percent of total billed charges,97% of total billed charges,4738.68,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4942.5,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3566.75,25056.97,
37191-IVC Filter with S&I,3560667,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,4585.82,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4076.29,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4585.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4942.5,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.73,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3566.75,70,,,percent of total billed charges,70% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4382.01,86,,,percent of total billed charges,86% of total billed charges,4076.29,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4942.5,97,,,percent of total billed charges,97% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4942.5,97,,,percent of total billed charges,97% of total billed charges,4738.68,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4942.5,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3566.75,25056.97,
37191-IVC insertion,3431867,CDM,481,RC,37191,HCPCS,Outpatient,,,5095.36,2547.68,,4585.82,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4076.29,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4585.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4942.5,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4687.73,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3566.75,70,,,percent of total billed charges,70% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4840.59,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4382.01,86,,,percent of total billed charges,86% of total billed charges,4076.29,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4942.5,97,,,percent of total billed charges,97% of total billed charges,4585.82,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4942.5,97,,,percent of total billed charges,97% of total billed charges,4738.68,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4942.5,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3566.75,25056.97,
IVC Filter Insertion,,,761,RC,37191,HCPCS,Outpatient,,,4818.95,2409.48,,4337.06,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3855.16,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4337.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4674.38,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4433.43,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4337.06,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3373.27,70,,,percent of total billed charges,70% of total billed charges,4337.06,90,,,percent of total billed charges,90% of total billed charges,4578,95,,,percent of total billed charges,95% of total billed charges,4578,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4144.3,86,,,percent of total billed charges,86% of total billed charges,3855.16,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4674.38,97,,,percent of total billed charges,97% of total billed charges,4337.06,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4674.38,97,,,percent of total billed charges,97% of total billed charges,4481.62,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4674.38,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3373.27,25056.97,
Read,597013,CDM,972,RC,37191,HCPCS,Outpatient,,,1927.58,963.79,,1734.82,90,,,percent of total billed charges,90% of total Billed charges,2134.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,191.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,338.24,155,,,Fee Schedule,155% of CMS OPPS Rate,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,347.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,347.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,436.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,410.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,274.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,338.24,155,,,Fee Schedule,155% of CMS OPPS Rate,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,3308.07,155,,,Fee Schedule,155% of CMS OPPS Rate,3308.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2287.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.12,3308.07,
37192-IVC Filter Reposition,3431868,CDM,481,RC,37192,HCPCS,Outpatient,,,3269.03,1634.52,,2942.13,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2615.22,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2942.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3170.96,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3007.51,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2942.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2288.32,70,,,percent of total billed charges,70% of total billed charges,2942.13,90,,,percent of total billed charges,90% of total billed charges,3105.58,95,,,percent of total billed charges,95% of total billed charges,3105.58,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2811.37,86,,,percent of total billed charges,86% of total billed charges,2615.22,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3170.96,97,,,percent of total billed charges,97% of total billed charges,2942.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3170.96,97,,,percent of total billed charges,97% of total billed charges,3040.2,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3170.96,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2288.32,14522.85,
37192-IVC reposition,3431869,CDM,481,RC,37192,HCPCS,Outpatient,,,3269.03,1634.52,,2942.13,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2615.22,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2942.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3170.96,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3007.51,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2942.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2288.32,70,,,percent of total billed charges,70% of total billed charges,2942.13,90,,,percent of total billed charges,90% of total billed charges,3105.58,95,,,percent of total billed charges,95% of total billed charges,3105.58,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2811.37,86,,,percent of total billed charges,86% of total billed charges,2615.22,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3170.96,97,,,percent of total billed charges,97% of total billed charges,2942.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3170.96,97,,,percent of total billed charges,97% of total billed charges,3040.2,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3170.96,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2288.32,14522.85,
IVC Filter Reposition,,,761,RC,37192,HCPCS,Outpatient,,,3120.64,1560.32,,2808.58,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2496.51,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2808.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3027.02,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2870.99,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2808.58,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2184.45,70,,,percent of total billed charges,70% of total billed charges,2808.58,90,,,percent of total billed charges,90% of total billed charges,2964.61,95,,,percent of total billed charges,95% of total billed charges,2964.61,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2683.75,86,,,percent of total billed charges,86% of total billed charges,2496.51,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3027.02,97,,,percent of total billed charges,97% of total billed charges,2808.58,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.02,97,,,percent of total billed charges,97% of total billed charges,2902.2,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3027.02,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2184.45,14522.85,
37193- Remove IVC filter,3430912,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,3398.85,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3021.2,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3398.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3663.21,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3474.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2643.55,70,,,percent of total billed charges,70% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3247.79,86,,,percent of total billed charges,86% of total billed charges,3021.2,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3663.21,97,,,percent of total billed charges,97% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3663.21,97,,,percent of total billed charges,97% of total billed charges,3512.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3663.21,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
37193-IVC Filter Removal,3431870,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,3398.85,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3021.2,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3398.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3663.21,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3474.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2643.55,70,,,percent of total billed charges,70% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3247.79,86,,,percent of total billed charges,86% of total billed charges,3021.2,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3663.21,97,,,percent of total billed charges,97% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3663.21,97,,,percent of total billed charges,97% of total billed charges,3512.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3663.21,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
37193-IVC removal,3431871,CDM,481,RC,37193,HCPCS,Outpatient,,,3776.5,1888.25,,3398.85,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3021.2,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3398.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3663.21,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3474.38,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2643.55,70,,,percent of total billed charges,70% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,3587.68,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3247.79,86,,,percent of total billed charges,86% of total billed charges,3021.2,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3663.21,97,,,percent of total billed charges,97% of total billed charges,3398.85,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3663.21,97,,,percent of total billed charges,97% of total billed charges,3512.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3663.21,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
IVC Filter Removal,,,761,RC,37193,HCPCS,Outpatient,,,3613.38,1806.69,,3252.04,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2890.7,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3252.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3504.98,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3324.31,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3252.04,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2529.37,70,,,percent of total billed charges,70% of total billed charges,3252.04,90,,,percent of total billed charges,90% of total billed charges,3432.71,95,,,percent of total billed charges,95% of total billed charges,3432.71,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3107.51,86,,,percent of total billed charges,86% of total billed charges,2890.7,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3504.98,97,,,percent of total billed charges,97% of total billed charges,3252.04,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3504.98,97,,,percent of total billed charges,97% of total billed charges,3360.44,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3504.98,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,14522.85,
"37195 - Thrombolysis, cerebral, by intravenous infusion",3999137,CDM,960,RC,37195,HCPCS,Outpatient,,,865.98,432.99,,779.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1183.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1331.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1331.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1430.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1430.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.73,1430.75,
37195-PF THROMBOLYSIS CEREBRAL IV INFUSION,4321446,CDM,981,RC,37195,HCPCS,Outpatient,,,1045,522.50,,940.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1183.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1331.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1331.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1430.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1430.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.73,1430.75,
37197-Foreign Body Removal,3431872,CDM,481,RC,37197,HCPCS,Outpatient,,,3929.59,1964.80,,3536.63,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3143.67,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3536.63,90,,,Percent of total Billed charges,90% of total billed charges,266.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3811.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3615.22,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3536.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2750.71,70,,,percent of total billed charges,70% of total billed charges,3536.63,90,,,percent of total billed charges,90% of total billed charges,3733.11,95,,,percent of total billed charges,95% of total billed charges,3733.11,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3379.45,86,,,percent of total billed charges,86% of total billed charges,3143.67,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3811.7,97,,,percent of total billed charges,97% of total billed charges,3536.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3811.7,97,,,percent of total billed charges,97% of total billed charges,3654.52,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3811.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,242.3,14522.85,
37197-PF Foreign Body Removal,3580887,CDM,960,RC,37197,HCPCS,Outpatient,,,3929.59,1964.80,,3536.63,90,,,percent of total billed charges,90% of total Billed charges,1774.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,296.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,459.9,155,,,Fee Schedule,155% of CMS OPPS Rate,296.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,446.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,502.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,471.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,471.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,257.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,378.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,459.9,155,,,Fee Schedule,155% of CMS OPPS Rate,296.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2750.27,155,,,Fee Schedule,155% of CMS OPPS Rate,2750.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,296.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1366.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,296.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.3,3536.63,
37211- Thrombolysis/artery/S&I/initial tx,3430734,CDM,510,RC,37211,HCPCS,Outpatient,,,1033.38,516.69,,930.04,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,826.7,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.04,90,,,Percent of total Billed charges,90% of total billed charges,356.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1002.38,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,950.71,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.04,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,723.37,70,,,percent of total billed charges,70% of total billed charges,930.04,90,,,percent of total billed charges,90% of total billed charges,981.71,95,,,percent of total billed charges,95% of total billed charges,981.71,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.71,86,,,percent of total billed charges,86% of total billed charges,826.7,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.38,97,,,percent of total billed charges,97% of total billed charges,930.04,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.38,97,,,percent of total billed charges,97% of total billed charges,961.04,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1002.38,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,323.85,25056.97,
37211-Periph Thrombolysis Insertion Artery,3431873,CDM,481,RC,37211,HCPCS,Outpatient,,,1033.38,516.69,,930.04,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,826.7,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.04,90,,,Percent of total Billed charges,90% of total billed charges,356.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1002.38,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,950.71,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.04,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,723.37,70,,,percent of total billed charges,70% of total billed charges,930.04,90,,,percent of total billed charges,90% of total billed charges,981.71,95,,,percent of total billed charges,95% of total billed charges,981.71,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.71,86,,,percent of total billed charges,86% of total billed charges,826.7,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.38,97,,,percent of total billed charges,97% of total billed charges,930.04,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.38,97,,,percent of total billed charges,97% of total billed charges,961.04,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1002.38,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,323.85,25056.97,
Periph Thrombolysis Insertion Artery,,,761,RC,37211,HCPCS,Outpatient,,,1016.17,508.09,,914.55,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,812.94,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,914.55,90,,,Percent of total Billed charges,90% of total billed charges,356.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,985.68,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,934.88,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,914.55,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,711.32,70,,,percent of total billed charges,70% of total billed charges,914.55,90,,,percent of total billed charges,90% of total billed charges,965.36,95,,,percent of total billed charges,95% of total billed charges,965.36,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,873.91,86,,,percent of total billed charges,86% of total billed charges,812.94,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,985.68,97,,,percent of total billed charges,97% of total billed charges,914.55,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,985.68,97,,,percent of total billed charges,97% of total billed charges,945.04,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,985.68,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,323.85,25056.97,
37212- Thrombolysis/venous/S&I/initial tx,3430735,CDM,320,RC,37212,HCPCS,Outpatient,,,898.34,449.17,,808.51,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,718.67,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.51,90,,,Percent of total Billed charges,90% of total billed charges,314.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,871.39,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,826.47,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,808.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,628.84,70,,,percent of total billed charges,70% of total billed charges,808.51,90,,,percent of total billed charges,90% of total billed charges,853.42,95,,,percent of total billed charges,95% of total billed charges,853.42,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,772.57,86,,,percent of total billed charges,86% of total billed charges,718.67,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,871.39,97,,,percent of total billed charges,97% of total billed charges,808.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.39,97,,,percent of total billed charges,97% of total billed charges,835.46,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,871.39,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.92,14522.85,
37212-Periph Thromobolysis Insertion Venous,3431874,CDM,481,RC,37212,HCPCS,Outpatient,,,898.34,449.17,,808.51,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,718.67,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.51,90,,,Percent of total Billed charges,90% of total billed charges,314.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,871.39,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,826.47,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,808.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,628.84,70,,,percent of total billed charges,70% of total billed charges,808.51,90,,,percent of total billed charges,90% of total billed charges,853.42,95,,,percent of total billed charges,95% of total billed charges,853.42,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,772.57,86,,,percent of total billed charges,86% of total billed charges,718.67,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,871.39,97,,,percent of total billed charges,97% of total billed charges,808.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.39,97,,,percent of total billed charges,97% of total billed charges,835.46,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,871.39,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.92,14522.85,
37212-PF THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX,4321656,CDM,981,RC,37212,HCPCS,Outpatient,,,668.66,334.33,,601.79,90,,,percent of total billed charges,90% of total Billed charges,672.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,285.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,518.21,155,,,Fee Schedule,155% of CMS OPPS Rate,334.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,564.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,530.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,530.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,303.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,625.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,430.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,518.21,155,,,Fee Schedule,155% of CMS OPPS Rate,334.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1041.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1041.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,334.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,332.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,334.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.92,1041.8,
Periph Thromobolysis Insertion Venous,,,761,RC,37212,HCPCS,Outpatient,,,885.98,442.99,,797.38,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,708.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.38,90,,,Percent of total Billed charges,90% of total billed charges,314.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,859.4,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,815.1,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,797.38,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,620.19,70,,,percent of total billed charges,70% of total billed charges,797.38,90,,,percent of total billed charges,90% of total billed charges,841.68,95,,,percent of total billed charges,95% of total billed charges,841.68,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,761.94,86,,,percent of total billed charges,86% of total billed charges,708.78,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,859.4,97,,,percent of total billed charges,97% of total billed charges,797.38,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.4,97,,,percent of total billed charges,97% of total billed charges,823.96,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,859.4,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.92,14522.85,
37213- Thrombolysis/art/ven/S&I/subs tx,3430736,CDM,320,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,557.51,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.57,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.88,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,569.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,433.62,70,,,percent of total billed charges,70% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.74,86,,,percent of total billed charges,86% of total billed charges,495.57,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,600.88,97,,,percent of total billed charges,97% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.88,97,,,percent of total billed charges,97% of total billed charges,576.1,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.88,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.62,14522.85,
37213-Periph Thromboysis Cath Relook,3431875,CDM,481,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,557.51,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.57,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.88,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,569.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,433.62,70,,,percent of total billed charges,70% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.74,86,,,percent of total billed charges,86% of total billed charges,495.57,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,600.88,97,,,percent of total billed charges,97% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.88,97,,,percent of total billed charges,97% of total billed charges,576.1,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.88,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.62,14522.85,
37213-Peripheral Thrombolysis Relook,3431876,CDM,320,RC,37213,HCPCS,Outpatient,,,619.46,309.73,,557.51,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,495.57,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.88,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,569.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,433.62,70,,,percent of total billed charges,70% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,588.49,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.74,86,,,percent of total billed charges,86% of total billed charges,495.57,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,600.88,97,,,percent of total billed charges,97% of total billed charges,557.51,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.88,97,,,percent of total billed charges,97% of total billed charges,576.1,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.88,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.62,14522.85,
Periph Thromboysis Cath Relook,,,761,RC,37213,HCPCS,Outpatient,,,607.49,303.75,,546.74,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,485.99,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,589.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,558.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,546.74,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,425.24,70,,,percent of total billed charges,70% of total billed charges,546.74,90,,,percent of total billed charges,90% of total billed charges,577.12,95,,,percent of total billed charges,95% of total billed charges,577.12,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,522.44,86,,,percent of total billed charges,86% of total billed charges,485.99,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,589.27,97,,,percent of total billed charges,97% of total billed charges,546.74,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.27,97,,,percent of total billed charges,97% of total billed charges,564.97,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,425.24,14522.85,
Peripheral Thrombolysis Relook,,,761,RC,37213,HCPCS,Outpatient,,,607.49,303.75,,546.74,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,485.99,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,589.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,558.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,546.74,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,425.24,70,,,percent of total billed charges,70% of total billed charges,546.74,90,,,percent of total billed charges,90% of total billed charges,577.12,95,,,percent of total billed charges,95% of total billed charges,577.12,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,522.44,86,,,percent of total billed charges,86% of total billed charges,485.99,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,589.27,97,,,percent of total billed charges,97% of total billed charges,546.74,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.27,97,,,percent of total billed charges,97% of total billed charges,564.97,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,425.24,14522.85,
37214- Trans cath cessation/thrombolysis,3430737,CDM,320,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,292.4,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,259.91,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,315.14,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,298.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,227.42,70,,,percent of total billed charges,70% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,279.41,86,,,percent of total billed charges,86% of total billed charges,259.91,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,315.14,97,,,percent of total billed charges,97% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.14,97,,,percent of total billed charges,97% of total billed charges,302.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,315.14,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,227.42,14522.85,
37214-Periph Thrombolysis Cath Removal,3431877,CDM,481,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,292.4,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,259.91,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,315.14,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,298.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,227.42,70,,,percent of total billed charges,70% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,279.41,86,,,percent of total billed charges,86% of total billed charges,259.91,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,315.14,97,,,percent of total billed charges,97% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.14,97,,,percent of total billed charges,97% of total billed charges,302.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,315.14,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,227.42,14522.85,
37214-Peripheral Thrombolysis Reposition,3431878,CDM,320,RC,37214,HCPCS,Outpatient,,,324.89,162.45,,292.4,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,259.91,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,315.14,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,298.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,227.42,70,,,percent of total billed charges,70% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,308.65,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,279.41,86,,,percent of total billed charges,86% of total billed charges,259.91,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,315.14,97,,,percent of total billed charges,97% of total billed charges,292.4,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.14,97,,,percent of total billed charges,97% of total billed charges,302.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,315.14,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,227.42,14522.85,
Periph Thrombolysis Cath Removal,,,761,RC,37214,HCPCS,Outpatient,,,321.92,160.96,,289.73,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,257.54,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,312.26,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,296.17,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,289.73,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,225.34,70,,,percent of total billed charges,70% of total billed charges,289.73,90,,,percent of total billed charges,90% of total billed charges,305.82,95,,,percent of total billed charges,95% of total billed charges,305.82,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,276.85,86,,,percent of total billed charges,86% of total billed charges,257.54,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,312.26,97,,,percent of total billed charges,97% of total billed charges,289.73,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.26,97,,,percent of total billed charges,97% of total billed charges,299.39,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,312.26,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.34,14522.85,
Peripheral Thrombolysis Reposition,,,761,RC,37214,HCPCS,Outpatient,,,321.92,160.96,,289.73,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,257.54,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,312.26,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,296.17,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,289.73,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,225.34,70,,,percent of total billed charges,70% of total billed charges,289.73,90,,,percent of total billed charges,90% of total billed charges,305.82,95,,,percent of total billed charges,95% of total billed charges,305.82,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,276.85,86,,,percent of total billed charges,86% of total billed charges,257.54,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,312.26,97,,,percent of total billed charges,97% of total billed charges,289.73,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.26,97,,,percent of total billed charges,97% of total billed charges,299.39,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,312.26,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.34,14522.85,
37215- Transca stent/cerv carot/emb prot,3430738,CDM,360,RC,37215,HCPCS,Outpatient,,,2672.28,1336.14,,2405.05,90,,,percent of total billed charges,90% of total Billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2137.82,80,,,Percent of total Billed charges,80% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2405.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2592.11,97,,,Percent of total billed charges,97% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2458.5,92,,,Percent of total billed charges,92% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2405.05,90,,,percent of total billed charges,90% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1870.6,70,,,percent of total billed charges,70% of total billed charges,2405.05,90,,,percent of total billed charges,90% of total billed charges,2538.67,95,,,percent of total billed charges,95% of total billed charges,2538.67,95,,,percent of total billed charges,95% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2298.16,86,,,percent of total billed charges,86% of total billed charges,2137.82,80,,,percent of total billed charges,80% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.11,97,,,percent of total billed charges,97% of total billed charges,2405.05,90,,,percent of total billed charges,90% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.11,97,,,percent of total billed charges,97% of total billed charges,2485.22,93,,,percent of total billed charges,93% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2592.11,97,,,percent of total billed charges,97% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1870.6,2672.28,
37215-Carotid Stent w embolic protection,3431879,CDM,481,RC,37215,HCPCS,Outpatient,,,2672.28,1336.14,,2405.05,90,,,percent of total billed charges,90% of total Billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2137.82,80,,,Percent of total Billed charges,80% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2405.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2592.11,97,,,Percent of total billed charges,97% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2458.5,92,,,Percent of total billed charges,92% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2405.05,90,,,percent of total billed charges,90% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1870.6,70,,,percent of total billed charges,70% of total billed charges,2405.05,90,,,percent of total billed charges,90% of total billed charges,2538.67,95,,,percent of total billed charges,95% of total billed charges,2538.67,95,,,percent of total billed charges,95% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2298.16,86,,,percent of total billed charges,86% of total billed charges,2137.82,80,,,percent of total billed charges,80% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.11,97,,,percent of total billed charges,97% of total billed charges,2405.05,90,,,percent of total billed charges,90% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.11,97,,,percent of total billed charges,97% of total billed charges,2485.22,93,,,percent of total billed charges,93% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2592.11,97,,,percent of total billed charges,97% of total billed charges,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2672.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1870.6,2672.28,
Carotid Stent w embolic protection,,,761,RC,37215,HCPCS,Outpatient,,,2625.09,1312.55,,2362.58,90,,,percent of total billed charges,90% of total Billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2100.07,80,,,Percent of total Billed charges,80% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2362.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2546.34,97,,,Percent of total billed charges,97% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2415.08,92,,,Percent of total billed charges,92% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2362.58,90,,,percent of total billed charges,90% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1837.56,70,,,percent of total billed charges,70% of total billed charges,2362.58,90,,,percent of total billed charges,90% of total billed charges,2493.84,95,,,percent of total billed charges,95% of total billed charges,2493.84,95,,,percent of total billed charges,95% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2257.58,86,,,percent of total billed charges,86% of total billed charges,2100.07,80,,,percent of total billed charges,80% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2546.34,97,,,percent of total billed charges,97% of total billed charges,2362.58,90,,,percent of total billed charges,90% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2546.34,97,,,percent of total billed charges,97% of total billed charges,2441.33,93,,,percent of total billed charges,93% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2546.34,97,,,percent of total billed charges,97% of total billed charges,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1837.56,2625.09,
37216-Carotid stent wo embolic protection,3431880,CDM,481,RC,37216,HCPCS,Outpatient,,,3063,1531.50,,2756.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2450.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2756.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2971.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2817.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1956.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2409.12,78.65,,,percent of total billed charges,78.65% of total billed charges,2736.23,89.33,,,percent of total billed charges,89.33% of total billed charges,2756.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2144.1,70,,,percent of total billed charges,70% of total billed charges,2756.7,90,,,percent of total billed charges,90% of total billed charges,2909.85,95,,,percent of total billed charges,95% of total billed charges,2909.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2634.18,86,,,percent of total billed charges,86% of total billed charges,2450.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2971.11,97,,,percent of total billed charges,97% of total billed charges,2756.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2971.11,97,,,percent of total billed charges,97% of total billed charges,2848.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2971.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1956.1,2971.11,
"37217 - PF - Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery",3640915,CDM,510,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2630.3,90,,,percent of total billed charges,90% of total Billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2338.05,80,,,Percent of total Billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2834.88,97,,,Percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.76,92,,,Percent of total billed charges,92% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,70,,,percent of total billed charges,70% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.4,86,,,percent of total billed charges,86% of total billed charges,2338.05,80,,,percent of total billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2717.98,93,,,percent of total billed charges,93% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2834.88,97,,,percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,2922.56,
"37217-Carotid Stenting, common or innominate, retrograde open",4331297,CDM,481,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2630.3,90,,,percent of total billed charges,90% of total Billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2338.05,80,,,Percent of total Billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2834.88,97,,,Percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.76,92,,,Percent of total billed charges,92% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,70,,,percent of total billed charges,70% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.4,86,,,percent of total billed charges,86% of total billed charges,2338.05,80,,,percent of total billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2717.98,93,,,percent of total billed charges,93% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2834.88,97,,,percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,2922.56,
"37217-PF Carotid Stenting, common or innominate, retrograde open",4331298,CDM,960,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2630.3,90,,,percent of total billed charges,90% of total Billed charges,2185.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1683.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1086.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1803.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1712.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1712.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,935.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2172.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2020.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1485.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1683.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,3387.15,155,,,Fee Schedule,155% of CMS OPPS Rate,3387.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1264.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.54,3387.15,
Carotid Stent LT,,,761,RC,37217,HCPCS,Outpatient,,,2878.67,1439.34,,2590.8,90,,,percent of total billed charges,90% of total Billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2302.94,80,,,Percent of total Billed charges,80% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2590.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2792.31,97,,,Percent of total billed charges,97% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2648.38,92,,,Percent of total billed charges,92% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2590.8,90,,,percent of total billed charges,90% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2015.07,70,,,percent of total billed charges,70% of total billed charges,2590.8,90,,,percent of total billed charges,90% of total billed charges,2734.74,95,,,percent of total billed charges,95% of total billed charges,2734.74,95,,,percent of total billed charges,95% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2475.66,86,,,percent of total billed charges,86% of total billed charges,2302.94,80,,,percent of total billed charges,80% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2792.31,97,,,percent of total billed charges,97% of total billed charges,2590.8,90,,,percent of total billed charges,90% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2792.31,97,,,percent of total billed charges,97% of total billed charges,2677.16,93,,,percent of total billed charges,93% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2792.31,97,,,percent of total billed charges,97% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2015.07,2878.67,
Carotid Stent RT,,,761,RC,37217,HCPCS,Outpatient,,,2878.67,1439.34,,2590.8,90,,,percent of total billed charges,90% of total Billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2302.94,80,,,Percent of total Billed charges,80% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2590.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2792.31,97,,,Percent of total billed charges,97% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2648.38,92,,,Percent of total billed charges,92% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2590.8,90,,,percent of total billed charges,90% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2015.07,70,,,percent of total billed charges,70% of total billed charges,2590.8,90,,,percent of total billed charges,90% of total billed charges,2734.74,95,,,percent of total billed charges,95% of total billed charges,2734.74,95,,,percent of total billed charges,95% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2475.66,86,,,percent of total billed charges,86% of total billed charges,2302.94,80,,,percent of total billed charges,80% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2792.31,97,,,percent of total billed charges,97% of total billed charges,2590.8,90,,,percent of total billed charges,90% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2792.31,97,,,percent of total billed charges,97% of total billed charges,2677.16,93,,,percent of total billed charges,93% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2792.31,97,,,percent of total billed charges,97% of total billed charges,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2878.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2015.07,2878.67,
"Carotid Stenting, common or innominate, retrograde open",,,761,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2630.3,90,,,percent of total billed charges,90% of total Billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2338.05,80,,,Percent of total Billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2834.88,97,,,Percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.76,92,,,Percent of total billed charges,92% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,70,,,percent of total billed charges,70% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2776.43,95,,,percent of total billed charges,95% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.4,86,,,percent of total billed charges,86% of total billed charges,2338.05,80,,,percent of total billed charges,80% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2630.3,90,,,percent of total billed charges,90% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.88,97,,,percent of total billed charges,97% of total billed charges,2717.98,93,,,percent of total billed charges,93% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2834.88,97,,,percent of total billed charges,97% of total billed charges,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2922.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.79,2922.56,
37218-Common Carotid or Innominate Artery Stent via antegrade approach,4271236,CDM,481,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,1565.57,90,,,percent of total billed charges,90% of total Billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1391.62,80,,,Percent of total Billed charges,80% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1565.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1687.33,97,,,Percent of total billed charges,97% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1600.36,92,,,Percent of total billed charges,92% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1565.57,90,,,percent of total billed charges,90% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1217.66,70,,,percent of total billed charges,70% of total billed charges,1565.57,90,,,percent of total billed charges,90% of total billed charges,1652.54,95,,,percent of total billed charges,95% of total billed charges,1652.54,95,,,percent of total billed charges,95% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.99,86,,,percent of total billed charges,86% of total billed charges,1391.62,80,,,percent of total billed charges,80% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1687.33,97,,,percent of total billed charges,97% of total billed charges,1565.57,90,,,percent of total billed charges,90% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1687.33,97,,,percent of total billed charges,97% of total billed charges,1617.75,93,,,percent of total billed charges,93% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1687.33,97,,,percent of total billed charges,97% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1217.66,1739.52,
37218-PF Common Carotid or Innominate Artery Stent via antegrade approach,4271237,CDM,960,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,1565.57,90,,,percent of total billed charges,90% of total Billed charges,1643.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,820.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1271.81,155,,,Fee Schedule,155% of CMS OPPS Rate,820.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1214.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,820.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1366.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1366.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1284.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1284.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,706.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1641.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1515.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1092.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1271.81,155,,,Fee Schedule,155% of CMS OPPS Rate,820.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,2547.49,155,,,Fee Schedule,155% of CMS OPPS Rate,2547.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,820.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,928.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,820.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.56,2547.49,
Common Carotid or Innominate Artery Stent via antegrade approach,4271238,CDM,761,RC,37218,HCPCS,Outpatient,,,1739.52,869.76,,1565.57,90,,,percent of total billed charges,90% of total Billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1391.62,80,,,Percent of total Billed charges,80% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1565.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1687.33,97,,,Percent of total billed charges,97% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1600.36,92,,,Percent of total billed charges,92% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1565.57,90,,,percent of total billed charges,90% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1217.66,70,,,percent of total billed charges,70% of total billed charges,1565.57,90,,,percent of total billed charges,90% of total billed charges,1652.54,95,,,percent of total billed charges,95% of total billed charges,1652.54,95,,,percent of total billed charges,95% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.99,86,,,percent of total billed charges,86% of total billed charges,1391.62,80,,,percent of total billed charges,80% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1687.33,97,,,percent of total billed charges,97% of total billed charges,1565.57,90,,,percent of total billed charges,90% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1687.33,97,,,percent of total billed charges,97% of total billed charges,1617.75,93,,,percent of total billed charges,93% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1687.33,97,,,percent of total billed charges,97% of total billed charges,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1739.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1217.66,1739.52,
37220- Angioplasty/iliac/init ves/unilat,3430739,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,5705.3,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5071.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5705.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6149.04,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5832.08,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4437.45,70,,,percent of total billed charges,70% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5451.73,86,,,percent of total billed charges,86% of total billed charges,5071.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6149.04,97,,,percent of total billed charges,97% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6149.04,97,,,percent of total billed charges,97% of total billed charges,5895.47,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6149.04,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37220-ILIAC ANGIOPLASTY UNILATERAL,3431883,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,5705.3,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5071.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5705.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6149.04,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5832.08,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4437.45,70,,,percent of total billed charges,70% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5451.73,86,,,percent of total billed charges,86% of total billed charges,5071.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6149.04,97,,,percent of total billed charges,97% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6149.04,97,,,percent of total billed charges,97% of total billed charges,5895.47,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6149.04,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37220-Peripheral Angio Iliac w PTA,3431884,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,5705.3,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5071.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5705.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6149.04,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5832.08,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4437.45,70,,,percent of total billed charges,70% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5451.73,86,,,percent of total billed charges,86% of total billed charges,5071.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6149.04,97,,,percent of total billed charges,97% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6149.04,97,,,percent of total billed charges,97% of total billed charges,5895.47,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6149.04,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37220-Peripheral Angio Iliac w PTA RT,3431885,CDM,481,RC,37220,HCPCS,Outpatient,,,6339.22,3169.61,,5705.3,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5071.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5705.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6149.04,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5832.08,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4437.45,70,,,percent of total billed charges,70% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,6022.26,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5451.73,86,,,percent of total billed charges,86% of total billed charges,5071.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6149.04,97,,,percent of total billed charges,97% of total billed charges,5705.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6149.04,97,,,percent of total billed charges,97% of total billed charges,5895.47,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6149.04,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
Peripheral Angio Iliac w PTA LT,,,761,RC,37220,HCPCS,Outpatient,,,5995.89,2997.95,,5396.3,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4796.71,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5396.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5816.01,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5516.22,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5396.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4197.12,70,,,percent of total billed charges,70% of total billed charges,5396.3,90,,,percent of total billed charges,90% of total billed charges,5696.1,95,,,percent of total billed charges,95% of total billed charges,5696.1,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5156.47,86,,,percent of total billed charges,86% of total billed charges,4796.71,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5816.01,97,,,percent of total billed charges,97% of total billed charges,5396.3,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5816.01,97,,,percent of total billed charges,97% of total billed charges,5576.18,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5816.01,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
Peripheral Angio Iliac w PTA RT,3427184,CDM,960,RC,37220,HCPCS,Outpatient,,,5995.89,2997.95,,5396.3,90,,,percent of total billed charges,90% of total Billed charges,2784.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.56,155,,,Fee Schedule,155% of CMS OPPS Rate,400.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,400.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,670.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,638,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,638,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,752.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,549.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,620.56,155,,,Fee Schedule,155% of CMS OPPS Rate,400.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,4315.39,155,,,Fee Schedule,155% of CMS OPPS Rate,4315.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,400.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3008.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,400.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,6347.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,6347.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.02,6347.8,
37221- Stent iliac/open or perc/uni/init,3430740,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,7040.07,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6257.84,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7040.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7587.63,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7196.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5475.61,70,,,percent of total billed charges,70% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6727.18,86,,,percent of total billed charges,86% of total billed charges,6257.84,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7587.63,97,,,percent of total billed charges,97% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7587.63,97,,,percent of total billed charges,97% of total billed charges,7274.74,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7587.63,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5475.61,51750.98,
37221-ILIAC STENT W/WO ANGIOPLASTY UNILAT,3431886,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,7040.07,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6257.84,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7040.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7587.63,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7196.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5475.61,70,,,percent of total billed charges,70% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6727.18,86,,,percent of total billed charges,86% of total billed charges,6257.84,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7587.63,97,,,percent of total billed charges,97% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7587.63,97,,,percent of total billed charges,97% of total billed charges,7274.74,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7587.63,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5475.61,51750.98,
37221-Peripheral Angio Iliac Stent,3431887,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,7040.07,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6257.84,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7040.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7587.63,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7196.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5475.61,70,,,percent of total billed charges,70% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6727.18,86,,,percent of total billed charges,86% of total billed charges,6257.84,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7587.63,97,,,percent of total billed charges,97% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7587.63,97,,,percent of total billed charges,97% of total billed charges,7274.74,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7587.63,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5475.61,51750.98,
37221-Peripheral Angio Iliac Stent RT,3431888,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,7040.07,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6257.84,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7040.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7587.63,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7196.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5475.61,70,,,percent of total billed charges,70% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6727.18,86,,,percent of total billed charges,86% of total billed charges,6257.84,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7587.63,97,,,percent of total billed charges,97% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7587.63,97,,,percent of total billed charges,97% of total billed charges,7274.74,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7587.63,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5475.61,51750.98,
37221-Peripheral Intervention Iliac,3431889,CDM,481,RC,37221,HCPCS,Outpatient,,,7822.3,3911.15,,7040.07,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6257.84,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7040.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7587.63,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7196.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5475.61,70,,,percent of total billed charges,70% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,7431.19,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6727.18,86,,,percent of total billed charges,86% of total billed charges,6257.84,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7587.63,97,,,percent of total billed charges,97% of total billed charges,7040.07,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7587.63,97,,,percent of total billed charges,97% of total billed charges,7274.74,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7587.63,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5475.61,51750.98,
Peripheral Angio Iliac Stent LT,3427185,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.70,,6641.46,90,,,percent of total billed charges,90% of total Billed charges,3434.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,827.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,928.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,676.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5324.11,155,,,Fee Schedule,155% of CMS OPPS Rate,5324.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4446.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9379.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9379.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.68,9379.24,
Peripheral Angio Iliac Stent RT,3427186,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.70,,6641.46,90,,,percent of total billed charges,90% of total Billed charges,3434.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,827.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,928.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,676.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5324.11,155,,,Fee Schedule,155% of CMS OPPS Rate,5324.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4446.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9379.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9379.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.68,9379.24,
Peripheral Intervention Iliac,3427216,CDM,960,RC,37221,HCPCS,Outpatient,,,7379.4,3689.70,,6641.46,90,,,percent of total billed charges,90% of total Billed charges,3434.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,735.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,827.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,786.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,986.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,928.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,676.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,764.85,155,,,Fee Schedule,155% of CMS OPPS Rate,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5324.11,155,,,Fee Schedule,155% of CMS OPPS Rate,5324.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4446.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,493.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9379.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9379.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.68,9379.24,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,510,RC,37222,HCPCS,Outpatient,,,1569.3,784.65,,1412.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1255.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1412.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1443.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1002.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1234.29,78.65,,,percent of total billed charges,78.65% of total billed charges,1401.88,89.33,,,percent of total billed charges,89.33% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1098.51,70,,,percent of total billed charges,70% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,1490.84,95,,,percent of total billed charges,95% of total billed charges,1490.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,86,,,percent of total billed charges,86% of total billed charges,1255.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,1459.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.19,1522.22,
37222-Peripheral Angio Iliac PTA add,3431890,CDM,481,RC,37222,HCPCS,Outpatient,,,1569.3,784.65,,1412.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1255.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1412.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1443.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1002.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1234.29,78.65,,,percent of total billed charges,78.65% of total billed charges,1401.88,89.33,,,percent of total billed charges,89.33% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1098.51,70,,,percent of total billed charges,70% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,1490.84,95,,,percent of total billed charges,95% of total billed charges,1490.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1349.6,86,,,percent of total billed charges,86% of total billed charges,1255.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,1412.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,1459.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.19,1522.22,
Peripheral Angio Iliac PTA add,3427187,CDM,960,RC,37222,HCPCS,Outpatient,,,1503.24,751.62,,1352.92,90,,,percent of total billed charges,90% of total Billed charges,775.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.96,155,,,Fee Schedule,155% of CMS OPPS Rate,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,163.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,257.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.96,155,,,Fee Schedule,155% of CMS OPPS Rate,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1202.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,867.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1830.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1830.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,163.43,1830.56,
37223- Stent iliac/open/perc/ea ad/ipsila,3430741,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2913.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2590.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2913.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2978.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2067.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2546.4,78.65,,,percent of total billed charges,78.65% of total billed charges,2892.15,89.33,,,percent of total billed charges,89.33% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2266.28,70,,,percent of total billed charges,70% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2784.28,86,,,percent of total billed charges,86% of total billed charges,2590.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,3010.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.56,3140.41,
37223-Iliac Stent Additional,3560665,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2913.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2590.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2913.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2978.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2067.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2546.4,78.65,,,percent of total billed charges,78.65% of total billed charges,2892.15,89.33,,,percent of total billed charges,89.33% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2266.28,70,,,percent of total billed charges,70% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2784.28,86,,,percent of total billed charges,86% of total billed charges,2590.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,3010.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.56,3140.41,
37223-Peripheral Angio Iliac stent add,3431891,CDM,481,RC,37223,HCPCS,Outpatient,,,3237.54,1618.77,,2913.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2590.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2913.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2978.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2067.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2546.4,78.65,,,percent of total billed charges,78.65% of total billed charges,2892.15,89.33,,,percent of total billed charges,89.33% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2266.28,70,,,percent of total billed charges,70% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,3075.66,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2784.28,86,,,percent of total billed charges,86% of total billed charges,2590.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,2913.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,3010.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3140.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2067.56,3140.41,
Peripheral Angio Iliac stent add,3427188,CDM,960,RC,37223,HCPCS,Outpatient,,,3053.65,1526.83,,2748.29,90,,,percent of total billed charges,90% of total Billed charges,1429.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,212.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.31,155,,,Fee Schedule,155% of CMS OPPS Rate,212.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,339.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,339.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,185.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,292.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,329.31,155,,,Fee Schedule,155% of CMS OPPS Rate,212.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.31,155,,,Fee Schedule,155% of CMS OPPS Rate,2216.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,212.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2485.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,212.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,5165.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,5165.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,185.63,5165.28,
37224- Angioplasty fem/pop unilat,3430742,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,6665.25,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5924.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6665.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7183.66,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6813.36,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5184.08,70,,,percent of total billed charges,70% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6369.01,86,,,percent of total billed charges,86% of total billed charges,5924.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7183.66,97,,,percent of total billed charges,97% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7183.66,97,,,percent of total billed charges,97% of total billed charges,6887.42,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7183.66,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37224-FEM POPLITEAL TERRITORY PTA UNILAT,3431892,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,6665.25,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5924.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6665.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7183.66,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6813.36,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5184.08,70,,,percent of total billed charges,70% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6369.01,86,,,percent of total billed charges,86% of total billed charges,5924.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7183.66,97,,,percent of total billed charges,97% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7183.66,97,,,percent of total billed charges,97% of total billed charges,6887.42,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7183.66,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37224-Peripheral Angio PTA,3431893,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,6665.25,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5924.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6665.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7183.66,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6813.36,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5184.08,70,,,percent of total billed charges,70% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6369.01,86,,,percent of total billed charges,86% of total billed charges,5924.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7183.66,97,,,percent of total billed charges,97% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7183.66,97,,,percent of total billed charges,97% of total billed charges,6887.42,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7183.66,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37224-Peripheral Angio PTA RT,3431894,CDM,481,RC,37224,HCPCS,Outpatient,,,7405.83,3702.92,,6665.25,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5924.66,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6665.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7183.66,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6813.36,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5184.08,70,,,percent of total billed charges,70% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,7035.54,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6369.01,86,,,percent of total billed charges,86% of total billed charges,5924.66,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7183.66,97,,,percent of total billed charges,97% of total billed charges,6665.25,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7183.66,97,,,percent of total billed charges,97% of total billed charges,6887.42,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7183.66,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
Peripheral Angio PTA LT,,,761,RC,37224,HCPCS,Outpatient,,,6987.34,3493.67,,6288.61,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5589.87,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6288.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6777.72,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6428.35,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6288.61,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4891.14,70,,,percent of total billed charges,70% of total billed charges,6288.61,90,,,percent of total billed charges,90% of total billed charges,6637.97,95,,,percent of total billed charges,95% of total billed charges,6637.97,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6009.11,86,,,percent of total billed charges,86% of total billed charges,5589.87,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6777.72,97,,,percent of total billed charges,97% of total billed charges,6288.61,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6777.72,97,,,percent of total billed charges,97% of total billed charges,6498.23,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6777.72,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
Peripheral Angio PTA RT,,,761,RC,37224,HCPCS,Outpatient,,,6987.34,3493.67,,6288.61,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,5589.87,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6288.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6777.72,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,6428.35,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6288.61,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4891.14,70,,,percent of total billed charges,70% of total billed charges,6288.61,90,,,percent of total billed charges,90% of total billed charges,6637.97,95,,,percent of total billed charges,95% of total billed charges,6637.97,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6009.11,86,,,percent of total billed charges,86% of total billed charges,5589.87,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6777.72,97,,,percent of total billed charges,97% of total billed charges,6288.61,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,6777.72,97,,,percent of total billed charges,97% of total billed charges,6498.23,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6777.72,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4026.39,25425.73,
37225- Athrectomy fem/pop/unilateral,3430913,CDM,481,RC,37225,HCPCS,Outpatient,,,22029.29,11014.65,,19826.36,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17623.43,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,19826.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21368.41,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20266.95,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19826.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15420.5,70,,,percent of total billed charges,70% of total billed charges,19826.36,90,,,percent of total billed charges,90% of total billed charges,20927.83,95,,,percent of total billed charges,95% of total billed charges,20927.83,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18945.19,86,,,percent of total billed charges,86% of total billed charges,17623.43,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21368.41,97,,,percent of total billed charges,97% of total billed charges,19826.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21368.41,97,,,percent of total billed charges,97% of total billed charges,20487.24,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21368.41,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
37225-Periph Angio Athrectomy PTA Femoral Pop,3431895,CDM,481,RC,37225,HCPCS,Outpatient,,,22029.29,11014.65,,19826.36,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17623.43,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,19826.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21368.41,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,20266.95,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19826.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15420.5,70,,,percent of total billed charges,70% of total billed charges,19826.36,90,,,percent of total billed charges,90% of total billed charges,20927.83,95,,,percent of total billed charges,95% of total billed charges,20927.83,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18945.19,86,,,percent of total billed charges,86% of total billed charges,17623.43,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21368.41,97,,,percent of total billed charges,97% of total billed charges,19826.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21368.41,97,,,percent of total billed charges,97% of total billed charges,20487.24,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21368.41,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
Periph Angio Athrectomy PTA Femoral Pop,,,761,RC,37225,HCPCS,Outpatient,,,20652.06,10326.03,,18586.85,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16521.65,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18586.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20032.5,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,18999.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18586.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14456.44,70,,,percent of total billed charges,70% of total billed charges,18586.85,90,,,percent of total billed charges,90% of total billed charges,19619.46,95,,,percent of total billed charges,95% of total billed charges,19619.46,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17760.77,86,,,percent of total billed charges,86% of total billed charges,16521.65,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20032.5,97,,,percent of total billed charges,97% of total billed charges,18586.85,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20032.5,97,,,percent of total billed charges,97% of total billed charges,19206.42,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20032.5,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
"37226 - (50)  Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), u",3699317,CDM,960,RC,37226,HCPCS,Outpatient,,,1652.71,826.36,,1487.44,90,,,percent of total billed charges,90% of total Billed charges,2172.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,870.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,713.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3367.25,155,,,Fee Schedule,155% of CMS OPPS Rate,3367.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8046.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18020.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,18020.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.53,18020.68,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,881.45,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1068.76,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.67,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,771.27,70,,,percent of total billed charges,70% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,947.56,86,,,percent of total billed charges,86% of total billed charges,881.45,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1068.76,97,,,percent of total billed charges,97% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.76,97,,,percent of total billed charges,97% of total billed charges,1024.68,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1068.76,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,771.27,51750.98,
37226- Stent fem/pop/open or perc/unilat,3430743,CDM,960,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,1621.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,870.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,713.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2513.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2513.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8046.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18020.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,18020.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.53,18020.68,
37226-FEM POP TERRITORY STENT W/WO PTA UN,3431896,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,881.45,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1068.76,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.67,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,771.27,70,,,percent of total billed charges,70% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,947.56,86,,,percent of total billed charges,86% of total billed charges,881.45,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1068.76,97,,,percent of total billed charges,97% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.76,97,,,percent of total billed charges,97% of total billed charges,1024.68,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1068.76,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,771.27,51750.98,
37226-Periph Angio Femoral Pop Stent wwo PTA,3431897,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,881.45,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1068.76,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.67,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,771.27,70,,,percent of total billed charges,70% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,947.56,86,,,percent of total billed charges,86% of total billed charges,881.45,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1068.76,97,,,percent of total billed charges,97% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.76,97,,,percent of total billed charges,97% of total billed charges,1024.68,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1068.76,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,771.27,51750.98,
Periph Angio Femoral Pop Stent wwo PTA,3427181,CDM,481,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,881.45,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1068.76,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.67,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,771.27,70,,,percent of total billed charges,70% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,1046.72,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,947.56,86,,,percent of total billed charges,86% of total billed charges,881.45,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1068.76,97,,,percent of total billed charges,97% of total billed charges,991.63,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.76,97,,,percent of total billed charges,97% of total billed charges,1024.68,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1068.76,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,771.27,51750.98,
37227- Stent/athrectomy/fem/pop/unilat,3430914,CDM,960,RC,37227,HCPCS,Outpatient,,,1519.59,759.80,,1367.63,90,,,percent of total billed charges,90% of total Billed charges,2236.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,716.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.01,155,,,Fee Schedule,155% of CMS OPPS Rate,716.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1078.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,716.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1213.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1213.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1153.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1153.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,645.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1433.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1361,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,991.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1111.01,155,,,Fee Schedule,155% of CMS OPPS Rate,716.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,3466.37,155,,,Fee Schedule,155% of CMS OPPS Rate,3466.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,716.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13119.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,716.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,29106.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,29106.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,645.2,29106.04,
37227-Fem/ Pop w/Ather/Stent/W or w/o PTA,3560656,CDM,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.80,,1367.63,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.67,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1367.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1474,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1398.02,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.71,70,,,percent of total billed charges,70% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1306.85,86,,,percent of total billed charges,86% of total billed charges,1215.67,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1474,97,,,percent of total billed charges,97% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474,97,,,percent of total billed charges,97% of total billed charges,1413.22,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1474,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1063.71,83742.97,
37227-Periph Angio Fem Pop Stent w ath wwo PTA,3431898,CDM,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.80,,1367.63,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.67,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1367.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1474,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1398.02,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.71,70,,,percent of total billed charges,70% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1306.85,86,,,percent of total billed charges,86% of total billed charges,1215.67,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1474,97,,,percent of total billed charges,97% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474,97,,,percent of total billed charges,97% of total billed charges,1413.22,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1474,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1063.71,83742.97,
Periph Angio Fem Pop Stent w ath wwo PTA,,,481,RC,37227,HCPCS,Outpatient,,,1519.59,759.80,,1367.63,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.67,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1367.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1474,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1398.02,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.71,70,,,percent of total billed charges,70% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,1443.61,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1306.85,86,,,percent of total billed charges,86% of total billed charges,1215.67,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1474,97,,,percent of total billed charges,97% of total billed charges,1367.63,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474,97,,,percent of total billed charges,97% of total billed charges,1413.22,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1474,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1063.71,83742.97,
37228- Angio tib/peroneal/init ves/unila,3430744,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,9446.97,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8397.3,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9446.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10181.73,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9656.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7347.64,70,,,percent of total billed charges,70% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9027.1,86,,,percent of total billed charges,86% of total billed charges,8397.3,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10181.73,97,,,percent of total billed charges,97% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10181.73,97,,,percent of total billed charges,97% of total billed charges,9761.87,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10181.73,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7347.64,51750.98,
37228-Peripheral Angio Tibial Peroneal PTA LT,3431899,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,9446.97,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8397.3,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9446.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10181.73,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9656.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7347.64,70,,,percent of total billed charges,70% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9027.1,86,,,percent of total billed charges,86% of total billed charges,8397.3,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10181.73,97,,,percent of total billed charges,97% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10181.73,97,,,percent of total billed charges,97% of total billed charges,9761.87,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10181.73,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7347.64,51750.98,
37228-Peripheral Angio Tibial Peroneal PTA RT,3431900,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,9446.97,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8397.3,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9446.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10181.73,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9656.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7347.64,70,,,percent of total billed charges,70% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9027.1,86,,,percent of total billed charges,86% of total billed charges,8397.3,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10181.73,97,,,percent of total billed charges,97% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10181.73,97,,,percent of total billed charges,97% of total billed charges,9761.87,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10181.73,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7347.64,51750.98,
37228-TIB PERONEAL TERRITORY PTA UNILA,3431901,CDM,481,RC,37228,HCPCS,Outpatient,,,10496.63,5248.32,,9446.97,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8397.3,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9446.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10181.73,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9656.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7347.64,70,,,percent of total billed charges,70% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9971.8,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9027.1,86,,,percent of total billed charges,86% of total billed charges,8397.3,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10181.73,97,,,percent of total billed charges,97% of total billed charges,9446.97,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10181.73,97,,,percent of total billed charges,97% of total billed charges,9761.87,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10181.73,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7347.64,51750.98,
Peripheral Angio Tibial Peroneal PTA LT,3427193,CDM,960,RC,37228,HCPCS,Outpatient,,,9885.3,4942.65,,8896.77,90,,,percent of total billed charges,90% of total Billed charges,4488.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.73,155,,,Fee Schedule,155% of CMS OPPS Rate,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,907.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,863.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,863.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,484.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1019.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,741.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,839.73,155,,,Fee Schedule,155% of CMS OPPS Rate,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,6957.73,155,,,Fee Schedule,155% of CMS OPPS Rate,6957.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5136.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,10855.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,10855.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,484.6,10855.52,
Peripheral Angio Tibial Peroneal PTA RT,3427194,CDM,960,RC,37228,HCPCS,Outpatient,,,9885.3,4942.65,,8896.77,90,,,percent of total billed charges,90% of total Billed charges,4488.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.73,155,,,Fee Schedule,155% of CMS OPPS Rate,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,907.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,863.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,863.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,484.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1083.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1019.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,741.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,839.73,155,,,Fee Schedule,155% of CMS OPPS Rate,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,6957.73,155,,,Fee Schedule,155% of CMS OPPS Rate,6957.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5136.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,541.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,10855.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,10855.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,484.6,10855.52,
37229- Athrectomy tib/pero/unilat/ini ves,3430915,CDM,960,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,1318.92,90,,,percent of total billed charges,90% of total Billed charges,2156.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,691.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071.44,155,,,Fee Schedule,155% of CMS OPPS Rate,691.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1175.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1115.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1115.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,626.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,691.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1382.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1316.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,950.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1071.44,155,,,Fee Schedule,155% of CMS OPPS Rate,691.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3342.92,155,,,Fee Schedule,155% of CMS OPPS Rate,3342.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,691.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9534.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,691.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,21345.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,21345.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,626.05,21345.88,
37229-Peripheral Angio Tibial Per Ath w PTA,3431902,CDM,481,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,1318.92,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.38,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1421.51,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.23,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1318.92,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.83,70,,,percent of total billed charges,70% of total billed charges,1318.92,90,,,percent of total billed charges,90% of total billed charges,1392.2,95,,,percent of total billed charges,95% of total billed charges,1392.2,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1260.3,86,,,percent of total billed charges,86% of total billed charges,1172.38,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1421.51,97,,,percent of total billed charges,97% of total billed charges,1318.92,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1421.51,97,,,percent of total billed charges,97% of total billed charges,1362.89,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1421.51,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1025.83,83742.97,
Peripheral Angio Tibial Per Ath w PTA,3427195,CDM,481,RC,37229,HCPCS,Outpatient,,,1465.47,732.74,,1318.92,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.38,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1421.51,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.23,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1318.92,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.83,70,,,percent of total billed charges,70% of total billed charges,1318.92,90,,,percent of total billed charges,90% of total billed charges,1392.2,95,,,percent of total billed charges,95% of total billed charges,1392.2,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1260.3,86,,,percent of total billed charges,86% of total billed charges,1172.38,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1421.51,97,,,percent of total billed charges,97% of total billed charges,1318.92,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1421.51,97,,,percent of total billed charges,97% of total billed charges,1362.89,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1421.51,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1025.83,83742.97,
"37230 - PF - Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilate",3640898,CDM,510,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,20225.19,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17977.94,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,20225.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21798.26,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,20674.64,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15730.7,70,,,percent of total billed charges,70% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,19326.29,86,,,percent of total billed charges,86% of total billed charges,17977.94,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21798.26,97,,,percent of total billed charges,97% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,21798.26,97,,,percent of total billed charges,97% of total billed charges,20899.36,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21798.26,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
37230-Peripheral Angio Tibial Peroneal Stent,3431903,CDM,481,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,20225.19,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17977.94,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,20225.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21798.26,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,20674.64,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15730.7,70,,,percent of total billed charges,70% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,19326.29,86,,,percent of total billed charges,86% of total billed charges,17977.94,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21798.26,97,,,percent of total billed charges,97% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,21798.26,97,,,percent of total billed charges,97% of total billed charges,20899.36,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21798.26,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
37230-Peripheral Intervention Tibal Peroneal,3431904,CDM,481,RC,37230,HCPCS,Outpatient,,,22472.43,11236.22,,20225.19,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17977.94,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,20225.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21798.26,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,20674.64,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15730.7,70,,,percent of total billed charges,70% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,21348.81,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,19326.29,86,,,percent of total billed charges,86% of total billed charges,17977.94,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21798.26,97,,,percent of total billed charges,97% of total billed charges,20225.19,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,21798.26,97,,,percent of total billed charges,97% of total billed charges,20899.36,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21798.26,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
Peripheral Angio Tibial Peroneal Stent,,,761,RC,37230,HCPCS,Outpatient,,,21051.05,10525.53,,18945.95,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16840.84,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18945.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20419.52,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,19366.97,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18945.95,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14735.74,70,,,percent of total billed charges,70% of total billed charges,18945.95,90,,,percent of total billed charges,90% of total billed charges,19998.5,95,,,percent of total billed charges,95% of total billed charges,19998.5,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18103.9,86,,,percent of total billed charges,86% of total billed charges,16840.84,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20419.52,97,,,percent of total billed charges,97% of total billed charges,18945.95,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,20419.52,97,,,percent of total billed charges,97% of total billed charges,19577.48,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20419.52,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
Peripheral Intervention Tibal Peroneal,,,761,RC,37230,HCPCS,Outpatient,,,21051.05,10525.53,,18945.95,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,16840.84,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18945.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20419.52,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,19366.97,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18945.95,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,14735.74,70,,,percent of total billed charges,70% of total billed charges,18945.95,90,,,percent of total billed charges,90% of total billed charges,19998.5,95,,,percent of total billed charges,95% of total billed charges,19998.5,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18103.9,86,,,percent of total billed charges,86% of total billed charges,16840.84,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20419.52,97,,,percent of total billed charges,97% of total billed charges,18945.95,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,20419.52,97,,,percent of total billed charges,97% of total billed charges,19577.48,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20419.52,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1389.43,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1497.5,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.31,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.67,70,,,percent of total billed charges,70% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1327.68,86,,,percent of total billed charges,86% of total billed charges,1235.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1497.5,97,,,percent of total billed charges,97% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.5,97,,,percent of total billed charges,97% of total billed charges,1435.74,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1497.5,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1080.67,83742.97,
37231-Periph Angio Tib Per Stent w Ath w PTA,3431905,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1389.43,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1497.5,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.31,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.67,70,,,percent of total billed charges,70% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1327.68,86,,,percent of total billed charges,86% of total billed charges,1235.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1497.5,97,,,percent of total billed charges,97% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.5,97,,,percent of total billed charges,97% of total billed charges,1435.74,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1497.5,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1080.67,83742.97,
"37231-Tib/Peroneal Stent, Ather, PTA",3560674,CDM,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1389.43,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1497.5,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.31,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.67,70,,,percent of total billed charges,70% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1327.68,86,,,percent of total billed charges,86% of total billed charges,1235.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1497.5,97,,,percent of total billed charges,97% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.5,97,,,percent of total billed charges,97% of total billed charges,1435.74,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1497.5,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1080.67,83742.97,
Periph Angio Tib Per Stent w Ath w PTA,,,481,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1389.43,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1497.5,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.31,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.67,70,,,percent of total billed charges,70% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,1466.62,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1327.68,86,,,percent of total billed charges,86% of total billed charges,1235.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1497.5,97,,,percent of total billed charges,97% of total billed charges,1389.43,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.5,97,,,percent of total billed charges,97% of total billed charges,1435.74,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1497.5,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1080.67,83742.97,
37232- Angioplasty tib/pero/unilat/ea add,3430916,CDM,510,RC,37232,HCPCS,Outpatient,,,2082.6,1041.30,,1874.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1666.08,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1874.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1915.99,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1329.99,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1638.01,78.65,,,percent of total billed charges,78.65% of total billed charges,1860.42,89.33,,,percent of total billed charges,89.33% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1457.82,70,,,percent of total billed charges,70% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,1978.47,95,,,percent of total billed charges,95% of total billed charges,1978.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1791.04,86,,,percent of total billed charges,86% of total billed charges,1666.08,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,1936.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.99,2020.12,
37232-Peripheral Angio Tibial Peroneal PTA add,3431906,CDM,481,RC,37232,HCPCS,Outpatient,,,2082.6,1041.30,,1874.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1666.08,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1874.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1915.99,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1329.99,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1638.01,78.65,,,percent of total billed charges,78.65% of total billed charges,1860.42,89.33,,,percent of total billed charges,89.33% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1457.82,70,,,percent of total billed charges,70% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,1978.47,95,,,percent of total billed charges,95% of total billed charges,1978.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1791.04,86,,,percent of total billed charges,86% of total billed charges,1666.08,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,1874.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,1936.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2020.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1329.99,2020.12,
Peripheral Angio Tibial Peroneal PTA add,,,761,RC,37232,HCPCS,Outpatient,,,1985.09,992.55,,1786.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1588.07,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1786.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1925.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1826.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1267.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1561.32,78.65,,,percent of total billed charges,78.65% of total billed charges,1773.31,89.33,,,percent of total billed charges,89.33% of total billed charges,1786.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1389.56,70,,,percent of total billed charges,70% of total billed charges,1786.58,90,,,percent of total billed charges,90% of total billed charges,1885.84,95,,,percent of total billed charges,95% of total billed charges,1885.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1707.18,86,,,percent of total billed charges,86% of total billed charges,1588.07,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1925.54,97,,,percent of total billed charges,97% of total billed charges,1786.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1925.54,97,,,percent of total billed charges,97% of total billed charges,1846.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1925.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1267.72,1925.54,
37233-Periph Angio Tibial Peroneal Ath add,3431907,CDM,481,RC,37233,HCPCS,Outpatient,,,2639.9,1319.95,,2375.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2111.92,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2375.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2560.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2428.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1685.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2076.34,78.65,,,percent of total billed charges,78.65% of total billed charges,2358.26,89.33,,,percent of total billed charges,89.33% of total billed charges,2375.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1847.93,70,,,percent of total billed charges,70% of total billed charges,2375.91,90,,,percent of total billed charges,90% of total billed charges,2507.91,95,,,percent of total billed charges,95% of total billed charges,2507.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2270.31,86,,,percent of total billed charges,86% of total billed charges,2111.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2560.7,97,,,percent of total billed charges,97% of total billed charges,2375.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2560.7,97,,,percent of total billed charges,97% of total billed charges,2455.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2560.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1685.9,2560.7,
Periph Angio Tibial Peroneal Ath add,,,761,RC,37233,HCPCS,Outpatient,,,2547.29,1273.65,,2292.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2037.83,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2292.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2470.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2343.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1626.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2003.5,78.65,,,percent of total billed charges,78.65% of total billed charges,2275.53,89.33,,,percent of total billed charges,89.33% of total billed charges,2292.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1783.1,70,,,percent of total billed charges,70% of total billed charges,2292.56,90,,,percent of total billed charges,90% of total billed charges,2419.93,95,,,percent of total billed charges,95% of total billed charges,2419.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190.67,86,,,percent of total billed charges,86% of total billed charges,2037.83,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2470.87,97,,,percent of total billed charges,97% of total billed charges,2292.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2470.87,97,,,percent of total billed charges,97% of total billed charges,2368.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2470.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1626.76,2470.87,
37234- Stent/tib/peroneal/unilat/ea add,3430917,CDM,510,RC,37234,HCPCS,Outpatient,,,9054.14,4527.07,,8148.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7243.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8148.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8329.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5782.17,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,7121.28,78.65,,,percent of total billed charges,78.65% of total billed charges,8088.21,89.33,,,percent of total billed charges,89.33% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6337.9,70,,,percent of total billed charges,70% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,8601.43,95,,,percent of total billed charges,95% of total billed charges,8601.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.56,86,,,percent of total billed charges,86% of total billed charges,7243.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,8420.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5782.17,8782.52,
37234-Periph Angio Tibial Peroneal Stent add,3431908,CDM,481,RC,37234,HCPCS,Outpatient,,,9054.14,4527.07,,8148.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7243.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8148.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8329.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5782.17,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,7121.28,78.65,,,percent of total billed charges,78.65% of total billed charges,8088.21,89.33,,,percent of total billed charges,89.33% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6337.9,70,,,percent of total billed charges,70% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,8601.43,95,,,percent of total billed charges,95% of total billed charges,8601.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.56,86,,,percent of total billed charges,86% of total billed charges,7243.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,8148.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,8420.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8782.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5782.17,8782.52,
Periph Angio Tibial Peroneal Stent add,,,761,RC,37234,HCPCS,Outpatient,,,8569.23,4284.62,,7712.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,6855.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7712.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8312.15,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,7883.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5472.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,6739.89,78.65,,,percent of total billed charges,78.65% of total billed charges,7655.03,89.33,,,percent of total billed charges,89.33% of total billed charges,7712.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5998.46,70,,,percent of total billed charges,70% of total billed charges,7712.31,90,,,percent of total billed charges,90% of total billed charges,8140.77,95,,,percent of total billed charges,95% of total billed charges,8140.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7369.54,86,,,percent of total billed charges,86% of total billed charges,6855.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8312.15,97,,,percent of total billed charges,97% of total billed charges,7712.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8312.15,97,,,percent of total billed charges,97% of total billed charges,7969.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8312.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5472.5,8312.15,
37235-Periph Angio Tib Per Stent w Ath ea add,3431909,CDM,481,RC,37235,HCPCS,Outpatient,,,9714.6,4857.30,,8743.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7771.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8743.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9423.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8937.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,6203.96,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,7640.75,78.65,,,percent of total billed charges,78.65% of total billed charges,8678.21,89.33,,,percent of total billed charges,89.33% of total billed charges,8743.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6800.22,70,,,percent of total billed charges,70% of total billed charges,8743.14,90,,,percent of total billed charges,90% of total billed charges,9228.87,95,,,percent of total billed charges,95% of total billed charges,9228.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8354.56,86,,,percent of total billed charges,86% of total billed charges,7771.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9423.16,97,,,percent of total billed charges,97% of total billed charges,8743.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9423.16,97,,,percent of total billed charges,97% of total billed charges,9034.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9423.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6203.96,9423.16,
Periph Angio Tib Per Stent w Ath ea add,,,761,RC,37235,HCPCS,Outpatient,,,9360.94,4680.47,,8424.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7488.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8424.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9080.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8612.06,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5978.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,7362.59,78.65,,,percent of total billed charges,78.65% of total billed charges,8362.28,89.33,,,percent of total billed charges,89.33% of total billed charges,8424.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6552.66,70,,,percent of total billed charges,70% of total billed charges,8424.85,90,,,percent of total billed charges,90% of total billed charges,8892.89,95,,,percent of total billed charges,95% of total billed charges,8892.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8050.41,86,,,percent of total billed charges,86% of total billed charges,7488.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9080.11,97,,,percent of total billed charges,97% of total billed charges,8424.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9080.11,97,,,percent of total billed charges,97% of total billed charges,8705.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9080.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5978.1,9080.11,
37236-Insertion of Aortic Stent,3581331,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Peripheral Angio Stent w PTA,3431910,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Peripheral Intervention Celiac,3431911,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Peripheral Intervention Mesenteric,3431912,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Peripheral Intervention Splenic,3431913,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-PF Insertion of Aortic Stent,3581339,CDM,960,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,3055.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,381.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,832.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4735.75,155,,,Fee Schedule,155% of CMS OPPS Rate,4735.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2936.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.11,6254.37,
37236-Renal Angiography stent w PTA,3431914,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Renal Artery Intervention LT,3431915,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Renal Artery Intervention RT,3431916,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Stent Place S/I RT other,3560644,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-STENT PLMT LT LOWER EXT S&I,3431917,CDM,481,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Subclavian Angiography with PTA,3431918,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Subclavian Intervention LT,3431919,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37236-Subclavian Intervention RT,3431920,CDM,360,RC,37236,HCPCS,Outpatient,,,6949.3,3474.65,,6254.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5559.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6254.37,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6740.82,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6393.36,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4864.51,70,,,percent of total billed charges,70% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,6601.84,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5976.4,86,,,percent of total billed charges,86% of total billed charges,5559.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6740.82,97,,,percent of total billed charges,97% of total billed charges,6254.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6740.82,97,,,percent of total billed charges,97% of total billed charges,6462.85,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6740.82,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Insertion of Aortic Stent,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
IR Stent Placement Bilat S and I,603514,CDM,320,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
IR Stent Placement Lt S and I,603484,CDM,320,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Peripheral Angio Stent w PTA,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Peripheral Intervention Celiac,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Peripheral Intervention Mesenteric,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Peripheral Intervention Splenic,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Renal Angiography stent w PTA,3427241,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,3055.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,381.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,832.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4735.75,155,,,Fee Schedule,155% of CMS OPPS Rate,4735.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2936.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.11,5918.57,
Renal Artery Intervention LT,3427304,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,3055.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,381.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,832.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4735.75,155,,,Fee Schedule,155% of CMS OPPS Rate,4735.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2936.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.11,5918.57,
Renal Artery Intervention RT,3427305,CDM,960,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,3055.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,381.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,743.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,743.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,705.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,884.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,832.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,685.33,155,,,Fee Schedule,155% of CMS OPPS Rate,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4735.75,155,,,Fee Schedule,155% of CMS OPPS Rate,4735.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2936.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.11,5918.57,
Subclavian Angiography with PTA,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Subclavian Intervention LT,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
Subclavian Intervention RT,,,761,RC,37236,HCPCS,Outpatient,,,6576.19,3288.10,,5918.57,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5260.95,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,5918.57,90,,,Percent of total Billed charges,90% of total billed charges,420.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6378.9,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6050.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4603.33,70,,,percent of total billed charges,70% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,6247.38,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5655.52,86,,,percent of total billed charges,86% of total billed charges,5260.95,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6378.9,97,,,percent of total billed charges,97% of total billed charges,5918.57,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,6378.9,97,,,percent of total billed charges,97% of total billed charges,6115.86,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6378.9,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381.86,51750.98,
37237 - PF Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) fo,3714921,CDM,510,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2932.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2606.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2932.12,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3160.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2997.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2080.57,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2562.42,78.65,,,percent of total billed charges,78.65% of total billed charges,2910.34,89.33,,,percent of total billed charges,89.33% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2280.54,70,,,percent of total billed charges,70% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.8,86,,,percent of total billed charges,86% of total billed charges,2606.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,3029.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3160.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3160.17,
37237-Periph Angio Stent w PTA ea add,3431921,CDM,481,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2932.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2606.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2932.12,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3160.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2997.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2080.57,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2562.42,78.65,,,percent of total billed charges,78.65% of total billed charges,2910.34,89.33,,,percent of total billed charges,89.33% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2280.54,70,,,percent of total billed charges,70% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.8,86,,,percent of total billed charges,86% of total billed charges,2606.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,3029.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3160.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3160.17,
37237-Renal Angiography stent w PTA add,3431922,CDM,360,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2932.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2606.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2932.12,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3160.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2997.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2080.57,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2562.42,78.65,,,percent of total billed charges,78.65% of total billed charges,2910.34,89.33,,,percent of total billed charges,89.33% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2280.54,70,,,percent of total billed charges,70% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.8,86,,,percent of total billed charges,86% of total billed charges,2606.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,3029.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3160.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3160.17,
37237-Subclavian Stent w PTA add,3431923,CDM,360,RC,37237,HCPCS,Outpatient,,,3257.91,1628.96,,2932.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2606.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2932.12,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3160.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2997.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2080.57,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2562.42,78.65,,,percent of total billed charges,78.65% of total billed charges,2910.34,89.33,,,percent of total billed charges,89.33% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2280.54,70,,,percent of total billed charges,70% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,3095.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2801.8,86,,,percent of total billed charges,86% of total billed charges,2606.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,2932.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3160.17,97,,,percent of total billed charges,97% of total billed charges,3029.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3160.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3160.17,
Periph Angio Stent w PTA ea add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2783.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2474.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2783.82,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3000.34,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2845.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1975.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2432.81,78.65,,,percent of total billed charges,78.65% of total billed charges,2763.14,89.33,,,percent of total billed charges,89.33% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2165.19,70,,,percent of total billed charges,70% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660.09,86,,,percent of total billed charges,86% of total billed charges,2474.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2876.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3000.34,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3000.34,
Renal Angiography stent w PTA add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2783.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2474.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2783.82,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3000.34,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2845.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1975.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2432.81,78.65,,,percent of total billed charges,78.65% of total billed charges,2763.14,89.33,,,percent of total billed charges,89.33% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2165.19,70,,,percent of total billed charges,70% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660.09,86,,,percent of total billed charges,86% of total billed charges,2474.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2876.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3000.34,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3000.34,
Subclavian Stent w PTA add,,,761,RC,37237,HCPCS,Outpatient,,,3093.13,1546.57,,2783.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2474.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2783.82,90,,,Percent of total Billed charges,90% of total billed charges,196.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3000.34,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2845.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1975.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2432.81,78.65,,,percent of total billed charges,78.65% of total billed charges,2763.14,89.33,,,percent of total billed charges,89.33% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2165.19,70,,,percent of total billed charges,70% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,2938.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2660.09,86,,,percent of total billed charges,86% of total billed charges,2474.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2783.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3000.34,97,,,percent of total billed charges,97% of total billed charges,2876.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3000.34,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.71,3000.34,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,510,RC,37238,HCPCS,Outpatient,,,8606.54,4303.27,,7745.89,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6885.23,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7745.89,90,,,Percent of total Billed charges,90% of total billed charges,294.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8348.34,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7918.02,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7745.89,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6024.58,70,,,percent of total billed charges,70% of total billed charges,7745.89,90,,,percent of total billed charges,90% of total billed charges,8176.21,95,,,percent of total billed charges,95% of total billed charges,8176.21,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7401.62,86,,,percent of total billed charges,86% of total billed charges,6885.23,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8348.34,97,,,percent of total billed charges,97% of total billed charges,7745.89,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8348.34,97,,,percent of total billed charges,97% of total billed charges,8004.08,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8348.34,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,267.48,51750.98,
37238-Venography Stent open/perc w PTA initial,3431924,CDM,481,RC,37238,HCPCS,Outpatient,,,8606.54,4303.27,,7745.89,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6885.23,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7745.89,90,,,Percent of total Billed charges,90% of total billed charges,294.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8348.34,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7918.02,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7745.89,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6024.58,70,,,percent of total billed charges,70% of total billed charges,7745.89,90,,,percent of total billed charges,90% of total billed charges,8176.21,95,,,percent of total billed charges,95% of total billed charges,8176.21,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7401.62,86,,,percent of total billed charges,86% of total billed charges,6885.23,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8348.34,97,,,percent of total billed charges,97% of total billed charges,7745.89,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8348.34,97,,,percent of total billed charges,97% of total billed charges,8004.08,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8348.34,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,267.48,51750.98,
Venography Stent open/perc w PTA initial,,,761,RC,37238,HCPCS,Outpatient,,,8153.18,4076.59,,7337.86,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6522.54,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7337.86,90,,,Percent of total Billed charges,90% of total billed charges,294.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7908.58,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7500.93,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7337.86,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5707.23,70,,,percent of total billed charges,70% of total billed charges,7337.86,90,,,percent of total billed charges,90% of total billed charges,7745.52,95,,,percent of total billed charges,95% of total billed charges,7745.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7011.73,86,,,percent of total billed charges,86% of total billed charges,6522.54,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7908.58,97,,,percent of total billed charges,97% of total billed charges,7337.86,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7908.58,97,,,percent of total billed charges,97% of total billed charges,7582.46,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7908.58,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,267.48,51750.98,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,510,RC,37239,HCPCS,Outpatient,,,4254.69,2127.35,,3829.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3403.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3829.22,90,,,Percent of total Billed charges,90% of total billed charges,137.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4127.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3914.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2717.14,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3346.41,78.65,,,percent of total billed charges,78.65% of total billed charges,3800.78,89.33,,,percent of total billed charges,89.33% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2978.28,70,,,percent of total billed charges,70% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,4041.96,95,,,percent of total billed charges,95% of total billed charges,4041.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3659.03,86,,,percent of total billed charges,86% of total billed charges,3403.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4127.05,97,,,percent of total billed charges,97% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4127.05,97,,,percent of total billed charges,97% of total billed charges,3956.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4127.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,4127.05,
37239-Venography each add vein,3431925,CDM,481,RC,37239,HCPCS,Outpatient,,,4254.69,2127.35,,3829.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3403.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3829.22,90,,,Percent of total Billed charges,90% of total billed charges,137.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4127.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3914.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2717.14,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3346.41,78.65,,,percent of total billed charges,78.65% of total billed charges,3800.78,89.33,,,percent of total billed charges,89.33% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2978.28,70,,,percent of total billed charges,70% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,4041.96,95,,,percent of total billed charges,95% of total billed charges,4041.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3659.03,86,,,percent of total billed charges,86% of total billed charges,3403.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4127.05,97,,,percent of total billed charges,97% of total billed charges,3829.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4127.05,97,,,percent of total billed charges,97% of total billed charges,3956.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4127.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,4127.05,
Venography each add vein,,,761,RC,37239,HCPCS,Outpatient,,,4048.91,2024.46,,3644.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3239.13,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3644.02,90,,,Percent of total Billed charges,90% of total billed charges,137.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3927.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3725,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2585.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3184.56,78.65,,,percent of total billed charges,78.65% of total billed charges,3616.96,89.33,,,percent of total billed charges,89.33% of total billed charges,3644.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2834.24,70,,,percent of total billed charges,70% of total billed charges,3644.02,90,,,percent of total billed charges,90% of total billed charges,3846.46,95,,,percent of total billed charges,95% of total billed charges,3846.46,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3482.06,86,,,percent of total billed charges,86% of total billed charges,3239.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3927.44,97,,,percent of total billed charges,97% of total billed charges,3644.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3927.44,97,,,percent of total billed charges,97% of total billed charges,3765.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3927.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,3927.44,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,510,RC,37241,HCPCS,Outpatient,,,11686.98,5843.49,,10518.28,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9349.58,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10518.28,90,,,Percent of total Billed charges,90% of total billed charges,402.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,11336.37,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,10752.02,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10518.28,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8180.89,70,,,percent of total billed charges,70% of total billed charges,10518.28,90,,,percent of total billed charges,90% of total billed charges,11102.63,95,,,percent of total billed charges,95% of total billed charges,11102.63,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10050.8,86,,,percent of total billed charges,86% of total billed charges,9349.58,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11336.37,97,,,percent of total billed charges,97% of total billed charges,10518.28,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,11336.37,97,,,percent of total billed charges,97% of total billed charges,10868.89,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,11336.37,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,366.22,51750.98,
"37241-Embolization/Occlusion Venous, other than hemorrhage",4271183,CDM,481,RC,37241,HCPCS,Outpatient,,,8827.13,4413.57,,7944.42,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7061.7,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7944.42,90,,,Percent of total Billed charges,90% of total billed charges,402.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8562.32,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8120.96,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7944.42,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6178.99,70,,,percent of total billed charges,70% of total billed charges,7944.42,90,,,percent of total billed charges,90% of total billed charges,8385.77,95,,,percent of total billed charges,95% of total billed charges,8385.77,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7591.33,86,,,percent of total billed charges,86% of total billed charges,7061.7,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8562.32,97,,,percent of total billed charges,97% of total billed charges,7944.42,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8562.32,97,,,percent of total billed charges,97% of total billed charges,8209.23,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8562.32,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,366.22,51750.98,
"37241-PF Embolization/Occlusion Venous, other than hemorrhage",4271184,CDM,960,RC,37241,HCPCS,Outpatient,,,8827.13,4413.57,,7944.42,90,,,percent of total billed charges,90% of total Billed charges,4818.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,366.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,730.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,685.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,685.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,382.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,808.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,552.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,7469.17,155,,,Fee Schedule,155% of CMS OPPS Rate,7469.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4728.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.22,7944.42,
37242-Coil Embolization-AVM/AVF-Arterial,3938925,CDM,481,RC,37242,HCPCS,Outpatient,,,17804.35,8902.18,,16023.92,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14243.48,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,16023.92,90,,,Percent of total Billed charges,90% of total billed charges,449.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,17270.22,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16380,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16023.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,12463.05,70,,,percent of total billed charges,70% of total billed charges,16023.92,90,,,percent of total billed charges,90% of total billed charges,16914.13,95,,,percent of total billed charges,95% of total billed charges,16914.13,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15311.74,86,,,percent of total billed charges,86% of total billed charges,14243.48,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17270.22,97,,,percent of total billed charges,97% of total billed charges,16023.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,17270.22,97,,,percent of total billed charges,97% of total billed charges,16558.05,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,17270.22,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,408.94,51750.98,
37242-PF Coil Embolization-AVM/AVF-Arterial,3938927,CDM,960,RC,37242,HCPCS,Outpatient,,,17804.35,8902.18,,16023.92,90,,,percent of total billed charges,90% of total Billed charges,7166.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,471.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,408.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,730.79,155,,,Fee Schedule,155% of CMS OPPS Rate,471.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,796.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,747.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,747.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,386.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,881.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,595.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,730.79,155,,,Fee Schedule,155% of CMS OPPS Rate,471.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,11108.12,155,,,Fee Schedule,155% of CMS OPPS Rate,11108.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,471.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7945.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,471.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.93,16023.92,
Coil Embolization-AVM/AVF-Arterial,,,761,RC,37242,HCPCS,Outpatient,,,16783.25,8391.63,,15104.93,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13426.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,15104.93,90,,,Percent of total Billed charges,90% of total billed charges,449.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,16279.75,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15440.59,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15104.93,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11748.28,70,,,percent of total billed charges,70% of total billed charges,15104.93,90,,,percent of total billed charges,90% of total billed charges,15944.09,95,,,percent of total billed charges,95% of total billed charges,15944.09,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14433.6,86,,,percent of total billed charges,86% of total billed charges,13426.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16279.75,97,,,percent of total billed charges,97% of total billed charges,15104.93,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,16279.75,97,,,percent of total billed charges,97% of total billed charges,15608.42,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,16279.75,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,408.94,51750.98,
Embolization (Cardiology),,,761,RC,37242,HCPCS,Outpatient,,,16783.25,8391.63,,15104.93,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13426.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,15104.93,90,,,Percent of total Billed charges,90% of total billed charges,449.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,16279.75,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15440.59,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15104.93,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11748.28,70,,,percent of total billed charges,70% of total billed charges,15104.93,90,,,percent of total billed charges,90% of total billed charges,15944.09,95,,,percent of total billed charges,95% of total billed charges,15944.09,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14433.6,86,,,percent of total billed charges,86% of total billed charges,13426.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16279.75,97,,,percent of total billed charges,97% of total billed charges,15104.93,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,16279.75,97,,,percent of total billed charges,97% of total billed charges,15608.42,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,16279.75,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,408.94,51750.98,
37244-Coil Embolization-Art or Vein-W/Hemorrhage,3938926,CDM,481,RC,37244,HCPCS,Outpatient,,,16456.48,8228.24,,14810.83,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13165.18,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,14810.83,90,,,Percent of total Billed charges,90% of total billed charges,625.66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15962.79,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15139.96,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14810.83,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11519.54,70,,,percent of total billed charges,70% of total billed charges,14810.83,90,,,percent of total billed charges,90% of total billed charges,15633.66,95,,,percent of total billed charges,95% of total billed charges,15633.66,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14152.57,86,,,percent of total billed charges,86% of total billed charges,13165.18,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15962.79,97,,,percent of total billed charges,97% of total billed charges,14810.83,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,15962.79,97,,,percent of total billed charges,97% of total billed charges,15304.53,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,568.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15962.79,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,568.78,51750.98,
37244-PF Coil Embolization-Art or Vein-W/Hemorrhage,3938928,CDM,960,RC,37244,HCPCS,Outpatient,,,16456.48,8228.24,,14810.83,90,,,percent of total billed charges,90% of total Billed charges,6834.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,646.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,568.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1002.48,155,,,Fee Schedule,155% of CMS OPPS Rate,646.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,986.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,646.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1109.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1109.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1028.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1028.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,569.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1293.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1213.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,771.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1002.48,155,,,Fee Schedule,155% of CMS OPPS Rate,646.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,10594.2,155,,,Fee Schedule,155% of CMS OPPS Rate,10594.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,646.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,568.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7041.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,646.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.78,14810.83,
Coil Embolization-Art or Vein-W/Hemorrhage,,,761,RC,37244,HCPCS,Outpatient,,,15614.36,7807.18,,14052.92,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,12491.49,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,14052.92,90,,,Percent of total Billed charges,90% of total billed charges,625.66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15145.93,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14365.21,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14052.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,10930.05,70,,,percent of total billed charges,70% of total billed charges,14052.92,90,,,percent of total billed charges,90% of total billed charges,14833.64,95,,,percent of total billed charges,95% of total billed charges,14833.64,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13428.35,86,,,percent of total billed charges,86% of total billed charges,12491.49,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15145.93,97,,,percent of total billed charges,97% of total billed charges,14052.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,15145.93,97,,,percent of total billed charges,97% of total billed charges,14521.35,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,568.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15145.93,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,568.78,51750.98,
37246 - (50) Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3699318,CDM,510,RC,37246,HCPCS,Outpatient,,,4619.23,2309.62,,4157.31,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4157.31,90,,,Percent of total Billed charges,90% of total billed charges,320.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4480.65,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4249.69,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4157.31,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3233.46,70,,,percent of total billed charges,70% of total billed charges,4157.31,90,,,percent of total billed charges,90% of total billed charges,4388.27,95,,,percent of total billed charges,95% of total billed charges,4388.27,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3972.54,86,,,percent of total billed charges,86% of total billed charges,3695.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4480.65,97,,,percent of total billed charges,97% of total billed charges,4157.31,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4480.65,97,,,percent of total billed charges,97% of total billed charges,4295.88,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4480.65,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.76,25425.73,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,510,RC,37246,HCPCS,Outpatient,,,4619.23,2309.62,,4157.31,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4157.31,90,,,Percent of total Billed charges,90% of total billed charges,320.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4480.65,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4249.69,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4157.31,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3233.46,70,,,percent of total billed charges,70% of total billed charges,4157.31,90,,,percent of total billed charges,90% of total billed charges,4388.27,95,,,percent of total billed charges,95% of total billed charges,4388.27,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3972.54,86,,,percent of total billed charges,86% of total billed charges,3695.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4480.65,97,,,percent of total billed charges,97% of total billed charges,4157.31,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4480.65,97,,,percent of total billed charges,97% of total billed charges,4295.88,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4480.65,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.76,25425.73,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,510,RC,37247,HCPCS,Outpatient,,,1400.67,700.34,,1260.6,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1120.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1260.6,90,,,Percent of total Billed charges,90% of total billed charges,159.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1358.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1288.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,894.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1101.66,78.65,,,percent of total billed charges,78.65% of total billed charges,1251.24,89.33,,,percent of total billed charges,89.33% of total billed charges,1260.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.47,70,,,percent of total billed charges,70% of total billed charges,1260.6,90,,,percent of total billed charges,90% of total billed charges,1330.64,95,,,percent of total billed charges,95% of total billed charges,1330.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1204.58,86,,,percent of total billed charges,86% of total billed charges,1120.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1358.65,97,,,percent of total billed charges,97% of total billed charges,1260.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1358.65,97,,,percent of total billed charges,97% of total billed charges,1302.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1358.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,1358.65,
"37247-Balloon Angioplasty (except LE arteries, coronary, pulmonary, or dialysis) each add't",4271256,CDM,481,RC,37247,HCPCS,Outpatient,,,1103.76,551.88,,993.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,883.01,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,993.38,90,,,Percent of total Billed charges,90% of total billed charges,159.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1070.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1015.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,704.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,868.13,78.65,,,percent of total billed charges,78.65% of total billed charges,986.01,89.33,,,percent of total billed charges,89.33% of total billed charges,993.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,772.63,70,,,percent of total billed charges,70% of total billed charges,993.38,90,,,percent of total billed charges,90% of total billed charges,1048.57,95,,,percent of total billed charges,95% of total billed charges,1048.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.23,86,,,percent of total billed charges,86% of total billed charges,883.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1070.65,97,,,percent of total billed charges,97% of total billed charges,993.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1070.65,97,,,percent of total billed charges,97% of total billed charges,1026.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1070.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,1070.65,
"37247-PF Balloon Angioplasty (except LE arteries, coronary, pulmonary, or dialysis) each add't",4271257,CDM,960,RC,37247,HCPCS,Outpatient,,,1103.76,551.88,,993.38,90,,,percent of total billed charges,90% of total Billed charges,699.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,172.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1083.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1083.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,914.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,1083.54,
"37248 - (50) Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3699319,CDM,510,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,3103.68,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2758.82,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3103.68,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3345.07,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3172.65,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.97,70,,,percent of total billed charges,70% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2965.74,86,,,percent of total billed charges,86% of total billed charges,2758.82,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3345.07,97,,,percent of total billed charges,97% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3345.07,97,,,percent of total billed charges,97% of total billed charges,3207.13,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3345.07,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,510,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,3103.68,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2758.82,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3103.68,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3345.07,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3172.65,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.97,70,,,percent of total billed charges,70% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2965.74,86,,,percent of total billed charges,86% of total billed charges,2758.82,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3345.07,97,,,percent of total billed charges,97% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3345.07,97,,,percent of total billed charges,97% of total billed charges,3207.13,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3345.07,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
37248-PTA Vein,3560635,CDM,481,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,3103.68,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2758.82,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3103.68,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3345.07,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3172.65,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.97,70,,,percent of total billed charges,70% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2965.74,86,,,percent of total billed charges,86% of total billed charges,2758.82,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3345.07,97,,,percent of total billed charges,97% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3345.07,97,,,percent of total billed charges,97% of total billed charges,3207.13,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3345.07,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
37248-Venography Transluminal PTA initial vein,3431928,CDM,481,RC,37248,HCPCS,Outpatient,,,3448.53,1724.27,,3103.68,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2758.82,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3103.68,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3345.07,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3172.65,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2413.97,70,,,percent of total billed charges,70% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,3276.1,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2965.74,86,,,percent of total billed charges,86% of total billed charges,2758.82,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3345.07,97,,,percent of total billed charges,97% of total billed charges,3103.68,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3345.07,97,,,percent of total billed charges,97% of total billed charges,3207.13,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3345.07,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
Venography Transluminal PTA initial vein,3427277,CDM,481,RC,37248,HCPCS,Outpatient,,,3262.76,1631.38,,2936.48,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2610.21,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2936.48,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3164.88,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3001.74,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2936.48,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2283.93,70,,,percent of total billed charges,70% of total billed charges,2936.48,90,,,percent of total billed charges,90% of total billed charges,3099.62,95,,,percent of total billed charges,95% of total billed charges,3099.62,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2805.97,86,,,percent of total billed charges,86% of total billed charges,2610.21,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3164.88,97,,,percent of total billed charges,97% of total billed charges,2936.48,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3164.88,97,,,percent of total billed charges,97% of total billed charges,3034.37,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3164.88,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
37249-PF Venography each add vein,3580888,CDM,960,RC,37249,HCPCS,Outpatient,,,1128.33,564.17,,1015.5,90,,,percent of total billed charges,90% of total Billed charges,568.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,123.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,223.79,155,,,Fee Schedule,155% of CMS OPPS Rate,144.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,184.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,223.79,155,,,Fee Schedule,155% of CMS OPPS Rate,144.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,881.44,155,,,Fee Schedule,155% of CMS OPPS Rate,881.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,144.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,672.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,144.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.1,1015.5,
37249-Venography each add vein,3431929,CDM,481,RC,37249,HCPCS,Outpatient,,,1128.33,564.17,,1015.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,902.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1015.5,90,,,Percent of total Billed charges,90% of total billed charges,135.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1094.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1038.06,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,720.58,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,887.46,78.65,,,percent of total billed charges,78.65% of total billed charges,1007.96,89.33,,,percent of total billed charges,89.33% of total billed charges,1015.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,789.83,70,,,percent of total billed charges,70% of total billed charges,1015.5,90,,,percent of total billed charges,90% of total billed charges,1071.91,95,,,percent of total billed charges,95% of total billed charges,1071.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,970.36,86,,,percent of total billed charges,86% of total billed charges,902.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1094.48,97,,,percent of total billed charges,97% of total billed charges,1015.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1094.48,97,,,percent of total billed charges,97% of total billed charges,1049.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1094.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.1,1094.48,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,510,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,2137.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1900.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2137.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2185.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1516.96,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1868.27,78.65,,,percent of total billed charges,78.65% of total billed charges,2121.95,89.33,,,percent of total billed charges,89.33% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1662.75,70,,,percent of total billed charges,70% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2042.81,86,,,percent of total billed charges,86% of total billed charges,1900.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2209.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.96,2304.1,
37252-IVUS Non Coronary,3560638,CDM,481,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,2137.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1900.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2137.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2185.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1516.96,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1868.27,78.65,,,percent of total billed charges,78.65% of total billed charges,2121.95,89.33,,,percent of total billed charges,89.33% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1662.75,70,,,percent of total billed charges,70% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2042.81,86,,,percent of total billed charges,86% of total billed charges,1900.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2209.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.96,2304.1,
37252-Noncoronary IVUS,3431930,CDM,481,RC,37252,HCPCS,Outpatient,,,2375.36,1187.68,,2137.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1900.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2137.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2185.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1516.96,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1868.27,78.65,,,percent of total billed charges,78.65% of total billed charges,2121.95,89.33,,,percent of total billed charges,89.33% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1662.75,70,,,percent of total billed charges,70% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,2256.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2042.81,86,,,percent of total billed charges,86% of total billed charges,1900.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2137.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,2209.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2304.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1516.96,2304.1,
Noncoronary IVUS,,,761,RC,37252,HCPCS,Outpatient,,,2254.17,1127.09,,2028.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1803.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2028.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2186.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2073.84,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1439.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1772.95,78.65,,,percent of total billed charges,78.65% of total billed charges,2013.69,89.33,,,percent of total billed charges,89.33% of total billed charges,2028.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1577.92,70,,,percent of total billed charges,70% of total billed charges,2028.75,90,,,percent of total billed charges,90% of total billed charges,2141.46,95,,,percent of total billed charges,95% of total billed charges,2141.46,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1938.59,86,,,percent of total billed charges,86% of total billed charges,1803.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2186.54,97,,,percent of total billed charges,97% of total billed charges,2028.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2186.54,97,,,percent of total billed charges,97% of total billed charges,2096.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2186.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1439.56,2186.54,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,510,RC,37253,HCPCS,Outpatient,,,426.98,213.49,,384.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,341.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,384.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,392.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,272.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,335.83,78.65,,,percent of total billed charges,78.65% of total billed charges,381.43,89.33,,,percent of total billed charges,89.33% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,298.89,70,,,percent of total billed charges,70% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,405.63,95,,,percent of total billed charges,95% of total billed charges,405.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,86,,,percent of total billed charges,86% of total billed charges,341.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,397.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.68,414.17,
37253-IVUS non add,3431931,CDM,481,RC,37253,HCPCS,Outpatient,,,426.98,213.49,,384.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,341.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,384.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,392.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,272.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,335.83,78.65,,,percent of total billed charges,78.65% of total billed charges,381.43,89.33,,,percent of total billed charges,89.33% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,298.89,70,,,percent of total billed charges,70% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,405.63,95,,,percent of total billed charges,95% of total billed charges,405.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.2,86,,,percent of total billed charges,86% of total billed charges,341.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,384.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,397.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.68,414.17,
IVUS non add,,,761,RC,37253,HCPCS,Outpatient,,,422.99,211.50,,380.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,338.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,380.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,410.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,389.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,270.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,332.69,78.65,,,percent of total billed charges,78.65% of total billed charges,377.86,89.33,,,percent of total billed charges,89.33% of total billed charges,380.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,296.09,70,,,percent of total billed charges,70% of total billed charges,380.69,90,,,percent of total billed charges,90% of total billed charges,401.84,95,,,percent of total billed charges,95% of total billed charges,401.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.77,86,,,percent of total billed charges,86% of total billed charges,338.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,410.3,97,,,percent of total billed charges,97% of total billed charges,380.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,410.3,97,,,percent of total billed charges,97% of total billed charges,393.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.13,410.3,
37607- Ligation or banding of angioaccess AV fistula,3569416,CDM,510,RC,37607,HCPCS,Outpatient,,,998.13,499.07,,898.32,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,798.5,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,968.19,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,918.28,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,898.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,698.69,70,,,percent of total billed charges,70% of total billed charges,898.32,90,,,percent of total billed charges,90% of total billed charges,948.22,95,,,percent of total billed charges,95% of total billed charges,948.22,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,858.39,86,,,percent of total billed charges,86% of total billed charges,798.5,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,968.19,97,,,percent of total billed charges,97% of total billed charges,898.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,968.19,97,,,percent of total billed charges,97% of total billed charges,928.26,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,968.19,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,698.69,14522.85,
37609- Ligation/biopsy/temporal artery,3430918,CDM,761,RC,37609,HCPCS,Outpatient,,,804.5,402.25,,724.05,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,643.6,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.05,90,,,Percent of total Billed charges,90% of total billed charges,136.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,780.37,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,740.14,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,724.05,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,563.15,70,,,percent of total billed charges,70% of total billed charges,724.05,90,,,percent of total billed charges,90% of total billed charges,764.28,95,,,percent of total billed charges,95% of total billed charges,764.28,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,691.87,86,,,percent of total billed charges,86% of total billed charges,643.6,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,780.37,97,,,percent of total billed charges,97% of total billed charges,724.05,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,780.37,97,,,percent of total billed charges,97% of total billed charges,748.19,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,124,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,780.37,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,124,7310.49,
"37617 - PF Ligation, major artery (eg, post-traumatic, rupture); abdomen",3699320,CDM,510,RC,37617,HCPCS,Outpatient,,,3547.97,1773.99,,3193.17,90,,,percent of total billed charges,90% of total Billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2838.38,80,,,Percent of total Billed charges,80% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3193.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3441.53,97,,,Percent of total billed charges,97% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3264.13,92,,,Percent of total billed charges,92% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3193.17,90,,,percent of total billed charges,90% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2483.58,70,,,percent of total billed charges,70% of total billed charges,3193.17,90,,,percent of total billed charges,90% of total billed charges,3370.57,95,,,percent of total billed charges,95% of total billed charges,3370.57,95,,,percent of total billed charges,95% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3051.25,86,,,percent of total billed charges,86% of total billed charges,2838.38,80,,,percent of total billed charges,80% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3441.53,97,,,percent of total billed charges,97% of total billed charges,3193.17,90,,,percent of total billed charges,90% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3441.53,97,,,percent of total billed charges,97% of total billed charges,3299.61,93,,,percent of total billed charges,93% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3441.53,97,,,percent of total billed charges,97% of total billed charges,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3547.97,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2483.58,3547.97,
"37618- Arteriovenous anastomosis, open; by upper arm cephalic vein transposition",3566785,CDM,510,RC,37618,HCPCS,Outpatient,,,1034.14,517.07,,930.73,90,,,percent of total billed charges,90% of total Billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,827.31,80,,,Percent of total Billed charges,80% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,930.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1003.12,97,,,Percent of total billed charges,97% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,951.41,92,,,Percent of total billed charges,92% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,930.73,90,,,percent of total billed charges,90% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.9,70,,,percent of total billed charges,70% of total billed charges,930.73,90,,,percent of total billed charges,90% of total billed charges,982.43,95,,,percent of total billed charges,95% of total billed charges,982.43,95,,,percent of total billed charges,95% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,889.36,86,,,percent of total billed charges,86% of total billed charges,827.31,80,,,percent of total billed charges,80% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1003.12,97,,,percent of total billed charges,97% of total billed charges,930.73,90,,,percent of total billed charges,90% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1003.12,97,,,percent of total billed charges,97% of total billed charges,961.75,93,,,percent of total billed charges,93% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1003.12,97,,,percent of total billed charges,97% of total billed charges,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1034.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.9,1034.14,
37700- Ligation/divis of long saph vein,3430748,CDM,510,RC,37700,HCPCS,Outpatient,,,651.32,325.66,,586.19,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,521.06,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,631.78,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,599.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,586.19,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,455.92,70,,,percent of total billed charges,70% of total billed charges,586.19,90,,,percent of total billed charges,90% of total billed charges,618.75,95,,,percent of total billed charges,95% of total billed charges,618.75,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,560.14,86,,,percent of total billed charges,86% of total billed charges,521.06,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,631.78,97,,,percent of total billed charges,97% of total billed charges,586.19,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.78,97,,,percent of total billed charges,97% of total billed charges,605.73,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,631.78,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,455.92,14522.85,
"37722 - (50) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral j",3699326,CDM,510,RC,37722,HCPCS,Outpatient,,,1258.4,629.20,,1132.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.72,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1132.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1220.65,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1157.73,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1132.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,880.88,70,,,percent of total billed charges,70% of total billed charges,1132.56,90,,,percent of total billed charges,90% of total billed charges,1195.48,95,,,percent of total billed charges,95% of total billed charges,1195.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1082.22,86,,,percent of total billed charges,86% of total billed charges,1006.72,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1220.65,97,,,percent of total billed charges,97% of total billed charges,1132.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.65,97,,,percent of total billed charges,97% of total billed charges,1170.31,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1220.65,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,880.88,14522.85,
"37722 - (PF) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral",3634911,CDM,510,RC,37722,HCPCS,Outpatient,,,1258.4,629.20,,1132.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.72,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1132.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1220.65,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1157.73,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1132.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,880.88,70,,,percent of total billed charges,70% of total billed charges,1132.56,90,,,percent of total billed charges,90% of total billed charges,1195.48,95,,,percent of total billed charges,95% of total billed charges,1195.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1082.22,86,,,percent of total billed charges,86% of total billed charges,1006.72,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1220.65,97,,,percent of total billed charges,97% of total billed charges,1132.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.65,97,,,percent of total billed charges,97% of total billed charges,1170.31,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1220.65,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,880.88,14522.85,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,360,RC,37765,HCPCS,Outpatient,,,1113.38,556.69,,1002.04,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,890.7,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1079.98,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.31,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1002.04,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,779.37,70,,,percent of total billed charges,70% of total billed charges,1002.04,90,,,percent of total billed charges,90% of total billed charges,1057.71,95,,,percent of total billed charges,95% of total billed charges,1057.71,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,957.51,86,,,percent of total billed charges,86% of total billed charges,890.7,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1079.98,97,,,percent of total billed charges,97% of total billed charges,1002.04,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1079.98,97,,,percent of total billed charges,97% of total billed charges,1035.44,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1079.98,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,779.37,14522.85,
37766- Stab phlebectomy/1 ext/> 20 incis,3430750,CDM,510,RC,37766,HCPCS,Outpatient,,,1304.91,652.46,,1174.42,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.93,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1265.76,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1200.52,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1174.42,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,913.44,70,,,percent of total billed charges,70% of total billed charges,1174.42,90,,,percent of total billed charges,90% of total billed charges,1239.66,95,,,percent of total billed charges,95% of total billed charges,1239.66,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1122.22,86,,,percent of total billed charges,86% of total billed charges,1043.93,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1265.76,97,,,percent of total billed charges,97% of total billed charges,1174.42,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1265.76,97,,,percent of total billed charges,97% of total billed charges,1213.57,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1265.76,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,913.44,14522.85,
37799- Vasc Surg/Unlisted Procedure,3430751,CDM,360,RC,37799,HCPCS,Outpatient,,,2993.07,1496.54,,2693.76,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2394.46,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2693.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2903.28,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2753.62,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2693.76,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2095.15,70,,,percent of total billed charges,70% of total billed charges,2693.76,90,,,percent of total billed charges,90% of total billed charges,2843.42,95,,,percent of total billed charges,95% of total billed charges,2843.42,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2574.04,86,,,percent of total billed charges,86% of total billed charges,2394.46,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2903.28,97,,,percent of total billed charges,97% of total billed charges,2693.76,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2903.28,97,,,percent of total billed charges,97% of total billed charges,2783.56,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2903.28,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2903.28,
37799-Fibrin sheath disrupt/remove using angioplasty balloon,4331300,CDM,481,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,415.31,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,369.17,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,447.62,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,424.54,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,415.31,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,323.02,70,,,percent of total billed charges,70% of total billed charges,415.31,90,,,percent of total billed charges,90% of total billed charges,438.39,95,,,percent of total billed charges,95% of total billed charges,438.39,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,396.86,86,,,percent of total billed charges,86% of total billed charges,369.17,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,447.62,97,,,percent of total billed charges,97% of total billed charges,415.31,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,447.62,97,,,percent of total billed charges,97% of total billed charges,429.16,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,447.62,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,323.02,2820.25,
37799-PF Fibrin sheath disrupt/remove using angioplasty balloon,4331301,CDM,960,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,415.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.44,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.44,415.31,
Fibrin sheath disrupt/remove using angioplasty balloon,,,761,RC,37799,HCPCS,Outpatient,,,461.46,230.73,,415.31,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,369.17,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,447.62,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,424.54,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,415.31,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,323.02,70,,,percent of total billed charges,70% of total billed charges,415.31,90,,,percent of total billed charges,90% of total billed charges,438.39,95,,,percent of total billed charges,95% of total billed charges,438.39,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,396.86,86,,,percent of total billed charges,86% of total billed charges,369.17,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,447.62,97,,,percent of total billed charges,97% of total billed charges,415.31,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,447.62,97,,,percent of total billed charges,97% of total billed charges,429.16,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,447.62,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,323.02,2820.25,
38100 - PF Splenectomy Total Separate Procedure,4311503,CDM,960,RC,38100,HCPCS,Outpatient,,,2745.67,1372.84,,2471.1,90,,,percent of total billed charges,90% of total Billed charges,2324.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1156.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,563,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1792.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1156.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1717.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1156.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1931.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1931.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1805.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1805.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,932.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1156.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2312.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2130.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1537.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1792.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1156.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,3602.34,155,,,Fee Schedule,155% of CMS OPPS Rate,3602.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1156.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,563,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1058.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1156.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2337.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2337.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,563,3602.34,
38100- Splenectomy/total,3431444,CDM,510,RC,38100,HCPCS,Outpatient,,,3105.41,1552.71,,2794.87,90,,,percent of total billed charges,90% of total Billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2484.33,80,,,Percent of total Billed charges,80% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2794.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3012.25,97,,,Percent of total billed charges,97% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2856.98,92,,,Percent of total billed charges,92% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2794.87,90,,,percent of total billed charges,90% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2173.79,70,,,percent of total billed charges,70% of total billed charges,2794.87,90,,,percent of total billed charges,90% of total billed charges,2950.14,95,,,percent of total billed charges,95% of total billed charges,2950.14,95,,,percent of total billed charges,95% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2670.65,86,,,percent of total billed charges,86% of total billed charges,2484.33,80,,,percent of total billed charges,80% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3012.25,97,,,percent of total billed charges,97% of total billed charges,2794.87,90,,,percent of total billed charges,90% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3012.25,97,,,percent of total billed charges,97% of total billed charges,2888.03,93,,,percent of total billed charges,93% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3012.25,97,,,percent of total billed charges,97% of total billed charges,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3105.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2173.79,3105.41,
38101- PF Spelenectomy Parital Separate Procedure,4311504,CDM,960,RC,38101,HCPCS,Outpatient,,,2784.54,1392.27,,2506.09,90,,,percent of total billed charges,90% of total Billed charges,2358.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1172.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,563,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1817.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1172.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1735.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1172.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1952.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1952.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1826.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1826.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,933.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2345.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2155.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1566.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1817.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1172.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,3655.54,155,,,Fee Schedule,155% of CMS OPPS Rate,3655.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1172.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,563,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,889.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1172.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,2361.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2361.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,563,3655.54,
38102 - PF Splec Tot En Block Extnsv DS Conjunt w/ Oth Px,4311506,CDM,960,RC,38102,HCPCS,Outpatient,,,627.55,313.78,,564.8,90,,,percent of total billed charges,90% of total Billed charges,529.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,409.65,155,,,Fee Schedule,155% of CMS OPPS Rate,264.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,264.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,452.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,413.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,413.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,487.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,351.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,409.65,155,,,Fee Schedule,155% of CMS OPPS Rate,264.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,820.94,155,,,Fee Schedule,155% of CMS OPPS Rate,820.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,264.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,332.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,264.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,534.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,212.08,820.94,
38102-PF REMOVAL OF SPLEEN,3429787,CDM,510,RC,38102,HCPCS,Outpatient,,,705.65,352.83,,635.09,90,,,percent of total billed charges,90% of total Billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,564.52,80,,,Percent of total Billed charges,80% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,635.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,684.48,97,,,Percent of total billed charges,97% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,649.2,92,,,Percent of total billed charges,92% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,635.09,90,,,percent of total billed charges,90% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,493.96,70,,,percent of total billed charges,70% of total billed charges,635.09,90,,,percent of total billed charges,90% of total billed charges,670.37,95,,,percent of total billed charges,95% of total billed charges,670.37,95,,,percent of total billed charges,95% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,606.86,86,,,percent of total billed charges,86% of total billed charges,564.52,80,,,percent of total billed charges,80% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,684.48,97,,,percent of total billed charges,97% of total billed charges,635.09,90,,,percent of total billed charges,90% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,684.48,97,,,percent of total billed charges,97% of total billed charges,656.25,93,,,percent of total billed charges,93% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,684.48,97,,,percent of total billed charges,97% of total billed charges,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,705.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,493.96,705.65,
38120 - PF Laparascopic Surgical Splenectomy,4311507,CDM,960,RC,38120,HCPCS,Outpatient,,,2516.54,1258.27,,2264.89,90,,,percent of total billed charges,90% of total Billed charges,2128.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1059.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,563,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1642.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1059.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1616.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1059.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1818.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1818.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1640.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1640.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,850.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1059.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2119.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1935.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1390.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1642.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1059.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,3299.92,155,,,Fee Schedule,155% of CMS OPPS Rate,3299.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1059.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,563,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,987.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1059.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,2133.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2133.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,563,3299.92,
38120- Splenectomy/laparoscopy,3431445,CDM,510,RC,38120,HCPCS,Outpatient,,,2843.19,1421.60,,2558.87,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2274.55,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2558.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2757.89,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2615.73,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2558.87,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.23,70,,,percent of total billed charges,70% of total billed charges,2558.87,90,,,percent of total billed charges,90% of total billed charges,2701.03,95,,,percent of total billed charges,95% of total billed charges,2701.03,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2445.14,86,,,percent of total billed charges,86% of total billed charges,2274.55,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2757.89,97,,,percent of total billed charges,97% of total billed charges,2558.87,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2757.89,97,,,percent of total billed charges,97% of total billed charges,2644.17,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2757.89,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1990.23,44301.74,
38220- Bone marrow aspiration only,3431446,CDM,360,RC,38220,HCPCS,Outpatient,,,384.89,192.45,,346.4,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,307.91,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.4,90,,,Percent of total Billed charges,90% of total billed charges,60.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,373.34,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,354.1,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,346.4,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,269.42,70,,,percent of total billed charges,70% of total billed charges,346.4,90,,,percent of total billed charges,90% of total billed charges,365.65,95,,,percent of total billed charges,95% of total billed charges,365.65,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,331.01,86,,,percent of total billed charges,86% of total billed charges,307.91,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,373.34,97,,,percent of total billed charges,97% of total billed charges,346.4,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.34,97,,,percent of total billed charges,97% of total billed charges,357.95,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.34,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.68,7310.49,
38221- Diagnostic bone marrow; biopsy(ies),3431447,CDM,360,RC,38221,HCPCS,Outpatient,,,400.91,200.46,,360.82,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,320.73,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.82,90,,,Percent of total Billed charges,90% of total billed charges,76.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,388.88,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,368.84,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,360.82,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,280.64,70,,,percent of total billed charges,70% of total billed charges,360.82,90,,,percent of total billed charges,90% of total billed charges,380.86,95,,,percent of total billed charges,95% of total billed charges,380.86,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,344.78,86,,,percent of total billed charges,86% of total billed charges,320.73,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,388.88,97,,,percent of total billed charges,97% of total billed charges,360.82,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,388.88,97,,,percent of total billed charges,97% of total billed charges,372.85,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,388.88,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69.82,7310.49,
38221-PF DIAGNOSTIC BONE MARROW BIOPSIES,4321447,CDM,981,RC,38221,HCPCS,Outpatient,,,135.54,67.77,,121.99,90,,,percent of total billed charges,90% of total Billed charges,203.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,105.04,155,,,Fee Schedule,155% of CMS OPPS Rate,67.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,105.04,155,,,Fee Schedule,155% of CMS OPPS Rate,67.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.13,155,,,Fee Schedule,155% of CMS OPPS Rate,315.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,298.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.01,315.13,
38222-ZSW DX BONE MARROW BX & ASPIR,3435574,CDM,510,RC,38222,HCPCS,Outpatient,,,435.23,217.62,,391.71,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,348.18,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.71,90,,,Percent of total Billed charges,90% of total billed charges,69.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,422.17,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,391.71,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,304.66,70,,,percent of total billed charges,70% of total billed charges,391.71,90,,,percent of total billed charges,90% of total billed charges,413.47,95,,,percent of total billed charges,95% of total billed charges,413.47,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.3,86,,,percent of total billed charges,86% of total billed charges,348.18,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.17,97,,,percent of total billed charges,97% of total billed charges,391.71,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.17,97,,,percent of total billed charges,97% of total billed charges,404.76,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,422.17,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.32,12593.67,
38241- HPC/autologous transplantation,3431448,CDM,510,RC,38241,HCPCS,Outpatient,,,459.53,229.77,,413.58,90,,,percent of total billed charges,90% of total Billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,367.62,80,,,Percent of total Billed charges,80% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,445.74,97,,,Percent of total billed charges,97% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,422.77,92,,,Percent of total billed charges,92% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,3283,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1235.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5233.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6629.38,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,413.58,90,,,percent of total billed charges,90% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,321.67,70,,,percent of total billed charges,70% of total billed charges,413.58,90,,,percent of total billed charges,90% of total billed charges,436.55,95,,,percent of total billed charges,95% of total billed charges,436.55,95,,,percent of total billed charges,95% of total billed charges,1235.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2470.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,395.2,86,,,percent of total billed charges,86% of total billed charges,367.62,80,,,percent of total billed charges,80% of total billed charges,1368.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,445.74,97,,,percent of total billed charges,97% of total billed charges,413.58,90,,,percent of total billed charges,90% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.74,97,,,percent of total billed charges,97% of total billed charges,427.36,93,,,percent of total billed charges,93% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,445.74,97,,,percent of total billed charges,97% of total billed charges,1235.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1049.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,321.67,6629.38,
38300-PF DRAINAGE LYMPH NODE LESION,4321448,CDM,981,RC,38300,HCPCS,Outpatient,,,404.66,202.33,,364.19,90,,,percent of total billed charges,90% of total Billed charges,527.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,313.61,155,,,Fee Schedule,155% of CMS OPPS Rate,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,286.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,146.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,245.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,313.61,155,,,Fee Schedule,155% of CMS OPPS Rate,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,817.02,155,,,Fee Schedule,155% of CMS OPPS Rate,817.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,546.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64,817.02,
MA DRAIN LYMPH NODE ABSCESS/LYMPHA,3527856,CDM,960,RC,38300,HCPCS,Outpatient,,,863.7,431.85,,777.33,90,,,percent of total billed charges,90% of total Billed charges,527.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,313.61,155,,,Fee Schedule,155% of CMS OPPS Rate,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,286.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,146.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,245.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,313.61,155,,,Fee Schedule,155% of CMS OPPS Rate,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,817.02,155,,,Fee Schedule,155% of CMS OPPS Rate,817.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,202.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,546.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64,817.02,
38305-PF DRG LYMPH NODE ABSC/LYMPHADENITIS EXTNSV,4321449,CDM,981,RC,38305,HCPCS,Outpatient,,,974.3,487.15,,876.87,90,,,percent of total billed charges,90% of total Billed charges,978.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,487.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,755.07,155,,,Fee Schedule,155% of CMS OPPS Rate,487.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,487.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,686.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,686.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,741.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,741.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,487.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,974.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,875.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,614.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,755.07,155,,,Fee Schedule,155% of CMS OPPS Rate,487.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1516.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1516.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,487.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,508.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,487.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,930.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,105.5,1516.33,
38308- Lymphangiotomy/lymph channel ops,3431449,CDM,510,RC,38308,HCPCS,Outpatient,,,1226.98,613.49,,1104.28,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,981.58,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1104.28,90,,,Percent of total Billed charges,90% of total billed charges,144.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1190.17,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.82,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1104.28,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,858.89,70,,,percent of total billed charges,70% of total billed charges,1104.28,90,,,percent of total billed charges,90% of total billed charges,1165.63,95,,,percent of total billed charges,95% of total billed charges,1165.63,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1055.2,86,,,percent of total billed charges,86% of total billed charges,981.58,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1190.17,97,,,percent of total billed charges,97% of total billed charges,1104.28,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1190.17,97,,,percent of total billed charges,97% of total billed charges,1141.09,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1190.17,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131,16759.7,
38380 - Suture and/or ligation of thoracic duct; cervical approach,3760893,CDM,983,RC,38380,HCPCS,Outpatient,,,1487.23,743.62,,1338.51,90,,,percent of total billed charges,90% of total Billed charges,1118.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,374.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,867.15,155,,,Fee Schedule,155% of CMS OPPS Rate,559.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,852.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,852.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,853.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,853.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,449.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1118.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1007.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,667.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,867.15,155,,,Fee Schedule,155% of CMS OPPS Rate,559.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1733.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1733.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,559.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,558.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,559.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1196.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,374.5,1733.97,
38500 - PF Bx/ Exc Lymph Node Open Superficial,4311508,CDM,960,RC,38500,HCPCS,Outpatient,,,601.13,300.57,,541.02,90,,,percent of total billed charges,90% of total Billed charges,583.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.4,155,,,Fee Schedule,155% of CMS OPPS Rate,253.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,389.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,389.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,460.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,392.4,155,,,Fee Schedule,155% of CMS OPPS Rate,253.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,903.7,155,,,Fee Schedule,155% of CMS OPPS Rate,903.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,356.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,659.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,205.22,903.7,
38500- Bx/exc lymph node/open/superfic,3431450,CDM,510,RC,38500,HCPCS,Outpatient,,,877.26,438.63,,789.53,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,701.81,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,789.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,850.94,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,807.08,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,789.53,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,614.08,70,,,percent of total billed charges,70% of total billed charges,789.53,90,,,percent of total billed charges,90% of total billed charges,833.4,95,,,percent of total billed charges,95% of total billed charges,833.4,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,754.44,86,,,percent of total billed charges,86% of total billed charges,701.81,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,850.94,97,,,percent of total billed charges,97% of total billed charges,789.53,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,850.94,97,,,percent of total billed charges,97% of total billed charges,815.85,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,850.94,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,614.08,16759.7,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,510,RC,38505,HCPCS,Outpatient,,,446.02,223.01,,401.42,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,356.82,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.42,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,432.64,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,410.34,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,401.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,312.21,70,,,percent of total billed charges,70% of total billed charges,401.42,90,,,percent of total billed charges,90% of total billed charges,423.72,95,,,percent of total billed charges,95% of total billed charges,423.72,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.58,86,,,percent of total billed charges,86% of total billed charges,356.82,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,432.64,97,,,percent of total billed charges,97% of total billed charges,401.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.64,97,,,percent of total billed charges,97% of total billed charges,414.8,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,432.64,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,320,RC,38505,HCPCS,Outpatient,,,446.02,223.01,,401.42,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,356.82,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.42,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,432.64,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,410.34,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,401.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,312.21,70,,,percent of total billed charges,70% of total billed charges,401.42,90,,,percent of total billed charges,90% of total billed charges,423.72,95,,,percent of total billed charges,95% of total billed charges,423.72,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.58,86,,,percent of total billed charges,86% of total billed charges,356.82,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,432.64,97,,,percent of total billed charges,97% of total billed charges,401.42,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.64,97,,,percent of total billed charges,97% of total billed charges,414.8,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,432.64,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
CT add Needle Bx Lymph Node,3347324,CDM,320,RC,38505,HCPCS,Outpatient,,,435.5,217.75,,391.95,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,348.4,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.95,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,422.44,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,400.66,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,391.95,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,304.85,70,,,percent of total billed charges,70% of total billed charges,391.95,90,,,percent of total billed charges,90% of total billed charges,413.73,95,,,percent of total billed charges,95% of total billed charges,413.73,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.53,86,,,percent of total billed charges,86% of total billed charges,348.4,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.44,97,,,percent of total billed charges,97% of total billed charges,391.95,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.44,97,,,percent of total billed charges,97% of total billed charges,405.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,422.44,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
Read,4181202,CDM,972,RC,38505,HCPCS,Outpatient,,,174.2,87.10,,156.78,90,,,percent of total billed charges,90% of total Billed charges,251.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,390,155,,,Fee Schedule,155% of CMS OPPS Rate,390,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,243.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.95,390,
US add Needle Bx Lymph Node,3334648,CDM,320,RC,38505,HCPCS,Outpatient,,,435.5,217.75,,391.95,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,348.4,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.95,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,422.44,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,400.66,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,391.95,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,304.85,70,,,percent of total billed charges,70% of total billed charges,391.95,90,,,percent of total billed charges,90% of total billed charges,413.73,95,,,percent of total billed charges,95% of total billed charges,413.73,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.53,86,,,percent of total billed charges,86% of total billed charges,348.4,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.44,97,,,percent of total billed charges,97% of total billed charges,391.95,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.44,97,,,percent of total billed charges,97% of total billed charges,405.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,422.44,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
38510 - PF Bx/ Exc Lymph Node Open Deep Cervical Node,4311509,CDM,960,RC,38510,HCPCS,Outpatient,,,985.47,492.74,,886.92,90,,,percent of total billed charges,90% of total Billed charges,933.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,415.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,136,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,643.3,155,,,Fee Schedule,155% of CMS OPPS Rate,415.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,521.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,415.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,586.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,639.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,639.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,337.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,754.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,517.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,643.3,155,,,Fee Schedule,155% of CMS OPPS Rate,415.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1446.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1446.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,415.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,136,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,415.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1056.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1056.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,136,1446.69,
38510- Bx/exc lymph node/open/deep cervic,3431452,CDM,510,RC,38510,HCPCS,Outpatient,,,1378.41,689.21,,1240.57,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.73,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1240.57,90,,,Percent of total Billed charges,90% of total billed charges,149.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1337.06,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.14,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1240.57,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,964.89,70,,,percent of total billed charges,70% of total billed charges,1240.57,90,,,percent of total billed charges,90% of total billed charges,1309.49,95,,,percent of total billed charges,95% of total billed charges,1309.49,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1185.43,86,,,percent of total billed charges,86% of total billed charges,1102.73,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1337.06,97,,,percent of total billed charges,97% of total billed charges,1240.57,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1337.06,97,,,percent of total billed charges,97% of total billed charges,1281.92,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,136,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1337.06,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,136,16759.7,
38525 - PF Bx/ Exc Lymph Node Open Deep Axillary Node,4311510,CDM,960,RC,38525,HCPCS,Outpatient,,,1038.51,519.26,,934.66,90,,,percent of total billed charges,90% of total Billed charges,878.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,156,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,677.92,155,,,Fee Schedule,155% of CMS OPPS Rate,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,437.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,616.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,671.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,671.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,353.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,791.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,559.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,677.92,155,,,Fee Schedule,155% of CMS OPPS Rate,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1361.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,156,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,426.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,876.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,156,1361.09,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,510,RC,38525,HCPCS,Outpatient,,,1172.13,586.07,,1054.92,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,937.7,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.92,90,,,Percent of total Billed charges,90% of total billed charges,171.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1136.97,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1078.36,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1054.92,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,820.49,70,,,percent of total billed charges,70% of total billed charges,1054.92,90,,,percent of total billed charges,90% of total billed charges,1113.52,95,,,percent of total billed charges,95% of total billed charges,1113.52,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1008.03,86,,,percent of total billed charges,86% of total billed charges,937.7,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1136.97,97,,,percent of total billed charges,97% of total billed charges,1054.92,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1136.97,97,,,percent of total billed charges,97% of total billed charges,1090.08,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,156,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1136.97,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,156,16759.7,
38530- Bx/exc lymph node/open/int mammary,3431454,CDM,510,RC,38530,HCPCS,Outpatient,,,1480.66,740.33,,1332.59,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1184.53,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1332.59,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1436.24,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1362.21,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1332.59,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.46,70,,,percent of total billed charges,70% of total billed charges,1332.59,90,,,percent of total billed charges,90% of total billed charges,1406.63,95,,,percent of total billed charges,95% of total billed charges,1406.63,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1273.37,86,,,percent of total billed charges,86% of total billed charges,1184.53,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1436.24,97,,,percent of total billed charges,97% of total billed charges,1332.59,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1436.24,97,,,percent of total billed charges,97% of total billed charges,1377.01,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1436.24,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,16759.7,
38531-MA EXCISION OF LYMPH NODE,3429800,CDM,510,RC,38531,HCPCS,Outpatient,,,1185.98,592.99,,1067.38,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,948.78,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1067.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1150.4,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.1,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1067.38,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,830.19,70,,,percent of total billed charges,70% of total billed charges,1067.38,90,,,percent of total billed charges,90% of total billed charges,1126.68,95,,,percent of total billed charges,95% of total billed charges,1126.68,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1019.94,86,,,percent of total billed charges,86% of total billed charges,948.78,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1150.4,97,,,percent of total billed charges,97% of total billed charges,1067.38,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.4,97,,,percent of total billed charges,97% of total billed charges,1102.96,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1150.4,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,830.19,16759.7,
38562 - Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic,3783256,CDM,510,RC,38562,HCPCS,Outpatient,,,1856.31,928.16,,1670.68,90,,,percent of total billed charges,90% of total Billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1485.05,80,,,Percent of total Billed charges,80% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1670.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1800.62,97,,,Percent of total billed charges,97% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1707.81,92,,,Percent of total billed charges,92% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1670.68,90,,,percent of total billed charges,90% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1299.42,70,,,percent of total billed charges,70% of total billed charges,1670.68,90,,,percent of total billed charges,90% of total billed charges,1763.49,95,,,percent of total billed charges,95% of total billed charges,1763.49,95,,,percent of total billed charges,95% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1596.43,86,,,percent of total billed charges,86% of total billed charges,1485.05,80,,,percent of total billed charges,80% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1800.62,97,,,percent of total billed charges,97% of total billed charges,1670.68,90,,,percent of total billed charges,90% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1800.62,97,,,percent of total billed charges,97% of total billed charges,1726.37,93,,,percent of total billed charges,93% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1800.62,97,,,percent of total billed charges,97% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1299.42,1856.31,
38562 - PF Lmtd Lmphadec Staging Spx Pel&Para-Aortic,4311511,CDM,960,RC,38562,HCPCS,Outpatient,,,1644.27,822.14,,1479.84,90,,,percent of total billed charges,90% of total Billed charges,1390.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,692.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,346,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1073.38,155,,,Fee Schedule,155% of CMS OPPS Rate,692.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,692.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,990.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1073.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1073.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,567.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1385,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1267.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,857.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1073.38,155,,,Fee Schedule,155% of CMS OPPS Rate,692.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2155.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2155.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,692.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,346,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,711.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,692.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1404.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1404.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,346,2155.32,
38562- Lymphadenect/stage/pelv/paraaortic,3431455,CDM,510,RC,38562,HCPCS,Outpatient,,,1856.31,928.16,,1670.68,90,,,percent of total billed charges,90% of total Billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1485.05,80,,,Percent of total Billed charges,80% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1670.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1800.62,97,,,Percent of total billed charges,97% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1707.81,92,,,Percent of total billed charges,92% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1670.68,90,,,percent of total billed charges,90% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1299.42,70,,,percent of total billed charges,70% of total billed charges,1670.68,90,,,percent of total billed charges,90% of total billed charges,1763.49,95,,,percent of total billed charges,95% of total billed charges,1763.49,95,,,percent of total billed charges,95% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1596.43,86,,,percent of total billed charges,86% of total billed charges,1485.05,80,,,percent of total billed charges,80% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1800.62,97,,,percent of total billed charges,97% of total billed charges,1670.68,90,,,percent of total billed charges,90% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1800.62,97,,,percent of total billed charges,97% of total billed charges,1726.37,93,,,percent of total billed charges,93% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1800.62,97,,,percent of total billed charges,97% of total billed charges,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1856.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1299.42,1856.31,
38570- Laparoscopy/surg/retroper lymph bx,3431456,CDM,510,RC,38570,HCPCS,Outpatient,,,1360.33,680.17,,1224.3,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.26,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1224.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1319.52,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1251.5,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1224.3,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,952.23,70,,,percent of total billed charges,70% of total billed charges,1224.3,90,,,percent of total billed charges,90% of total billed charges,1292.31,95,,,percent of total billed charges,95% of total billed charges,1292.31,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1169.88,86,,,percent of total billed charges,86% of total billed charges,1088.26,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1319.52,97,,,percent of total billed charges,97% of total billed charges,1224.3,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1319.52,97,,,percent of total billed charges,97% of total billed charges,1265.11,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1319.52,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,952.23,25409.89,
38571- Lap/surg/bilat pelvic lymphadenect,3431457,CDM,510,RC,38571,HCPCS,Outpatient,,,1738.1,869.05,,1564.29,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1390.48,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1564.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1685.96,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1599.05,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1564.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1216.67,70,,,percent of total billed charges,70% of total billed charges,1564.29,90,,,percent of total billed charges,90% of total billed charges,1651.2,95,,,percent of total billed charges,95% of total billed charges,1651.2,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1494.77,86,,,percent of total billed charges,86% of total billed charges,1390.48,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1685.96,97,,,percent of total billed charges,97% of total billed charges,1564.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1685.96,97,,,percent of total billed charges,97% of total billed charges,1616.43,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1685.96,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1216.67,44301.74,
"38572-PF LAPAROSCOPY, LYMPHADENECTOMY",3429808,CDM,510,RC,38572,HCPCS,Outpatient,,,2395.41,1197.71,,2155.87,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1916.33,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2155.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2323.55,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2203.78,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2155.87,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1676.79,70,,,percent of total billed charges,70% of total billed charges,2155.87,90,,,percent of total billed charges,90% of total billed charges,2275.64,95,,,percent of total billed charges,95% of total billed charges,2275.64,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2060.05,86,,,percent of total billed charges,86% of total billed charges,1916.33,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2323.55,97,,,percent of total billed charges,97% of total billed charges,2155.87,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2323.55,97,,,percent of total billed charges,97% of total billed charges,2227.73,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2323.55,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1676.79,44301.74,
38573-PF LAPS PELVIC LYMPHADEC,3429810,CDM,510,RC,38573,HCPCS,Outpatient,,,3097.78,1548.89,,2788,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2478.22,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2788,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3004.85,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2849.96,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2788,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2168.45,70,,,percent of total billed charges,70% of total billed charges,2788,90,,,percent of total billed charges,90% of total billed charges,2942.89,95,,,percent of total billed charges,95% of total billed charges,2942.89,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2664.09,86,,,percent of total billed charges,86% of total billed charges,2478.22,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3004.85,97,,,percent of total billed charges,97% of total billed charges,2788,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,3004.85,97,,,percent of total billed charges,97% of total billed charges,2880.94,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3004.85,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2168.45,44301.74,
38700- Suprahyoid lymphadenectomy,3431458,CDM,510,RC,38700,HCPCS,Outpatient,,,2115.28,1057.64,,1903.75,90,,,percent of total billed charges,90% of total Billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1692.22,80,,,Percent of total Billed charges,80% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1903.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2051.82,97,,,Percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.06,92,,,Percent of total billed charges,92% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14348.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22874.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28973.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1903.75,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.7,70,,,percent of total billed charges,70% of total billed charges,1903.75,90,,,percent of total billed charges,90% of total billed charges,2009.52,95,,,percent of total billed charges,95% of total billed charges,2009.52,95,,,percent of total billed charges,95% of total billed charges,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10795.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1819.14,86,,,percent of total billed charges,86% of total billed charges,1692.22,80,,,percent of total billed charges,80% of total billed charges,5414.7,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2051.82,97,,,percent of total billed charges,97% of total billed charges,1903.75,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2051.82,97,,,percent of total billed charges,97% of total billed charges,1967.21,93,,,percent of total billed charges,93% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2051.82,97,,,percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,5397.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4588.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1480.7,28973.61,
38724- Radical neck dissection/modified,3431459,CDM,510,RC,38724,HCPCS,Outpatient,,,3812.41,1906.21,,3431.17,90,,,percent of total billed charges,90% of total Billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3049.93,80,,,Percent of total Billed charges,80% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3698.04,97,,,Percent of total billed charges,97% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3507.42,92,,,Percent of total billed charges,92% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.17,90,,,percent of total billed charges,90% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.69,70,,,percent of total billed charges,70% of total billed charges,3431.17,90,,,percent of total billed charges,90% of total billed charges,3621.79,95,,,percent of total billed charges,95% of total billed charges,3621.79,95,,,percent of total billed charges,95% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3278.67,86,,,percent of total billed charges,86% of total billed charges,3049.93,80,,,percent of total billed charges,80% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3698.04,97,,,percent of total billed charges,97% of total billed charges,3431.17,90,,,percent of total billed charges,90% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3698.04,97,,,percent of total billed charges,97% of total billed charges,3545.54,93,,,percent of total billed charges,93% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3698.04,97,,,percent of total billed charges,97% of total billed charges,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3812.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2668.69,3812.41,
38740- Axillary lymphadenect/superficial,3431460,CDM,510,RC,38740,HCPCS,Outpatient,,,1872.88,936.44,,1685.59,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1498.3,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1685.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1816.69,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1723.05,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1685.59,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.02,70,,,percent of total billed charges,70% of total billed charges,1685.59,90,,,percent of total billed charges,90% of total billed charges,1779.24,95,,,percent of total billed charges,95% of total billed charges,1779.24,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1610.68,86,,,percent of total billed charges,86% of total billed charges,1498.3,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1816.69,97,,,percent of total billed charges,97% of total billed charges,1685.59,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1816.69,97,,,percent of total billed charges,97% of total billed charges,1741.78,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1816.69,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1311.02,25409.89,
38745- Axillary lymphadenectomy/complete,3431461,CDM,510,RC,38745,HCPCS,Outpatient,,,2363.05,1181.53,,2126.75,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1890.44,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2126.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2292.16,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2174.01,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2126.75,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1654.14,70,,,percent of total billed charges,70% of total billed charges,2126.75,90,,,percent of total billed charges,90% of total billed charges,2244.9,95,,,percent of total billed charges,95% of total billed charges,2244.9,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2032.22,86,,,percent of total billed charges,86% of total billed charges,1890.44,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2292.16,97,,,percent of total billed charges,97% of total billed charges,2126.75,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2292.16,97,,,percent of total billed charges,97% of total billed charges,2197.64,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2292.16,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1654.14,25409.89,
38746- Thoracic lymphadenect/thoracotomy,3431462,CDM,510,RC,38746,HCPCS,Outpatient,,,581.96,290.98,,523.76,90,,,percent of total billed charges,90% of total Billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,465.57,80,,,Percent of total Billed charges,80% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,523.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,564.5,97,,,Percent of total billed charges,97% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,535.4,92,,,Percent of total billed charges,92% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,523.76,90,,,percent of total billed charges,90% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,407.37,70,,,percent of total billed charges,70% of total billed charges,523.76,90,,,percent of total billed charges,90% of total billed charges,552.86,95,,,percent of total billed charges,95% of total billed charges,552.86,95,,,percent of total billed charges,95% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,500.49,86,,,percent of total billed charges,86% of total billed charges,465.57,80,,,percent of total billed charges,80% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,564.5,97,,,percent of total billed charges,97% of total billed charges,523.76,90,,,percent of total billed charges,90% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,564.5,97,,,percent of total billed charges,97% of total billed charges,541.22,93,,,percent of total billed charges,93% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,564.5,97,,,percent of total billed charges,97% of total billed charges,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,581.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,407.37,581.96,
38746-PF Remove Thoracic Lymp Nodes,4322100,CDM,960,RC,38746,HCPCS,Outpatient,,,423.46,211.73,,381.11,90,,,percent of total billed charges,90% of total Billed charges,434.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,236.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,333.75,155,,,Fee Schedule,155% of CMS OPPS Rate,215.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,357.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,401.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,333.75,155,,,Fee Schedule,155% of CMS OPPS Rate,215.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,672.93,155,,,Fee Schedule,155% of CMS OPPS Rate,672.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,215.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,255.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,215.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,531.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,531.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.16,672.93,
38747- Abdominal lymphadenectomy,3431463,CDM,510,RC,38747,HCPCS,Outpatient,,,723.39,361.70,,651.05,90,,,percent of total billed charges,90% of total Billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,578.71,80,,,Percent of total Billed charges,80% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,651.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.69,97,,,Percent of total billed charges,97% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,665.52,92,,,Percent of total billed charges,92% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,651.05,90,,,percent of total billed charges,90% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,506.37,70,,,percent of total billed charges,70% of total billed charges,651.05,90,,,percent of total billed charges,90% of total billed charges,687.22,95,,,percent of total billed charges,95% of total billed charges,687.22,95,,,percent of total billed charges,95% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,622.12,86,,,percent of total billed charges,86% of total billed charges,578.71,80,,,percent of total billed charges,80% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,701.69,97,,,percent of total billed charges,97% of total billed charges,651.05,90,,,percent of total billed charges,90% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,701.69,97,,,percent of total billed charges,97% of total billed charges,672.75,93,,,percent of total billed charges,93% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,701.69,97,,,percent of total billed charges,97% of total billed charges,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,723.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,506.37,723.39,
38760- Inguinofem lymphadenec/superficial,3431464,CDM,510,RC,38760,HCPCS,Outpatient,,,2226.98,1113.49,,2004.28,90,,,percent of total billed charges,90% of total Billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.58,80,,,Percent of total Billed charges,80% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2004.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2160.17,97,,,Percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2048.82,92,,,Percent of total billed charges,92% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,14348.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22874.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28973.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2004.28,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1558.89,70,,,percent of total billed charges,70% of total billed charges,2004.28,90,,,percent of total billed charges,90% of total billed charges,2115.63,95,,,percent of total billed charges,95% of total billed charges,2115.63,95,,,percent of total billed charges,95% of total billed charges,5397.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10795.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1915.2,86,,,percent of total billed charges,86% of total billed charges,1781.58,80,,,percent of total billed charges,80% of total billed charges,5414.7,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2160.17,97,,,percent of total billed charges,97% of total billed charges,2004.28,90,,,percent of total billed charges,90% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2160.17,97,,,percent of total billed charges,97% of total billed charges,2071.09,93,,,percent of total billed charges,93% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2160.17,97,,,percent of total billed charges,97% of total billed charges,5397.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,5397.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4588.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1558.89,28973.61,
38765-MA REMOVE GROIN LYMPH NODES,3429825,CDM,510,RC,38765,HCPCS,Outpatient,,,3490.85,1745.43,,3141.77,90,,,percent of total billed charges,90% of total Billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2792.68,80,,,Percent of total Billed charges,80% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3141.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3386.12,97,,,Percent of total billed charges,97% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3211.58,92,,,Percent of total billed charges,92% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3141.77,90,,,percent of total billed charges,90% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2443.6,70,,,percent of total billed charges,70% of total billed charges,3141.77,90,,,percent of total billed charges,90% of total billed charges,3316.31,95,,,percent of total billed charges,95% of total billed charges,3316.31,95,,,percent of total billed charges,95% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3002.13,86,,,percent of total billed charges,86% of total billed charges,2792.68,80,,,percent of total billed charges,80% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3386.12,97,,,percent of total billed charges,97% of total billed charges,3141.77,90,,,percent of total billed charges,90% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3386.12,97,,,percent of total billed charges,97% of total billed charges,3246.49,93,,,percent of total billed charges,93% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3386.12,97,,,percent of total billed charges,97% of total billed charges,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3490.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2443.6,3490.85,
38780-PF REMOVE ABDOMEN LYMPH NODES,3429827,CDM,510,RC,38780,HCPCS,Outpatient,,,2748.65,1374.33,,2473.79,90,,,percent of total billed charges,90% of total Billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2198.92,80,,,Percent of total Billed charges,80% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2666.19,97,,,Percent of total billed charges,97% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2528.76,92,,,Percent of total billed charges,92% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.79,90,,,percent of total billed charges,90% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1924.06,70,,,percent of total billed charges,70% of total billed charges,2473.79,90,,,percent of total billed charges,90% of total billed charges,2611.22,95,,,percent of total billed charges,95% of total billed charges,2611.22,95,,,percent of total billed charges,95% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2363.84,86,,,percent of total billed charges,86% of total billed charges,2198.92,80,,,percent of total billed charges,80% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2666.19,97,,,percent of total billed charges,97% of total billed charges,2473.79,90,,,percent of total billed charges,90% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2666.19,97,,,percent of total billed charges,97% of total billed charges,2556.24,93,,,percent of total billed charges,93% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2666.19,97,,,percent of total billed charges,97% of total billed charges,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2748.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1924.06,2748.65,
MA INJECT FOR LYMPHATIC X-RAY,3527842,CDM,960,RC,38790,HCPCS,Outpatient,,,211.05,105.53,,189.95,90,,,percent of total billed charges,90% of total Billed charges,159.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,123.5,155,,,Fee Schedule,155% of CMS OPPS Rate,79.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,123.5,155,,,Fee Schedule,155% of CMS OPPS Rate,79.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.5,155,,,Fee Schedule,155% of CMS OPPS Rate,246.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,79.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,566.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,79.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.76,566.64,
38792- Lymphangiography/sentinel node,3431465,CDM,510,RC,38792,HCPCS,Outpatient,,,205.57,102.79,,185.01,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,164.46,80,,,Percent of total Billed charges,80% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,199.4,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,189.12,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,185.01,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,143.9,70,,,percent of total billed charges,70% of total billed charges,185.01,90,,,percent of total billed charges,90% of total billed charges,195.29,95,,,percent of total billed charges,95% of total billed charges,195.29,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,176.79,86,,,percent of total billed charges,86% of total billed charges,164.46,80,,,percent of total billed charges,80% of total billed charges,380.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,199.4,97,,,percent of total billed charges,97% of total billed charges,185.01,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.4,97,,,percent of total billed charges,97% of total billed charges,191.18,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,199.4,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,143.9,1894.86,
38900- Intraop map/sentinel node/inj dye,3431466,CDM,510,RC,38900,HCPCS,Outpatient,,,373.61,186.81,,336.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,298.89,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,336.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,362.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,343.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,238.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,293.85,78.65,,,percent of total billed charges,78.65% of total billed charges,333.75,89.33,,,percent of total billed charges,89.33% of total billed charges,336.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,261.53,70,,,percent of total billed charges,70% of total billed charges,336.25,90,,,percent of total billed charges,90% of total billed charges,354.93,95,,,percent of total billed charges,95% of total billed charges,354.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.3,86,,,percent of total billed charges,86% of total billed charges,298.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,362.4,97,,,percent of total billed charges,97% of total billed charges,336.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,362.4,97,,,percent of total billed charges,97% of total billed charges,347.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.6,362.4,
"38999 - Unlisted procedure, hemic or lymphatic system",4037546,CDM,983,RC,38999,HCPCS,Outpatient,,,979.11,489.56,,881.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.73,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.73,881.2,
"39010 - PF - Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transtho",3640921,CDM,510,RC,39010,HCPCS,Outpatient,,,2104.86,1052.43,,1894.37,90,,,percent of total billed charges,90% of total Billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1683.89,80,,,Percent of total Billed charges,80% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1894.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2041.71,97,,,Percent of total billed charges,97% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1936.47,92,,,Percent of total billed charges,92% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1894.37,90,,,percent of total billed charges,90% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.4,70,,,percent of total billed charges,70% of total billed charges,1894.37,90,,,percent of total billed charges,90% of total billed charges,1999.62,95,,,percent of total billed charges,95% of total billed charges,1999.62,95,,,percent of total billed charges,95% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1810.18,86,,,percent of total billed charges,86% of total billed charges,1683.89,80,,,percent of total billed charges,80% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2041.71,97,,,percent of total billed charges,97% of total billed charges,1894.37,90,,,percent of total billed charges,90% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2041.71,97,,,percent of total billed charges,97% of total billed charges,1957.52,93,,,percent of total billed charges,93% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2041.71,97,,,percent of total billed charges,97% of total billed charges,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2104.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1473.4,2104.86,
EXPLORATION OF CHEST,3527864,CDM,960,RC,39010,HCPCS,Outpatient,,,3050.25,1525.13,,2745.23,90,,,percent of total billed charges,90% of total Billed charges,1573.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1214.07,155,,,Fee Schedule,155% of CMS OPPS Rate,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,783.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1308,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,635.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1440.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1032.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1214.07,155,,,Fee Schedule,155% of CMS OPPS Rate,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,2439.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2439.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,973.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1625.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1625.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,635.91,2745.23,
SURG AST EXPLORATION OF CHEST,3527878,CDM,960,RC,39010,HCPCS,Outpatient,,,610.32,305.16,,549.29,90,,,percent of total billed charges,90% of total Billed charges,1220.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,610.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,946,155,,,Fee Schedule,155% of CMS OPPS Rate,610.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,610.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1308,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,635.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1220.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,610.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1032.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,946,155,,,Fee Schedule,155% of CMS OPPS Rate,610.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1891.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1891.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,610.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,973.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,610.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1625.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1625.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,549.29,1891.99,
39220 - PF Resection Mediasstinal Tumor,4301611,CDM,960,RC,39220,HCPCS,Outpatient,,,2394.84,1197.42,,2155.36,90,,,percent of total billed charges,90% of total Billed charges,2266.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1129.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1750.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1129.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1676.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1129.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1885.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1885.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1763.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1763.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,915.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1129.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2259.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2080.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1487.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1750.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1129.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,3513.68,155,,,Fee Schedule,155% of CMS OPPS Rate,3513.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1129.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1356.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1129.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2341.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2341.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,3513.68,
39401-MEDIASTINOSCOPY W/MEDSTNL BX,3430921,CDM,510,RC,39401,HCPCS,Outpatient,,,864.28,432.14,,777.85,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,691.42,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,777.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,838.35,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,795.14,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,777.85,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,605,70,,,percent of total billed charges,70% of total billed charges,777.85,90,,,percent of total billed charges,90% of total billed charges,821.07,95,,,percent of total billed charges,95% of total billed charges,821.07,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,743.28,86,,,percent of total billed charges,86% of total billed charges,691.42,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,838.35,97,,,percent of total billed charges,97% of total billed charges,777.85,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,838.35,97,,,percent of total billed charges,97% of total billed charges,803.78,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,838.35,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,605,25409.89,
39401-PF Mediastinoscopy w/Medstnl Bx,4322101,CDM,960,RC,39401,HCPCS,Outpatient,,,603.22,301.61,,542.9,90,,,percent of total billed charges,90% of total Billed charges,618.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,743.5,90,,,Percent of total Billed charges,90% of total billed charges,254.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,476.55,155,,,Fee Schedule,155% of CMS OPPS Rate,307.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,513.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,482.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,482.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,276.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,569.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,413.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,476.55,155,,,Fee Schedule,155% of CMS OPPS Rate,307.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,958.01,155,,,Fee Schedule,155% of CMS OPPS Rate,958.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,351.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.02,958.01,
39402-MEDIASTINOSCOPY W/LMPH NOD BX,3430922,CDM,510,RC,39402,HCPCS,Outpatient,,,1134.2,567.10,,1020.78,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,907.36,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1100.17,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.46,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1020.78,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,793.94,70,,,percent of total billed charges,70% of total billed charges,1020.78,90,,,percent of total billed charges,90% of total billed charges,1077.49,95,,,percent of total billed charges,95% of total billed charges,1077.49,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,975.41,86,,,percent of total billed charges,86% of total billed charges,907.36,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1100.17,97,,,percent of total billed charges,97% of total billed charges,1020.78,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.17,97,,,percent of total billed charges,97% of total billed charges,1054.81,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1100.17,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,793.94,25409.89,
39402-PF Medistinoscopy w/Lmph Nod Bx,4322102,CDM,960,RC,39402,HCPCS,Outpatient,,,791.02,395.51,,711.92,90,,,percent of total billed charges,90% of total Billed charges,809.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,402.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.55,90,,,Percent of total Billed charges,90% of total billed charges,332.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,624.37,155,,,Fee Schedule,155% of CMS OPPS Rate,402.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,402.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,671.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,632.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,632.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,359.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,805.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,746.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,542.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,624.37,155,,,Fee Schedule,155% of CMS OPPS Rate,402.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1254.59,155,,,Fee Schedule,155% of CMS OPPS Rate,1254.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,402.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,458.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,402.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.13,1254.59,
39501 - PF Repair Laceration Diaphragm Any Approach,4327194,CDM,960,RC,39501,HCPCS,Outpatient,,,1672,836.00,,1504.8,90,,,percent of total billed charges,90% of total Billed charges,1707.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,847.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,743.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1313.16,155,,,Fee Schedule,155% of CMS OPPS Rate,847.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1266.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,847.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1424.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1424.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1324.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1324.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1694.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1562.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1113.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1313.16,155,,,Fee Schedule,155% of CMS OPPS Rate,847.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,2647.23,155,,,Fee Schedule,155% of CMS OPPS Rate,2647.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,847.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,743.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,997.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,847.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1725.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,684.98,2647.23,
39545-PF Imbrication Diaphragm Eventration,4322103,CDM,960,RC,39545,HCPCS,Outpatient,,,1749.16,874.58,,1574.24,90,,,percent of total billed charges,90% of total Billed charges,1789.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,890.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,806.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1380.24,155,,,Fee Schedule,155% of CMS OPPS Rate,890.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1362.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,890.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1532.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1532.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1382.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1382.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,715.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1780.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1631.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1165.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1380.24,155,,,Fee Schedule,155% of CMS OPPS Rate,890.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,2773.31,155,,,Fee Schedule,155% of CMS OPPS Rate,2773.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,890.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,806.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,898.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,890.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1825.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1825.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,715.8,2773.31,
39560-PF Resect Diaphargm w/Smpl Rpr,4322104,CDM,960,RC,39560,HCPCS,Outpatient,,,1565.44,782.72,,1408.9,90,,,percent of total billed charges,90% of total Billed charges,1598.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,797.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,683.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1235.47,155,,,Fee Schedule,155% of CMS OPPS Rate,797.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1183.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,797.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1330.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1330.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1235.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1235.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,644.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1594.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1457.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1031.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1235.47,155,,,Fee Schedule,155% of CMS OPPS Rate,797.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2478.12,155,,,Fee Schedule,155% of CMS OPPS Rate,2478.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,797.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,683.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,745.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,797.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1611.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1611.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,644.81,2478.12,
39561-PF Resect Disphragm w/Cmplx Rpr,4322105,CDM,960,RC,39561,HCPCS,Outpatient,,,2449.78,1224.89,,2204.8,90,,,percent of total billed charges,90% of total Billed charges,2491.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1244.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,935.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1928.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1244.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1244.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2062.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2062.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1913.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1913.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1004.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1244.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2488.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2258.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1605.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1928.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1244.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,3862.07,155,,,Fee Schedule,155% of CMS OPPS Rate,3862.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1244.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,935.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1184.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1244.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2539.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2539.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,935.54,3862.07,
40490- Biopsy of lip,3431096,CDM,510,RC,40490,HCPCS,Outpatient,,,139.2,69.60,,125.28,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,111.36,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.28,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.02,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,128.06,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.28,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,97.44,70,,,percent of total billed charges,70% of total billed charges,125.28,90,,,percent of total billed charges,90% of total billed charges,132.24,95,,,percent of total billed charges,95% of total billed charges,132.24,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.71,86,,,percent of total billed charges,86% of total billed charges,111.36,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.02,97,,,percent of total billed charges,97% of total billed charges,125.28,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.02,97,,,percent of total billed charges,97% of total billed charges,129.46,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.02,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,1013.19,
40510- Lip exc/transverse wedge/w closure,3431097,CDM,510,RC,40510,HCPCS,Outpatient,,,1241.69,620.85,,1117.52,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,993.35,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.52,90,,,Percent of total Billed charges,90% of total billed charges,340.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1204.44,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.35,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.52,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,869.18,70,,,percent of total billed charges,70% of total billed charges,1117.52,90,,,percent of total billed charges,90% of total billed charges,1179.61,95,,,percent of total billed charges,95% of total billed charges,1179.61,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.85,86,,,percent of total billed charges,86% of total billed charges,993.35,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.44,97,,,percent of total billed charges,97% of total billed charges,1117.52,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.44,97,,,percent of total billed charges,97% of total billed charges,1154.77,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1204.44,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,309.31,13869.87,
40520- V-exc/lip/w/pri linear closure,3431098,CDM,510,RC,40520,HCPCS,Outpatient,,,1272.86,636.43,,1145.57,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.29,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.57,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.67,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.03,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.57,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,891,70,,,percent of total billed charges,70% of total billed charges,1145.57,90,,,percent of total billed charges,90% of total billed charges,1209.22,95,,,percent of total billed charges,95% of total billed charges,1209.22,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.66,86,,,percent of total billed charges,86% of total billed charges,1018.29,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.67,97,,,percent of total billed charges,97% of total billed charges,1145.57,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.67,97,,,percent of total billed charges,97% of total billed charges,1183.76,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.67,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,13869.87,
40530- Resect lip/> one-fourth/w/o recon,3431099,CDM,510,RC,40530,HCPCS,Outpatient,,,1420.32,710.16,,1278.29,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1136.26,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1278.29,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1377.71,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1306.69,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1278.29,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,994.22,70,,,percent of total billed charges,70% of total billed charges,1278.29,90,,,percent of total billed charges,90% of total billed charges,1349.3,95,,,percent of total billed charges,95% of total billed charges,1349.3,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1221.48,86,,,percent of total billed charges,86% of total billed charges,1136.26,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1377.71,97,,,percent of total billed charges,97% of total billed charges,1278.29,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1377.71,97,,,percent of total billed charges,97% of total billed charges,1320.9,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1377.71,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,13869.87,
40650- Rpr lip/full thick/vermilion only,3431100,CDM,510,RC,40650,HCPCS,Outpatient,,,1210.07,605.04,,1089.06,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,968.06,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.06,90,,,Percent of total Billed charges,90% of total billed charges,273.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1173.77,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.26,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1089.06,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,847.05,70,,,percent of total billed charges,70% of total billed charges,1089.06,90,,,percent of total billed charges,90% of total billed charges,1149.57,95,,,percent of total billed charges,95% of total billed charges,1149.57,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1040.66,86,,,percent of total billed charges,86% of total billed charges,968.06,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1173.77,97,,,percent of total billed charges,97% of total billed charges,1089.06,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.77,97,,,percent of total billed charges,97% of total billed charges,1125.37,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1173.77,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,248.93,2227.05,
40650-PF RPR LIP FULL THICKNESS VERMILION ONLY,4321655,CDM,981,RC,40650,HCPCS,Outpatient,,,606.76,303.38,,546.08,90,,,percent of total billed charges,90% of total Billed charges,758.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,303.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,470.22,155,,,Fee Schedule,155% of CMS OPPS Rate,303.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,458.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,458.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,451.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,451.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,240.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,532.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,350.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,470.22,155,,,Fee Schedule,155% of CMS OPPS Rate,303.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1175.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,303.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,347.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,303.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,845.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,845.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,240.89,1175.5,
40654- Lip rpr/> half vert height/complex,3431101,CDM,510,RC,40654,HCPCS,Outpatient,,,1471.51,735.76,,1324.36,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1177.21,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1324.36,90,,,Percent of total Billed charges,90% of total billed charges,405.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1427.36,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.79,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1324.36,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1030.06,70,,,percent of total billed charges,70% of total billed charges,1324.36,90,,,percent of total billed charges,90% of total billed charges,1397.93,95,,,percent of total billed charges,95% of total billed charges,1397.93,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.5,86,,,percent of total billed charges,86% of total billed charges,1177.21,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1427.36,97,,,percent of total billed charges,97% of total billed charges,1324.36,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1427.36,97,,,percent of total billed charges,97% of total billed charges,1368.5,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1427.36,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,368.26,6767.35,
40654-PF RPR LIP FULL THKNS >ONE-HALF VERT HEIGHT/COMPLE,4321654,CDM,981,RC,40654,HCPCS,Outpatient,,,819.46,409.73,,737.51,90,,,percent of total billed charges,90% of total Billed charges,963.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,635.07,155,,,Fee Schedule,155% of CMS OPPS Rate,409.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,623.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,623.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,344.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,819.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,735.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,472.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,635.07,155,,,Fee Schedule,155% of CMS OPPS Rate,409.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1492.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1492.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1155.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,344.58,1492.73,
40800- Vestibule mouth/drain abs/cyst/hem,3431103,CDM,510,RC,40800,HCPCS,Outpatient,,,502.29,251.15,,452.06,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,401.83,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,452.06,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,487.22,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,462.11,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,452.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,351.6,70,,,percent of total billed charges,70% of total billed charges,452.06,90,,,percent of total billed charges,90% of total billed charges,477.18,95,,,percent of total billed charges,95% of total billed charges,477.18,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,431.97,86,,,percent of total billed charges,86% of total billed charges,401.83,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,487.22,97,,,percent of total billed charges,97% of total billed charges,452.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,487.22,97,,,percent of total billed charges,97% of total billed charges,467.13,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,487.22,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,3163.8,
40800-PF DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL,4321450,CDM,981,RC,40800,HCPCS,Outpatient,,,221.3,110.65,,199.17,90,,,percent of total billed charges,90% of total Billed charges,299.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,171.51,155,,,Fee Schedule,155% of CMS OPPS Rate,110.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,171.51,155,,,Fee Schedule,155% of CMS OPPS Rate,110.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.26,155,,,Fee Schedule,155% of CMS OPPS Rate,464.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,420.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.5,464.26,
40805- Foreign body remov/vest/mouth/comp,3431104,CDM,510,RC,40805,HCPCS,Outpatient,,,713.88,356.94,,642.49,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,571.1,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,642.49,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,692.46,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,656.77,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,642.49,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,499.72,70,,,percent of total billed charges,70% of total billed charges,642.49,90,,,percent of total billed charges,90% of total billed charges,678.19,95,,,percent of total billed charges,95% of total billed charges,678.19,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,613.94,86,,,percent of total billed charges,86% of total billed charges,571.1,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,692.46,97,,,percent of total billed charges,97% of total billed charges,642.49,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.46,97,,,percent of total billed charges,97% of total billed charges,663.91,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,692.46,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,2227.05,
40806- Frenotomy,3431105,CDM,510,RC,40806,HCPCS,Outpatient,,,240.62,120.31,,216.56,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,192.5,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,233.4,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,221.37,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.56,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,168.43,70,,,percent of total billed charges,70% of total billed charges,216.56,90,,,percent of total billed charges,90% of total billed charges,228.59,95,,,percent of total billed charges,95% of total billed charges,228.59,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.93,86,,,percent of total billed charges,86% of total billed charges,192.5,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.4,97,,,percent of total billed charges,97% of total billed charges,216.56,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.4,97,,,percent of total billed charges,97% of total billed charges,223.78,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.4,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,168.43,2227.05,
40808- Biopsy/vestibule of mouth,3431106,CDM,510,RC,40808,HCPCS,Outpatient,,,415.92,207.96,,374.33,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,332.74,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.33,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,403.44,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,382.65,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,374.33,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,291.14,70,,,percent of total billed charges,70% of total billed charges,374.33,90,,,percent of total billed charges,90% of total billed charges,395.12,95,,,percent of total billed charges,95% of total billed charges,395.12,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,357.69,86,,,percent of total billed charges,86% of total billed charges,332.74,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,403.44,97,,,percent of total billed charges,97% of total billed charges,374.33,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.44,97,,,percent of total billed charges,97% of total billed charges,386.81,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,403.44,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,2227.05,
40810- Exc les/mucos/sub/ves mouth/no rpr,3431107,CDM,510,RC,40810,HCPCS,Outpatient,,,536.33,268.17,,482.7,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,429.06,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.7,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,520.24,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,493.42,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,482.7,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,375.43,70,,,percent of total billed charges,70% of total billed charges,482.7,90,,,percent of total billed charges,90% of total billed charges,509.51,95,,,percent of total billed charges,95% of total billed charges,509.51,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,461.24,86,,,percent of total billed charges,86% of total billed charges,429.06,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,520.24,97,,,percent of total billed charges,97% of total billed charges,482.7,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.24,97,,,percent of total billed charges,97% of total billed charges,498.79,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,520.24,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,13869.87,
40812- Exc les/mucos/sub/ves mouth/no rpr,3431108,CDM,510,RC,40812,HCPCS,Outpatient,,,714.69,357.35,,643.22,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,571.75,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,643.22,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,693.25,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,657.51,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,643.22,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,500.28,70,,,percent of total billed charges,70% of total billed charges,643.22,90,,,percent of total billed charges,90% of total billed charges,678.96,95,,,percent of total billed charges,95% of total billed charges,678.96,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,614.63,86,,,percent of total billed charges,86% of total billed charges,571.75,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,693.25,97,,,percent of total billed charges,97% of total billed charges,643.22,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,693.25,97,,,percent of total billed charges,97% of total billed charges,664.66,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,693.25,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,6767.35,
40814- Mouth vestibule bx/w complex rpr,3431109,CDM,510,RC,40814,HCPCS,Outpatient,,,937.99,469.00,,844.19,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,750.39,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,844.19,90,,,Percent of total Billed charges,90% of total billed charges,195.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,909.85,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,862.95,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,844.19,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,656.59,70,,,percent of total billed charges,70% of total billed charges,844.19,90,,,percent of total billed charges,90% of total billed charges,891.09,95,,,percent of total billed charges,95% of total billed charges,891.09,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,806.67,86,,,percent of total billed charges,86% of total billed charges,750.39,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,909.85,97,,,percent of total billed charges,97% of total billed charges,844.19,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.85,97,,,percent of total billed charges,97% of total billed charges,872.33,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,909.85,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.5,13869.87,
40819- Excision of frenum/labial/buccal,3431110,CDM,510,RC,40819,HCPCS,Outpatient,,,673.74,336.87,,606.37,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,538.99,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,606.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,653.53,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,619.84,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,606.37,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,471.62,70,,,percent of total billed charges,70% of total billed charges,606.37,90,,,percent of total billed charges,90% of total billed charges,640.05,95,,,percent of total billed charges,95% of total billed charges,640.05,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,579.42,86,,,percent of total billed charges,86% of total billed charges,538.99,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,653.53,97,,,percent of total billed charges,97% of total billed charges,606.37,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,653.53,97,,,percent of total billed charges,97% of total billed charges,626.58,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,653.53,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,471.62,6767.35,
40830- Close lac/mouth vest/2.5 cm or <,3431111,CDM,510,RC,40830,HCPCS,Outpatient,,,589.06,294.53,,530.15,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,471.25,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,530.15,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,571.39,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,541.94,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,530.15,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,412.34,70,,,percent of total billed charges,70% of total billed charges,530.15,90,,,percent of total billed charges,90% of total billed charges,559.61,95,,,percent of total billed charges,95% of total billed charges,559.61,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,506.59,86,,,percent of total billed charges,86% of total billed charges,471.25,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,571.39,97,,,percent of total billed charges,97% of total billed charges,530.15,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,571.39,97,,,percent of total billed charges,97% of total billed charges,547.83,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,571.39,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,1013.19,
40830-PF CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/<,4321653,CDM,981,RC,40830,HCPCS,Outpatient,,,277.44,138.72,,249.7,90,,,percent of total billed charges,90% of total Billed charges,360.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,215.02,155,,,Fee Schedule,155% of CMS OPPS Rate,138.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,245.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,245.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,186.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,215.02,155,,,Fee Schedule,155% of CMS OPPS Rate,138.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.36,155,,,Fee Schedule,155% of CMS OPPS Rate,558.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,138.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,205.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,558.36,
40831-PF CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL,4321652,CDM,981,RC,40831,HCPCS,Outpatient,,,383.24,191.62,,344.92,90,,,percent of total billed charges,90% of total Billed charges,484.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,297.01,155,,,Fee Schedule,155% of CMS OPPS Rate,191.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,337.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,337.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,184.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,255.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,297.01,155,,,Fee Schedule,155% of CMS OPPS Rate,191.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,751.53,155,,,Fee Schedule,155% of CMS OPPS Rate,751.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,265.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,673.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,751.53,
41010- Incision/lingual frenum/frenotomy,3431113,CDM,510,RC,41010,HCPCS,Outpatient,,,540.19,270.10,,486.17,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,432.15,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.17,90,,,Percent of total Billed charges,90% of total billed charges,49.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,523.98,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,496.97,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,486.17,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,378.13,70,,,percent of total billed charges,70% of total billed charges,486.17,90,,,percent of total billed charges,90% of total billed charges,513.18,95,,,percent of total billed charges,95% of total billed charges,513.18,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,464.56,86,,,percent of total billed charges,86% of total billed charges,432.15,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,523.98,97,,,percent of total billed charges,97% of total billed charges,486.17,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.98,97,,,percent of total billed charges,97% of total billed charges,502.38,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.98,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45,6767.35,
41100- Tongue biopsy/anterior two-thirds,3431114,CDM,510,RC,41100,HCPCS,Outpatient,,,469.05,234.53,,422.15,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,375.24,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.15,90,,,Percent of total Billed charges,90% of total billed charges,68.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,454.98,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,431.53,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,422.15,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,328.34,70,,,percent of total billed charges,70% of total billed charges,422.15,90,,,percent of total billed charges,90% of total billed charges,445.6,95,,,percent of total billed charges,95% of total billed charges,445.6,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,403.38,86,,,percent of total billed charges,86% of total billed charges,375.24,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,454.98,97,,,percent of total billed charges,97% of total billed charges,422.15,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.98,97,,,percent of total billed charges,97% of total billed charges,436.22,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,454.98,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62,2227.05,
41105- Tongue biopsy/posterior one-third,3431115,CDM,510,RC,41105,HCPCS,Outpatient,,,468.92,234.46,,422.03,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,375.14,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.03,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,454.85,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,431.41,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,422.03,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,328.24,70,,,percent of total billed charges,70% of total billed charges,422.03,90,,,percent of total billed charges,90% of total billed charges,445.47,95,,,percent of total billed charges,95% of total billed charges,445.47,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,403.27,86,,,percent of total billed charges,86% of total billed charges,375.14,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,454.85,97,,,percent of total billed charges,97% of total billed charges,422.03,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.85,97,,,percent of total billed charges,97% of total billed charges,436.1,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,454.85,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,13869.87,
41108- Biopsy/floor of mouth,3431116,CDM,510,RC,41108,HCPCS,Outpatient,,,415.92,207.96,,374.33,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,332.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.33,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,403.44,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,382.65,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,374.33,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,291.14,70,,,percent of total billed charges,70% of total billed charges,374.33,90,,,percent of total billed charges,90% of total billed charges,395.12,95,,,percent of total billed charges,95% of total billed charges,395.12,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,357.69,86,,,percent of total billed charges,86% of total billed charges,332.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,403.44,97,,,percent of total billed charges,97% of total billed charges,374.33,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.44,97,,,percent of total billed charges,97% of total billed charges,386.81,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,403.44,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,7310.49,
41112- Ex tongue lesion/w clos/anter 2/3,3431117,CDM,510,RC,41112,HCPCS,Outpatient,,,848.3,424.15,,763.47,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,678.64,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,763.47,90,,,Percent of total Billed charges,90% of total billed charges,234.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,822.85,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,780.44,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,763.47,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,593.81,70,,,percent of total billed charges,70% of total billed charges,763.47,90,,,percent of total billed charges,90% of total billed charges,805.89,95,,,percent of total billed charges,95% of total billed charges,805.89,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,729.54,86,,,percent of total billed charges,86% of total billed charges,678.64,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,822.85,97,,,percent of total billed charges,97% of total billed charges,763.47,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,822.85,97,,,percent of total billed charges,97% of total billed charges,788.92,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,822.85,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.75,13869.87,
41115- Frenectomy,3431118,CDM,510,RC,41115,HCPCS,Outpatient,,,655.02,327.51,,589.52,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,524.02,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,635.37,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,602.62,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,589.52,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,458.51,70,,,percent of total billed charges,70% of total billed charges,589.52,90,,,percent of total billed charges,90% of total billed charges,622.27,95,,,percent of total billed charges,95% of total billed charges,622.27,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,563.32,86,,,percent of total billed charges,86% of total billed charges,524.02,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,635.37,97,,,percent of total billed charges,97% of total billed charges,589.52,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,635.37,97,,,percent of total billed charges,97% of total billed charges,609.17,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,635.37,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,458.51,6767.35,
41250-PF RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG,4321651,CDM,981,RC,41250,HCPCS,Outpatient,,,297.48,148.74,,267.73,90,,,percent of total billed charges,90% of total Billed charges,415.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.53,155,,,Fee Schedule,155% of CMS OPPS Rate,148.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,177.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.53,155,,,Fee Schedule,155% of CMS OPPS Rate,148.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.77,155,,,Fee Schedule,155% of CMS OPPS Rate,644.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,148.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,510,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,510,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,644.77,
41251-PF RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE,4321650,CDM,981,RC,41251,HCPCS,Outpatient,,,356.66,178.33,,320.99,90,,,percent of total billed charges,90% of total Billed charges,474.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.4,155,,,Fee Schedule,155% of CMS OPPS Rate,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,274.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,276.4,155,,,Fee Schedule,155% of CMS OPPS Rate,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,735.34,155,,,Fee Schedule,155% of CMS OPPS Rate,735.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,208.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,547.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,547.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,735.34,
41252- Rpr lac/tong/mouth floor>2.6cm/com,3431119,CDM,510,RC,41252,HCPCS,Outpatient,,,833.68,416.84,,750.31,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,666.94,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.31,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.67,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,766.99,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.31,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,583.58,70,,,percent of total billed charges,70% of total billed charges,750.31,90,,,percent of total billed charges,90% of total billed charges,792,95,,,percent of total billed charges,95% of total billed charges,792,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.96,86,,,percent of total billed charges,86% of total billed charges,666.94,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.67,97,,,percent of total billed charges,97% of total billed charges,750.31,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.67,97,,,percent of total billed charges,97% of total billed charges,775.32,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.67,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,1013.19,
41252-PF RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX,4321649,CDM,981,RC,41252,HCPCS,Outpatient,,,408.18,204.09,,367.36,90,,,percent of total billed charges,90% of total Billed charges,517.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,316.32,155,,,Fee Schedule,155% of CMS OPPS Rate,204.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,312.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,312.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,171.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,368.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,242.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,316.32,155,,,Fee Schedule,155% of CMS OPPS Rate,204.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,802.22,155,,,Fee Schedule,155% of CMS OPPS Rate,802.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,204.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,643.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,643.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.5,802.22,
41520- Frenoplasty/surgical revision,3431120,CDM,510,RC,41520,HCPCS,Outpatient,,,916.49,458.25,,824.84,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,733.19,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,824.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,889,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,843.17,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,824.84,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,641.54,70,,,percent of total billed charges,70% of total billed charges,824.84,90,,,percent of total billed charges,90% of total billed charges,870.67,95,,,percent of total billed charges,95% of total billed charges,870.67,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,788.18,86,,,percent of total billed charges,86% of total billed charges,733.19,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,889,97,,,percent of total billed charges,97% of total billed charges,824.84,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,889,97,,,percent of total billed charges,97% of total billed charges,852.34,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,641.54,13869.87,
41599-PF UNLISTED PROCEDURE TONGUE FLOOR MOUTH,4321451,CDM,981,RC,41599,HCPCS,Outpatient,,,587,293.50,,528.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.1,528.3,
41800- Dentoalveolar/drain abs/cyst/hema,3431122,CDM,510,RC,41800,HCPCS,Outpatient,,,715.33,357.67,,643.8,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,572.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,643.8,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,693.87,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,658.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,643.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,500.73,70,,,percent of total billed charges,70% of total billed charges,643.8,90,,,percent of total billed charges,90% of total billed charges,679.56,95,,,percent of total billed charges,95% of total billed charges,679.56,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,615.18,86,,,percent of total billed charges,86% of total billed charges,572.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,693.87,97,,,percent of total billed charges,97% of total billed charges,643.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,693.87,97,,,percent of total billed charges,97% of total billed charges,665.26,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,693.87,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,693.87,
41800-PF DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS,4321648,CDM,981,RC,41800,HCPCS,Outpatient,,,287.38,143.69,,258.64,90,,,percent of total billed charges,90% of total Billed charges,412.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,143.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,222.72,155,,,Fee Schedule,155% of CMS OPPS Rate,143.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,217.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,217.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,160.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,222.72,155,,,Fee Schedule,155% of CMS OPPS Rate,143.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,639.65,155,,,Fee Schedule,155% of CMS OPPS Rate,639.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,143.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,143.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,520.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,639.65,
41821-PF OPRCULECTOMY EXC PRICORONAL TISSUE,4321452,CDM,981,RC,41821,HCPCS,Outpatient,,,113,56.50,,101.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,82.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18,344.29,
41825-PF EXC LESION/TUMOR DENTOALVEOLAR STRUX W/O RPR,4321453,CDM,981,RC,41825,HCPCS,Outpatient,,,229.64,114.82,,206.68,90,,,percent of total billed charges,90% of total Billed charges,319.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,110.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,177.96,155,,,Fee Schedule,155% of CMS OPPS Rate,114.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,203.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,124.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,177.96,155,,,Fee Schedule,155% of CMS OPPS Rate,114.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.53,155,,,Fee Schedule,155% of CMS OPPS Rate,494.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,114.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,423.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99.92,494.53,
41872-PF GINGIVOPLASTY EACH QUADRANT SPECIFY,4321647,CDM,981,RC,41872,HCPCS,Outpatient,,,574.68,287.34,,517.21,90,,,percent of total billed charges,90% of total Billed charges,725.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,287.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.36,155,,,Fee Schedule,155% of CMS OPPS Rate,287.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,444.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,430.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,430.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,215.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,574.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,508.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,325.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,445.36,155,,,Fee Schedule,155% of CMS OPPS Rate,287.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1124.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,287.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,287.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,215.49,1124.65,
42000-PF DRAINAGE ABSCESS PALATE UVULA,4321454,CDM,981,RC,42000,HCPCS,Outpatient,,,207.96,103.98,,187.16,90,,,percent of total billed charges,90% of total Billed charges,255.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.17,155,,,Fee Schedule,155% of CMS OPPS Rate,103.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,151.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,151.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.17,155,,,Fee Schedule,155% of CMS OPPS Rate,103.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.66,155,,,Fee Schedule,155% of CMS OPPS Rate,396.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,396.66,
42100- Biopsy/palate/uvula,3431124,CDM,510,RC,42100,HCPCS,Outpatient,,,370.84,185.42,,333.76,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,296.67,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.76,90,,,Percent of total Billed charges,90% of total billed charges,78.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,359.71,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,341.17,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,333.76,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,259.59,70,,,percent of total billed charges,70% of total billed charges,333.76,90,,,percent of total billed charges,90% of total billed charges,352.3,95,,,percent of total billed charges,95% of total billed charges,352.3,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,318.92,86,,,percent of total billed charges,86% of total billed charges,296.67,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,359.71,97,,,percent of total billed charges,97% of total billed charges,333.76,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.71,97,,,percent of total billed charges,97% of total billed charges,344.88,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,359.71,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,71.5,6767.35,
42104- Ex palate/uvula lesion w/o closure,3431125,CDM,510,RC,42104,HCPCS,Outpatient,,,541.44,270.72,,487.3,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,433.15,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,487.3,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,525.2,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,498.12,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,487.3,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,379.01,70,,,percent of total billed charges,70% of total billed charges,487.3,90,,,percent of total billed charges,90% of total billed charges,514.37,95,,,percent of total billed charges,95% of total billed charges,514.37,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,465.64,86,,,percent of total billed charges,86% of total billed charges,433.15,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,525.2,97,,,percent of total billed charges,97% of total billed charges,487.3,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.2,97,,,percent of total billed charges,97% of total billed charges,503.54,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.2,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,13869.87,
42140- Uvulectomy/excision of uvula,3431126,CDM,510,RC,42140,HCPCS,Outpatient,,,771.18,385.59,,694.06,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,616.94,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,748.04,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,709.49,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,694.06,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,539.83,70,,,percent of total billed charges,70% of total billed charges,694.06,90,,,percent of total billed charges,90% of total billed charges,732.62,95,,,percent of total billed charges,95% of total billed charges,732.62,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,663.21,86,,,percent of total billed charges,86% of total billed charges,616.94,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,748.04,97,,,percent of total billed charges,97% of total billed charges,694.06,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,748.04,97,,,percent of total billed charges,97% of total billed charges,717.2,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,748.04,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,539.83,13869.87,
42180- PF Repair Laceration Palate <2cm,4365276,CDM,960,RC,42180,HCPCS,Outpatient,,,360.42,180.21,,324.38,90,,,percent of total billed charges,90% of total Billed charges,425.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,280.74,155,,,Fee Schedule,155% of CMS OPPS Rate,181.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,181.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,275.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,362.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,206.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,280.74,155,,,Fee Schedule,155% of CMS OPPS Rate,181.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.53,155,,,Fee Schedule,155% of CMS OPPS Rate,659.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,181.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,181.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,467.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,467.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,659.53,
42182 - PF Repair Laceration Palate >2cm/Complex,4311512,CDM,960,RC,42182,HCPCS,Outpatient,,,597.85,298.93,,538.07,90,,,percent of total billed charges,90% of total Billed charges,571.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,251.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,390.26,155,,,Fee Schedule,155% of CMS OPPS Rate,251.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,381.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,381.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,450.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,292.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,390.26,155,,,Fee Schedule,155% of CMS OPPS Rate,251.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.49,155,,,Fee Schedule,155% of CMS OPPS Rate,886.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,251.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,329.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,251.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,669.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,669.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,886.49,
42330 Removal of salivary stone,3584870,CDM,960,RC,42330,HCPCS,Outpatient,,,589.6,294.80,,530.64,90,,,percent of total billed charges,90% of total Billed charges,381.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,159.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,247.52,155,,,Fee Schedule,155% of CMS OPPS Rate,159.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,241.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,241.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,319.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,284.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,182.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,247.52,155,,,Fee Schedule,155% of CMS OPPS Rate,159.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.15,155,,,Fee Schedule,155% of CMS OPPS Rate,591.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,159.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,186.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,159.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,480.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64,591.15,
"42400 Biopsy Salivary Gland, Needle",3584897,CDM,960,RC,42400,HCPCS,Outpatient,,,245.94,122.97,,221.35,90,,,percent of total billed charges,90% of total Billed charges,143.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,78.35,155,,,Fee Schedule,155% of CMS OPPS Rate,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,59.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,78.35,155,,,Fee Schedule,155% of CMS OPPS Rate,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.7,155,,,Fee Schedule,155% of CMS OPPS Rate,221.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,216.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,221.7,
42405- Biopsy/salivary gland/incisional,3431128,CDM,510,RC,42405,HCPCS,Outpatient,,,771.22,385.61,,694.1,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,616.98,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.1,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,748.08,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,709.52,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,694.1,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,539.85,70,,,percent of total billed charges,70% of total billed charges,694.1,90,,,percent of total billed charges,90% of total billed charges,732.66,95,,,percent of total billed charges,95% of total billed charges,732.66,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,663.25,86,,,percent of total billed charges,86% of total billed charges,616.98,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,748.08,97,,,percent of total billed charges,97% of total billed charges,694.1,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,748.08,97,,,percent of total billed charges,97% of total billed charges,717.23,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,748.08,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,6767.35,
42410- Ex parot tum/lat lob/w/o ner disce,3431129,CDM,510,RC,42410,HCPCS,Outpatient,,,1645.09,822.55,,1480.58,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1316.07,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1480.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1595.74,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1513.48,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1480.58,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.56,70,,,percent of total billed charges,70% of total billed charges,1480.58,90,,,percent of total billed charges,90% of total billed charges,1562.84,95,,,percent of total billed charges,95% of total billed charges,1562.84,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1414.78,86,,,percent of total billed charges,86% of total billed charges,1316.07,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1595.74,97,,,percent of total billed charges,97% of total billed charges,1480.58,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1595.74,97,,,percent of total billed charges,97% of total billed charges,1529.93,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1595.74,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1151.56,26031.56,
42415- Ex parot tum/la lobe/presv fac ner,3431130,CDM,510,RC,42415,HCPCS,Outpatient,,,2773.94,1386.97,,2496.55,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2219.15,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2496.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2690.72,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.02,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2496.55,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1941.76,70,,,percent of total billed charges,70% of total billed charges,2496.55,90,,,percent of total billed charges,90% of total billed charges,2635.24,95,,,percent of total billed charges,95% of total billed charges,2635.24,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2385.59,86,,,percent of total billed charges,86% of total billed charges,2219.15,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2690.72,97,,,percent of total billed charges,97% of total billed charges,2496.55,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2690.72,97,,,percent of total billed charges,97% of total billed charges,2579.76,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2690.72,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1941.76,26031.56,
42420- Exc parot tum/tot/presv face nerv,3431131,CDM,510,RC,42420,HCPCS,Outpatient,,,3114.36,1557.18,,2802.92,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2491.49,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2802.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3020.93,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2865.21,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2802.92,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2180.05,70,,,percent of total billed charges,70% of total billed charges,2802.92,90,,,percent of total billed charges,90% of total billed charges,2958.64,95,,,percent of total billed charges,95% of total billed charges,2958.64,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2678.35,86,,,percent of total billed charges,86% of total billed charges,2491.49,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3020.93,97,,,percent of total billed charges,97% of total billed charges,2802.92,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3020.93,97,,,percent of total billed charges,97% of total billed charges,2896.35,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3020.93,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2180.05,26031.56,
42440- Excision of submandibular gland,3431132,CDM,510,RC,42440,HCPCS,Outpatient,,,1079.32,539.66,,971.39,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,863.46,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,971.39,90,,,Percent of total Billed charges,90% of total billed charges,449.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1046.94,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,992.97,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,971.39,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,755.52,70,,,percent of total billed charges,70% of total billed charges,971.39,90,,,percent of total billed charges,90% of total billed charges,1025.35,95,,,percent of total billed charges,95% of total billed charges,1025.35,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,928.22,86,,,percent of total billed charges,86% of total billed charges,863.46,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1046.94,97,,,percent of total billed charges,97% of total billed charges,971.39,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1046.94,97,,,percent of total billed charges,97% of total billed charges,1003.77,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1046.94,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,408.33,26031.56,
42450- Excision of sublingual gland,3431133,CDM,510,RC,42450,HCPCS,Outpatient,,,1197.84,598.92,,1078.06,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,958.27,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1078.06,90,,,Percent of total Billed charges,90% of total billed charges,343.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1161.9,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.01,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1078.06,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,838.49,70,,,percent of total billed charges,70% of total billed charges,1078.06,90,,,percent of total billed charges,90% of total billed charges,1137.95,95,,,percent of total billed charges,95% of total billed charges,1137.95,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1030.14,86,,,percent of total billed charges,86% of total billed charges,958.27,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1161.9,97,,,percent of total billed charges,97% of total billed charges,1078.06,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1161.9,97,,,percent of total billed charges,97% of total billed charges,1113.99,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1161.9,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,312.22,26031.56,
42650- Dilation salivary duct,3431134,CDM,510,RC,42650,HCPCS,Outpatient,,,189.58,94.79,,170.62,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,151.66,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.62,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,183.89,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,174.41,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.62,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,132.71,70,,,percent of total billed charges,70% of total billed charges,170.62,90,,,percent of total billed charges,90% of total billed charges,180.1,95,,,percent of total billed charges,95% of total billed charges,180.1,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.04,86,,,percent of total billed charges,86% of total billed charges,151.66,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.89,97,,,percent of total billed charges,97% of total billed charges,170.62,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.89,97,,,percent of total billed charges,97% of total billed charges,176.31,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.89,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,6767.35,
42700- I & D abscess/peritonsillar,3431136,CDM,510,RC,42700,HCPCS,Outpatient,,,484.47,242.24,,436.02,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,387.58,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.02,90,,,Percent of total Billed charges,90% of total billed charges,68.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,469.94,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,445.71,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,436.02,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,339.13,70,,,percent of total billed charges,70% of total billed charges,436.02,90,,,percent of total billed charges,90% of total billed charges,460.25,95,,,percent of total billed charges,95% of total billed charges,460.25,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,416.64,86,,,percent of total billed charges,86% of total billed charges,387.58,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,469.94,97,,,percent of total billed charges,97% of total billed charges,436.02,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.94,97,,,percent of total billed charges,97% of total billed charges,450.56,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,469.94,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62,1013.19,
42700-PF I&D ABSCESS PERITONSILLAR,4321645,CDM,981,RC,42700,HCPCS,Outpatient,,,261.12,130.56,,235.01,90,,,percent of total billed charges,90% of total Billed charges,312.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202.35,155,,,Fee Schedule,155% of CMS OPPS Rate,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,201.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202.35,155,,,Fee Schedule,155% of CMS OPPS Rate,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,484.72,155,,,Fee Schedule,155% of CMS OPPS Rate,484.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,390.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62,484.72,
PHY-I&D ABSCESS PERITONSILLAR,3428509,CDM,981,RC,42700,HCPCS,Outpatient,,,484.47,242.24,,436.02,90,,,percent of total billed charges,90% of total Billed charges,312.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202.35,155,,,Fee Schedule,155% of CMS OPPS Rate,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,201.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202.35,155,,,Fee Schedule,155% of CMS OPPS Rate,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,484.72,155,,,Fee Schedule,155% of CMS OPPS Rate,484.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,390.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62,484.72,
42720- I & D abs/retro-paraphar/intraoral,3431137,CDM,510,RC,42720,HCPCS,Outpatient,,,1165.24,582.62,,1048.72,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,932.19,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1048.72,90,,,Percent of total Billed charges,90% of total billed charges,98.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1130.28,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.02,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1048.72,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,815.67,70,,,percent of total billed charges,70% of total billed charges,1048.72,90,,,percent of total billed charges,90% of total billed charges,1106.98,95,,,percent of total billed charges,95% of total billed charges,1106.98,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1002.11,86,,,percent of total billed charges,86% of total billed charges,932.19,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1130.28,97,,,percent of total billed charges,97% of total billed charges,1048.72,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.28,97,,,percent of total billed charges,97% of total billed charges,1083.67,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1130.28,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.5,13869.87,
42800- Biopsy/oropharyngeal,3431138,CDM,510,RC,42800,HCPCS,Outpatient,,,398.56,199.28,,358.7,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,318.85,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.7,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,386.6,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,366.68,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,358.7,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,278.99,70,,,percent of total billed charges,70% of total billed charges,358.7,90,,,percent of total billed charges,90% of total billed charges,378.63,95,,,percent of total billed charges,95% of total billed charges,378.63,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,342.76,86,,,percent of total billed charges,86% of total billed charges,318.85,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,386.6,97,,,percent of total billed charges,97% of total billed charges,358.7,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.6,97,,,percent of total billed charges,97% of total billed charges,370.66,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,386.6,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,6767.35,
42804- Bx/nasopharynx/visible lesion/simp,3431139,CDM,510,RC,42804,HCPCS,Outpatient,,,534.79,267.40,,481.31,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,427.83,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,481.31,90,,,Percent of total Billed charges,90% of total billed charges,67.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,518.75,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,492.01,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,481.31,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,374.35,70,,,percent of total billed charges,70% of total billed charges,481.31,90,,,percent of total billed charges,90% of total billed charges,508.05,95,,,percent of total billed charges,95% of total billed charges,508.05,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.92,86,,,percent of total billed charges,86% of total billed charges,427.83,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,518.75,97,,,percent of total billed charges,97% of total billed charges,481.31,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.75,97,,,percent of total billed charges,97% of total billed charges,497.35,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,518.75,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61,13869.87,
42806- Bx nasopharynx/unknown pri lesion,3431140,CDM,510,RC,42806,HCPCS,Outpatient,,,597.02,298.51,,537.32,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,477.62,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,537.32,90,,,Percent of total Billed charges,90% of total billed charges,67.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,579.11,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,549.26,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,537.32,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,417.91,70,,,percent of total billed charges,70% of total billed charges,537.32,90,,,percent of total billed charges,90% of total billed charges,567.17,95,,,percent of total billed charges,95% of total billed charges,567.17,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,513.44,86,,,percent of total billed charges,86% of total billed charges,477.62,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,579.11,97,,,percent of total billed charges,97% of total billed charges,537.32,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,579.11,97,,,percent of total billed charges,97% of total billed charges,555.23,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,579.11,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61,13869.87,
42809-PF Removal of foreign body from pharynx,4321455,CDM,981,RC,42809,HCPCS,Outpatient,,,246.54,123.27,,221.89,90,,,percent of total billed charges,90% of total Billed charges,316.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,191.05,155,,,Fee Schedule,155% of CMS OPPS Rate,123.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,185.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,185.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,218.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,143.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,191.05,155,,,Fee Schedule,155% of CMS OPPS Rate,123.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.33,155,,,Fee Schedule,155% of CMS OPPS Rate,490.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,123.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,490.33,
42820- T & A < 12 yrs,3431141,CDM,510,RC,42820,HCPCS,Outpatient,,,753.79,376.90,,678.41,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,603.03,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,678.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,731.18,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,693.49,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,678.41,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,70,,,percent of total billed charges,70% of total billed charges,678.41,90,,,percent of total billed charges,90% of total billed charges,716.1,95,,,percent of total billed charges,95% of total billed charges,716.1,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,648.26,86,,,percent of total billed charges,86% of total billed charges,603.03,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,731.18,97,,,percent of total billed charges,97% of total billed charges,678.41,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,731.18,97,,,percent of total billed charges,97% of total billed charges,701.02,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,731.18,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,527.65,26031.56,
42821- T & A/12 yrs or >,3431142,CDM,510,RC,42821,HCPCS,Outpatient,,,785.94,392.97,,707.35,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,628.75,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,762.36,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,723.06,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,707.35,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,550.16,70,,,percent of total billed charges,70% of total billed charges,707.35,90,,,percent of total billed charges,90% of total billed charges,746.64,95,,,percent of total billed charges,95% of total billed charges,746.64,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,675.91,86,,,percent of total billed charges,86% of total billed charges,628.75,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,762.36,97,,,percent of total billed charges,97% of total billed charges,707.35,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.36,97,,,percent of total billed charges,97% of total billed charges,730.92,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,762.36,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,550.16,13869.87,
42825- Tonsillectomy/pri/sec/<12 yrs,3431143,CDM,510,RC,42825,HCPCS,Outpatient,,,688.47,344.24,,619.62,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,550.78,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,667.82,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,633.39,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,619.62,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,481.93,70,,,percent of total billed charges,70% of total billed charges,619.62,90,,,percent of total billed charges,90% of total billed charges,654.05,95,,,percent of total billed charges,95% of total billed charges,654.05,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,592.08,86,,,percent of total billed charges,86% of total billed charges,550.78,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,667.82,97,,,percent of total billed charges,97% of total billed charges,619.62,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,667.82,97,,,percent of total billed charges,97% of total billed charges,640.28,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,667.82,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,481.93,26031.56,
42826- Tonsillectomy/pri/sec/12 yrs or >,3431144,CDM,510,RC,42826,HCPCS,Outpatient,,,657.68,328.84,,591.91,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,526.14,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,637.95,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,605.07,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,591.91,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,460.38,70,,,percent of total billed charges,70% of total billed charges,591.91,90,,,percent of total billed charges,90% of total billed charges,624.8,95,,,percent of total billed charges,95% of total billed charges,624.8,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,565.6,86,,,percent of total billed charges,86% of total billed charges,526.14,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,637.95,97,,,percent of total billed charges,97% of total billed charges,591.91,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,637.95,97,,,percent of total billed charges,97% of total billed charges,611.64,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637.95,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,460.38,13869.87,
42830- Adenoidectomy/primary/<12 yrs,3431145,CDM,510,RC,42830,HCPCS,Outpatient,,,542.72,271.36,,488.45,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,434.18,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,526.44,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,499.3,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,488.45,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,379.9,70,,,percent of total billed charges,70% of total billed charges,488.45,90,,,percent of total billed charges,90% of total billed charges,515.58,95,,,percent of total billed charges,95% of total billed charges,515.58,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,466.74,86,,,percent of total billed charges,86% of total billed charges,434.18,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,526.44,97,,,percent of total billed charges,97% of total billed charges,488.45,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.44,97,,,percent of total billed charges,97% of total billed charges,504.73,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,526.44,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,379.9,13869.87,
42831- Adenoidectomy/primary/12 yrs or >,3431146,CDM,510,RC,42831,HCPCS,Outpatient,,,587.76,293.88,,528.98,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,470.21,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,570.13,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,540.74,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,528.98,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,411.43,70,,,percent of total billed charges,70% of total billed charges,528.98,90,,,percent of total billed charges,90% of total billed charges,558.37,95,,,percent of total billed charges,95% of total billed charges,558.37,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,505.47,86,,,percent of total billed charges,86% of total billed charges,470.21,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,570.13,97,,,percent of total billed charges,97% of total billed charges,528.98,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,570.13,97,,,percent of total billed charges,97% of total billed charges,546.62,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,570.13,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,411.43,13869.87,
42900 - PF Suture Pharynx Wound/ Injury,4311513,CDM,960,RC,42900,HCPCS,Outpatient,,,771.91,385.96,,694.72,90,,,percent of total billed charges,90% of total Billed charges,650.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,309.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,503.89,155,,,Fee Schedule,155% of CMS OPPS Rate,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,498.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,499.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,499.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,270.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,589.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,384.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,503.89,155,,,Fee Schedule,155% of CMS OPPS Rate,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1008.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1008.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,410.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,325.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,716.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,270.9,1008.88,
42960- Control oropharyngeal hemorr/simp,3431147,CDM,510,RC,42960,HCPCS,Outpatient,,,418.87,209.44,,376.98,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,335.1,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.98,90,,,Percent of total Billed charges,90% of total billed charges,87.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,406.3,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,385.36,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,376.98,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,293.21,70,,,percent of total billed charges,70% of total billed charges,376.98,90,,,percent of total billed charges,90% of total billed charges,397.93,95,,,percent of total billed charges,95% of total billed charges,397.93,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,360.23,86,,,percent of total billed charges,86% of total billed charges,335.1,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,406.3,97,,,percent of total billed charges,97% of total billed charges,376.98,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.3,97,,,percent of total billed charges,97% of total billed charges,389.55,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,406.3,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79.5,2227.05,
42960-PF CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE,4321644,CDM,981,RC,42960,HCPCS,Outpatient,,,311.78,155.89,,280.6,90,,,percent of total billed charges,90% of total Billed charges,313.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,241.61,155,,,Fee Schedule,155% of CMS OPPS Rate,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,246.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,244.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,244.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,288.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,241.61,155,,,Fee Schedule,155% of CMS OPPS Rate,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.74,155,,,Fee Schedule,155% of CMS OPPS Rate,485.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,485.74,
42961- Oropharyngeal hemorr/comp/hospital,3431148,CDM,510,RC,42961,HCPCS,Outpatient,,,1082.85,541.43,,974.57,90,,,percent of total billed charges,90% of total Billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,866.28,80,,,Percent of total Billed charges,80% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,974.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1050.36,97,,,Percent of total billed charges,97% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,996.22,92,,,Percent of total billed charges,92% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,974.57,90,,,percent of total billed charges,90% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758,70,,,percent of total billed charges,70% of total billed charges,974.57,90,,,percent of total billed charges,90% of total billed charges,1028.71,95,,,percent of total billed charges,95% of total billed charges,1028.71,95,,,percent of total billed charges,95% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,931.25,86,,,percent of total billed charges,86% of total billed charges,866.28,80,,,percent of total billed charges,80% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1050.36,97,,,percent of total billed charges,97% of total billed charges,974.57,90,,,percent of total billed charges,90% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1050.36,97,,,percent of total billed charges,97% of total billed charges,1007.05,93,,,percent of total billed charges,93% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1050.36,97,,,percent of total billed charges,97% of total billed charges,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1082.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758,1082.85,
42961-PF CTRL OROPHARYNGEAL HEMORRHAGE COMP REQ HOSPITJ,4321643,CDM,981,RC,42961,HCPCS,Outpatient,,,813.46,406.73,,732.11,90,,,percent of total billed charges,90% of total Billed charges,813.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,406.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,630.43,155,,,Fee Schedule,155% of CMS OPPS Rate,406.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,406.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,685.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,614.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,614.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,339.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,813.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,724.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,465.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,630.43,155,,,Fee Schedule,155% of CMS OPPS Rate,406.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1261.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1261.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,406.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,401.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,406.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,883.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,883.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,1261.58,
42962- Oropharyngeal hemor/sec surg inter,3431149,CDM,510,RC,42962,HCPCS,Outpatient,,,1334.99,667.50,,1201.49,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1067.99,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1201.49,90,,,Percent of total Billed charges,90% of total billed charges,87.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1294.94,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1228.19,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1201.49,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,934.49,70,,,percent of total billed charges,70% of total billed charges,1201.49,90,,,percent of total billed charges,90% of total billed charges,1268.24,95,,,percent of total billed charges,95% of total billed charges,1268.24,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1148.09,86,,,percent of total billed charges,86% of total billed charges,1067.99,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1294.94,97,,,percent of total billed charges,97% of total billed charges,1201.49,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1294.94,97,,,percent of total billed charges,97% of total billed charges,1241.54,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1294.94,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79.5,13869.87,
42962-PF CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,4321642,CDM,981,RC,42962,HCPCS,Outpatient,,,1009.8,504.90,,908.82,90,,,percent of total billed charges,90% of total Billed charges,1006.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,504.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,782.6,155,,,Fee Schedule,155% of CMS OPPS Rate,504.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,504.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,765.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,760.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,760.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,417.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1009.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,577.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,782.6,155,,,Fee Schedule,155% of CMS OPPS Rate,504.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1560.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,504.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,530.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,504.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1088,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1088,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,1560.68,
42970-PF CTRL NASOPHARYNGEAL HEMRRG SMPL W/PST NSL PACKS,4321640,CDM,981,RC,42970,HCPCS,Outpatient,,,799.36,399.68,,719.42,90,,,percent of total billed charges,90% of total Billed charges,800.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,399.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,619.5,155,,,Fee Schedule,155% of CMS OPPS Rate,399.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,399.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,611.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,605.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,605.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,328.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,714.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,460.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,619.5,155,,,Fee Schedule,155% of CMS OPPS Rate,399.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1241.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1241.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,399.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,364.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,399.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,830.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,1241.09,
42971-PF CTRL NASOPHARYNGEAL HEMRRG COMP REQ HOSPIZATION,4321641,CDM,981,RC,42971,HCPCS,Outpatient,,,882.38,441.19,,794.14,90,,,percent of total billed charges,90% of total Billed charges,884.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,441.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,683.83,155,,,Fee Schedule,155% of CMS OPPS Rate,441.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,661.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,441.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,744.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,670.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,670.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,369.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,882.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,791.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,511.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,683.83,155,,,Fee Schedule,155% of CMS OPPS Rate,441.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1370.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1370.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,441.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,449.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,441.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,962.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,1370.42,
42972-PF CTRL NASOPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ,4321639,CDM,981,RC,42972,HCPCS,Outpatient,,,990.6,495.30,,891.54,90,,,percent of total billed charges,90% of total Billed charges,991.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,495.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,767.7,155,,,Fee Schedule,155% of CMS OPPS Rate,495.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,495.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,753.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,753.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,409.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,495.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,889.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,576.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,767.7,155,,,Fee Schedule,155% of CMS OPPS Rate,495.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1536.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1536.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,495.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,495.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1079.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1079.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,1536.28,
43130- Diverticulectomy/hypophar/esoph,3431152,CDM,510,RC,43130,HCPCS,Outpatient,,,2091.16,1045.58,,1882.04,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1672.93,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2028.43,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1923.87,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1882.04,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1463.81,70,,,percent of total billed charges,70% of total billed charges,1882.04,90,,,percent of total billed charges,90% of total billed charges,1986.6,95,,,percent of total billed charges,95% of total billed charges,1986.6,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1798.4,86,,,percent of total billed charges,86% of total billed charges,1672.93,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2028.43,97,,,percent of total billed charges,97% of total billed charges,1882.04,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2028.43,97,,,percent of total billed charges,97% of total billed charges,1944.78,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2028.43,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1463.81,26031.56,
43191- Esophagoscopy/rigid/diagnostic,3431153,CDM,510,RC,43191,HCPCS,Outpatient,,,403.39,201.70,,363.05,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,322.71,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,391.29,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,371.12,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,363.05,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,282.37,70,,,percent of total billed charges,70% of total billed charges,363.05,90,,,percent of total billed charges,90% of total billed charges,383.22,95,,,percent of total billed charges,95% of total billed charges,383.22,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,346.92,86,,,percent of total billed charges,86% of total billed charges,322.71,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,391.29,97,,,percent of total billed charges,97% of total billed charges,363.05,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.29,97,,,percent of total billed charges,97% of total billed charges,375.15,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,391.29,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,282.37,8490.45,
43194- Esophagoscopy w/foreign body remov,3431154,CDM,510,RC,43194,HCPCS,Outpatient,,,512.21,256.11,,460.99,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,409.77,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.99,90,,,Percent of total Billed charges,90% of total billed charges,144.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,496.84,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,471.23,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,460.99,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,358.55,70,,,percent of total billed charges,70% of total billed charges,460.99,90,,,percent of total billed charges,90% of total billed charges,486.6,95,,,percent of total billed charges,95% of total billed charges,486.6,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,440.5,86,,,percent of total billed charges,86% of total billed charges,409.77,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,496.84,97,,,percent of total billed charges,97% of total billed charges,460.99,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,496.84,97,,,percent of total billed charges,97% of total billed charges,476.36,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,496.84,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131.81,8490.45,
43200 - PF Esophagoscopy Flexible Transoral Dx,4311514,CDM,960,RC,43200,HCPCS,Outpatient,,,202.4,101.20,,182.16,90,,,percent of total billed charges,90% of total Billed charges,287.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,132.12,155,,,Fee Schedule,155% of CMS OPPS Rate,85.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,132.12,155,,,Fee Schedule,155% of CMS OPPS Rate,85.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.84,155,,,Fee Schedule,155% of CMS OPPS Rate,445.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,600.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,431.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,431.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.54,600.43,
43200- Esophagoscopy/flex/diagnostic,3431155,CDM,510,RC,43200,HCPCS,Outpatient,,,661.56,330.78,,595.4,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,529.25,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.4,90,,,Percent of total Billed charges,90% of total billed charges,102.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,641.71,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,608.64,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,595.4,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,463.09,70,,,percent of total billed charges,70% of total billed charges,595.4,90,,,percent of total billed charges,90% of total billed charges,628.48,95,,,percent of total billed charges,95% of total billed charges,628.48,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,568.94,86,,,percent of total billed charges,86% of total billed charges,529.25,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,641.71,97,,,percent of total billed charges,97% of total billed charges,595.4,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.71,97,,,percent of total billed charges,97% of total billed charges,615.25,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.71,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.47,4024.46,
43201- Esophagoscopy/submucosal injection,3431156,CDM,510,RC,43201,HCPCS,Outpatient,,,658.05,329.03,,592.25,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,526.44,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.25,90,,,Percent of total Billed charges,90% of total billed charges,125.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,638.31,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,605.41,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,592.25,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,460.64,70,,,percent of total billed charges,70% of total billed charges,592.25,90,,,percent of total billed charges,90% of total billed charges,625.15,95,,,percent of total billed charges,95% of total billed charges,625.15,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,565.92,86,,,percent of total billed charges,86% of total billed charges,526.44,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,638.31,97,,,percent of total billed charges,97% of total billed charges,592.25,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.31,97,,,percent of total billed charges,97% of total billed charges,611.99,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,638.31,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.13,8490.45,
43202 - PF Esophagoscopy Flexible Transoral w/ Bx,4311515,CDM,960,RC,43202,HCPCS,Outpatient,,,236.56,118.28,,212.9,90,,,percent of total billed charges,90% of total Billed charges,336.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.41,155,,,Fee Schedule,155% of CMS OPPS Rate,99.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,155.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,155.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.41,155,,,Fee Schedule,155% of CMS OPPS Rate,99.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,521.08,155,,,Fee Schedule,155% of CMS OPPS Rate,521.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,533.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,558.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,84.04,558.96,
43202- Esophagoscopy/w bx/single/mult,3431157,CDM,510,RC,43202,HCPCS,Outpatient,,,903.77,451.89,,813.39,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,723.02,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.39,90,,,Percent of total Billed charges,90% of total billed charges,111.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,876.66,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,831.47,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,813.39,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,632.64,70,,,percent of total billed charges,70% of total billed charges,813.39,90,,,percent of total billed charges,90% of total billed charges,858.58,95,,,percent of total billed charges,95% of total billed charges,858.58,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,777.24,86,,,percent of total billed charges,86% of total billed charges,723.02,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,876.66,97,,,percent of total billed charges,97% of total billed charges,813.39,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.66,97,,,percent of total billed charges,97% of total billed charges,840.51,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,876.66,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,101.48,8490.45,
43204- Esophagoscopy/inj sclero/esoph var,3431158,CDM,510,RC,43204,HCPCS,Outpatient,,,349.38,174.69,,314.44,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,279.5,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.44,90,,,Percent of total Billed charges,90% of total billed charges,212.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,338.9,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,321.43,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.44,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,244.57,70,,,percent of total billed charges,70% of total billed charges,314.44,90,,,percent of total billed charges,90% of total billed charges,331.91,95,,,percent of total billed charges,95% of total billed charges,331.91,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.47,86,,,percent of total billed charges,86% of total billed charges,279.5,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,338.9,97,,,percent of total billed charges,97% of total billed charges,314.44,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.9,97,,,percent of total billed charges,97% of total billed charges,324.92,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,338.9,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,192.95,8490.45,
43205- Esophagoscopy/band ligat/esop vari,3431159,CDM,510,RC,43205,HCPCS,Outpatient,,,363.45,181.73,,327.11,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,290.76,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,352.55,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,334.37,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.11,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,254.42,70,,,percent of total billed charges,70% of total billed charges,327.11,90,,,percent of total billed charges,90% of total billed charges,345.28,95,,,percent of total billed charges,95% of total billed charges,345.28,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,312.57,86,,,percent of total billed charges,86% of total billed charges,290.76,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,352.55,97,,,percent of total billed charges,97% of total billed charges,327.11,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.55,97,,,percent of total billed charges,97% of total billed charges,338.01,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,352.55,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,254.42,8490.45,
43212- Esophagoscopy flex/transoral/stent placement,3431160,CDM,510,RC,43212,HCPCS,Outpatient,,,500.51,250.26,,450.46,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,400.41,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,485.49,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,460.47,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,450.46,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,350.36,70,,,percent of total billed charges,70% of total billed charges,450.46,90,,,percent of total billed charges,90% of total billed charges,475.48,95,,,percent of total billed charges,95% of total billed charges,475.48,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,430.44,86,,,percent of total billed charges,86% of total billed charges,400.41,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,485.49,97,,,percent of total billed charges,97% of total billed charges,450.46,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.49,97,,,percent of total billed charges,97% of total billed charges,465.47,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,485.49,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,350.36,25549.17,
43213 - PF Esophagoscopy Retro Dilate Balloon/ Other,4311516,CDM,960,RC,43213,HCPCS,Outpatient,,,606.04,303.02,,545.44,90,,,percent of total billed charges,90% of total Billed charges,861.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,220.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,395.62,155,,,Fee Schedule,155% of CMS OPPS Rate,255.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,396.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,396.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,226.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,467.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,395.62,155,,,Fee Schedule,155% of CMS OPPS Rate,255.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1334.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1334.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,255.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1287.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,255.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.48,1334.98,
43215 - Esophagoscopy Flexible Removal Foreign Body,3899035,CDM,983,RC,43215,HCPCS,Outpatient,,,1002.06,501.03,,901.85,90,,,percent of total billed charges,90% of total Billed charges,514.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,213.28,155,,,Fee Schedule,155% of CMS OPPS Rate,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,215.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,215.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,213.28,155,,,Fee Schedule,155% of CMS OPPS Rate,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.32,155,,,Fee Schedule,155% of CMS OPPS Rate,797.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.38,901.85,
43215 - PF Esophagoscopy Flexible Removal Foreign Body,4311517,CDM,960,RC,43215,HCPCS,Outpatient,,,326.75,163.38,,294.08,90,,,percent of total billed charges,90% of total Billed charges,464.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,213.28,155,,,Fee Schedule,155% of CMS OPPS Rate,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,215.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,215.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,213.28,155,,,Fee Schedule,155% of CMS OPPS Rate,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.74,155,,,Fee Schedule,155% of CMS OPPS Rate,719.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.38,719.74,
43216- Esophagoscopy/remov tum/hot bx for,3431161,CDM,510,RC,43216,HCPCS,Outpatient,,,1040.68,520.34,,936.61,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,832.54,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,936.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1009.46,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,957.43,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,936.61,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,728.48,70,,,percent of total billed charges,70% of total billed charges,936.61,90,,,percent of total billed charges,90% of total billed charges,988.65,95,,,percent of total billed charges,95% of total billed charges,988.65,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,894.98,86,,,percent of total billed charges,86% of total billed charges,832.54,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1009.46,97,,,percent of total billed charges,97% of total billed charges,936.61,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1009.46,97,,,percent of total billed charges,97% of total billed charges,967.83,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1009.46,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,728.48,8490.45,
43217- Esophagoscopy/remove tumor/snare,3431162,CDM,510,RC,43217,HCPCS,Outpatient,,,1069.64,534.82,,962.68,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,855.71,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.68,90,,,Percent of total Billed charges,90% of total billed charges,164.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1037.55,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,984.07,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,962.68,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,748.75,70,,,percent of total billed charges,70% of total billed charges,962.68,90,,,percent of total billed charges,90% of total billed charges,1016.16,95,,,percent of total billed charges,95% of total billed charges,1016.16,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,919.89,86,,,percent of total billed charges,86% of total billed charges,855.71,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1037.55,97,,,percent of total billed charges,97% of total billed charges,962.68,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037.55,97,,,percent of total billed charges,97% of total billed charges,994.77,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1037.55,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,149.55,8490.45,
43220- Esophagoscopy/balloon dilat <30 mm,3431163,CDM,510,RC,43220,HCPCS,Outpatient,,,2266.97,1133.49,,2040.27,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1813.58,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,2040.27,90,,,Percent of total Billed charges,90% of total billed charges,122.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2198.96,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,2085.61,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2040.27,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1586.88,70,,,percent of total billed charges,70% of total billed charges,2040.27,90,,,percent of total billed charges,90% of total billed charges,2153.62,95,,,percent of total billed charges,95% of total billed charges,2153.62,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1949.59,86,,,percent of total billed charges,86% of total billed charges,1813.58,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2198.96,97,,,percent of total billed charges,97% of total billed charges,2040.27,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,2198.96,97,,,percent of total billed charges,97% of total billed charges,2108.28,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2198.96,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111.34,8490.45,
43226- Esophagoscopy/dilator over GW,3431164,CDM,510,RC,43226,HCPCS,Outpatient,,,976.08,488.04,,878.47,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,780.86,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.47,90,,,Percent of total Billed charges,90% of total billed charges,135.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,946.8,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,897.99,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,683.26,70,,,percent of total billed charges,70% of total billed charges,878.47,90,,,percent of total billed charges,90% of total billed charges,927.28,95,,,percent of total billed charges,95% of total billed charges,927.28,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.43,86,,,percent of total billed charges,86% of total billed charges,780.86,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,946.8,97,,,percent of total billed charges,97% of total billed charges,878.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.8,97,,,percent of total billed charges,97% of total billed charges,907.75,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,946.8,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,122.98,8490.45,
43227- Esophagoscopy/w bleeding control,3431165,CDM,510,RC,43227,HCPCS,Outpatient,,,1508.4,754.20,,1357.56,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.72,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1357.56,90,,,Percent of total Billed charges,90% of total billed charges,202.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1463.15,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1387.73,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1357.56,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1055.88,70,,,percent of total billed charges,70% of total billed charges,1357.56,90,,,percent of total billed charges,90% of total billed charges,1432.98,95,,,percent of total billed charges,95% of total billed charges,1432.98,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1297.22,86,,,percent of total billed charges,86% of total billed charges,1206.72,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1463.15,97,,,percent of total billed charges,97% of total billed charges,1357.56,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1463.15,97,,,percent of total billed charges,97% of total billed charges,1402.81,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1463.15,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.93,8490.45,
43229- Esophagoscopy/ablate tumor/polyp,3431166,CDM,360,RC,43229,HCPCS,Outpatient,,,1807.44,903.72,,1626.7,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1445.95,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1626.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1753.22,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1662.84,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1626.7,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,1265.21,70,,,percent of total billed charges,70% of total billed charges,1626.7,90,,,percent of total billed charges,90% of total billed charges,1717.07,95,,,percent of total billed charges,95% of total billed charges,1717.07,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1554.4,86,,,percent of total billed charges,86% of total billed charges,1445.95,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1753.22,97,,,percent of total billed charges,97% of total billed charges,1626.7,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1753.22,97,,,percent of total billed charges,97% of total billed charges,1680.92,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1753.22,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1265.21,15896.27,
43231 - Esophagoscopy Ultrasound Exam,3896917,CDM,983,RC,43231,HCPCS,Outpatient,,,412.04,206.02,,370.84,90,,,percent of total billed charges,90% of total Billed charges,307.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,236.13,155,,,Fee Schedule,155% of CMS OPPS Rate,152.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,216.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,283.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,179.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,236.13,155,,,Fee Schedule,155% of CMS OPPS Rate,152.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,476.28,155,,,Fee Schedule,155% of CMS OPPS Rate,476.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,263.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72,476.28,
43232 - Esophagoscopy W/ US Needle Bx,3896923,CDM,983,RC,43232,HCPCS,Outpatient,,,519.47,259.74,,467.52,90,,,percent of total billed charges,90% of total Billed charges,386.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,229.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.03,155,,,Fee Schedule,155% of CMS OPPS Rate,190.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,90,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,90,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,356.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.03,155,,,Fee Schedule,155% of CMS OPPS Rate,190.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.8,155,,,Fee Schedule,155% of CMS OPPS Rate,598.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,190.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,190.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,536.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,536.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90,598.8,
"43233- Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30",3621459,CDM,510,RC,43233,HCPCS,Outpatient,,,603.37,301.69,,543.03,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,482.7,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,585.27,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,555.1,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.03,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,422.36,70,,,percent of total billed charges,70% of total billed charges,543.03,90,,,percent of total billed charges,90% of total billed charges,573.2,95,,,percent of total billed charges,95% of total billed charges,573.2,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,518.9,86,,,percent of total billed charges,86% of total billed charges,482.7,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.27,97,,,percent of total billed charges,97% of total billed charges,543.03,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.27,97,,,percent of total billed charges,97% of total billed charges,561.13,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,585.27,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,422.36,8490.45,
43233-PF EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER,4321456,CDM,981,RC,43233,HCPCS,Outpatient,,,445.96,222.98,,401.36,90,,,percent of total billed charges,90% of total Billed charges,449.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,345.6,155,,,Fee Schedule,155% of CMS OPPS Rate,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,312.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,350.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,350.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,274.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.6,155,,,Fee Schedule,155% of CMS OPPS Rate,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.27,155,,,Fee Schedule,155% of CMS OPPS Rate,697.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.26,697.27,
43235 - PF EGD Diagnostic Brush Wash,4311518,CDM,960,RC,43235,HCPCS,Outpatient,,,281.15,140.58,,253.04,90,,,percent of total billed charges,90% of total Billed charges,399.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,183.52,155,,,Fee Schedule,155% of CMS OPPS Rate,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,185.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,185.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,142.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.52,155,,,Fee Schedule,155% of CMS OPPS Rate,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.3,155,,,Fee Schedule,155% of CMS OPPS Rate,619.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,333.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,575.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,103.8,619.3,
43235- EGD/flex/transoral/diag,3431167,CDM,510,RC,43235,HCPCS,Outpatient,,,752.89,376.45,,677.6,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,602.31,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,677.6,90,,,Percent of total Billed charges,90% of total billed charges,137.74,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,730.3,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,692.66,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,677.6,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,527.02,70,,,percent of total billed charges,70% of total billed charges,677.6,90,,,percent of total billed charges,90% of total billed charges,715.25,95,,,percent of total billed charges,95% of total billed charges,715.25,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,647.49,86,,,percent of total billed charges,86% of total billed charges,602.31,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,730.3,97,,,percent of total billed charges,97% of total billed charges,677.6,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.3,97,,,percent of total billed charges,97% of total billed charges,700.19,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,730.3,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.22,4024.46,
43235-PF ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC,4321461,CDM,981,RC,43235,HCPCS,Outpatient,,,236.82,118.41,,213.14,90,,,percent of total billed charges,90% of total Billed charges,355.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,183.52,155,,,Fee Schedule,155% of CMS OPPS Rate,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,185.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,185.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,142.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.52,155,,,Fee Schedule,155% of CMS OPPS Rate,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.59,155,,,Fee Schedule,155% of CMS OPPS Rate,550.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,333.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,575.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,103.8,575.96,
43236- EGD/directed submucosal injection,3431168,CDM,510,RC,43236,HCPCS,Outpatient,,,1018.18,509.09,,916.36,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,814.54,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.36,90,,,Percent of total Billed charges,90% of total billed charges,166.71,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,987.63,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,936.73,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,916.36,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,712.73,70,,,percent of total billed charges,70% of total billed charges,916.36,90,,,percent of total billed charges,90% of total billed charges,967.27,95,,,percent of total billed charges,95% of total billed charges,967.27,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,875.63,86,,,percent of total billed charges,86% of total billed charges,814.54,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,987.63,97,,,percent of total billed charges,97% of total billed charges,916.36,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,987.63,97,,,percent of total billed charges,97% of total billed charges,946.91,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,987.63,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,151.55,4024.46,
43237 - Endoscopic US Exam Esoph,3899036,CDM,983,RC,43237,HCPCS,Outpatient,,,510.01,255.01,,459.01,90,,,percent of total billed charges,90% of total Billed charges,381.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,169.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,293.32,155,,,Fee Schedule,155% of CMS OPPS Rate,189.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,265.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,296.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,296.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,349.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,223.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,293.32,155,,,Fee Schedule,155% of CMS OPPS Rate,189.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,590.57,155,,,Fee Schedule,155% of CMS OPPS Rate,590.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,189.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,262.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,189.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,480.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,169.93,590.57,
43238 - EGD US Fine Needle Bx/Aspir,3899037,CDM,983,RC,43238,HCPCS,Outpatient,,,603.48,301.74,,543.13,90,,,percent of total billed charges,90% of total Billed charges,451.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,224.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,210.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,347.77,155,,,Fee Schedule,155% of CMS OPPS Rate,224.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,224.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,315.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,352.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,352.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,415.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,265.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,347.77,155,,,Fee Schedule,155% of CMS OPPS Rate,224.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.52,155,,,Fee Schedule,155% of CMS OPPS Rate,699.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,224.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,224.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,598.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.98,699.52,
43239 - PF EGD Transoral Bx Sngl/ Mult,4311519,CDM,960,RC,43239,HCPCS,Outpatient,,,317.34,158.67,,285.61,90,,,percent of total billed charges,90% of total Billed charges,450.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.14,155,,,Fee Schedule,155% of CMS OPPS Rate,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,159.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,207.14,155,,,Fee Schedule,155% of CMS OPPS Rate,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.02,155,,,Fee Schedule,155% of CMS OPPS Rate,699.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,374.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,670.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,670.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,123.2,699.02,
43239- EGD w/biopsy/single/multiple,3431169,CDM,510,RC,43239,HCPCS,Outpatient,,,958,479.00,,862.2,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,766.4,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.2,90,,,Percent of total Billed charges,90% of total billed charges,163.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,929.26,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,881.36,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,862.2,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,670.6,70,,,percent of total billed charges,70% of total billed charges,862.2,90,,,percent of total billed charges,90% of total billed charges,910.1,95,,,percent of total billed charges,95% of total billed charges,910.1,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,823.88,86,,,percent of total billed charges,86% of total billed charges,766.4,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,929.26,97,,,percent of total billed charges,97% of total billed charges,862.2,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.26,97,,,percent of total billed charges,97% of total billed charges,890.94,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,929.26,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.58,4024.46,
43240 - EGD W/ Transmural Drain Cyst,3899038,CDM,983,RC,43240,HCPCS,Outpatient,,,1022.27,511.14,,920.04,90,,,percent of total billed charges,90% of total Billed charges,763.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,346.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,587.73,155,,,Fee Schedule,155% of CMS OPPS Rate,379.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,379.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,533.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,597.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,597.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,319.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,704.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,452.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,587.73,155,,,Fee Schedule,155% of CMS OPPS Rate,379.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1183.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,379.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,379.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,812.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,319.06,1183.55,
43241 - PF EGD Intraluminal Tube/ Cath Insertion,4311520,CDM,960,RC,43241,HCPCS,Outpatient,,,325.72,162.86,,293.15,90,,,percent of total billed charges,90% of total Billed charges,276.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,135.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,212.61,155,,,Fee Schedule,155% of CMS OPPS Rate,137.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,212.61,155,,,Fee Schedule,155% of CMS OPPS Rate,137.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.13,155,,,Fee Schedule,155% of CMS OPPS Rate,429.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.99,429.13,
43241- EGD/insert intraluminal tube/cath,3431170,CDM,510,RC,43241,HCPCS,Outpatient,,,371.51,185.76,,334.36,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,297.21,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.36,90,,,Percent of total Billed charges,90% of total billed charges,148.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,360.36,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,341.79,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,334.36,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,260.06,70,,,percent of total billed charges,70% of total billed charges,334.36,90,,,percent of total billed charges,90% of total billed charges,352.93,95,,,percent of total billed charges,95% of total billed charges,352.93,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,319.5,86,,,percent of total billed charges,86% of total billed charges,297.21,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,360.36,97,,,percent of total billed charges,97% of total billed charges,334.36,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.36,97,,,percent of total billed charges,97% of total billed charges,345.5,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,360.36,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.04,8490.45,
43242- EGD/transendoscopic US needle asp,3431171,CDM,510,RC,43242,HCPCS,Outpatient,,,685.29,342.65,,616.76,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,548.23,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.76,90,,,Percent of total Billed charges,90% of total billed charges,277.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,664.73,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,630.47,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,616.76,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,479.7,70,,,percent of total billed charges,70% of total billed charges,616.76,90,,,percent of total billed charges,90% of total billed charges,651.03,95,,,percent of total billed charges,95% of total billed charges,651.03,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,589.35,86,,,percent of total billed charges,86% of total billed charges,548.23,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,664.73,97,,,percent of total billed charges,97% of total billed charges,616.76,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,664.73,97,,,percent of total billed charges,97% of total billed charges,637.32,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,664.73,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,252.21,8490.45,
43243- EGD/inj scleros/esoph/gast varices,3431172,CDM,510,RC,43243,HCPCS,Outpatient,,,618.64,309.32,,556.78,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,494.91,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.08,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,569.15,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,556.78,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,433.05,70,,,percent of total billed charges,70% of total billed charges,556.78,90,,,percent of total billed charges,90% of total billed charges,587.71,95,,,percent of total billed charges,95% of total billed charges,587.71,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.03,86,,,percent of total billed charges,86% of total billed charges,494.91,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,600.08,97,,,percent of total billed charges,97% of total billed charges,556.78,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.08,97,,,percent of total billed charges,97% of total billed charges,575.34,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.08,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,433.05,8490.45,
43244- EGD/ band ligat esoph/gast varices,3431173,CDM,510,RC,43244,HCPCS,Outpatient,,,637.57,318.79,,573.81,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,510.06,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,618.44,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,586.56,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,573.81,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,446.3,70,,,percent of total billed charges,70% of total billed charges,573.81,90,,,percent of total billed charges,90% of total billed charges,605.69,95,,,percent of total billed charges,95% of total billed charges,605.69,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,548.31,86,,,percent of total billed charges,86% of total billed charges,510.06,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,618.44,97,,,percent of total billed charges,97% of total billed charges,573.81,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.44,97,,,percent of total billed charges,97% of total billed charges,592.94,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,618.44,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.3,8490.45,
43245 - PF EGD Dilation Gastric/ Duodenal Stricture,4311521,CDM,960,RC,43245,HCPCS,Outpatient,,,405.81,202.91,,365.23,90,,,percent of total billed charges,90% of total Billed charges,576.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,264.9,155,,,Fee Schedule,155% of CMS OPPS Rate,170.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,239.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,268.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,268.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,316.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,264.9,155,,,Fee Schedule,155% of CMS OPPS Rate,170.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,893.9,155,,,Fee Schedule,155% of CMS OPPS Rate,893.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,170.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,348.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,386.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,142.92,893.9,
43245- EGD/dilation gastric/duoden strict,3431174,CDM,510,RC,43245,HCPCS,Outpatient,,,1513.85,756.93,,1362.47,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1211.08,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1362.47,90,,,Percent of total Billed charges,90% of total billed charges,180.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1468.43,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1392.74,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1362.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.7,70,,,percent of total billed charges,70% of total billed charges,1362.47,90,,,percent of total billed charges,90% of total billed charges,1438.16,95,,,percent of total billed charges,95% of total billed charges,1438.16,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1301.91,86,,,percent of total billed charges,86% of total billed charges,1211.08,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1468.43,97,,,percent of total billed charges,97% of total billed charges,1362.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1468.43,97,,,percent of total billed charges,97% of total billed charges,1407.88,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1468.43,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,163.82,8490.45,
43246 - PF EGD Percut Plcmnt Gastrostomy Tube,4311522,CDM,960,RC,43246,HCPCS,Outpatient,,,465.31,232.66,,418.78,90,,,percent of total billed charges,90% of total Billed charges,393.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,219.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,303.75,155,,,Fee Schedule,155% of CMS OPPS Rate,195.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,195.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,273.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,307.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,307.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,391.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,241.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,303.75,155,,,Fee Schedule,155% of CMS OPPS Rate,195.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,610.5,155,,,Fee Schedule,155% of CMS OPPS Rate,610.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,195.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,379.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,195.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,516.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,516.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,180.44,610.5,
43246- EGD/perc gastrostomy tube place,3431175,CDM,510,RC,43246,HCPCS,Outpatient,,,526.31,263.16,,473.68,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,421.05,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,510.52,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,484.21,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,473.68,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,368.42,70,,,percent of total billed charges,70% of total billed charges,473.68,90,,,percent of total billed charges,90% of total billed charges,499.99,95,,,percent of total billed charges,95% of total billed charges,499.99,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,452.63,86,,,percent of total billed charges,86% of total billed charges,421.05,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,510.52,97,,,percent of total billed charges,97% of total billed charges,473.68,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.52,97,,,percent of total billed charges,97% of total billed charges,489.47,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,510.52,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,368.42,8490.45,
43247 - PF EGD Flexible Foreign Body Removal,4311523,CDM,960,RC,43247,HCPCS,Outpatient,,,407.23,203.62,,366.51,90,,,percent of total billed charges,90% of total Billed charges,540.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,174.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,265.83,155,,,Fee Schedule,155% of CMS OPPS Rate,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,240.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,317.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,206.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,265.83,155,,,Fee Schedule,155% of CMS OPPS Rate,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,837.39,155,,,Fee Schedule,155% of CMS OPPS Rate,837.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,345.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,410.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,144.41,837.39,
43247- EGD/foreign body removal,3431176,CDM,510,RC,43247,HCPCS,Outpatient,,,980.63,490.32,,882.57,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,784.5,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,882.57,90,,,Percent of total Billed charges,90% of total billed charges,191.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,951.21,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,902.18,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,882.57,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,686.44,70,,,percent of total billed charges,70% of total billed charges,882.57,90,,,percent of total billed charges,90% of total billed charges,931.6,95,,,percent of total billed charges,95% of total billed charges,931.6,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,843.34,86,,,percent of total billed charges,86% of total billed charges,784.5,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,951.21,97,,,percent of total billed charges,97% of total billed charges,882.57,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,951.21,97,,,percent of total billed charges,97% of total billed charges,911.99,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,951.21,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,174.03,4024.46,
43247-PF EGD FLEXIBLE FOREIGN BODY REMOVAL,4321638,CDM,981,RC,43247,HCPCS,Outpatient,,,343.02,171.51,,308.72,90,,,percent of total billed charges,90% of total Billed charges,514.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,174.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,265.83,155,,,Fee Schedule,155% of CMS OPPS Rate,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,240.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,317.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,206.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,265.83,155,,,Fee Schedule,155% of CMS OPPS Rate,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.51,155,,,Fee Schedule,155% of CMS OPPS Rate,797.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,345.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,410.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,144.41,797.51,
43248- EGD/dilator over guide wire,3431177,CDM,510,RC,43248,HCPCS,Outpatient,,,1051.95,525.98,,946.76,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,841.56,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1020.39,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,967.79,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,946.76,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,736.37,70,,,percent of total billed charges,70% of total billed charges,946.76,90,,,percent of total billed charges,90% of total billed charges,999.35,95,,,percent of total billed charges,95% of total billed charges,999.35,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,904.68,86,,,percent of total billed charges,86% of total billed charges,841.56,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1020.39,97,,,percent of total billed charges,97% of total billed charges,946.76,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.39,97,,,percent of total billed charges,97% of total billed charges,978.31,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1020.39,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4024.46,
43248-PF EGD Guid Wire Insertion,4322106,CDM,960,RC,43248,HCPCS,Outpatient,,,314.58,157.29,,283.12,90,,,percent of total billed charges,90% of total Billed charges,475.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,248.84,155,,,Fee Schedule,155% of CMS OPPS Rate,160.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,225.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,251.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,251.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,296.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,189.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,248.84,155,,,Fee Schedule,155% of CMS OPPS Rate,160.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,736.44,155,,,Fee Schedule,155% of CMS OPPS Rate,736.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,160.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,275.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,160.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135.82,736.44,
43249 - PF EGD Balloon Dilation Esophagus <30 mm Diam,4311524,CDM,960,RC,43249,HCPCS,Outpatient,,,308.35,154.18,,277.52,90,,,percent of total billed charges,90% of total Billed charges,457.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.59,155,,,Fee Schedule,155% of CMS OPPS Rate,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,232.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,232.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,274.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.59,155,,,Fee Schedule,155% of CMS OPPS Rate,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.54,155,,,Fee Schedule,155% of CMS OPPS Rate,708.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.1,708.54,
43249- PF EGD w/ balloon dilation/<30 mm,3431178,CDM,983,RC,43249,HCPCS,Outpatient,,,308.35,154.18,,277.52,90,,,percent of total billed charges,90% of total Billed charges,457.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.59,155,,,Fee Schedule,155% of CMS OPPS Rate,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,232.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,232.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,274.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.59,155,,,Fee Schedule,155% of CMS OPPS Rate,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.54,155,,,Fee Schedule,155% of CMS OPPS Rate,708.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.1,708.54,
43250 - PF EGD Flex Removal Lesion(s0 by Hot Bx Forceps,4311525,CDM,960,RC,43250,HCPCS,Outpatient,,,393.48,196.74,,354.13,90,,,percent of total billed charges,90% of total Billed charges,559.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.87,155,,,Fee Schedule,155% of CMS OPPS Rate,165.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,308.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,205.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.87,155,,,Fee Schedule,155% of CMS OPPS Rate,165.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,866.76,155,,,Fee Schedule,155% of CMS OPPS Rate,866.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,165.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,290.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,165.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,388.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,388.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,138.58,866.76,
43250- EGD/remov tum/polyp/hot bx forcep,3431179,CDM,510,RC,43250,HCPCS,Outpatient,,,1155.05,577.53,,1039.55,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,924.04,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1120.4,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1062.65,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1039.55,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,808.54,70,,,percent of total billed charges,70% of total billed charges,1039.55,90,,,percent of total billed charges,90% of total billed charges,1097.3,95,,,percent of total billed charges,95% of total billed charges,1097.3,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,993.34,86,,,percent of total billed charges,86% of total billed charges,924.04,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1120.4,97,,,percent of total billed charges,97% of total billed charges,1039.55,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1120.4,97,,,percent of total billed charges,97% of total billed charges,1074.2,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1120.4,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,808.54,8490.45,
43251 - PF EGD Remove Lesion Snare,4311526,CDM,960,RC,43251,HCPCS,Outpatient,,,450.68,225.34,,405.61,90,,,percent of total billed charges,90% of total Billed charges,640.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,294.21,155,,,Fee Schedule,155% of CMS OPPS Rate,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,159.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,226.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,294.21,155,,,Fee Schedule,155% of CMS OPPS Rate,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.76,155,,,Fee Schedule,155% of CMS OPPS Rate,992.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,446.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,446.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,159.28,992.76,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,510,RC,43251,HCPCS,Outpatient,,,1266.76,633.38,,1140.08,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.41,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1140.08,90,,,Percent of total Billed charges,90% of total billed charges,208.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1228.76,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1165.42,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1140.08,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,886.73,70,,,percent of total billed charges,70% of total billed charges,1140.08,90,,,percent of total billed charges,90% of total billed charges,1203.42,95,,,percent of total billed charges,95% of total billed charges,1203.42,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1089.41,86,,,percent of total billed charges,86% of total billed charges,1013.41,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1228.76,97,,,percent of total billed charges,97% of total billed charges,1140.08,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1228.76,97,,,percent of total billed charges,97% of total billed charges,1178.09,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1228.76,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.35,8490.45,
43253 - PF EGD US Guided Transmural Inj/Fiduc Mrkr,4361841,CDM,960,RC,43253,HCPCS,Outpatient,,,504.3,252.15,,453.87,90,,,percent of total billed charges,90% of total Billed charges,511.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,219.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,394.32,155,,,Fee Schedule,155% of CMS OPPS Rate,254.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,399.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,399.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,471.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,302.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,394.32,155,,,Fee Schedule,155% of CMS OPPS Rate,254.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,793.27,155,,,Fee Schedule,155% of CMS OPPS Rate,793.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,254.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,301.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,254.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.54,793.27,
43254 - EGD Endo Mucosal Resection,3899039,CDM,983,RC,43254,HCPCS,Outpatient,,,706.52,353.26,,635.87,90,,,percent of total billed charges,90% of total Billed charges,527,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,261.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,405.05,155,,,Fee Schedule,155% of CMS OPPS Rate,261.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,367.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,410.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,410.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,233.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,484.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,405.05,155,,,Fee Schedule,155% of CMS OPPS Rate,261.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.85,155,,,Fee Schedule,155% of CMS OPPS Rate,816.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,261.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,261.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.84,816.85,
43255 - PF EGD Transoral Control Bleeding Any Method,4311527,CDM,960,RC,43255,HCPCS,Outpatient,,,459.68,229.84,,413.71,90,,,percent of total billed charges,90% of total Billed charges,653.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,232.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,300.06,155,,,Fee Schedule,155% of CMS OPPS Rate,193.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,193.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,230.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,300.06,155,,,Fee Schedule,155% of CMS OPPS Rate,193.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1012.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1012.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,193.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,380.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,193.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,577.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,577.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193.59,1012.57,
43255- EGD/control bleeding/any method,3431181,CDM,510,RC,43255,HCPCS,Outpatient,,,1597.19,798.60,,1437.47,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1277.75,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1437.47,90,,,Percent of total Billed charges,90% of total billed charges,255.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1549.27,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.41,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1437.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.03,70,,,percent of total billed charges,70% of total billed charges,1437.47,90,,,percent of total billed charges,90% of total billed charges,1517.33,95,,,percent of total billed charges,95% of total billed charges,1517.33,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1373.58,86,,,percent of total billed charges,86% of total billed charges,1277.75,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1549.27,97,,,percent of total billed charges,97% of total billed charges,1437.47,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1549.27,97,,,percent of total billed charges,97% of total billed charges,1485.39,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1549.27,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,232.5,8490.45,
43257- EGD/themal energy/reflux disease,3431182,CDM,510,RC,43257,HCPCS,Outpatient,,,611.86,305.93,,550.67,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,489.49,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,593.5,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,562.91,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,550.67,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,428.3,70,,,percent of total billed charges,70% of total billed charges,550.67,90,,,percent of total billed charges,90% of total billed charges,581.27,95,,,percent of total billed charges,95% of total billed charges,581.27,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,526.2,86,,,percent of total billed charges,86% of total billed charges,489.49,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,593.5,97,,,percent of total billed charges,97% of total billed charges,550.67,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.5,97,,,percent of total billed charges,97% of total billed charges,569.03,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,593.5,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,428.3,15896.27,
43259- PF EGD/US/esoph/sto/duod/surg alt sto,3431184,CDM,983,RC,43259,HCPCS,Outpatient,,,451.67,225.84,,406.5,90,,,percent of total billed charges,90% of total Billed charges,438.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,210.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,337.22,155,,,Fee Schedule,155% of CMS OPPS Rate,217.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,343.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,343.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,405.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,258.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,337.22,155,,,Fee Schedule,155% of CMS OPPS Rate,217.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,678.93,155,,,Fee Schedule,155% of CMS OPPS Rate,678.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,217.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,331.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,217.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,620.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.05,678.93,
43260- ERCP/diagnostic,3431185,CDM,510,RC,43260,HCPCS,Outpatient,,,841.39,420.70,,757.25,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,673.11,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,757.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,816.15,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,774.08,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,757.25,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,588.97,70,,,percent of total billed charges,70% of total billed charges,757.25,90,,,percent of total billed charges,90% of total billed charges,799.32,95,,,percent of total billed charges,95% of total billed charges,799.32,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,723.6,86,,,percent of total billed charges,86% of total billed charges,673.11,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,816.15,97,,,percent of total billed charges,97% of total billed charges,757.25,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.15,97,,,percent of total billed charges,97% of total billed charges,782.49,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,816.15,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,588.97,15896.27,
43261 - PF ERCP W/ Bx Sngl/ Multiple,4311528,CDM,960,RC,43261,HCPCS,Outpatient,,,778.54,389.27,,700.69,90,,,percent of total billed charges,90% of total Billed charges,659.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,316.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,508.21,155,,,Fee Schedule,155% of CMS OPPS Rate,327.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,460,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,513.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,513.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,275.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,655.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,606.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,387.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,508.21,155,,,Fee Schedule,155% of CMS OPPS Rate,327.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1022.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1022.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,327.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,453.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,327.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,744.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,744.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,275.04,1022.43,
43261- ERCP w/ biopsy/single/multiple,3431186,CDM,510,RC,43261,HCPCS,Outpatient,,,882.26,441.13,,794.03,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,705.81,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,794.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,855.79,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,811.68,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,794.03,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,617.58,70,,,percent of total billed charges,70% of total billed charges,794.03,90,,,percent of total billed charges,90% of total billed charges,838.15,95,,,percent of total billed charges,95% of total billed charges,838.15,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,758.74,86,,,percent of total billed charges,86% of total billed charges,705.81,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,855.79,97,,,percent of total billed charges,97% of total billed charges,794.03,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,855.79,97,,,percent of total billed charges,97% of total billed charges,820.5,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,855.79,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,617.58,15896.27,
43262- ERCP/sphincterotomy/papillotomy,3431187,CDM,510,RC,43262,HCPCS,Outpatient,,,933.72,466.86,,840.35,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,746.98,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,840.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.71,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,859.02,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,840.35,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,653.6,70,,,percent of total billed charges,70% of total billed charges,840.35,90,,,percent of total billed charges,90% of total billed charges,887.03,95,,,percent of total billed charges,95% of total billed charges,887.03,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,803,86,,,percent of total billed charges,86% of total billed charges,746.98,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,905.71,97,,,percent of total billed charges,97% of total billed charges,840.35,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,905.71,97,,,percent of total billed charges,97% of total billed charges,868.36,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,905.71,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,653.6,15896.27,
43264- ERCP/remov calc/debri/bili/pan duc,3431188,CDM,510,RC,43264,HCPCS,Outpatient,,,949.62,474.81,,854.66,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,759.7,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,921.13,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,873.65,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,854.66,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,664.73,70,,,percent of total billed charges,70% of total billed charges,854.66,90,,,percent of total billed charges,90% of total billed charges,902.14,95,,,percent of total billed charges,95% of total billed charges,902.14,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,816.67,86,,,percent of total billed charges,86% of total billed charges,759.7,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,921.13,97,,,percent of total billed charges,97% of total billed charges,854.66,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,921.13,97,,,percent of total billed charges,97% of total billed charges,883.15,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,921.13,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,664.73,15896.27,
43265- ERCP w/destruction of calculi,3431189,CDM,510,RC,43265,HCPCS,Outpatient,,,1133.49,566.75,,1020.14,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,906.79,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1099.49,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1042.81,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1020.14,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,793.44,70,,,percent of total billed charges,70% of total billed charges,1020.14,90,,,percent of total billed charges,90% of total billed charges,1076.82,95,,,percent of total billed charges,95% of total billed charges,1076.82,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,974.8,86,,,percent of total billed charges,86% of total billed charges,906.79,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1099.49,97,,,percent of total billed charges,97% of total billed charges,1020.14,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1099.49,97,,,percent of total billed charges,97% of total billed charges,1054.15,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1099.49,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,793.44,25549.17,
43266 -PF EGD Endoscopic Stent Place,3899040,CDM,983,RC,43266,HCPCS,Outpatient,,,438.71,219.36,,394.84,90,,,percent of total billed charges,90% of total Billed charges,426.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,327.89,155,,,Fee Schedule,155% of CMS OPPS Rate,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,332.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,332.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,204.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,392.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,255.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,327.89,155,,,Fee Schedule,155% of CMS OPPS Rate,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.49,155,,,Fee Schedule,155% of CMS OPPS Rate,660.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.84,660.49,
43266-PF EGD Endoscopic Stent Place,4322107,CDM,960,RC,43266,HCPCS,Outpatient,,,438.71,219.36,,394.84,90,,,percent of total billed charges,90% of total Billed charges,426.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,327.89,155,,,Fee Schedule,155% of CMS OPPS Rate,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,296.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,332.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,332.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,204.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,423.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,392.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,255.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,327.89,155,,,Fee Schedule,155% of CMS OPPS Rate,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.49,155,,,Fee Schedule,155% of CMS OPPS Rate,660.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,211.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.84,660.49,
43270 - PF EGD Ablate Tumor Polyp/ Les w/  Dilat & Wire,4311529,CDM,960,RC,43270,HCPCS,Outpatient,,,514.82,257.41,,463.34,90,,,percent of total billed charges,90% of total Billed charges,731.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,216.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,198.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,336.07,155,,,Fee Schedule,155% of CMS OPPS Rate,216.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,216.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,305.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,433.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,402.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,258.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,336.07,155,,,Fee Schedule,155% of CMS OPPS Rate,216.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1134.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1134.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,216.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,762.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,216.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.18,1134.04,
43270- EGD w/ablation/tumor/polyp/lesion,3431192,CDM,510,RC,43270,HCPCS,Outpatient,,,1858.29,929.15,,1672.46,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1486.63,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1672.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1802.54,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1709.63,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1672.46,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1300.8,70,,,percent of total billed charges,70% of total billed charges,1672.46,90,,,percent of total billed charges,90% of total billed charges,1765.38,95,,,percent of total billed charges,95% of total billed charges,1765.38,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1598.13,86,,,percent of total billed charges,86% of total billed charges,1486.63,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1802.54,97,,,percent of total billed charges,97% of total billed charges,1672.46,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1802.54,97,,,percent of total billed charges,97% of total billed charges,1728.21,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1802.54,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1300.8,8490.45,
43273- PF Endoscop can/pap/vis panc/bile duc,3431194,CDM,983,RC,43273,HCPCS,Outpatient,,,239.39,119.70,,215.45,90,,,percent of total billed charges,90% of total Billed charges,232.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,178.54,155,,,Fee Schedule,155% of CMS OPPS Rate,115.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,183.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,183.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,216.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,178.54,155,,,Fee Schedule,155% of CMS OPPS Rate,115.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.78,155,,,Fee Schedule,155% of CMS OPPS Rate,360.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,115.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,115.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.7,360.78,
43274- PF ERCP w/stent placement/ea stent,3431195,CDM,983,RC,43274,HCPCS,Outpatient,,,928.98,464.49,,836.08,90,,,percent of total billed charges,90% of total Billed charges,902.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,448.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,390.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,694.42,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,448.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,629.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,629.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,704.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,704.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,399.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,448.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,896.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,532.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,694.42,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1399.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1399.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,448.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,448.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.95,1399.01,
43275- ERCP w/foreign body/stent removal,3431196,CDM,510,RC,43275,HCPCS,Outpatient,,,982.01,491.01,,883.81,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,785.61,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,883.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,952.55,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,903.45,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,883.81,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,687.41,70,,,percent of total billed charges,70% of total billed charges,883.81,90,,,percent of total billed charges,90% of total billed charges,932.91,95,,,percent of total billed charges,95% of total billed charges,932.91,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,844.53,86,,,percent of total billed charges,86% of total billed charges,785.61,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,952.55,97,,,percent of total billed charges,97% of total billed charges,883.81,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,952.55,97,,,percent of total billed charges,97% of total billed charges,913.27,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,952.55,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,687.41,15896.27,
43276- ERCP/remov/exch stent/bili/panc/ea,3431197,CDM,510,RC,43276,HCPCS,Outpatient,,,1258.74,629.37,,1132.87,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.99,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1132.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1220.98,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1158.04,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1132.87,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,881.12,70,,,percent of total billed charges,70% of total billed charges,1132.87,90,,,percent of total billed charges,90% of total billed charges,1195.8,95,,,percent of total billed charges,95% of total billed charges,1195.8,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1082.52,86,,,percent of total billed charges,86% of total billed charges,1006.99,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1220.98,97,,,percent of total billed charges,97% of total billed charges,1132.87,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.98,97,,,percent of total billed charges,97% of total billed charges,1170.63,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1220.98,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,881.12,25549.17,
43277- ERCP/endoscop balloon dil/ea duct,3431198,CDM,510,RC,43277,HCPCS,Outpatient,,,988.05,494.03,,889.25,90,,,percent of total billed charges,90% of total Billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,790.44,80,,,Percent of total Billed charges,80% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,889.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,958.41,97,,,Percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,909.01,92,,,Percent of total billed charges,92% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12549.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15896.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,889.25,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,691.64,70,,,percent of total billed charges,70% of total billed charges,889.25,90,,,percent of total billed charges,90% of total billed charges,938.65,95,,,percent of total billed charges,95% of total billed charges,938.65,95,,,percent of total billed charges,95% of total billed charges,2961.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5923.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,849.72,86,,,percent of total billed charges,86% of total billed charges,790.44,80,,,percent of total billed charges,80% of total billed charges,3100.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,958.41,97,,,percent of total billed charges,97% of total billed charges,889.25,90,,,percent of total billed charges,90% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,958.41,97,,,percent of total billed charges,97% of total billed charges,918.89,93,,,percent of total billed charges,93% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,958.41,97,,,percent of total billed charges,97% of total billed charges,2961.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2961.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2517.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,691.64,15896.27,
"43278 - ERCP w/ ablation of tumor(s), polyp(s), other lesion(s), including pre/post dilation and gui",3783104,CDM,983,RC,43278,HCPCS,Outpatient,,,1131.78,565.89,,1018.6,90,,,percent of total billed charges,90% of total Billed charges,844.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,418.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,649.06,155,,,Fee Schedule,155% of CMS OPPS Rate,418.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,418.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,589.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,659.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,659.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,376.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,837.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,778.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,499.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,649.06,155,,,Fee Schedule,155% of CMS OPPS Rate,418.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1308.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1308.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,418.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,506.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,418.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.72,1308.73,
"43279 - (PF) Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when",3634912,CDM,510,RC,43279,HCPCS,Outpatient,,,3475.34,1737.67,,3127.81,90,,,percent of total billed charges,90% of total Billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2780.27,80,,,Percent of total Billed charges,80% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3127.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3371.08,97,,,Percent of total billed charges,97% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3197.31,92,,,Percent of total billed charges,92% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3127.81,90,,,percent of total billed charges,90% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2432.74,70,,,percent of total billed charges,70% of total billed charges,3127.81,90,,,percent of total billed charges,90% of total billed charges,3301.57,95,,,percent of total billed charges,95% of total billed charges,3301.57,95,,,percent of total billed charges,95% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2988.79,86,,,percent of total billed charges,86% of total billed charges,2780.27,80,,,percent of total billed charges,80% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3371.08,97,,,percent of total billed charges,97% of total billed charges,3127.81,90,,,percent of total billed charges,90% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3371.08,97,,,percent of total billed charges,97% of total billed charges,3232.07,93,,,percent of total billed charges,93% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3371.08,97,,,percent of total billed charges,97% of total billed charges,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3475.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2432.74,3475.34,
43279-PF Laparoscopy Myotomy Heller,4322108,CDM,960,RC,43279,HCPCS,Outpatient,,,2536.28,1268.14,,2282.65,90,,,percent of total billed charges,90% of total Billed charges,2598.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,710.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2002.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1979.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1291.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2226.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2022.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2022.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1043.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2583.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2387.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1730.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2002.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,4027.95,155,,,Fee Schedule,155% of CMS OPPS Rate,4027.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1253.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2639.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2639.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,710.08,4027.95,
43280 - PF Laps Surg Esopg/ Gstr Fundoplasty,4311530,CDM,960,RC,43280,HCPCS,Outpatient,,,2573.99,1287.00,,2316.59,90,,,percent of total billed charges,90% of total Billed charges,2180.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,925.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1680.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1659.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1084.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1866.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1866.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1691.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1691.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,874.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2168.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1995.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1442.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1680.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3379.11,155,,,Fee Schedule,155% of CMS OPPS Rate,3379.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,925.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1190.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2199.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2199.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,874.24,3379.11,
"43280-Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)",3622755,CDM,510,RC,43280,HCPCS,Outpatient,,,2914.67,1457.34,,2623.2,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2331.74,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2623.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2827.23,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2681.5,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2623.2,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2040.27,70,,,percent of total billed charges,70% of total billed charges,2623.2,90,,,percent of total billed charges,90% of total billed charges,2768.94,95,,,percent of total billed charges,95% of total billed charges,2768.94,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2506.62,86,,,percent of total billed charges,86% of total billed charges,2331.74,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2827.23,97,,,percent of total billed charges,97% of total billed charges,2623.2,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2827.23,97,,,percent of total billed charges,97% of total billed charges,2710.64,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2827.23,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2040.27,44301.74,
43281 - PF Laps Rpr Paraesphgl Hrna Incl Fundplsty w/ o Mesh,4311694,CDM,960,RC,43281,HCPCS,Outpatient,,,3683.17,1841.59,,3314.85,90,,,percent of total billed charges,90% of total Billed charges,3119.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1551.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1232.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2404.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1551.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2373.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1551.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2669.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2669.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2428.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2428.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1248.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1551.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3102.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2865.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2084.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2404.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1551.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,4835.71,155,,,Fee Schedule,155% of CMS OPPS Rate,4835.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1551.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1232.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1454.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1551.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,3152.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3152.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1232.78,4835.71,
43281- Lap/surg/rpr paraeso hern w/o mesh,3431199,CDM,510,RC,43281,HCPCS,Outpatient,,,4171.5,2085.75,,3754.35,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3337.2,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,3754.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4046.36,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3837.78,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3754.35,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2920.05,70,,,percent of total billed charges,70% of total billed charges,3754.35,90,,,percent of total billed charges,90% of total billed charges,3962.93,95,,,percent of total billed charges,95% of total billed charges,3962.93,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3587.49,86,,,percent of total billed charges,86% of total billed charges,3337.2,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4046.36,97,,,percent of total billed charges,97% of total billed charges,3754.35,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,4046.36,97,,,percent of total billed charges,97% of total billed charges,3879.5,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4046.36,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2920.05,44301.74,
43282 - PF Laps Rpr Paraesphgl Hrna Incl Fundplasty w/  Mesh,4311695,CDM,960,RC,43282,HCPCS,Outpatient,,,4145.47,2072.74,,3730.92,90,,,percent of total billed charges,90% of total Billed charges,3510.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1745.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1386.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2706.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1745.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2668.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1745.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3001.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3001.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2733.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2733.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1404.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3491.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3224.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2349.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2706.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1745.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,5441.72,155,,,Fee Schedule,155% of CMS OPPS Rate,5441.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1745.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1386.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1619.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1745.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3542.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3542.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1386.18,5441.72,
43282- Lap/surg/rpr paraesoph hernia/mesh,3431200,CDM,510,RC,43282,HCPCS,Outpatient,,,4693.46,2346.73,,4224.11,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3754.77,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,4224.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4552.66,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,4317.98,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4224.11,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3285.42,70,,,percent of total billed charges,70% of total billed charges,4224.11,90,,,percent of total billed charges,90% of total billed charges,4458.79,95,,,percent of total billed charges,95% of total billed charges,4458.79,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4036.38,86,,,percent of total billed charges,86% of total billed charges,3754.77,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4552.66,97,,,percent of total billed charges,97% of total billed charges,4224.11,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,4552.66,97,,,percent of total billed charges,97% of total billed charges,4364.92,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4552.66,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3285.42,44301.74,
43283 - PF Laps Esophageal Lengthening Addl,4311696,CDM,960,RC,43283,HCPCS,Outpatient,,,378.53,189.27,,340.68,90,,,percent of total billed charges,90% of total Billed charges,321.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,247.09,155,,,Fee Schedule,155% of CMS OPPS Rate,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,250.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,250.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,295.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,247.09,155,,,Fee Schedule,155% of CMS OPPS Rate,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.25,155,,,Fee Schedule,155% of CMS OPPS Rate,498.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1336.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,159.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,328.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131.47,1336.21,
43287-PF Esophagetomy Distal 2/3 w/Laps Mobl,4322109,CDM,960,RC,43287,HCPCS,Outpatient,,,6985.4,3492.70,,6286.86,90,,,percent of total billed charges,90% of total Billed charges,7149.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3555.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2955.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,5511.01,155,,,Fee Schedule,155% of CMS OPPS Rate,3555.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5339.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3555.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6005.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6005.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5650.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5650.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3202.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3555.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7110.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6667.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,4867.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,5511.01,155,,,Fee Schedule,155% of CMS OPPS Rate,3555.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,11082.42,155,,,Fee Schedule,155% of CMS OPPS Rate,11082.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,3555.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,2955.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4038.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3555.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2955.5,11082.42,
43289 - PF Unlisted Laparoscopic Procedure Esophagus,4311697,CDM,960,RC,43289,HCPCS,Outpatient,,,2374.4,1187.20,,2136.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,2136.96,
43327- EG fundoplasty partial or complete;laparotomy,3569396,CDM,510,RC,43327,HCPCS,Outpatient,,,2207.82,1103.91,,1987.04,90,,,percent of total billed charges,90% of total Billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.26,80,,,Percent of total Billed charges,80% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1987.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2141.59,97,,,Percent of total billed charges,97% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2031.19,92,,,Percent of total billed charges,92% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1987.04,90,,,percent of total billed charges,90% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1545.47,70,,,percent of total billed charges,70% of total billed charges,1987.04,90,,,percent of total billed charges,90% of total billed charges,2097.43,95,,,percent of total billed charges,95% of total billed charges,2097.43,95,,,percent of total billed charges,95% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1898.73,86,,,percent of total billed charges,86% of total billed charges,1766.26,80,,,percent of total billed charges,80% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.59,97,,,percent of total billed charges,97% of total billed charges,1987.04,90,,,percent of total billed charges,90% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2141.59,97,,,percent of total billed charges,97% of total billed charges,2053.27,93,,,percent of total billed charges,93% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2141.59,97,,,percent of total billed charges,97% of total billed charges,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2207.82,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1545.47,2207.82,
43332- Lap rp/paraeso hiatal hern no mesh,3431201,CDM,510,RC,43332,HCPCS,Outpatient,,,3108.8,1554.40,,2797.92,90,,,percent of total billed charges,90% of total Billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2487.04,80,,,Percent of total Billed charges,80% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2797.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3015.54,97,,,Percent of total billed charges,97% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2860.1,92,,,Percent of total billed charges,92% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2797.92,90,,,percent of total billed charges,90% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.16,70,,,percent of total billed charges,70% of total billed charges,2797.92,90,,,percent of total billed charges,90% of total billed charges,2953.36,95,,,percent of total billed charges,95% of total billed charges,2953.36,95,,,percent of total billed charges,95% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2673.57,86,,,percent of total billed charges,86% of total billed charges,2487.04,80,,,percent of total billed charges,80% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3015.54,97,,,percent of total billed charges,97% of total billed charges,2797.92,90,,,percent of total billed charges,90% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3015.54,97,,,percent of total billed charges,97% of total billed charges,2891.18,93,,,percent of total billed charges,93% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3015.54,97,,,percent of total billed charges,97% of total billed charges,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.16,3108.8,
43333 - PF Lapt Rpr Paraesoph Hiatal Hernia w/  Mesh,4311698,CDM,960,RC,43333,HCPCS,Outpatient,,,3000.53,1500.27,,2700.48,90,,,percent of total billed charges,90% of total Billed charges,2540.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1263.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1026.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1958.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1263.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1940.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1263.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2183.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2183.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1981.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1981.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1025.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1263.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2527.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2338,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1693.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1958.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1263.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,3938.43,155,,,Fee Schedule,155% of CMS OPPS Rate,3938.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1263.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1026.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1385.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1263.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2571.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2571.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1025.2,3938.43,
43333- Lap rpr/paraesoph hiatal hern/mesh,3431202,CDM,510,RC,43333,HCPCS,Outpatient,,,3396.6,1698.30,,3056.94,90,,,percent of total billed charges,90% of total Billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2717.28,80,,,Percent of total Billed charges,80% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3056.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3294.7,97,,,Percent of total billed charges,97% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3124.87,92,,,Percent of total billed charges,92% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3056.94,90,,,percent of total billed charges,90% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2377.62,70,,,percent of total billed charges,70% of total billed charges,3056.94,90,,,percent of total billed charges,90% of total billed charges,3226.77,95,,,percent of total billed charges,95% of total billed charges,3226.77,95,,,percent of total billed charges,95% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2921.08,86,,,percent of total billed charges,86% of total billed charges,2717.28,80,,,percent of total billed charges,80% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3294.7,97,,,percent of total billed charges,97% of total billed charges,3056.94,90,,,percent of total billed charges,90% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3294.7,97,,,percent of total billed charges,97% of total billed charges,3158.84,93,,,percent of total billed charges,93% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3294.7,97,,,percent of total billed charges,97% of total billed charges,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3396.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2377.62,3396.6,
43415- Esophageal wnd sut/trans thor-abd,3431203,CDM,510,RC,43415,HCPCS,Outpatient,,,6866.34,3433.17,,6179.71,90,,,percent of total billed charges,90% of total Billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5493.07,80,,,Percent of total Billed charges,80% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6179.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6660.35,97,,,Percent of total billed charges,97% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6317.03,92,,,Percent of total billed charges,92% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6179.71,90,,,percent of total billed charges,90% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4806.44,70,,,percent of total billed charges,70% of total billed charges,6179.71,90,,,percent of total billed charges,90% of total billed charges,6523.02,95,,,percent of total billed charges,95% of total billed charges,6523.02,95,,,percent of total billed charges,95% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5905.05,86,,,percent of total billed charges,86% of total billed charges,5493.07,80,,,percent of total billed charges,80% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6660.35,97,,,percent of total billed charges,97% of total billed charges,6179.71,90,,,percent of total billed charges,90% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6660.35,97,,,percent of total billed charges,97% of total billed charges,6385.7,93,,,percent of total billed charges,93% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6660.35,97,,,percent of total billed charges,97% of total billed charges,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6866.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4806.44,6866.34,
43450 - PF Dilation Esoph Unguided Sound/ Bougie 1/ Mult Pass,4311699,CDM,960,RC,43450,HCPCS,Outpatient,,,183.28,91.64,,164.95,90,,,percent of total billed charges,90% of total Billed charges,254.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,87.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.71,155,,,Fee Schedule,155% of CMS OPPS Rate,394.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59,394.71,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,510,RC,43450,HCPCS,Outpatient,,,471.99,236.00,,424.79,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,377.59,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.79,90,,,Percent of total Billed charges,90% of total billed charges,64.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,457.83,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,434.23,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,424.79,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,330.39,70,,,percent of total billed charges,70% of total billed charges,424.79,90,,,percent of total billed charges,90% of total billed charges,448.39,95,,,percent of total billed charges,95% of total billed charges,448.39,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,405.91,86,,,percent of total billed charges,86% of total billed charges,377.59,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.83,97,,,percent of total billed charges,97% of total billed charges,424.79,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.83,97,,,percent of total billed charges,97% of total billed charges,438.95,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,457.83,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59,4024.46,
"43453 - Dilation of esophagus, over guide wire",3572802,CDM,983,RC,43453,HCPCS,Outpatient,,,2015.45,1007.73,,1813.91,90,,,percent of total billed charges,90% of total Billed charges,841.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.6,155,,,Fee Schedule,155% of CMS OPPS Rate,83.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.6,155,,,Fee Schedule,155% of CMS OPPS Rate,83.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1304.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1304.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,564.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59,1813.91,
43460-PF ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYPE,4321462,CDM,981,RC,43460,HCPCS,Outpatient,,,411.18,205.59,,370.06,90,,,percent of total billed charges,90% of total Billed charges,413.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,318.66,155,,,Fee Schedule,155% of CMS OPPS Rate,205.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,322.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,322.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,243.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,318.66,155,,,Fee Schedule,155% of CMS OPPS Rate,205.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,640.34,155,,,Fee Schedule,155% of CMS OPPS Rate,640.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,205.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,205.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,459.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,459.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.5,640.34,
43497 - PF Per Oral Endoscopic Myotomy POEM,4347163,CDM,960,RC,43497,HCPCS,Outpatient,,,1595.02,797.51,,1435.52,90,,,percent of total billed charges,90% of total Billed charges,1558.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,775.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.95,155,,,Fee Schedule,155% of CMS OPPS Rate,775.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.51,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1550.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.95,155,,,Fee Schedule,155% of CMS OPPS Rate,775.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2415.47,155,,,Fee Schedule,155% of CMS OPPS Rate,2415.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,775.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.51,2415.47,
"43499 - PF Unlisted procedure, esophagus",3641211,CDM,510,RC,43499,HCPCS,Outpatient,,,531.87,265.94,,478.68,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,425.5,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,478.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,515.91,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,489.32,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,478.68,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,372.31,70,,,percent of total billed charges,70% of total billed charges,478.68,90,,,percent of total billed charges,90% of total billed charges,505.28,95,,,percent of total billed charges,95% of total billed charges,505.28,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,457.41,86,,,percent of total billed charges,86% of total billed charges,425.5,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,515.91,97,,,percent of total billed charges,97% of total billed charges,478.68,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.91,97,,,percent of total billed charges,97% of total billed charges,494.64,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,515.91,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,372.31,4024.46,
43500 - PF Gastrotomy w/ Exploration/ Foreign Body Removal,4311700,CDM,960,RC,43500,HCPCS,Outpatient,,,1863.05,931.53,,1676.75,90,,,percent of total billed charges,90% of total Billed charges,1581.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,784.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,452,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1216.18,155,,,Fee Schedule,155% of CMS OPPS Rate,784.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,784.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1353.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1353.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1220.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1220.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,635.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1569.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1439.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1028.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1216.18,155,,,Fee Schedule,155% of CMS OPPS Rate,784.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,2451.74,155,,,Fee Schedule,155% of CMS OPPS Rate,2451.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,784.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,452,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,727.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,784.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1591.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1591.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,452,2451.74,
43605- Biopsy/stomach/laparotomy,3431206,CDM,510,RC,43605,HCPCS,Outpatient,,,2258.63,1129.32,,2032.77,90,,,percent of total billed charges,90% of total Billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1806.9,80,,,Percent of total Billed charges,80% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2032.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2190.87,97,,,Percent of total billed charges,97% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2077.94,92,,,Percent of total billed charges,92% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2032.77,90,,,percent of total billed charges,90% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1581.04,70,,,percent of total billed charges,70% of total billed charges,2032.77,90,,,percent of total billed charges,90% of total billed charges,2145.7,95,,,percent of total billed charges,95% of total billed charges,2145.7,95,,,percent of total billed charges,95% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1942.42,86,,,percent of total billed charges,86% of total billed charges,1806.9,80,,,percent of total billed charges,80% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2190.87,97,,,percent of total billed charges,97% of total billed charges,2032.77,90,,,percent of total billed charges,90% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2190.87,97,,,percent of total billed charges,97% of total billed charges,2100.53,93,,,percent of total billed charges,93% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2190.87,97,,,percent of total billed charges,97% of total billed charges,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2258.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1581.04,2258.63,
43610 - PF Exc Local Ulcer/ Benign Tumor Stomach,4311701,CDM,960,RC,43610,HCPCS,Outpatient,,,2337.48,1168.74,,2103.73,90,,,percent of total billed charges,90% of total Billed charges,1978.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,984.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1525.9,155,,,Fee Schedule,155% of CMS OPPS Rate,984.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1506.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,984.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1694.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1694.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1532.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1532.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,791.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,984.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1968.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1808.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1300.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1525.9,155,,,Fee Schedule,155% of CMS OPPS Rate,984.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3067.17,155,,,Fee Schedule,155% of CMS OPPS Rate,3067.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,984.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,914.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,984.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1991.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1991.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544,3067.17,
43610- Excision/ulcer/benign tum/stomach,3431207,CDM,510,RC,43610,HCPCS,Outpatient,,,2644.38,1322.19,,2379.94,90,,,percent of total billed charges,90% of total Billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2115.5,80,,,Percent of total Billed charges,80% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2379.94,90,,,Percent of total Billed charges,90% of total billed charges,598.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2565.05,97,,,Percent of total billed charges,97% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2432.83,92,,,Percent of total billed charges,92% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2379.94,90,,,percent of total billed charges,90% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1851.07,70,,,percent of total billed charges,70% of total billed charges,2379.94,90,,,percent of total billed charges,90% of total billed charges,2512.16,95,,,percent of total billed charges,95% of total billed charges,2512.16,95,,,percent of total billed charges,95% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2274.17,86,,,percent of total billed charges,86% of total billed charges,2115.5,80,,,percent of total billed charges,80% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2565.05,97,,,percent of total billed charges,97% of total billed charges,2379.94,90,,,percent of total billed charges,90% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2565.05,97,,,percent of total billed charges,97% of total billed charges,2459.27,93,,,percent of total billed charges,93% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2565.05,97,,,percent of total billed charges,97% of total billed charges,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544,2644.38,
43620 - PF Gstrct Tot W/  Esophagoenterostomy,4311702,CDM,960,RC,43620,HCPCS,Outpatient,,,4750.6,2375.30,,4275.54,90,,,percent of total billed charges,90% of total Billed charges,4025.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2000.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3101.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2000.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2959.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2000.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3328.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3328.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3123.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3123.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1590.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2000.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4001.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3685.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2689.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3101.16,155,,,Fee Schedule,155% of CMS OPPS Rate,2000.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,6239.71,155,,,Fee Schedule,155% of CMS OPPS Rate,6239.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2000.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1673.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2000.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,4001.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4001.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6239.71,
43621 - PF Gastrectomy Tot w/ Roux-En-Y Rcnst,4311703,CDM,960,RC,43621,HCPCS,Outpatient,,,5433.93,2716.97,,4890.54,90,,,percent of total billed charges,90% of total Billed charges,4604.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2288.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3547.25,155,,,Fee Schedule,155% of CMS OPPS Rate,2288.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3385.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2288.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3807.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3807.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3575.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3575.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1834.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4577.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4219.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3072.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3547.25,155,,,Fee Schedule,155% of CMS OPPS Rate,2288.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,7137.11,155,,,Fee Schedule,155% of CMS OPPS Rate,7137.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2288.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1658.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2288.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,4610.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4610.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,7137.11,
"43621 - PF Gastrectomy, total; with Roux-en-Y reconstruction",3714924,CDM,510,RC,43621,HCPCS,Outpatient,,,6159.11,3079.56,,5543.2,90,,,percent of total billed charges,90% of total Billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4927.29,80,,,Percent of total Billed charges,80% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5543.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5974.34,97,,,Percent of total billed charges,97% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5666.38,92,,,Percent of total billed charges,92% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5543.2,90,,,percent of total billed charges,90% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4311.38,70,,,percent of total billed charges,70% of total billed charges,5543.2,90,,,percent of total billed charges,90% of total billed charges,5851.15,95,,,percent of total billed charges,95% of total billed charges,5851.15,95,,,percent of total billed charges,95% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5296.83,86,,,percent of total billed charges,86% of total billed charges,4927.29,80,,,percent of total billed charges,80% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5974.34,97,,,percent of total billed charges,97% of total billed charges,5543.2,90,,,percent of total billed charges,90% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5974.34,97,,,percent of total billed charges,97% of total billed charges,5727.97,93,,,percent of total billed charges,93% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5974.34,97,,,percent of total billed charges,97% of total billed charges,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6159.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4311.38,6159.11,
43622 - PF Gastrectomy Tot w/ Frm Intstinal Pouch Any Type,4311704,CDM,960,RC,43622,HCPCS,Outpatient,,,5538.98,2769.49,,4985.08,90,,,percent of total billed charges,90% of total Billed charges,4693.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2332.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3615.81,155,,,Fee Schedule,155% of CMS OPPS Rate,2332.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3452.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2332.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3882.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3882.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3648.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3648.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1853.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2332.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4665.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4305.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3148.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3615.81,155,,,Fee Schedule,155% of CMS OPPS Rate,2332.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,7275.31,155,,,Fee Schedule,155% of CMS OPPS Rate,7275.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2332.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1748.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2332.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4682.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4682.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,7275.31,
43631 - PF Gastrectomy Prtl Dstl w/ Gastroduodenostomy,4311705,CDM,960,RC,43631,HCPCS,Outpatient,,,3455.42,1727.71,,3109.88,90,,,percent of total billed charges,90% of total Billed charges,2929.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1455.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2255.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1455.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2162.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1455.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2432.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2432.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2273.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2273.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1172.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1455.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2910.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2683.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1938.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2255.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1455.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,4540.07,155,,,Fee Schedule,155% of CMS OPPS Rate,4540.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1455.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1324.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1455.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2945.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2945.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4540.07,
43631- Gastrectomy/part/gastroduodenostom,3431208,CDM,510,RC,43631,HCPCS,Outpatient,,,3919.32,1959.66,,3527.39,90,,,percent of total billed charges,90% of total Billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.46,80,,,Percent of total Billed charges,80% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3527.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3801.74,97,,,Percent of total billed charges,97% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3605.77,92,,,Percent of total billed charges,92% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3527.39,90,,,percent of total billed charges,90% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2743.52,70,,,percent of total billed charges,70% of total billed charges,3527.39,90,,,percent of total billed charges,90% of total billed charges,3723.35,95,,,percent of total billed charges,95% of total billed charges,3723.35,95,,,percent of total billed charges,95% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3370.62,86,,,percent of total billed charges,86% of total billed charges,3135.46,80,,,percent of total billed charges,80% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3801.74,97,,,percent of total billed charges,97% of total billed charges,3527.39,90,,,percent of total billed charges,90% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3801.74,97,,,percent of total billed charges,97% of total billed charges,3644.97,93,,,percent of total billed charges,93% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3801.74,97,,,percent of total billed charges,97% of total billed charges,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2743.52,3919.32,
43632 - PF Gastrectomy Prtl Dstl w/ Gastrojejunostomy,4311706,CDM,960,RC,43632,HCPCS,Outpatient,,,4872.88,2436.44,,4385.59,90,,,percent of total billed charges,90% of total Billed charges,4123.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2052.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3181,155,,,Fee Schedule,155% of CMS OPPS Rate,2052.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3033.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2052.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3412.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3412.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3201.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3201.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1642.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2052.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4104.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3777.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2746.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3181,155,,,Fee Schedule,155% of CMS OPPS Rate,2052.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,6391.52,155,,,Fee Schedule,155% of CMS OPPS Rate,6391.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2052.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1840.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2052.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4128.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4128.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6391.52,
43632- Gastrectomy/part/gastrojejunostomy,3431209,CDM,510,RC,43632,HCPCS,Outpatient,,,5508.29,2754.15,,4957.46,90,,,percent of total billed charges,90% of total Billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4406.63,80,,,Percent of total Billed charges,80% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4957.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5343.04,97,,,Percent of total billed charges,97% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5067.63,92,,,Percent of total billed charges,92% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4957.46,90,,,percent of total billed charges,90% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3855.8,70,,,percent of total billed charges,70% of total billed charges,4957.46,90,,,percent of total billed charges,90% of total billed charges,5232.88,95,,,percent of total billed charges,95% of total billed charges,5232.88,95,,,percent of total billed charges,95% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4737.13,86,,,percent of total billed charges,86% of total billed charges,4406.63,80,,,percent of total billed charges,80% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5343.04,97,,,percent of total billed charges,97% of total billed charges,4957.46,90,,,percent of total billed charges,90% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5343.04,97,,,percent of total billed charges,97% of total billed charges,5122.71,93,,,percent of total billed charges,93% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5343.04,97,,,percent of total billed charges,97% of total billed charges,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5508.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3855.8,5508.29,
43633 - PF Gastrectomy Prtl Dstl w/ Roux-En-Y Rcnst,4311707,CDM,960,RC,43633,HCPCS,Outpatient,,,4599.9,2299.95,,4139.91,90,,,percent of total billed charges,90% of total Billed charges,3894.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3002.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2869.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1937.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3227.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3227.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3026.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3026.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1553.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3874.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3571.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2595.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3002.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,6036.71,155,,,Fee Schedule,155% of CMS OPPS Rate,6036.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1754.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,3906.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3906.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6036.71,
"43633- Gastrectomy, partial, distal; with Roux-en-Y reconstruction",3623575,CDM,510,RC,43633,HCPCS,Outpatient,,,5205.31,2602.66,,4684.78,90,,,percent of total billed charges,90% of total Billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4164.25,80,,,Percent of total Billed charges,80% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4684.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5049.15,97,,,Percent of total billed charges,97% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4788.89,92,,,Percent of total billed charges,92% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4684.78,90,,,percent of total billed charges,90% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3643.72,70,,,percent of total billed charges,70% of total billed charges,4684.78,90,,,percent of total billed charges,90% of total billed charges,4945.04,95,,,percent of total billed charges,95% of total billed charges,4945.04,95,,,percent of total billed charges,95% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4476.57,86,,,percent of total billed charges,86% of total billed charges,4164.25,80,,,percent of total billed charges,80% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5049.15,97,,,percent of total billed charges,97% of total billed charges,4684.78,90,,,percent of total billed charges,90% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5049.15,97,,,percent of total billed charges,97% of total billed charges,4840.94,93,,,percent of total billed charges,93% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5049.15,97,,,percent of total billed charges,97% of total billed charges,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5205.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3643.72,5205.31,
43634 - PF Gastrectomy Prtl Dstl w/ Frm Intstinal Pouch,4311708,CDM,960,RC,43634,HCPCS,Outpatient,,,5091.1,2545.55,,4581.99,90,,,percent of total billed charges,90% of total Billed charges,4314.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2144.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3323.43,155,,,Fee Schedule,155% of CMS OPPS Rate,2144.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3173.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2144.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3569.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3569.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3352.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3352.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1713.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2144.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4288.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3955.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2891.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3323.43,155,,,Fee Schedule,155% of CMS OPPS Rate,2144.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,6687.21,155,,,Fee Schedule,155% of CMS OPPS Rate,6687.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2144.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1912.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2144.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4321.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4321.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6687.21,
43644 - PF Laps Gstr Rstcv Px w/ Byp Roux-En-Y Limb <150 cm,4311709,CDM,960,RC,43644,HCPCS,Outpatient,,,4157.12,2078.56,,3741.41,90,,,percent of total billed charges,90% of total Billed charges,3520.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1750.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2713.74,155,,,Fee Schedule,155% of CMS OPPS Rate,1750.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2671.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1750.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3004.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3004.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2728.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2728.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1401.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1750.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3501.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3219.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2340.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2713.74,155,,,Fee Schedule,155% of CMS OPPS Rate,1750.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,5456.06,155,,,Fee Schedule,155% of CMS OPPS Rate,5456.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1750.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1708.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1750.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3518.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3518.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5456.06,
43645 - PF Laps Gstr Rstcv Px w/  Byp&Sm Int Rcnst,4311710,CDM,960,RC,43645,HCPCS,Outpatient,,,4417.36,2208.68,,3975.62,90,,,percent of total billed charges,90% of total Billed charges,3732.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1860.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2883.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1860.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2844.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1860.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3198.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2906.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2906.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1492.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1860.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3720.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3429.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2492.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2883.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1860.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,5785.98,155,,,Fee Schedule,155% of CMS OPPS Rate,5785.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1860.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1730.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1860.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3763.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3763.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1492.65,5785.98,
43651 - PF Laps Surg Trnsx Vagus Nrv Truncal,4311711,CDM,960,RC,43651,HCPCS,Outpatient,,,1559.25,779.63,,1403.33,90,,,percent of total billed charges,90% of total Billed charges,1319.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,503.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1017.87,155,,,Fee Schedule,155% of CMS OPPS Rate,656.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1005.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1131.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1131.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1015.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1015.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,528.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1313.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1198.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,857.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1017.87,155,,,Fee Schedule,155% of CMS OPPS Rate,656.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2045.88,155,,,Fee Schedule,155% of CMS OPPS Rate,2045.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,656.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,840.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1321.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1321.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,503.14,2045.88,
43652 - PF Laps Surg Trnsx Vagus Nrv Slctv/ Hily Slctv,4311717,CDM,960,RC,43652,HCPCS,Outpatient,,,1824.02,912.01,,1641.62,90,,,percent of total billed charges,90% of total Billed charges,1543.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,768.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1190.71,155,,,Fee Schedule,155% of CMS OPPS Rate,768.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,768.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1321.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1190.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1190.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,619.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1536.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1404.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1010.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1190.71,155,,,Fee Schedule,155% of CMS OPPS Rate,768.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,2392.64,155,,,Fee Schedule,155% of CMS OPPS Rate,2392.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,768.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,970.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,768.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1545.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1545.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,600.84,2392.64,
43653 - PF Laps Surg Gastrostomy w/ o Const Gstr Tube Spx,4311718,CDM,960,RC,43653,HCPCS,Outpatient,,,1364.05,682.03,,1227.65,90,,,percent of total billed charges,90% of total Billed charges,1154.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,436.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,890.43,155,,,Fee Schedule,155% of CMS OPPS Rate,574.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,574.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,991.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,991.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,883.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,883.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,463.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1042.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,735.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,890.43,155,,,Fee Schedule,155% of CMS OPPS Rate,574.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1789.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1789.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,574.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,574.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1150.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,436.53,1789.79,
43653- Gastrostomy/laparoscopy,3431210,CDM,510,RC,43653,HCPCS,Outpatient,,,1543.03,771.52,,1388.73,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1234.42,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1388.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1496.74,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.59,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1388.73,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.12,70,,,percent of total billed charges,70% of total billed charges,1388.73,90,,,percent of total billed charges,90% of total billed charges,1465.88,95,,,percent of total billed charges,95% of total billed charges,1465.88,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1327.01,86,,,percent of total billed charges,86% of total billed charges,1234.42,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1496.74,97,,,percent of total billed charges,97% of total billed charges,1388.73,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1496.74,97,,,percent of total billed charges,97% of total billed charges,1435.02,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1496.74,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1080.12,25409.89,
43659 - PF Unlisted Laparoscopy Procedure Stomach,4311719,CDM,960,RC,43659,HCPCS,Outpatient,,,1424.64,712.32,,1282.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.39,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.39,1282.18,
"43659 - Unlisted laparoscopy procedure, stomach",4241828,CDM,960,RC,43659,HCPCS,Outpatient,,,4912.04,2456.02,,4420.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1473.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1473.61,4420.84,
43752 - PF Naso/ Oro-Gastric Tube Plmt Req Phys&Fluor Gdnce,4311720,CDM,960,RC,43752,HCPCS,Outpatient,,,94.74,47.37,,85.27,90,,,percent of total billed charges,90% of total Billed charges,79.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.94,155,,,Fee Schedule,155% of CMS OPPS Rate,123.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.39,123.94,
43752-PF NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE,4321463,CDM,981,RC,43752,HCPCS,Outpatient,,,79.8,39.90,,71.82,90,,,percent of total billed charges,90% of total Billed charges,79.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.94,155,,,Fee Schedule,155% of CMS OPPS Rate,123.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.39,123.94,
Read,602156,CDM,972,RC,43752,HCPCS,Outpatient,,,42.29,21.15,,38.06,90,,,percent of total billed charges,90% of total Billed charges,79.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.83,155,,,Fee Schedule,155% of CMS OPPS Rate,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.94,155,,,Fee Schedule,155% of CMS OPPS Rate,123.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.39,123.94,
43753 - PF Gastric Intubat & Aspira w/ Phys Skill/ Lavage,4311721,CDM,960,RC,43753,HCPCS,Outpatient,,,51.97,25.99,,46.77,90,,,percent of total billed charges,90% of total Billed charges,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.91,155,,,Fee Schedule,155% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.91,155,,,Fee Schedule,155% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,68.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,22.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,41.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.51,68.9,
43753-PF GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE,4321466,CDM,981,RC,43753,HCPCS,Outpatient,,,43.78,21.89,,39.4,90,,,percent of total billed charges,90% of total Billed charges,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.91,155,,,Fee Schedule,155% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.91,155,,,Fee Schedule,155% of CMS OPPS Rate,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,68.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,22.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,41.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.51,68.9,
43754 - PF Gastric Intubat Dx w/  Asp Sngl Spec,4311722,CDM,960,RC,43754,HCPCS,Outpatient,,,85.84,42.92,,77.26,90,,,percent of total billed charges,90% of total Billed charges,121.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,56.03,155,,,Fee Schedule,155% of CMS OPPS Rate,36.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.03,155,,,Fee Schedule,155% of CMS OPPS Rate,36.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.08,155,,,Fee Schedule,155% of CMS OPPS Rate,189.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,157.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.89,189.08,
43755 - PF Gastric Intuba Dx & Aspirat Mult Spec,4311723,CDM,960,RC,43755,HCPCS,Outpatient,,,135.98,67.99,,122.38,90,,,percent of total billed charges,90% of total Billed charges,193.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.75,155,,,Fee Schedule,155% of CMS OPPS Rate,57.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,64.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.75,155,,,Fee Schedule,155% of CMS OPPS Rate,57.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.52,155,,,Fee Schedule,155% of CMS OPPS Rate,299.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,57.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.65,299.52,
43761 - PF Repos Naso/ Oro Gastric Feeding Tube Thru Duo,4311724,CDM,960,RC,43761,HCPCS,Outpatient,,,247.89,123.95,,223.1,90,,,percent of total billed charges,90% of total Billed charges,227.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.82,155,,,Fee Schedule,155% of CMS OPPS Rate,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.82,155,,,Fee Schedule,155% of CMS OPPS Rate,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.78,155,,,Fee Schedule,155% of CMS OPPS Rate,352.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.93,352.78,
43761-PF REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO,4321637,CDM,981,RC,43761,HCPCS,Outpatient,,,208.8,104.40,,187.92,90,,,percent of total billed charges,90% of total Billed charges,227.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.82,155,,,Fee Schedule,155% of CMS OPPS Rate,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.82,155,,,Fee Schedule,155% of CMS OPPS Rate,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.78,155,,,Fee Schedule,155% of CMS OPPS Rate,352.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.93,352.78,
43762 - PF Perq Replc Gtube Not Req Rev Gstrst Trc,4311725,CDM,960,RC,43762,HCPCS,Outpatient,,,87.81,43.91,,79.03,90,,,percent of total billed charges,90% of total Billed charges,124.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.41,155,,,Fee Schedule,155% of CMS OPPS Rate,193.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.1,236.47,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,360,RC,43762,HCPCS,Outpatient,,,567.08,283.54,,510.37,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,453.66,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.37,90,,,Percent of total Billed charges,90% of total billed charges,34.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,550.07,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,521.71,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,510.37,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,396.96,70,,,percent of total billed charges,70% of total billed charges,510.37,90,,,percent of total billed charges,90% of total billed charges,538.73,95,,,percent of total billed charges,95% of total billed charges,538.73,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,487.69,86,,,percent of total billed charges,86% of total billed charges,453.66,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,550.07,97,,,percent of total billed charges,97% of total billed charges,510.37,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.07,97,,,percent of total billed charges,97% of total billed charges,527.38,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,550.07,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.1,1047.51,
43762-PF PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,4321636,CDM,981,RC,43762,HCPCS,Outpatient,,,73.96,36.98,,66.56,90,,,percent of total billed charges,90% of total Billed charges,110.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.94,155,,,Fee Schedule,155% of CMS OPPS Rate,171.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.1,236.47,
43763 - PF Perq Replc Gtube Req Rev Gstrst Trc,4311726,CDM,960,RC,43763,HCPCS,Outpatient,,,203.91,101.96,,183.52,90,,,percent of total billed charges,90% of total Billed charges,289.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.11,155,,,Fee Schedule,155% of CMS OPPS Rate,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,104.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,133.11,155,,,Fee Schedule,155% of CMS OPPS Rate,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.17,155,,,Fee Schedule,155% of CMS OPPS Rate,449.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,352.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.84,449.17,
43763-MSA CHANGE GASTROSTOMY TUBE W/ REVI,3429903,CDM,360,RC,43763,HCPCS,Outpatient,,,812.23,406.12,,731.01,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,649.78,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,731.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,787.86,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,747.25,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,731.01,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,568.56,70,,,percent of total billed charges,70% of total billed charges,731.01,90,,,percent of total billed charges,90% of total billed charges,771.62,95,,,percent of total billed charges,95% of total billed charges,771.62,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,698.52,86,,,percent of total billed charges,86% of total billed charges,649.78,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,787.86,97,,,percent of total billed charges,97% of total billed charges,731.01,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.86,97,,,percent of total billed charges,97% of total billed charges,755.37,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,787.86,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,1047.51,
43763-PF PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,4321467,CDM,981,RC,43763,HCPCS,Outpatient,,,171.76,85.88,,154.58,90,,,percent of total billed charges,90% of total Billed charges,257.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.11,155,,,Fee Schedule,155% of CMS OPPS Rate,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,104.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,133.11,155,,,Fee Schedule,155% of CMS OPPS Rate,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.34,155,,,Fee Schedule,155% of CMS OPPS Rate,399.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,352.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.84,399.34,
43770 - PF Laps Gastric Restrictive Px Place Device,4311727,CDM,960,RC,43770,HCPCS,Outpatient,,,2681.33,1340.67,,2413.2,90,,,percent of total billed charges,90% of total Billed charges,2272.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1129.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,748.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1750.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1129.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1729.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1129.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1945.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1945.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1753.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1753.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,905.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1129.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2258.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2069.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1491.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1750.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1129.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3522.98,155,,,Fee Schedule,155% of CMS OPPS Rate,3522.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1129.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,748.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1036.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1129.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,2265.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2265.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,748.92,3522.98,
43771 - PF Laps Gastric Restrictive Px Revision Device,4311728,CDM,960,RC,43771,HCPCS,Outpatient,,,3051.51,1525.76,,2746.36,90,,,percent of total billed charges,90% of total Billed charges,2584.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,856.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1992,155,,,Fee Schedule,155% of CMS OPPS Rate,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1285.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2210.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1996.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1996.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1028.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2570.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2356.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1702,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1992,155,,,Fee Schedule,155% of CMS OPPS Rate,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,4006.64,155,,,Fee Schedule,155% of CMS OPPS Rate,4006.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,856.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1085.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,2581.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2581.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,856.42,4006.64,
43772 - PF Laps Gastric Restrictive Px Remove Device,4311729,CDM,960,RC,43772,HCPCS,Outpatient,,,2264.39,1132.20,,2037.95,90,,,percent of total billed charges,90% of total Billed charges,1919.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,953.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,645.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1478.19,155,,,Fee Schedule,155% of CMS OPPS Rate,953.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,953.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1645.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1645.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1489.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1489.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,765.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1757.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1272.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1478.19,155,,,Fee Schedule,155% of CMS OPPS Rate,953.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2975.66,155,,,Fee Schedule,155% of CMS OPPS Rate,2975.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,953.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,897.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,953.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1940.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1940.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,645.31,2975.66,
43773 - PF Laps Gastric Restrictive Px Remove&Rplcmt Device,4311730,CDM,960,RC,43773,HCPCS,Outpatient,,,3051.51,1525.76,,2746.36,90,,,percent of total billed charges,90% of total Billed charges,2584.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,856.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1992,155,,,Fee Schedule,155% of CMS OPPS Rate,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1965.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1285.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2210.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2210.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1996.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1996.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1030.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2570.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2356.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1702,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1992,155,,,Fee Schedule,155% of CMS OPPS Rate,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,4006.64,155,,,Fee Schedule,155% of CMS OPPS Rate,4006.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,856.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1091.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1285.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,2580.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2580.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,856.66,4006.64,
43774 - PF Laps Gastric Restricitve Px Remove Device & Port,4311731,CDM,960,RC,43774,HCPCS,Outpatient,,,2295.33,1147.67,,2065.8,90,,,percent of total billed charges,90% of total Billed charges,1943.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,648.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1498.37,155,,,Fee Schedule,155% of CMS OPPS Rate,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1476.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,966.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1660.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1501.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1501.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,775.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1933.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1771.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1278.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1498.37,155,,,Fee Schedule,155% of CMS OPPS Rate,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,3011.76,155,,,Fee Schedule,155% of CMS OPPS Rate,3011.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,894.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1944.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1944.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,648.41,3011.76,
43774PF Lap Gastric Restrictive Procedure Remove Adjustable,4281202,CDM,960,RC,43774,HCPCS,Outpatient,,,2049.4,1024.70,,1844.46,90,,,percent of total billed charges,90% of total Billed charges,1943.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,648.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1498.37,155,,,Fee Schedule,155% of CMS OPPS Rate,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1476.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,966.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1660.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1660.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1501.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1501.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,775.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1933.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1771.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1278.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1498.37,155,,,Fee Schedule,155% of CMS OPPS Rate,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,3011.76,155,,,Fee Schedule,155% of CMS OPPS Rate,3011.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,894.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,966.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1944.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1944.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,648.41,3011.76,
43775 - PF Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy,4311732,CDM,960,RC,43775,HCPCS,Outpatient,,,2677.63,1338.82,,2409.87,90,,,percent of total billed charges,90% of total Billed charges,2268.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1127.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1033.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1747.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1127.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1716.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1127.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1931.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1931.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1771.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1771.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,969.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2090.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1538.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1747.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1127.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3516.31,155,,,Fee Schedule,155% of CMS OPPS Rate,3516.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1127.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1033.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1331.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1127.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2600.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2600.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,969.41,3516.31,
43820 - PF Gastrojejunostomy w/ o Vagotomy,4311733,CDM,960,RC,43820,HCPCS,Outpatient,,,3208.05,1604.03,,2887.25,90,,,percent of total billed charges,90% of total Billed charges,2716.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1351.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2094.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1351.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2002.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1351.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2252.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2252.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2104.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2104.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1084.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2483.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1794.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2094.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1351.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,4210.7,155,,,Fee Schedule,155% of CMS OPPS Rate,4210.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1351.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,848.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1351.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,2722.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2722.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,4210.7,
43820- Gastrojejunostomy w/o vagotomy,3431213,CDM,510,RC,43820,HCPCS,Outpatient,,,3631.28,1815.64,,3268.15,90,,,percent of total billed charges,90% of total Billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2905.02,80,,,Percent of total Billed charges,80% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3522.34,97,,,Percent of total billed charges,97% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3340.78,92,,,Percent of total billed charges,92% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.15,90,,,percent of total billed charges,90% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2541.9,70,,,percent of total billed charges,70% of total billed charges,3268.15,90,,,percent of total billed charges,90% of total billed charges,3449.72,95,,,percent of total billed charges,95% of total billed charges,3449.72,95,,,percent of total billed charges,95% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3122.9,86,,,percent of total billed charges,86% of total billed charges,2905.02,80,,,percent of total billed charges,80% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3522.34,97,,,percent of total billed charges,97% of total billed charges,3268.15,90,,,percent of total billed charges,90% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3522.34,97,,,percent of total billed charges,97% of total billed charges,3377.09,93,,,percent of total billed charges,93% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3522.34,97,,,percent of total billed charges,97% of total billed charges,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2541.9,3631.28,
43830- Gastrostomy w/o construct/g tube,3431214,CDM,510,RC,43830,HCPCS,Outpatient,,,1884.32,942.16,,1695.89,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1507.46,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1695.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1827.79,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1733.57,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1695.89,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1319.02,70,,,percent of total billed charges,70% of total billed charges,1695.89,90,,,percent of total billed charges,90% of total billed charges,1790.1,95,,,percent of total billed charges,95% of total billed charges,1790.1,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1620.52,86,,,percent of total billed charges,86% of total billed charges,1507.46,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1827.79,97,,,percent of total billed charges,97% of total billed charges,1695.89,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1827.79,97,,,percent of total billed charges,97% of total billed charges,1752.42,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1827.79,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1319.02,8490.45,
43830 -PF Gastrostomy Opn w/ o Const Gstr Tube Spx,4311734,CDM,960,RC,43830,HCPCS,Outpatient,,,1666.5,833.25,,1499.85,90,,,percent of total billed charges,90% of total Billed charges,1410.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,701.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,298,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1087.87,155,,,Fee Schedule,155% of CMS OPPS Rate,701.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1077.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,701.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1211.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1211.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1085.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1085.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,564.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1403.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1281.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,910.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1087.87,155,,,Fee Schedule,155% of CMS OPPS Rate,701.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,2186.15,155,,,Fee Schedule,155% of CMS OPPS Rate,2186.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,701.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,298,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,640.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,701.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298,2186.15,
43840- Gastrorrhaphy,3431215,CDM,510,RC,43840,HCPCS,Outpatient,,,3674.18,1837.09,,3306.76,90,,,percent of total billed charges,90% of total Billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2939.34,80,,,Percent of total Billed charges,80% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3563.95,97,,,Percent of total billed charges,97% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3380.25,92,,,Percent of total billed charges,92% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.76,90,,,percent of total billed charges,90% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2571.93,70,,,percent of total billed charges,70% of total billed charges,3306.76,90,,,percent of total billed charges,90% of total billed charges,3490.47,95,,,percent of total billed charges,95% of total billed charges,3490.47,95,,,percent of total billed charges,95% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3159.79,86,,,percent of total billed charges,86% of total billed charges,2939.34,80,,,percent of total billed charges,80% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3563.95,97,,,percent of total billed charges,97% of total billed charges,3306.76,90,,,percent of total billed charges,90% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3563.95,97,,,percent of total billed charges,97% of total billed charges,3416.99,93,,,percent of total billed charges,93% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3563.95,97,,,percent of total billed charges,97% of total billed charges,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2571.93,3674.18,
43842 - PF Gastric Rstcv w/ o Byp Vert-Banded Gastroply,4311735,CDM,960,RC,43842,HCPCS,Outpatient,,,2374.4,1187.20,,2136.96,90,,,percent of total billed charges,90% of total Billed charges,2255.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1127.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,797,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1747.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1127.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1761.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1127.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1980.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1980.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1748.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1748.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,834.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1127.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2062.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1279.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1747.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1127.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,3495.72,155,,,Fee Schedule,155% of CMS OPPS Rate,3495.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1127.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,797,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1223.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1127.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2322.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2322.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,797,3495.72,
43843 - PF Gstr Rstcv w/ o Byp Oth/ Thn Ver-Banded Gstp,4311736,CDM,960,RC,43843,HCPCS,Outpatient,,,3068.18,1534.09,,2761.36,90,,,percent of total billed charges,90% of total Billed charges,2599.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1292.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,797,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2002.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1292.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1972.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1292.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2218.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2218.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2008.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2008.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1026.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1292.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2584.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2370.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1717.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2002.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1292.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,4029.46,155,,,Fee Schedule,155% of CMS OPPS Rate,4029.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1292.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,797,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1333.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1292.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2595.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2595.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,797,4029.46,
43845 - PF Gastric Rstcv w/ Prtl Gastrectomy 50-100 cm,4311737,CDM,960,RC,43845,HCPCS,Outpatient,,,4686.55,2343.28,,4217.9,90,,,percent of total billed charges,90% of total Billed charges,3964.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3059.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2903.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1973.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3265.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3056.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3056.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1586,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1973.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3947.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3607.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2608.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3059.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,6145.38,155,,,Fee Schedule,155% of CMS OPPS Rate,6145.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1714.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1973.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3988.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3988.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1586,6145.38,
43846 - PF Gastric Rstcv w/ Byp w/ Short Limb 150 cm/ <,4311738,CDM,960,RC,43846,HCPCS,Outpatient,,,3948.39,1974.20,,3553.55,90,,,percent of total billed charges,90% of total Billed charges,3344.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1662.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2577.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1662.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2422.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1662.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2724.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2724.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2546.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2546.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1308.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1662.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3325.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3005.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2171.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2577.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1662.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,5183.7,155,,,Fee Schedule,155% of CMS OPPS Rate,5183.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1662.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1701.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1662.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3312.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3312.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5183.7,
43847 - PF Gastric Rstcv w/ Byp w/ Sm Int Rcnst Limit Absrp,4311739,CDM,960,RC,43847,HCPCS,Outpatient,,,4324.99,2162.50,,3892.49,90,,,percent of total billed charges,90% of total Billed charges,3664.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1821.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2823.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1821.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2693.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1821.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3029.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3029.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2834.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2834.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1433.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1821.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3344.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2430.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2823.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1821.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,5679.62,155,,,Fee Schedule,155% of CMS OPPS Rate,5679.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1821.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1583.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1821.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,3657.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3657.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5679.62,
43848 - PF Revision Open Gastric Restrictive Px Not Device,4311740,CDM,960,RC,43848,HCPCS,Outpatient,,,4619.85,2309.93,,4157.87,90,,,percent of total billed charges,90% of total Billed charges,3910.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1945.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3015.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1945.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2977.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1945.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3349.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3349.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3038.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3038.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1554.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1945.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3891.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3585.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2598.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3015.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1945.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,6060.67,155,,,Fee Schedule,155% of CMS OPPS Rate,6060.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1945.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1725.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1945.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,3924.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3924.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6060.67,
43860 - PF Rev Gstr/  Anast w/ Rcnst w/ o Vgtmy,4311741,CDM,960,RC,43860,HCPCS,Outpatient,,,3911.21,1955.61,,3520.09,90,,,percent of total billed charges,90% of total Billed charges,3311.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,632.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2553.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2515.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1647.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2829.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2829.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2565.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2565.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1321.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3027.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2183.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2553.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,5133.01,155,,,Fee Schedule,155% of CMS OPPS Rate,5133.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,632.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1346.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3317.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3317.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,632.5,5133.01,
43860PF Revision Gastrojejunal Anastomosis w/Reconstruction,4281205,CDM,960,RC,43860,HCPCS,Outpatient,,,3492.15,1746.08,,3142.94,90,,,percent of total billed charges,90% of total Billed charges,3311.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,632.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2553.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2515.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1647.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2829.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2829.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2565.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2565.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1321.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3294.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3027.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2183.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2553.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,5133.01,155,,,Fee Schedule,155% of CMS OPPS Rate,5133.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,632.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1346.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1647.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3317.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3317.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,632.5,5133.01,
43865 - PF Rev Gstr/  Anast w/ Rcnst w/  Vgtmy,4311742,CDM,960,RC,43865,HCPCS,Outpatient,,,4093.42,2046.71,,3684.08,90,,,percent of total billed charges,90% of total Billed charges,3468.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1723.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,861,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2672.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1723.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2551.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1723.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2870.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2870.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2689.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2689.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1368.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1723.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3447.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3174.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2312.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2672.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1723.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,5376.49,155,,,Fee Schedule,155% of CMS OPPS Rate,5376.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1723.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,861,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1502.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1723.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,3470.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3470.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,861,5376.49,
"43870 - Closure of gastrostomy, surgical",3800915,CDM,983,RC,43870,HCPCS,Outpatient,,,1908.12,954.06,,1717.31,90,,,percent of total billed charges,90% of total Billed charges,1428.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1101.4,155,,,Fee Schedule,155% of CMS OPPS Rate,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,710.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1226.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1102.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1102.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1300.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,924.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1101.4,155,,,Fee Schedule,155% of CMS OPPS Rate,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2213.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2213.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,654.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1440.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1440.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2213.56,
43870 - PF Closure Gastrostomy Surg,4311743,CDM,960,RC,43870,HCPCS,Outpatient,,,1687.22,843.61,,1518.5,90,,,percent of total billed charges,90% of total Billed charges,1428.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1101.4,155,,,Fee Schedule,155% of CMS OPPS Rate,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,710.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1226.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1102.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1102.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1300.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,924.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1101.4,155,,,Fee Schedule,155% of CMS OPPS Rate,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2213.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2213.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,654.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,710.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1440.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1440.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2213.56,
43886 - PF Gstr Rstcv Px Opn Rev Subq Port Component Only,4311744,CDM,960,RC,43886,HCPCS,Outpatient,,,857.2,428.60,,771.48,90,,,percent of total billed charges,90% of total Billed charges,725.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,361.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.57,155,,,Fee Schedule,155% of CMS OPPS Rate,361.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,361.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,627.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,550.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,550.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,293.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,649.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,450.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,559.57,155,,,Fee Schedule,155% of CMS OPPS Rate,361.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1124.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,361.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,275.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,361.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,725.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,725.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,275.21,1124.32,
43887 - PF Gstr Rstcv Px Opn Rmvl Subq Port Component Only,4311745,CDM,960,RC,43887,HCPCS,Outpatient,,,775.22,387.61,,697.7,90,,,percent of total billed charges,90% of total Billed charges,655.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.06,155,,,Fee Schedule,155% of CMS OPPS Rate,326.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,564.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,497.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,497.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,264.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,586.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,407.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,506.06,155,,,Fee Schedule,155% of CMS OPPS Rate,326.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1015.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1015.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,654.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,249.63,1015.84,
43888 - PF Gstr Rstcv Opn Rmvl & Rplcmt Subq Port,4311746,CDM,960,RC,43888,HCPCS,Outpatient,,,1093.2,546.60,,983.88,90,,,percent of total billed charges,90% of total Billed charges,926.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,460.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.64,155,,,Fee Schedule,155% of CMS OPPS Rate,460.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,460.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,798.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,707.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,707.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,370.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,920.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,834.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,587.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,713.64,155,,,Fee Schedule,155% of CMS OPPS Rate,460.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1435.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1435.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,460.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,406.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,460.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,924.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,370.63,1435.35,
43999 - PF Unlisted Procedure Stomach,4311747,CDM,960,RC,43999,HCPCS,Outpatient,,,949.76,474.88,,854.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.93,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.93,854.78,
44005 - PF Enterolss Fring Intstinal Adhesion Spx,4311748,CDM,960,RC,44005,HCPCS,Outpatient,,,2601.73,1300.87,,2341.56,90,,,percent of total billed charges,90% of total Billed charges,2204.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1095.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2585.9,90,,,Percent of total Billed charges,90% of total billed charges,481,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1698.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1095.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1679,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1095.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1888.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1888.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1710.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1710.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,885.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2191.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2018.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1451.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1698.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1095.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.63,155,,,Fee Schedule,155% of CMS OPPS Rate,3417.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1095.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,481,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1024.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1095.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2220.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2220.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,481,3417.63,
44005- Enterolysis,3431217,CDM,510,RC,44005,HCPCS,Outpatient,,,2949.73,1474.87,,2654.76,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2359.78,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2654.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2861.24,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2713.75,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2654.76,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2064.81,70,,,percent of total billed charges,70% of total billed charges,2654.76,90,,,percent of total billed charges,90% of total billed charges,2802.24,95,,,percent of total billed charges,95% of total billed charges,2802.24,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2536.77,86,,,percent of total billed charges,86% of total billed charges,2359.78,80,,,percent of total billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2861.24,97,,,percent of total billed charges,97% of total billed charges,2654.76,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2861.24,97,,,percent of total billed charges,97% of total billed charges,2743.25,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2861.24,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.73,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2064.81,2949.73,
44010- Duodenotomy/explore/bx/FB removal,3431218,CDM,510,RC,44010,HCPCS,Outpatient,,,2277.91,1138.96,,2050.12,90,,,percent of total billed charges,90% of total Billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1822.33,80,,,Percent of total Billed charges,80% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2050.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2209.57,97,,,Percent of total billed charges,97% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2095.68,92,,,Percent of total billed charges,92% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2050.12,90,,,percent of total billed charges,90% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.54,70,,,percent of total billed charges,70% of total billed charges,2050.12,90,,,percent of total billed charges,90% of total billed charges,2164.01,95,,,percent of total billed charges,95% of total billed charges,2164.01,95,,,percent of total billed charges,95% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1959,86,,,percent of total billed charges,86% of total billed charges,1822.33,80,,,percent of total billed charges,80% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2209.57,97,,,percent of total billed charges,97% of total billed charges,2050.12,90,,,percent of total billed charges,90% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2209.57,97,,,percent of total billed charges,97% of total billed charges,2118.46,93,,,percent of total billed charges,93% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2209.57,97,,,percent of total billed charges,97% of total billed charges,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.54,2277.91,
44015 - PF Tube/ Needle Cath Jejunostomy Any Method,4311749,CDM,960,RC,44015,HCPCS,Outpatient,,,342.08,171.04,,307.87,90,,,percent of total billed charges,90% of total Billed charges,289.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,223.29,155,,,Fee Schedule,155% of CMS OPPS Rate,144.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,195.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,225.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,225.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,266.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,195.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,223.29,155,,,Fee Schedule,155% of CMS OPPS Rate,144.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.21,155,,,Fee Schedule,155% of CMS OPPS Rate,448.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,144.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,144.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.31,448.21,
44015- Jejunostomy/tube/needle,3431219,CDM,510,RC,44015,HCPCS,Outpatient,,,385.9,192.95,,347.31,90,,,percent of total billed charges,90% of total Billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,308.72,80,,,Percent of total Billed charges,80% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,347.31,90,,,Percent of total Billed charges,90% of total billed charges,140.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,374.32,97,,,Percent of total billed charges,97% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,355.03,92,,,Percent of total billed charges,92% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,347.31,90,,,percent of total billed charges,90% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,270.13,70,,,percent of total billed charges,70% of total billed charges,347.31,90,,,percent of total billed charges,90% of total billed charges,366.61,95,,,percent of total billed charges,95% of total billed charges,366.61,95,,,percent of total billed charges,95% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,331.87,86,,,percent of total billed charges,86% of total billed charges,308.72,80,,,percent of total billed charges,80% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,374.32,97,,,percent of total billed charges,97% of total billed charges,347.31,90,,,percent of total billed charges,90% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,374.32,97,,,percent of total billed charges,97% of total billed charges,358.89,93,,,percent of total billed charges,93% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,127.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,374.32,97,,,percent of total billed charges,97% of total billed charges,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,385.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,127.64,385.9,
44020 - Enterotomy- Explore Small Intestine,3899043,CDM,983,RC,44020,HCPCS,Outpatient,,,2633.03,1316.52,,2369.73,90,,,percent of total billed charges,90% of total Billed charges,1967.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1514.49,155,,,Fee Schedule,155% of CMS OPPS Rate,977.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1496.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,977.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1682.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1682.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1522.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1522.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,786.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,977.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1954.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1796.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1293.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1514.49,155,,,Fee Schedule,155% of CMS OPPS Rate,977.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,3049.14,155,,,Fee Schedule,155% of CMS OPPS Rate,3049.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,977.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,904.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,977.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1975.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1975.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,3049.14,
44025 - Incision of Large Bowel,4189306,CDM,960,RC,44025,HCPCS,Outpatient,,,2356.19,1178.10,,2120.57,90,,,percent of total billed charges,90% of total Billed charges,1973.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,981.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,464,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1521.28,155,,,Fee Schedule,155% of CMS OPPS Rate,981.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1462.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,981.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1644.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1644.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1532.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1532.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,793.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,981.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1962.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1808.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1289.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1521.28,155,,,Fee Schedule,155% of CMS OPPS Rate,981.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,3059.39,155,,,Fee Schedule,155% of CMS OPPS Rate,3059.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,981.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,464,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,816.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,981.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2006,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2006,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,464,3059.39,
44050 - PF Rdct Volvulus Intussusception Int Hrna Lapt,4311751,CDM,960,RC,44050,HCPCS,Outpatient,,,2231.44,1115.72,,2008.3,90,,,percent of total billed charges,90% of total Billed charges,1889.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,939.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,490.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1456.66,155,,,Fee Schedule,155% of CMS OPPS Rate,939.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1436.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,939.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1615.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1615.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1460.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1460.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,755.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1879.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1723.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1238.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1456.66,155,,,Fee Schedule,155% of CMS OPPS Rate,939.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,2928.21,155,,,Fee Schedule,155% of CMS OPPS Rate,2928.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,939.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,872.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,939.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1896.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1896.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,490.5,2928.21,
44050- Reduce bowel obstruct/laparotomy,3431220,CDM,510,RC,44050,HCPCS,Outpatient,,,2524.74,1262.37,,2272.27,90,,,percent of total billed charges,90% of total Billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2019.79,80,,,Percent of total Billed charges,80% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2449,97,,,Percent of total billed charges,97% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2322.76,92,,,Percent of total billed charges,92% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.27,90,,,percent of total billed charges,90% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1767.32,70,,,percent of total billed charges,70% of total billed charges,2272.27,90,,,percent of total billed charges,90% of total billed charges,2398.5,95,,,percent of total billed charges,95% of total billed charges,2398.5,95,,,percent of total billed charges,95% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2171.28,86,,,percent of total billed charges,86% of total billed charges,2019.79,80,,,percent of total billed charges,80% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2449,97,,,percent of total billed charges,97% of total billed charges,2272.27,90,,,percent of total billed charges,90% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2449,97,,,percent of total billed charges,97% of total billed charges,2348.01,93,,,percent of total billed charges,93% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2449,97,,,percent of total billed charges,97% of total billed charges,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2524.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1767.32,2524.74,
44055 - CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS,3999139,CDM,960,RC,44055,HCPCS,Outpatient,,,4027.7,2013.85,,3624.93,90,,,percent of total billed charges,90% of total Billed charges,3011.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1496.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,515,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2319.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1496.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2289.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1496.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2575.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2575.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2338.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2338.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1204.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1496.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2993.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2759.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1994.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2319.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1496.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,4667.16,155,,,Fee Schedule,155% of CMS OPPS Rate,4667.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1496.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,515,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1397.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1496.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,3038.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3038.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,515,4667.16,
44110 - PF Exc 1/ > Sm/ Lg Lesions Intestine Enterotom,4311752,CDM,960,RC,44110,HCPCS,Outpatient,,,2001.83,1000.92,,1801.65,90,,,percent of total billed charges,90% of total Billed charges,1693.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,843.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1306.77,155,,,Fee Schedule,155% of CMS OPPS Rate,843.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,843.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1455,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1307.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1307.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,688.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1542.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1078.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1306.77,155,,,Fee Schedule,155% of CMS OPPS Rate,843.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2625.64,155,,,Fee Schedule,155% of CMS OPPS Rate,2625.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,843.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,787.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,843.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1721.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1721.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2625.64,
44110-PF EXCISE INTESTINE LESION(S),3429919,CDM,510,RC,44110,HCPCS,Outpatient,,,2262.77,1131.39,,2036.49,90,,,percent of total billed charges,90% of total Billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1810.22,80,,,Percent of total Billed charges,80% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2036.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2194.89,97,,,Percent of total billed charges,97% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2081.75,92,,,Percent of total billed charges,92% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2036.49,90,,,percent of total billed charges,90% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1583.94,70,,,percent of total billed charges,70% of total billed charges,2036.49,90,,,percent of total billed charges,90% of total billed charges,2149.63,95,,,percent of total billed charges,95% of total billed charges,2149.63,95,,,percent of total billed charges,95% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1945.98,86,,,percent of total billed charges,86% of total billed charges,1810.22,80,,,percent of total billed charges,80% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.89,97,,,percent of total billed charges,97% of total billed charges,2036.49,90,,,percent of total billed charges,90% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.89,97,,,percent of total billed charges,97% of total billed charges,2104.38,93,,,percent of total billed charges,93% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2194.89,97,,,percent of total billed charges,97% of total billed charges,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2262.77,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1583.94,2262.77,
44120 - PF Entrc Resc Sm Intestine 1 Resc & Anast,4311753,CDM,960,RC,44120,HCPCS,Outpatient,,,2913.01,1456.51,,2621.71,90,,,percent of total billed charges,90% of total Billed charges,2466.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1226.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,630.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1901.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1226.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1821.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1226.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2048.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2048.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1915.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1915.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,988.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1226.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2453.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2259.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1627.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1901.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1226.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,3823.83,155,,,Fee Schedule,155% of CMS OPPS Rate,3823.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1226.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1300.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1226.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2484.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,630.5,3823.83,
44120-PF REMOVAL OF SMALL INTESTINE,3429921,CDM,510,RC,44120,HCPCS,Outpatient,,,3298,1649.00,,2968.2,90,,,percent of total billed charges,90% of total Billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2638.4,80,,,Percent of total Billed charges,80% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2968.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3199.06,97,,,Percent of total billed charges,97% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3034.16,92,,,Percent of total billed charges,92% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2968.2,90,,,percent of total billed charges,90% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2308.6,70,,,percent of total billed charges,70% of total billed charges,2968.2,90,,,percent of total billed charges,90% of total billed charges,3133.1,95,,,percent of total billed charges,95% of total billed charges,3133.1,95,,,percent of total billed charges,95% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2836.28,86,,,percent of total billed charges,86% of total billed charges,2638.4,80,,,percent of total billed charges,80% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3199.06,97,,,percent of total billed charges,97% of total billed charges,2968.2,90,,,percent of total billed charges,90% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3199.06,97,,,percent of total billed charges,97% of total billed charges,3067.14,93,,,percent of total billed charges,93% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3199.06,97,,,percent of total billed charges,97% of total billed charges,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3298,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2308.6,3298,
44121 - PF Enterectomy Resc Sm Intestine Ea Resc & Ana,4313636,CDM,960,RC,44121,HCPCS,Outpatient,,,577.05,288.53,,519.35,90,,,percent of total billed charges,90% of total Billed charges,488.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,215.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,376.68,155,,,Fee Schedule,155% of CMS OPPS Rate,243.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,382.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,382.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,195.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,486.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,450.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,328.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,376.68,155,,,Fee Schedule,155% of CMS OPPS Rate,243.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,756.77,155,,,Fee Schedule,155% of CMS OPPS Rate,756.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,243.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,215.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,243.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,493.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,195.95,756.77,
"44121- Enterectomy, resect small intes; ea addl resec & anast",3569415,CDM,510,RC,44121,HCPCS,Outpatient,,,652.15,326.08,,586.94,90,,,percent of total billed charges,90% of total Billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,521.72,80,,,Percent of total Billed charges,80% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,586.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,632.59,97,,,Percent of total billed charges,97% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,599.98,92,,,Percent of total billed charges,92% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,586.94,90,,,percent of total billed charges,90% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,456.51,70,,,percent of total billed charges,70% of total billed charges,586.94,90,,,percent of total billed charges,90% of total billed charges,619.54,95,,,percent of total billed charges,95% of total billed charges,619.54,95,,,percent of total billed charges,95% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,560.85,86,,,percent of total billed charges,86% of total billed charges,521.72,80,,,percent of total billed charges,80% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,632.59,97,,,percent of total billed charges,97% of total billed charges,586.94,90,,,percent of total billed charges,90% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,632.59,97,,,percent of total billed charges,97% of total billed charges,606.5,93,,,percent of total billed charges,93% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,632.59,97,,,percent of total billed charges,97% of total billed charges,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,652.15,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,456.51,652.15,
44125 - PF Enterectomy Resc Sm Intestine w/ Enterostomy,4311754,CDM,960,RC,44125,HCPCS,Outpatient,,,2790.19,1395.10,,2511.17,90,,,percent of total billed charges,90% of total Billed charges,2365.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,623.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1821.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1809.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1175.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2035.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2035.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1840.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1840.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,953.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2172.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1550.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1821.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,3667.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3667.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1104.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,2400.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2400.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,623.5,3667.28,
"44125- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3622968,CDM,510,RC,44125,HCPCS,Outpatient,,,3166.96,1583.48,,2850.26,90,,,percent of total billed charges,90% of total Billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2533.57,80,,,Percent of total Billed charges,80% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2850.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3071.95,97,,,Percent of total billed charges,97% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2913.6,92,,,Percent of total billed charges,92% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2850.26,90,,,percent of total billed charges,90% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2216.87,70,,,percent of total billed charges,70% of total billed charges,2850.26,90,,,percent of total billed charges,90% of total billed charges,3008.61,95,,,percent of total billed charges,95% of total billed charges,3008.61,95,,,percent of total billed charges,95% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2723.59,86,,,percent of total billed charges,86% of total billed charges,2533.57,80,,,percent of total billed charges,80% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3071.95,97,,,percent of total billed charges,97% of total billed charges,2850.26,90,,,percent of total billed charges,90% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3071.95,97,,,percent of total billed charges,97% of total billed charges,2945.27,93,,,percent of total billed charges,93% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3071.95,97,,,percent of total billed charges,97% of total billed charges,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3166.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2216.87,3166.96,
"44130- Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separ",3622980,CDM,510,RC,44130,HCPCS,Outpatient,,,3543.12,1771.56,,3188.81,90,,,percent of total billed charges,90% of total Billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2834.5,80,,,Percent of total Billed charges,80% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3188.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3436.83,97,,,Percent of total billed charges,97% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3259.67,92,,,Percent of total billed charges,92% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3188.81,90,,,percent of total billed charges,90% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2480.18,70,,,percent of total billed charges,70% of total billed charges,3188.81,90,,,percent of total billed charges,90% of total billed charges,3365.96,95,,,percent of total billed charges,95% of total billed charges,3365.96,95,,,percent of total billed charges,95% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3047.08,86,,,percent of total billed charges,86% of total billed charges,2834.5,80,,,percent of total billed charges,80% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3436.83,97,,,percent of total billed charges,97% of total billed charges,3188.81,90,,,percent of total billed charges,90% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3436.83,97,,,percent of total billed charges,97% of total billed charges,3295.1,93,,,percent of total billed charges,93% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3436.83,97,,,percent of total billed charges,97% of total billed charges,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3543.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2480.18,3543.12,
44139 - PF Mobl Splenic Flxr Pfrmd Conjunt w/ Prtl Colct,4311755,CDM,960,RC,44139,HCPCS,Outpatient,,,287.47,143.74,,258.72,90,,,percent of total billed charges,90% of total Billed charges,243.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,107.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,187.66,155,,,Fee Schedule,155% of CMS OPPS Rate,121.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,187.66,155,,,Fee Schedule,155% of CMS OPPS Rate,121.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.06,155,,,Fee Schedule,155% of CMS OPPS Rate,378.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,121.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,98.22,378.06,
44139-PF MOBILIZATION OF COLON,3429923,CDM,510,RC,44139,HCPCS,Outpatient,,,326.67,163.34,,294,90,,,percent of total billed charges,90% of total Billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,261.34,80,,,Percent of total Billed charges,80% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,294,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,316.87,97,,,Percent of total billed charges,97% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,300.54,92,,,Percent of total billed charges,92% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,294,90,,,percent of total billed charges,90% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,228.67,70,,,percent of total billed charges,70% of total billed charges,294,90,,,percent of total billed charges,90% of total billed charges,310.34,95,,,percent of total billed charges,95% of total billed charges,310.34,95,,,percent of total billed charges,95% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,280.94,86,,,percent of total billed charges,86% of total billed charges,261.34,80,,,percent of total billed charges,80% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,316.87,97,,,percent of total billed charges,97% of total billed charges,294,90,,,percent of total billed charges,90% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,316.87,97,,,percent of total billed charges,97% of total billed charges,303.8,93,,,percent of total billed charges,93% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,316.87,97,,,percent of total billed charges,97% of total billed charges,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,326.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,228.67,326.67,
44140 - PF Colectomy Partial w/ Anastomosis,4311756,CDM,960,RC,44140,HCPCS,Outpatient,,,3190.1,1595.05,,2871.09,90,,,percent of total billed charges,90% of total Billed charges,2702.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,3167.84,90,,,Percent of total Billed charges,90% of total billed charges,683,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2082.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1997.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1343.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2246.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2246.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2095.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2095.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1084.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2687.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2472.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1770.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2082.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,4188.53,155,,,Fee Schedule,155% of CMS OPPS Rate,4188.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,683,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1412.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2724.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2724.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,683,4188.53,
44140-PF PARTIAL REMOVAL OF COLON,3429925,CDM,510,RC,44140,HCPCS,Outpatient,,,3613.34,1806.67,,3252.01,90,,,percent of total billed charges,90% of total Billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2890.67,80,,,Percent of total Billed charges,80% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3252.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3504.94,97,,,Percent of total billed charges,97% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3324.27,92,,,Percent of total billed charges,92% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3252.01,90,,,percent of total billed charges,90% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2529.34,70,,,percent of total billed charges,70% of total billed charges,3252.01,90,,,percent of total billed charges,90% of total billed charges,3432.67,95,,,percent of total billed charges,95% of total billed charges,3432.67,95,,,percent of total billed charges,95% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3107.47,86,,,percent of total billed charges,86% of total billed charges,2890.67,80,,,percent of total billed charges,80% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3504.94,97,,,percent of total billed charges,97% of total billed charges,3252.01,90,,,percent of total billed charges,90% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3504.94,97,,,percent of total billed charges,97% of total billed charges,3360.41,93,,,percent of total billed charges,93% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3504.94,97,,,percent of total billed charges,97% of total billed charges,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3613.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2529.34,3613.34,
MA PARTIAL REMOVAL OF COLON,3527854,CDM,960,RC,44140,HCPCS,Outpatient,,,3613.34,1806.67,,3252.01,90,,,percent of total billed charges,90% of total Billed charges,2702.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,3167.84,90,,,Percent of total Billed charges,90% of total billed charges,683,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2082.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1997.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1343.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2246.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2246.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2095.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2095.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1084.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2687.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2472.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1770.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2082.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,4188.53,155,,,Fee Schedule,155% of CMS OPPS Rate,4188.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,683,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1412.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1343.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2724.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2724.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,683,4188.53,
"44141 - Colectomy, partial; with skin level cecostomy or colostomy",3572788,CDM,983,RC,44141,HCPCS,Outpatient,,,4876.65,2438.33,,4388.99,90,,,percent of total billed charges,90% of total Billed charges,3642.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,681.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2803.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1808.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3144.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3144.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2834.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2834.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1477.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3344.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2384.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2803.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5646.23,155,,,Fee Schedule,155% of CMS OPPS Rate,5646.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1278.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,3705.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3705.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,681.5,5646.23,
44141 - PF Colectomy Prtl w/ Skin Level Cecost/ Colostomy,4311757,CDM,960,RC,44141,HCPCS,Outpatient,,,4295.19,2147.60,,3865.67,90,,,percent of total billed charges,90% of total Billed charges,3642.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,681.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2803.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2796.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1808.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3144.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3144.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2834.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2834.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1477.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3617.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3344.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2384.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2803.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5646.23,155,,,Fee Schedule,155% of CMS OPPS Rate,5646.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1278.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1808.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,3705.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3705.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,681.5,5646.23,
44143 - PF Colectomy Prtl w/ End Colostomy & Clsr Dstl Sgmt,4311758,CDM,960,RC,44143,HCPCS,Outpatient,,,3927.3,1963.65,,3534.57,90,,,percent of total billed charges,90% of total Billed charges,3328.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1654.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,681.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2563.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1654.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2551.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1654.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2870.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2870.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2593.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2593.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1346.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1654.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3308.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3059.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2187.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2563.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1654.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,5159.83,155,,,Fee Schedule,155% of CMS OPPS Rate,5159.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1654.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1546.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1654.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,3383.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3383.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,681.5,5159.83,
44143- Colectomy/end colost/close dis seg,3431221,CDM,510,RC,44143,HCPCS,Outpatient,,,4454.14,2227.07,,4008.73,90,,,percent of total billed charges,90% of total Billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3563.31,80,,,Percent of total Billed charges,80% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4008.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4320.52,97,,,Percent of total billed charges,97% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4097.81,92,,,Percent of total billed charges,92% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4008.73,90,,,percent of total billed charges,90% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3117.9,70,,,percent of total billed charges,70% of total billed charges,4008.73,90,,,percent of total billed charges,90% of total billed charges,4231.43,95,,,percent of total billed charges,95% of total billed charges,4231.43,95,,,percent of total billed charges,95% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3830.56,86,,,percent of total billed charges,86% of total billed charges,3563.31,80,,,percent of total billed charges,80% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4320.52,97,,,percent of total billed charges,97% of total billed charges,4008.73,90,,,percent of total billed charges,90% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4320.52,97,,,percent of total billed charges,97% of total billed charges,4142.35,93,,,percent of total billed charges,93% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4320.52,97,,,percent of total billed charges,97% of total billed charges,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4454.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3117.9,4454.14,
44144 - PF Colectomy Prtl w/ Colost/ Ileost & Mucofistula,4311759,CDM,960,RC,44144,HCPCS,Outpatient,,,4192.9,2096.45,,3773.61,90,,,percent of total billed charges,90% of total Billed charges,3548.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1765.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,681.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2737.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1765.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2629.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1765.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2956.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2956.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2757.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2757.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1430.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1765.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3531.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3254.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2326,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2737.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1765.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,5500.33,155,,,Fee Schedule,155% of CMS OPPS Rate,5500.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1765.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1619.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1765.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,3600.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3600.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,681.5,5500.33,
44144- Colectomy/w colostomy or ileostomy,3431222,CDM,510,RC,44144,HCPCS,Outpatient,,,4740.87,2370.44,,4266.78,90,,,percent of total billed charges,90% of total Billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3792.7,80,,,Percent of total Billed charges,80% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4266.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4598.64,97,,,Percent of total billed charges,97% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4361.6,92,,,Percent of total billed charges,92% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4266.78,90,,,percent of total billed charges,90% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.61,70,,,percent of total billed charges,70% of total billed charges,4266.78,90,,,percent of total billed charges,90% of total billed charges,4503.83,95,,,percent of total billed charges,95% of total billed charges,4503.83,95,,,percent of total billed charges,95% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4077.15,86,,,percent of total billed charges,86% of total billed charges,3792.7,80,,,percent of total billed charges,80% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4598.64,97,,,percent of total billed charges,97% of total billed charges,4266.78,90,,,percent of total billed charges,90% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4598.64,97,,,percent of total billed charges,97% of total billed charges,4409.01,93,,,percent of total billed charges,93% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4598.64,97,,,percent of total billed charges,97% of total billed charges,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4740.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3318.61,4740.87,
"44145- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3623381,CDM,510,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,3981.18,90,,,percent of total billed charges,90% of total Billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3538.82,80,,,Percent of total Billed charges,80% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3981.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4290.82,97,,,Percent of total billed charges,97% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4069.65,92,,,Percent of total billed charges,92% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3981.18,90,,,percent of total billed charges,90% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3096.47,70,,,percent of total billed charges,70% of total billed charges,3981.18,90,,,percent of total billed charges,90% of total billed charges,4202.35,95,,,percent of total billed charges,95% of total billed charges,4202.35,95,,,percent of total billed charges,95% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3804.24,86,,,percent of total billed charges,86% of total billed charges,3538.82,80,,,percent of total billed charges,80% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4290.82,97,,,percent of total billed charges,97% of total billed charges,3981.18,90,,,percent of total billed charges,90% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4290.82,97,,,percent of total billed charges,97% of total billed charges,4113.88,93,,,percent of total billed charges,93% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4290.82,97,,,percent of total billed charges,97% of total billed charges,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4423.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3096.47,4423.53,
44145- PF PART REMOVAL OF COLON,4133405,CDM,960,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,3981.18,90,,,percent of total billed charges,90% of total Billed charges,3309.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,794,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2456.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2763.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1338.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3039.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2149.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,5129.77,155,,,Fee Schedule,155% of CMS OPPS Rate,5129.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,794,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1568.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3378.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3378.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,794,5129.77,
MA AST PART REMOVAL OF COLON,3527849,CDM,960,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,3981.18,90,,,percent of total billed charges,90% of total Billed charges,3309.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,794,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2456.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2763.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1338.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3039.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2149.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,5129.77,155,,,Fee Schedule,155% of CMS OPPS Rate,5129.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,794,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1568.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3378.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3378.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,794,5129.77,
"44146-PF COLECTOMY,PART W/END COLOSTOMY",3429931,CDM,510,RC,44146,HCPCS,Outpatient,,,5612.4,2806.20,,5051.16,90,,,percent of total billed charges,90% of total Billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4489.92,80,,,Percent of total Billed charges,80% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5051.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5444.03,97,,,Percent of total billed charges,97% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5163.41,92,,,Percent of total billed charges,92% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5051.16,90,,,percent of total billed charges,90% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3928.68,70,,,percent of total billed charges,70% of total billed charges,5051.16,90,,,percent of total billed charges,90% of total billed charges,5331.78,95,,,percent of total billed charges,95% of total billed charges,5331.78,95,,,percent of total billed charges,95% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4826.66,86,,,percent of total billed charges,86% of total billed charges,4489.92,80,,,percent of total billed charges,80% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5444.03,97,,,percent of total billed charges,97% of total billed charges,5051.16,90,,,percent of total billed charges,90% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5444.03,97,,,percent of total billed charges,97% of total billed charges,5219.53,93,,,percent of total billed charges,93% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5444.03,97,,,percent of total billed charges,97% of total billed charges,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5612.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3928.68,5612.4,
"44147 - (PF) Colectomy, partial; abdominal and transanal approach",3634913,CDM,510,RC,44147,HCPCS,Outpatient,,,5200.83,2600.42,,4680.75,90,,,percent of total billed charges,90% of total Billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4160.66,80,,,Percent of total Billed charges,80% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5044.81,97,,,Percent of total billed charges,97% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4784.76,92,,,Percent of total billed charges,92% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4680.75,90,,,percent of total billed charges,90% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3640.58,70,,,percent of total billed charges,70% of total billed charges,4680.75,90,,,percent of total billed charges,90% of total billed charges,4940.79,95,,,percent of total billed charges,95% of total billed charges,4940.79,95,,,percent of total billed charges,95% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4472.71,86,,,percent of total billed charges,86% of total billed charges,4160.66,80,,,percent of total billed charges,80% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5044.81,97,,,percent of total billed charges,97% of total billed charges,4680.75,90,,,percent of total billed charges,90% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5044.81,97,,,percent of total billed charges,97% of total billed charges,4836.77,93,,,percent of total billed charges,93% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5044.81,97,,,percent of total billed charges,97% of total billed charges,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5200.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3640.58,5200.83,
"44150 - (PF) Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy",3634914,CDM,510,RC,44150,HCPCS,Outpatient,,,4946.61,2473.31,,4451.95,90,,,percent of total billed charges,90% of total Billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3957.29,80,,,Percent of total Billed charges,80% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4798.21,97,,,Percent of total billed charges,97% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4550.88,92,,,Percent of total billed charges,92% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4451.95,90,,,percent of total billed charges,90% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3462.63,70,,,percent of total billed charges,70% of total billed charges,4451.95,90,,,percent of total billed charges,90% of total billed charges,4699.28,95,,,percent of total billed charges,95% of total billed charges,4699.28,95,,,percent of total billed charges,95% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4254.08,86,,,percent of total billed charges,86% of total billed charges,3957.29,80,,,percent of total billed charges,80% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4798.21,97,,,percent of total billed charges,97% of total billed charges,4451.95,90,,,percent of total billed charges,90% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4798.21,97,,,percent of total billed charges,97% of total billed charges,4600.35,93,,,percent of total billed charges,93% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4798.21,97,,,percent of total billed charges,97% of total billed charges,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4946.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3462.63,4946.61,
44150 - PF Colct Tot Abdl w/ o Prctect w/ Iliost/ Ileopxts,4311760,CDM,960,RC,44150,HCPCS,Outpatient,,,4368.38,2184.19,,3931.54,90,,,percent of total billed charges,90% of total Billed charges,3699.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,923.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2851.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2768.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1839.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3113.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2883.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2883.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1511.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3679.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3402.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2397.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2851.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,5734.78,155,,,Fee Schedule,155% of CMS OPPS Rate,5734.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1707.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3798.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3798.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,923.5,5734.78,
44151 - PF Colct Tot Abdl w/ o Prctect w/ Continent Ileost,4311761,CDM,960,RC,44151,HCPCS,Outpatient,,,5113.37,2556.69,,4602.03,90,,,percent of total billed charges,90% of total Billed charges,4336.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2153.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3337.97,155,,,Fee Schedule,155% of CMS OPPS Rate,2153.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3217.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2153.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3619.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3619.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3370.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3370.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1725.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2153.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4307.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3976.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2872.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3337.97,155,,,Fee Schedule,155% of CMS OPPS Rate,2153.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,6721.95,155,,,Fee Schedule,155% of CMS OPPS Rate,6721.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2153.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1593.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2153.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,4349.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4349.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6721.95,
44155 - PF Colectomy Tot Abdl w/ Proctectomy w/ Ileostomy,4311762,CDM,960,RC,44155,HCPCS,Outpatient,,,4853.58,2426.79,,4368.22,90,,,percent of total billed charges,90% of total Billed charges,4113.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2044.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,976,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3168.39,155,,,Fee Schedule,155% of CMS OPPS Rate,2044.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3070.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2044.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3453.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3453.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3194.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3194.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1683.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2044.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4088.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3769.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2616.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3168.39,155,,,Fee Schedule,155% of CMS OPPS Rate,2044.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,6376.65,155,,,Fee Schedule,155% of CMS OPPS Rate,6376.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2044.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,976,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1755.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2044.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,4232.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4232.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,976,6376.65,
44156 - PF Colectomy Tot Abdl w/ Proctectomy w/ Contnt Ileost,4311763,CDM,960,RC,44156,HCPCS,Outpatient,,,5470.02,2735.01,,4923.02,90,,,percent of total billed charges,90% of total Billed charges,4639.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2303.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3570.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2303.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3445.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2303.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3875.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3875.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3608.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3608.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1834.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2303.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4607.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4258.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3075.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3570.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2303.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,7190.65,155,,,Fee Schedule,155% of CMS OPPS Rate,7190.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2303.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1933.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2303.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4687.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4687.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,7190.65,
"44157 - (PF) Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop",3635060,CDM,510,RC,44157,HCPCS,Outpatient,,,5901.29,2950.65,,5311.16,90,,,percent of total billed charges,90% of total Billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4721.03,80,,,Percent of total Billed charges,80% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5311.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5724.25,97,,,Percent of total billed charges,97% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5429.19,92,,,Percent of total billed charges,92% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5311.16,90,,,percent of total billed charges,90% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4130.9,70,,,percent of total billed charges,70% of total billed charges,5311.16,90,,,percent of total billed charges,90% of total billed charges,5606.23,95,,,percent of total billed charges,95% of total billed charges,5606.23,95,,,percent of total billed charges,95% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5075.11,86,,,percent of total billed charges,86% of total billed charges,4721.03,80,,,percent of total billed charges,80% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5724.25,97,,,percent of total billed charges,97% of total billed charges,5311.16,90,,,percent of total billed charges,90% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5724.25,97,,,percent of total billed charges,97% of total billed charges,5488.2,93,,,percent of total billed charges,93% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5724.25,97,,,percent of total billed charges,97% of total billed charges,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5901.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4130.9,5901.29,
44160 - PF Colectomy Prtl w/ Rmvl Terminal Ileum & Ileocolos,4311764,CDM,960,RC,44160,HCPCS,Outpatient,,,2948.74,1474.37,,2653.87,90,,,percent of total billed charges,90% of total Billed charges,2496.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1241.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,683,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1924.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1241.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1847.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1241.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2077.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2077.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1936.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1936.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1003.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1241.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2483.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2284.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1629.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1924.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1241.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,3869.73,155,,,Fee Schedule,155% of CMS OPPS Rate,3869.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1241.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,683,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1277.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1241.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,2524.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2524.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,683,3869.73,
44160-PF REMOVAL OF COLON,3429933,CDM,510,RC,44160,HCPCS,Outpatient,,,3336.71,1668.36,,3003.04,90,,,percent of total billed charges,90% of total Billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2669.37,80,,,Percent of total Billed charges,80% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3003.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3236.61,97,,,Percent of total billed charges,97% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3069.77,92,,,Percent of total billed charges,92% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3003.04,90,,,percent of total billed charges,90% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2335.7,70,,,percent of total billed charges,70% of total billed charges,3003.04,90,,,percent of total billed charges,90% of total billed charges,3169.87,95,,,percent of total billed charges,95% of total billed charges,3169.87,95,,,percent of total billed charges,95% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2869.57,86,,,percent of total billed charges,86% of total billed charges,2669.37,80,,,percent of total billed charges,80% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.61,97,,,percent of total billed charges,97% of total billed charges,3003.04,90,,,percent of total billed charges,90% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.61,97,,,percent of total billed charges,97% of total billed charges,3103.14,93,,,percent of total billed charges,93% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3236.61,97,,,percent of total billed charges,97% of total billed charges,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3336.71,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2335.7,3336.71,
44180 - PF LAP ENTEROLYSIS,3527847,CDM,960,RC,44180,HCPCS,Outpatient,,,2480.59,1240.30,,2232.53,90,,,percent of total billed charges,90% of total Billed charges,1855.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,586.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1588.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1588.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,742.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1693.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1215.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2876.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2876.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,943.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1867.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1867.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,586.74,2876.35,
44180 - PF Laparoscopy Enterolysis Separate Proc,4311765,CDM,960,RC,44180,HCPCS,Outpatient,,,2191.4,1095.70,,1972.26,90,,,percent of total billed charges,90% of total Billed charges,1855.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,586.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1588.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1588.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,742.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1693.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1215.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2876.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2876.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,943.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1867.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1867.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,586.74,2876.35,
MA LAP ENTEROLYSIS,3527841,CDM,960,RC,44180,HCPCS,Outpatient,,,2480.59,1240.30,,2232.53,90,,,percent of total billed charges,90% of total Billed charges,1855.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,586.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1588.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1588.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1435.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,742.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1845.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1693.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1215.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1430.53,155,,,Fee Schedule,155% of CMS OPPS Rate,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2876.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2876.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,943.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,922.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1867.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1867.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,586.74,2876.35,
44186 - Laparoscopy Surgical Jejunostomy,4169584,CDM,983,RC,44186,HCPCS,Outpatient,,,1565.02,782.51,,1408.52,90,,,percent of total billed charges,90% of total Billed charges,1310.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,411.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1010.01,155,,,Fee Schedule,155% of CMS OPPS Rate,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,651.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1125.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1012.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1012.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,526.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1195.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,856.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1010.01,155,,,Fee Schedule,155% of CMS OPPS Rate,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2031.63,155,,,Fee Schedule,155% of CMS OPPS Rate,2031.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1320.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1320.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,411.66,2031.63,
44186-PF Lap Surgical Jejunostomy,4322110,CDM,960,RC,44186,HCPCS,Outpatient,,,1281.58,640.79,,1153.42,90,,,percent of total billed charges,90% of total Billed charges,1310.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,411.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1010.01,155,,,Fee Schedule,155% of CMS OPPS Rate,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,651.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1125.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1125.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1012.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1012.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,526.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1195.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,856.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1010.01,155,,,Fee Schedule,155% of CMS OPPS Rate,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2031.63,155,,,Fee Schedule,155% of CMS OPPS Rate,2031.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,651.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1320.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1320.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,411.66,2031.63,
"44188 - (PF) Laparoscopy, surgical, colostomy or skin level cecostomy",3635061,CDM,510,RC,44188,HCPCS,Outpatient,,,3236.21,1618.11,,2912.59,90,,,percent of total billed charges,90% of total Billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2588.97,80,,,Percent of total Billed charges,80% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2912.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3139.12,97,,,Percent of total billed charges,97% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.31,92,,,Percent of total billed charges,92% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2912.59,90,,,percent of total billed charges,90% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2265.35,70,,,percent of total billed charges,70% of total billed charges,2912.59,90,,,percent of total billed charges,90% of total billed charges,3074.4,95,,,percent of total billed charges,95% of total billed charges,3074.4,95,,,percent of total billed charges,95% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2783.14,86,,,percent of total billed charges,86% of total billed charges,2588.97,80,,,percent of total billed charges,80% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3139.12,97,,,percent of total billed charges,97% of total billed charges,2912.59,90,,,percent of total billed charges,90% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3139.12,97,,,percent of total billed charges,97% of total billed charges,3009.68,93,,,percent of total billed charges,93% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3139.12,97,,,percent of total billed charges,97% of total billed charges,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3236.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2265.35,3236.21,
"44202 - (PF) Laparoscopy, surgical; enterectomy, resection of small intestine, single resection",3635062,CDM,510,RC,44202,HCPCS,Outpatient,,,3734.9,1867.45,,3361.41,90,,,percent of total billed charges,90% of total Billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2987.92,80,,,Percent of total Billed charges,80% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3361.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3622.85,97,,,Percent of total billed charges,97% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3436.11,92,,,Percent of total billed charges,92% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3361.41,90,,,percent of total billed charges,90% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2614.43,70,,,percent of total billed charges,70% of total billed charges,3361.41,90,,,percent of total billed charges,90% of total billed charges,3548.16,95,,,percent of total billed charges,95% of total billed charges,3548.16,95,,,percent of total billed charges,95% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3212.01,86,,,percent of total billed charges,86% of total billed charges,2987.92,80,,,percent of total billed charges,80% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3622.85,97,,,percent of total billed charges,97% of total billed charges,3361.41,90,,,percent of total billed charges,90% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3622.85,97,,,percent of total billed charges,97% of total billed charges,3473.46,93,,,percent of total billed charges,93% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3622.85,97,,,percent of total billed charges,97% of total billed charges,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3734.9,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2614.43,3734.9,
44202 - PF Laps Enterect Resc 1 Sm Intest Resc & Ana,4311766,CDM,960,RC,44202,HCPCS,Outpatient,,,3300.78,1650.39,,2970.7,90,,,percent of total billed charges,90% of total Billed charges,2794.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2154.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2062.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1390.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2319.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2319.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2164.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2164.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1120,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2780.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2553.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1829.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2154.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4331.63,155,,,Fee Schedule,155% of CMS OPPS Rate,4331.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1304.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2819.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2819.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4331.63,
44203 - PF Laparoscopy Sm Intestine Resc & Anastomosis,4311767,CDM,960,RC,44203,HCPCS,Outpatient,,,580.09,290.05,,522.08,90,,,percent of total billed charges,90% of total Billed charges,489.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,198.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,378.68,155,,,Fee Schedule,155% of CMS OPPS Rate,244.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,402.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,379.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,379.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,447.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,378.68,155,,,Fee Schedule,155% of CMS OPPS Rate,244.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,758.68,155,,,Fee Schedule,155% of CMS OPPS Rate,758.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,244.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,294.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,244.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,495.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.91,758.68,
"44204 - Laparoscopy, surgical; colectomy, partial, with anastomosis",3572789,CDM,960,RC,44204,HCPCS,Outpatient,,,4119.99,2060.00,,3707.99,90,,,percent of total billed charges,90% of total Billed charges,3081.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1251.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2374.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2356.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1532.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2650.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2650.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2395.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2395.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1242.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2826.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2000.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2374.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4775.97,155,,,Fee Schedule,155% of CMS OPPS Rate,4775.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1251.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1455.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,3137.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3137.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1242.33,4775.97,
44204 - PF Laparoscopy Colectomy Prtl w/ Anastomosis,4311768,CDM,960,RC,44204,HCPCS,Outpatient,,,3637.66,1818.83,,3273.89,90,,,percent of total billed charges,90% of total Billed charges,3081.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1251.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2374.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2356.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1532.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2650.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2650.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2395.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2395.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1242.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3064.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2826.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2000.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2374.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4775.97,155,,,Fee Schedule,155% of CMS OPPS Rate,4775.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1251.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1455.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1532.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,3137.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3137.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1242.33,4775.97,
44205 - PF Laps Colectomy Prtl w/ Rmvl Terminal Ileum,4311769,CDM,960,RC,44205,HCPCS,Outpatient,,,3153.99,1577.00,,2838.59,90,,,percent of total billed charges,90% of total Billed charges,2671.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1328.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1094.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2058.9,155,,,Fee Schedule,155% of CMS OPPS Rate,1328.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1984.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1328.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2231.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2231.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2077.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2077.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1080.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1328.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2656.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2451.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1725.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2058.9,155,,,Fee Schedule,155% of CMS OPPS Rate,1328.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,4141.26,155,,,Fee Schedule,155% of CMS OPPS Rate,4141.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1328.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1271.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1328.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,2730.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2730.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1080.34,4141.26,
"44205- Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy",3566786,CDM,510,RC,44205,HCPCS,Outpatient,,,3572.7,1786.35,,3215.43,90,,,percent of total billed charges,90% of total Billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2858.16,80,,,Percent of total Billed charges,80% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3215.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3465.52,97,,,Percent of total billed charges,97% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3286.88,92,,,Percent of total billed charges,92% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3215.43,90,,,percent of total billed charges,90% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2500.89,70,,,percent of total billed charges,70% of total billed charges,3215.43,90,,,percent of total billed charges,90% of total billed charges,3394.07,95,,,percent of total billed charges,95% of total billed charges,3394.07,95,,,percent of total billed charges,95% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3072.52,86,,,percent of total billed charges,86% of total billed charges,2858.16,80,,,percent of total billed charges,80% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.52,97,,,percent of total billed charges,97% of total billed charges,3215.43,90,,,percent of total billed charges,90% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.52,97,,,percent of total billed charges,97% of total billed charges,3322.61,93,,,percent of total billed charges,93% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3465.52,97,,,percent of total billed charges,97% of total billed charges,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2500.89,3572.7,
44206 - Lap Part Colectomy W/Stoma,3899046,CDM,983,RC,44206,HCPCS,Outpatient,,,4668.85,2334.43,,4201.97,90,,,percent of total billed charges,90% of total Billed charges,3490.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2688.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2677.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1734.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3011.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3011.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2718.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2718.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1414.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3469.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3207.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2267.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2688.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,5410.18,155,,,Fee Schedule,155% of CMS OPPS Rate,5410.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1533.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3579.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3579.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5410.18,
44206 - PF Laps Colectomy Prtl w/ End Clst & Clsr Dstl Sgm,4311770,CDM,960,RC,44206,HCPCS,Outpatient,,,4119.11,2059.56,,3707.2,90,,,percent of total billed charges,90% of total Billed charges,3490.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2688.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2677.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1734.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3011.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3011.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2718.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2718.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1414.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3469.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3207.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2267.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2688.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,5410.18,155,,,Fee Schedule,155% of CMS OPPS Rate,5410.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1533.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1734.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3579.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3579.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5410.18,
44207 - PF Laps Colectomy Prtl w/ Colopxtstmy Lw Anast,4311771,CDM,960,RC,44207,HCPCS,Outpatient,,,4275.51,2137.76,,3847.96,90,,,percent of total billed charges,90% of total Billed charges,3622.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1800.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2791.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1800.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2777.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1800.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3124.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3124.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2821.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2821.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1468.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1800.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3601.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3329.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2329.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2791.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1800.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,5614.3,155,,,Fee Schedule,155% of CMS OPPS Rate,5614.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1800.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1786.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1800.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3732.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3732.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5614.3,
"44207- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3569387,CDM,510,RC,44207,HCPCS,Outpatient,,,4843.88,2421.94,,4359.49,90,,,percent of total billed charges,90% of total Billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3875.1,80,,,Percent of total Billed charges,80% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4359.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4698.56,97,,,Percent of total billed charges,97% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4456.37,92,,,Percent of total billed charges,92% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4359.49,90,,,percent of total billed charges,90% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3390.72,70,,,percent of total billed charges,70% of total billed charges,4359.49,90,,,percent of total billed charges,90% of total billed charges,4601.69,95,,,percent of total billed charges,95% of total billed charges,4601.69,95,,,percent of total billed charges,95% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4165.74,86,,,percent of total billed charges,86% of total billed charges,3875.1,80,,,percent of total billed charges,80% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4698.56,97,,,percent of total billed charges,97% of total billed charges,4359.49,90,,,percent of total billed charges,90% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4698.56,97,,,percent of total billed charges,97% of total billed charges,4504.81,93,,,percent of total billed charges,93% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4698.56,97,,,percent of total billed charges,97% of total billed charges,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4843.88,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3390.72,4843.88,
44208 - PF Laps Colectomy Prtl w/ Colopxtstmy Lw Anast w/ Clst,4311772,CDM,960,RC,44208,HCPCS,Outpatient,,,4639.6,2319.80,,4175.64,90,,,percent of total billed charges,90% of total Billed charges,3929.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3028.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3024.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1954.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3402.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3402.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3060.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3060.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1603.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3908.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3611.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2507.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3028.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,6091.1,155,,,Fee Schedule,155% of CMS OPPS Rate,6091.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1634.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,4056.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4056.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6091.1,
"44208- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3623578,CDM,510,RC,44208,HCPCS,Outpatient,,,5254.12,2627.06,,4728.71,90,,,percent of total billed charges,90% of total Billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4203.3,80,,,Percent of total Billed charges,80% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4728.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5096.5,97,,,Percent of total billed charges,97% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4833.79,92,,,Percent of total billed charges,92% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4728.71,90,,,percent of total billed charges,90% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3677.88,70,,,percent of total billed charges,70% of total billed charges,4728.71,90,,,percent of total billed charges,90% of total billed charges,4991.41,95,,,percent of total billed charges,95% of total billed charges,4991.41,95,,,percent of total billed charges,95% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4518.54,86,,,percent of total billed charges,86% of total billed charges,4203.3,80,,,percent of total billed charges,80% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5096.5,97,,,percent of total billed charges,97% of total billed charges,4728.71,90,,,percent of total billed charges,90% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5096.5,97,,,percent of total billed charges,97% of total billed charges,4886.33,93,,,percent of total billed charges,93% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5096.5,97,,,percent of total billed charges,97% of total billed charges,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5254.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3677.88,5254.12,
44210 - PF Laps Colectomy Tot w/ o Prctect w/  Ileost/ Ileopxts,4311773,CDM,960,RC,44210,HCPCS,Outpatient,,,4147.1,2073.55,,3732.39,90,,,percent of total billed charges,90% of total Billed charges,3509.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1746.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2707.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1746.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2624.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1746.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2951.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2951.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2726.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2726.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1436.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1746.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3493.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3217.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2200.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2707.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1746.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,5440.3,155,,,Fee Schedule,155% of CMS OPPS Rate,5440.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1746.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1544.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1746.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,3657.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3657.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5440.3,
44211 - PF Laps Colct TTL Abd w/ Prctect Ileoanal Anastomsis,4311774,CDM,960,RC,44211,HCPCS,Outpatient,,,4902.21,2451.11,,4411.99,90,,,percent of total billed charges,90% of total Billed charges,4146.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2064.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3200.15,155,,,Fee Schedule,155% of CMS OPPS Rate,2064.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3129.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2064.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3519.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3519.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3226.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3226.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1762.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2064.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4129.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3806.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2481.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3200.15,155,,,Fee Schedule,155% of CMS OPPS Rate,2064.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,6426.73,155,,,Fee Schedule,155% of CMS OPPS Rate,6426.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2064.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2121.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2064.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,4580.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4580.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6426.73,
44212 - PF Laps Colectomy Abdl w/ Proctectomy w/ Ileostomy,4311775,CDM,960,RC,44212,HCPCS,Outpatient,,,4717.91,2358.96,,4246.12,90,,,percent of total billed charges,90% of total Billed charges,4000.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1986.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3079.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1986.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3016.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1986.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3393.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3393.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3128.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3128.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1649.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1986.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3973.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3691.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2503.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3079.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1986.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,6200.59,155,,,Fee Schedule,155% of CMS OPPS Rate,6200.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1986.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1752.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1986.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,4192.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4192.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6200.59,
"44213- Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction w",3566787,CDM,510,RC,44213,HCPCS,Outpatient,,,504.14,252.07,,453.73,90,,,percent of total billed charges,90% of total Billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,403.31,80,,,Percent of total Billed charges,80% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,453.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,489.02,97,,,Percent of total billed charges,97% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,463.81,92,,,Percent of total billed charges,92% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,453.73,90,,,percent of total billed charges,90% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,352.9,70,,,percent of total billed charges,70% of total billed charges,453.73,90,,,percent of total billed charges,90% of total billed charges,478.93,95,,,percent of total billed charges,95% of total billed charges,478.93,95,,,percent of total billed charges,95% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,433.56,86,,,percent of total billed charges,86% of total billed charges,403.31,80,,,percent of total billed charges,80% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,489.02,97,,,percent of total billed charges,97% of total billed charges,453.73,90,,,percent of total billed charges,90% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,489.02,97,,,percent of total billed charges,97% of total billed charges,468.85,93,,,percent of total billed charges,93% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,489.02,97,,,percent of total billed charges,97% of total billed charges,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,504.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,352.9,504.14,
"44227 - PF Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection a",3714927,CDM,510,RC,44227,HCPCS,Outpatient,,,4457.14,2228.57,,4011.43,90,,,percent of total billed charges,90% of total Billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3565.71,80,,,Percent of total Billed charges,80% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4011.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4323.43,97,,,Percent of total billed charges,97% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4100.57,92,,,Percent of total billed charges,92% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4011.43,90,,,percent of total billed charges,90% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3120,70,,,percent of total billed charges,70% of total billed charges,4011.43,90,,,percent of total billed charges,90% of total billed charges,4234.28,95,,,percent of total billed charges,95% of total billed charges,4234.28,95,,,percent of total billed charges,95% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3833.14,86,,,percent of total billed charges,86% of total billed charges,3565.71,80,,,percent of total billed charges,80% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4323.43,97,,,percent of total billed charges,97% of total billed charges,4011.43,90,,,percent of total billed charges,90% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4323.43,97,,,percent of total billed charges,97% of total billed charges,4145.14,93,,,percent of total billed charges,93% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4323.43,97,,,percent of total billed charges,97% of total billed charges,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4457.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3120,4457.14,
44238 - PF Unlisted Laparoscopy Px Intestine XCP Rectum,4311776,CDM,960,RC,44238,HCPCS,Outpatient,,,3561.6,1780.80,,3205.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.48,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.48,3205.44,
"44238 - Unlisted laparoscopy procedure, intestine (except rectum)",3572803,CDM,960,RC,44238,HCPCS,Outpatient,,,5318.66,2659.33,,4786.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.6,4786.79,
"44300- Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate p",3622392,CDM,510,RC,44300,HCPCS,Outpatient,,,2267.21,1133.61,,2040.49,90,,,percent of total billed charges,90% of total Billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1813.77,80,,,Percent of total Billed charges,80% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2040.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2199.19,97,,,Percent of total billed charges,97% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2085.83,92,,,Percent of total billed charges,92% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2040.49,90,,,percent of total billed charges,90% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1587.05,70,,,percent of total billed charges,70% of total billed charges,2040.49,90,,,percent of total billed charges,90% of total billed charges,2153.85,95,,,percent of total billed charges,95% of total billed charges,2153.85,95,,,percent of total billed charges,95% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1949.8,86,,,percent of total billed charges,86% of total billed charges,1813.77,80,,,percent of total billed charges,80% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2199.19,97,,,percent of total billed charges,97% of total billed charges,2040.49,90,,,percent of total billed charges,90% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2199.19,97,,,percent of total billed charges,97% of total billed charges,2108.51,93,,,percent of total billed charges,93% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2199.19,97,,,percent of total billed charges,97% of total billed charges,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1587.05,2267.21,
44310 - PF ILEOSTOMY/JEJUNOSTOMY,3527859,CDM,960,RC,44310,HCPCS,Outpatient,,,2784.27,1392.14,,2505.84,90,,,percent of total billed charges,90% of total Billed charges,2083.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1036.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1606.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1036.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1546.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1036.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1739.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1739.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1616.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1616.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,842.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1036.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2073.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1907.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1343.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1606.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1036.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,3229.53,155,,,Fee Schedule,155% of CMS OPPS Rate,3229.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1036.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,984.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1036.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2122.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2122.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,3229.53,
44312-MA REVISION OF ILEOSTOMY,3429934,CDM,510,RC,44312,HCPCS,Outpatient,,,1587.86,793.93,,1429.07,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.29,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1540.22,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.83,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.07,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1111.5,70,,,percent of total billed charges,70% of total billed charges,1429.07,90,,,percent of total billed charges,90% of total billed charges,1508.47,95,,,percent of total billed charges,95% of total billed charges,1508.47,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1365.56,86,,,percent of total billed charges,86% of total billed charges,1270.29,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1540.22,97,,,percent of total billed charges,97% of total billed charges,1429.07,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1540.22,97,,,percent of total billed charges,97% of total billed charges,1476.71,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1540.22,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1111.5,15858.98,
44320PF Colostomy or Skin Level Cecostomy,4281201,CDM,960,RC,44320,HCPCS,Outpatient,,,2534.61,1267.31,,2281.15,90,,,percent of total billed charges,90% of total Billed charges,2404.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1195.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,418.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1853.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1195.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1840.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1195.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2069.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2069.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1865.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1865.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,970.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1195.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2391.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2200.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1560.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1853.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1195.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,3727.55,155,,,Fee Schedule,155% of CMS OPPS Rate,3727.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1195.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1141.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1195.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2440.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2440.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,418.5,3727.55,
44340 - (PF) Revision of colostomy; simple (release of superficial scar) (separate proc,3635063,CDM,510,RC,44340,HCPCS,Outpatient,,,1657.43,828.72,,1491.69,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.94,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1491.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1607.71,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.84,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1491.69,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.2,70,,,percent of total billed charges,70% of total billed charges,1491.69,90,,,percent of total billed charges,90% of total billed charges,1574.56,95,,,percent of total billed charges,95% of total billed charges,1574.56,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1425.39,86,,,percent of total billed charges,86% of total billed charges,1325.94,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1607.71,97,,,percent of total billed charges,97% of total billed charges,1491.69,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1607.71,97,,,percent of total billed charges,97% of total billed charges,1541.41,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1607.71,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1160.2,15858.98,
44345 - PF Rev Colostomy Comp Rcnst In-Depth Spx,4311777,CDM,960,RC,44345,HCPCS,Outpatient,,,2480.79,1240.40,,2232.71,90,,,percent of total billed charges,90% of total Billed charges,2097.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1044.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,359,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1619.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1044.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1558.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1044.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1752.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1752.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1622.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1622.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,849.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2089.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1914.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1340.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1619.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1044.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3251.87,155,,,Fee Schedule,155% of CMS OPPS Rate,3251.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1044.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,359,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,889.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1044.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2139.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2139.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,359,3251.87,
44346 - Revision of colostomy; with repair of paracolostomy hernia (separate procedure,3572790,CDM,983,RC,44346,HCPCS,Outpatient,,,3160.56,1580.28,,2844.5,90,,,percent of total billed charges,90% of total Billed charges,2365.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1177.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,493,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1824.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1177.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1811.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1177.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2037.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2037.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1833.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1833.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,955.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1177.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2354.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2163.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1525.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1824.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1177.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,3666.54,155,,,Fee Schedule,155% of CMS OPPS Rate,3666.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1177.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,493,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,969.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1177.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,2405.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2405.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,493,3666.54,
"44360- Small Bowel Endoscopy, Diagnostic",3431223,CDM,510,RC,44360,HCPCS,Outpatient,,,371.83,185.92,,334.65,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,297.46,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.65,90,,,Percent of total Billed charges,90% of total billed charges,149.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,360.68,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,342.08,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,334.65,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,260.28,70,,,percent of total billed charges,70% of total billed charges,334.65,90,,,percent of total billed charges,90% of total billed charges,353.24,95,,,percent of total billed charges,95% of total billed charges,353.24,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,319.77,86,,,percent of total billed charges,86% of total billed charges,297.46,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,360.68,97,,,percent of total billed charges,97% of total billed charges,334.65,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.68,97,,,percent of total billed charges,97% of total billed charges,345.8,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,360.68,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.46,8490.45,
"44361 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635065,CDM,510,RC,44361,HCPCS,Outpatient,,,412.28,206.14,,371.05,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,329.82,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.05,90,,,Percent of total Billed charges,90% of total billed charges,164.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,399.91,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,379.3,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,371.05,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,288.6,70,,,percent of total billed charges,70% of total billed charges,371.05,90,,,percent of total billed charges,90% of total billed charges,391.67,95,,,percent of total billed charges,95% of total billed charges,391.67,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,354.56,86,,,percent of total billed charges,86% of total billed charges,329.82,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,399.91,97,,,percent of total billed charges,97% of total billed charges,371.05,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.91,97,,,percent of total billed charges,97% of total billed charges,383.42,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,399.91,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,149.31,8490.45,
44361 - PF Endoscopy Upper Sm Intestine w/ Bx,4311778,CDM,960,RC,44361,HCPCS,Outpatient,,,362.4,181.20,,326.16,90,,,percent of total billed charges,90% of total Billed charges,307.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,236.56,155,,,Fee Schedule,155% of CMS OPPS Rate,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,236.56,155,,,Fee Schedule,155% of CMS OPPS Rate,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,476.86,155,,,Fee Schedule,155% of CMS OPPS Rate,476.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.14,476.86,
44364- Sm intes endo/remov tumor/snare,3431224,CDM,510,RC,44364,HCPCS,Outpatient,,,531.36,265.68,,478.22,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,425.09,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,478.22,90,,,Percent of total Billed charges,90% of total billed charges,210,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,515.42,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,488.85,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,478.22,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,371.95,70,,,percent of total billed charges,70% of total billed charges,478.22,90,,,percent of total billed charges,90% of total billed charges,504.79,95,,,percent of total billed charges,95% of total billed charges,504.79,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,456.97,86,,,percent of total billed charges,86% of total billed charges,425.09,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,515.42,97,,,percent of total billed charges,97% of total billed charges,478.22,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.42,97,,,percent of total billed charges,97% of total billed charges,494.16,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,515.42,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,190.91,8490.45,
44365- Sm intes/remov tum/hot bx for/caut,3431225,CDM,510,RC,44365,HCPCS,Outpatient,,,471.88,235.94,,424.69,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,377.5,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.69,90,,,Percent of total Billed charges,90% of total billed charges,187.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,457.72,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,434.13,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,424.69,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,330.32,70,,,percent of total billed charges,70% of total billed charges,424.69,90,,,percent of total billed charges,90% of total billed charges,448.29,95,,,percent of total billed charges,95% of total billed charges,448.29,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,405.82,86,,,percent of total billed charges,86% of total billed charges,377.5,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.72,97,,,percent of total billed charges,97% of total billed charges,424.69,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.72,97,,,percent of total billed charges,97% of total billed charges,438.85,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,457.72,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,170.51,8490.45,
44366- Sm intes endo/w bleeding control,3431226,CDM,510,RC,44366,HCPCS,Outpatient,,,622.2,311.10,,559.98,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,497.76,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.98,90,,,Percent of total Billed charges,90% of total billed charges,228.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,603.53,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,572.42,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,559.98,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,435.54,70,,,percent of total billed charges,70% of total billed charges,559.98,90,,,percent of total billed charges,90% of total billed charges,591.09,95,,,percent of total billed charges,95% of total billed charges,591.09,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,535.09,86,,,percent of total billed charges,86% of total billed charges,497.76,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,603.53,97,,,percent of total billed charges,97% of total billed charges,559.98,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.53,97,,,percent of total billed charges,97% of total billed charges,578.65,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,603.53,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,207.5,8490.45,
44369- Sm intes/abla/hot bx for/caut/snar,3431227,CDM,510,RC,44369,HCPCS,Outpatient,,,638.48,319.24,,574.63,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,510.78,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.63,90,,,Percent of total Billed charges,90% of total billed charges,228.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,619.33,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,587.4,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,574.63,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,446.94,70,,,percent of total billed charges,70% of total billed charges,574.63,90,,,percent of total billed charges,90% of total billed charges,606.56,95,,,percent of total billed charges,95% of total billed charges,606.56,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,549.09,86,,,percent of total billed charges,86% of total billed charges,510.78,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,619.33,97,,,percent of total billed charges,97% of total billed charges,574.63,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.33,97,,,percent of total billed charges,97% of total billed charges,593.79,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,619.33,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,207.5,8490.45,
44370- Sm intes endo/transendo stent plac,3431228,CDM,510,RC,44370,HCPCS,Outpatient,,,692.67,346.34,,623.4,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,554.14,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,671.89,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,637.26,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,623.4,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,484.87,70,,,percent of total billed charges,70% of total billed charges,623.4,90,,,percent of total billed charges,90% of total billed charges,658.04,95,,,percent of total billed charges,95% of total billed charges,658.04,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,595.7,86,,,percent of total billed charges,86% of total billed charges,554.14,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,671.89,97,,,percent of total billed charges,97% of total billed charges,623.4,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,671.89,97,,,percent of total billed charges,97% of total billed charges,644.18,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,671.89,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,484.87,25549.17,
44372 - ENTEROSCOPY > 2ND PRTN W/PLMT PRQ TUBE,3997184,CDM,960,RC,44372,HCPCS,Outpatient,,,626.92,313.46,,564.23,90,,,percent of total billed charges,90% of total Billed charges,468.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,207.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,360.65,155,,,Fee Schedule,155% of CMS OPPS Rate,232.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,365.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,365.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,195.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,431.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,281.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,360.65,155,,,Fee Schedule,155% of CMS OPPS Rate,232.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,726.05,155,,,Fee Schedule,155% of CMS OPPS Rate,726.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,232.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,232.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,524.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,195.59,726.05,
"44373 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635064,CDM,510,RC,44373,HCPCS,Outpatient,,,500.4,250.20,,450.36,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,400.32,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.36,90,,,Percent of total Billed charges,90% of total billed charges,196.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,485.39,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,460.37,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,450.36,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,350.28,70,,,percent of total billed charges,70% of total billed charges,450.36,90,,,percent of total billed charges,90% of total billed charges,475.38,95,,,percent of total billed charges,95% of total billed charges,475.38,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,430.34,86,,,percent of total billed charges,86% of total billed charges,400.32,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,485.39,97,,,percent of total billed charges,97% of total billed charges,450.36,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.39,97,,,percent of total billed charges,97% of total billed charges,465.37,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,485.39,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,178.5,8490.45,
44376PF Enteroscopy Beyond Second Portion Duodenum w/Ileum D,4281199,CDM,960,RC,44376,HCPCS,Outpatient,,,582.75,291.38,,524.48,90,,,percent of total billed charges,90% of total Billed charges,553.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,274.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,264.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,426.06,155,,,Fee Schedule,155% of CMS OPPS Rate,274.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,274.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,386.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,386.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,431.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,431.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,231.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,549.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,509.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,325.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,426.06,155,,,Fee Schedule,155% of CMS OPPS Rate,274.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.94,155,,,Fee Schedule,155% of CMS OPPS Rate,857.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,274.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,274.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,622.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,231.01,857.94,
44377 - ENTEROSC >2ND PRTN W/ILEUM W/BX SINGLE/MULTIPLE,4037558,CDM,983,RC,44377,HCPCS,Outpatient,,,779.71,389.86,,701.74,90,,,percent of total billed charges,90% of total Billed charges,583.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,290.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,279.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,449.87,155,,,Fee Schedule,155% of CMS OPPS Rate,290.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,361.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,290.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,406.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,406.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,454.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,454.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,243.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,580.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,536.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,343.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,449.87,155,,,Fee Schedule,155% of CMS OPPS Rate,290.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,904.33,155,,,Fee Schedule,155% of CMS OPPS Rate,904.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,290.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,290.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,656.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,656.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,243.43,904.33,
"44378 - PF Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileu",3714930,CDM,510,RC,44378,HCPCS,Outpatient,,,1004.14,502.07,,903.73,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,803.31,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,903.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,974.02,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,923.81,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,903.73,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,702.9,70,,,percent of total billed charges,70% of total billed charges,903.73,90,,,percent of total billed charges,90% of total billed charges,953.93,95,,,percent of total billed charges,95% of total billed charges,953.93,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,863.56,86,,,percent of total billed charges,86% of total billed charges,803.31,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,974.02,97,,,percent of total billed charges,97% of total billed charges,903.73,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.02,97,,,percent of total billed charges,97% of total billed charges,933.85,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,974.02,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,702.9,8490.45,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,510,RC,44380,HCPCS,Outpatient,,,486.68,243.34,,438.01,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,389.34,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.01,90,,,Percent of total Billed charges,90% of total billed charges,64.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,472.08,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,447.75,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,438.01,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,340.68,70,,,percent of total billed charges,70% of total billed charges,438.01,90,,,percent of total billed charges,90% of total billed charges,462.35,95,,,percent of total billed charges,95% of total billed charges,462.35,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,418.54,86,,,percent of total billed charges,86% of total billed charges,389.34,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,472.08,97,,,percent of total billed charges,97% of total billed charges,438.01,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.08,97,,,percent of total billed charges,97% of total billed charges,452.61,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,472.08,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.58,4024.46,
44381 - PF Ileoscopy Stoma w/ Balloon Dilation PF,4305372,CDM,960,RC,44381,HCPCS,Outpatient,,,173.88,86.94,,156.49,90,,,percent of total billed charges,90% of total Billed charges,255.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.12,155,,,Fee Schedule,155% of CMS OPPS Rate,82.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,125.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,125.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,94.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.12,155,,,Fee Schedule,155% of CMS OPPS Rate,82.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.63,155,,,Fee Schedule,155% of CMS OPPS Rate,396.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1044.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.58,1044.82,
44382- Ileoscopy/stoma/w bx/single/multi,3431229,CDM,510,RC,44382,HCPCS,Outpatient,,,748.65,374.33,,673.79,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,598.92,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.79,90,,,Percent of total Billed charges,90% of total billed charges,76.74,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,726.19,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,688.76,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,673.79,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,524.06,70,,,percent of total billed charges,70% of total billed charges,673.79,90,,,percent of total billed charges,90% of total billed charges,711.22,95,,,percent of total billed charges,95% of total billed charges,711.22,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,643.84,86,,,percent of total billed charges,86% of total billed charges,598.92,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,726.19,97,,,percent of total billed charges,97% of total billed charges,673.79,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,726.19,97,,,percent of total billed charges,97% of total billed charges,696.24,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,726.19,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69.76,4024.46,
44385- Endoscopic eval/sm intest pouch,3431230,CDM,510,RC,44385,HCPCS,Outpatient,,,538.19,269.10,,484.37,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,430.55,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,484.37,90,,,Percent of total Billed charges,90% of total billed charges,103.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,522.04,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,495.13,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,484.37,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,376.73,70,,,percent of total billed charges,70% of total billed charges,484.37,90,,,percent of total billed charges,90% of total billed charges,511.28,95,,,percent of total billed charges,95% of total billed charges,511.28,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,462.84,86,,,percent of total billed charges,86% of total billed charges,430.55,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,522.04,97,,,percent of total billed charges,97% of total billed charges,484.37,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.04,97,,,percent of total billed charges,97% of total billed charges,500.52,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,522.04,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.72,4051.42,
44386- Endoscopic eval/sm intest pouch/bx,3431231,CDM,510,RC,44386,HCPCS,Outpatient,,,785.46,392.73,,706.91,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,628.37,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.91,90,,,Percent of total Billed charges,90% of total billed charges,121.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,761.9,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,722.62,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,706.91,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,549.82,70,,,percent of total billed charges,70% of total billed charges,706.91,90,,,percent of total billed charges,90% of total billed charges,746.19,95,,,percent of total billed charges,95% of total billed charges,746.19,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,675.5,86,,,percent of total billed charges,86% of total billed charges,628.37,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,761.9,97,,,percent of total billed charges,97% of total billed charges,706.91,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.9,97,,,percent of total billed charges,97% of total billed charges,730.48,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.9,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.26,4051.42,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,510,RC,44388,HCPCS,Outpatient,,,806.87,403.44,,726.18,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,645.5,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,726.18,90,,,Percent of total Billed charges,90% of total billed charges,160.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,782.66,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,742.32,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,726.18,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,564.81,70,,,percent of total billed charges,70% of total billed charges,726.18,90,,,percent of total billed charges,90% of total billed charges,766.53,95,,,percent of total billed charges,95% of total billed charges,766.53,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,693.91,86,,,percent of total billed charges,86% of total billed charges,645.5,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,782.66,97,,,percent of total billed charges,97% of total billed charges,726.18,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,782.66,97,,,percent of total billed charges,97% of total billed charges,750.39,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,782.66,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,145.53,4051.42,
44388 - PF Colonoscopy Stoma Dx Incl Coll Spec Spx,4311779,CDM,960,RC,44388,HCPCS,Outpatient,,,362.4,181.20,,326.16,90,,,percent of total billed charges,90% of total Billed charges,456.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,236.53,155,,,Fee Schedule,155% of CMS OPPS Rate,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,188.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,236.53,155,,,Fee Schedule,155% of CMS OPPS Rate,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.82,155,,,Fee Schedule,155% of CMS OPPS Rate,706.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,694.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127.25,706.82,
44389- Colonoscopy/stoma/w bx/single/mult,3431232,CDM,510,RC,44389,HCPCS,Outpatient,,,1048.95,524.48,,944.06,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,839.16,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,944.06,90,,,Percent of total Billed charges,90% of total billed charges,177.36,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1017.48,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,965.03,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,944.06,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,734.27,70,,,percent of total billed charges,70% of total billed charges,944.06,90,,,percent of total billed charges,90% of total billed charges,996.5,95,,,percent of total billed charges,95% of total billed charges,996.5,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,902.1,86,,,percent of total billed charges,86% of total billed charges,839.16,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1017.48,97,,,percent of total billed charges,97% of total billed charges,944.06,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1017.48,97,,,percent of total billed charges,97% of total billed charges,975.52,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1017.48,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,161.24,5279.31,
44391- Colonoscopy/stoma/control bleeding,3431233,CDM,510,RC,44391,HCPCS,Outpatient,,,1630.53,815.27,,1467.48,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1304.42,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.48,90,,,Percent of total Billed charges,90% of total billed charges,241.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1581.61,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1500.09,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1467.48,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1141.37,70,,,percent of total billed charges,70% of total billed charges,1467.48,90,,,percent of total billed charges,90% of total billed charges,1549,95,,,percent of total billed charges,95% of total billed charges,1549,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1402.26,86,,,percent of total billed charges,86% of total billed charges,1304.42,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1581.61,97,,,percent of total billed charges,97% of total billed charges,1467.48,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.61,97,,,percent of total billed charges,97% of total billed charges,1516.39,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1581.61,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,219.95,5279.31,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,510,RC,44394,HCPCS,Outpatient,,,1126.86,563.43,,1014.17,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,901.49,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1093.05,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.71,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1014.17,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,788.8,70,,,percent of total billed charges,70% of total billed charges,1014.17,90,,,percent of total billed charges,90% of total billed charges,1070.52,95,,,percent of total billed charges,95% of total billed charges,1070.52,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,969.1,86,,,percent of total billed charges,86% of total billed charges,901.49,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1093.05,97,,,percent of total billed charges,97% of total billed charges,1014.17,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1093.05,97,,,percent of total billed charges,97% of total billed charges,1047.98,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1093.05,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,788.8,5279.31,
44401- Colonoscopy/stoma/ablation,3431234,CDM,510,RC,44401,HCPCS,Outpatient,,,6006.14,3003.07,,5405.53,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4804.91,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,5405.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5825.96,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5525.65,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5405.53,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.3,70,,,percent of total billed charges,70% of total billed charges,5405.53,90,,,percent of total billed charges,90% of total billed charges,5705.83,95,,,percent of total billed charges,95% of total billed charges,5705.83,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5165.28,86,,,percent of total billed charges,86% of total billed charges,4804.91,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5825.96,97,,,percent of total billed charges,97% of total billed charges,5405.53,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,5825.96,97,,,percent of total billed charges,97% of total billed charges,5585.71,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5825.96,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,836.02,5825.96,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,1076.1,538.05,,968.49,90,,,percent of total billed charges,90% of total Billed charges,572.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.72,155,,,Fee Schedule,155% of CMS OPPS Rate,886.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,453.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.71,968.49,
44602 - PF Enterorrhaphy Sngl Perforation,4311780,CDM,960,RC,44602,HCPCS,Outpatient,,,3365.54,1682.77,,3028.99,90,,,percent of total billed charges,90% of total Billed charges,2849.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1417.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,648.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2197,155,,,Fee Schedule,155% of CMS OPPS Rate,1417.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2166.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1417.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2436.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2436.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2215.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2215.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1140.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2834.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2614.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1887.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2197,155,,,Fee Schedule,155% of CMS OPPS Rate,1417.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,4417.48,155,,,Fee Schedule,155% of CMS OPPS Rate,4417.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1417.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1284.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1417.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2870.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2870.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,648.62,4417.48,
"44602 - PF Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, inju",3714933,CDM,510,RC,44602,HCPCS,Outpatient,,,3809.68,1904.84,,3428.71,90,,,percent of total billed charges,90% of total Billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3047.74,80,,,Percent of total Billed charges,80% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3428.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3695.39,97,,,Percent of total billed charges,97% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3504.91,92,,,Percent of total billed charges,92% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3428.71,90,,,percent of total billed charges,90% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2666.78,70,,,percent of total billed charges,70% of total billed charges,3428.71,90,,,percent of total billed charges,90% of total billed charges,3619.2,95,,,percent of total billed charges,95% of total billed charges,3619.2,95,,,percent of total billed charges,95% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3276.32,86,,,percent of total billed charges,86% of total billed charges,3047.74,80,,,percent of total billed charges,80% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3695.39,97,,,percent of total billed charges,97% of total billed charges,3428.71,90,,,percent of total billed charges,90% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3695.39,97,,,percent of total billed charges,97% of total billed charges,3543,93,,,percent of total billed charges,93% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3695.39,97,,,percent of total billed charges,97% of total billed charges,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3809.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2666.78,3809.68,
44603 - PF Enterorrhaphy Mult Perforations,4311781,CDM,960,RC,44603,HCPCS,Outpatient,,,3849.67,1924.84,,3464.7,90,,,percent of total billed charges,90% of total Billed charges,3258.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,785.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2513.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2485.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1621.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2795.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2536.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2536.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1310.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2992.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2144.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2513.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,5050.4,155,,,Fee Schedule,155% of CMS OPPS Rate,5050.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,785.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1471.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,3294.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3294.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,785.16,5050.4,
"44603- Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury o",3618862,CDM,510,RC,44603,HCPCS,Outpatient,,,4353.35,2176.68,,3918.02,90,,,percent of total billed charges,90% of total Billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3482.68,80,,,Percent of total Billed charges,80% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3918.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4222.75,97,,,Percent of total billed charges,97% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4005.08,92,,,Percent of total billed charges,92% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3918.02,90,,,percent of total billed charges,90% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3047.35,70,,,percent of total billed charges,70% of total billed charges,3918.02,90,,,percent of total billed charges,90% of total billed charges,4135.68,95,,,percent of total billed charges,95% of total billed charges,4135.68,95,,,percent of total billed charges,95% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3743.88,86,,,percent of total billed charges,86% of total billed charges,3482.68,80,,,percent of total billed charges,80% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.75,97,,,percent of total billed charges,97% of total billed charges,3918.02,90,,,percent of total billed charges,90% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.75,97,,,percent of total billed charges,97% of total billed charges,4048.62,93,,,percent of total billed charges,93% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4222.75,97,,,percent of total billed charges,97% of total billed charges,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4353.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3047.35,4353.35,
44604 - PF Sutr Lg Intestine 1/ Mult Perforat w/o Colostomy,4311782,CDM,960,RC,44604,HCPCS,Outpatient,,,2512.97,1256.49,,2261.67,90,,,percent of total billed charges,90% of total Billed charges,2125.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,698.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1640.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1573.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1058.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1769.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1653.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1653.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,855.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1951.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1396.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1640.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,3295.15,155,,,Fee Schedule,155% of CMS OPPS Rate,3295.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,904.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2149.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2149.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,698.84,3295.15,
44604 - PF SUTURE OF LARGE INTESTINE,3527840,CDM,960,RC,44604,HCPCS,Outpatient,,,2838.99,1419.50,,2555.09,90,,,percent of total billed charges,90% of total Billed charges,2125.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,698.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1640.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1573.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1058.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1769.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1769.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1653.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1653.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,855.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2116.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1951.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1396.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1640.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,3295.15,155,,,Fee Schedule,155% of CMS OPPS Rate,3295.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,904.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1058.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2149.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2149.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,698.84,3295.15,
"44615 - PF Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for i",3715386,CDM,510,RC,44615,HCPCS,Outpatient,,,2880.7,1440.35,,2592.63,90,,,percent of total billed charges,90% of total Billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2304.56,80,,,Percent of total Billed charges,80% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2794.28,97,,,Percent of total billed charges,97% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2650.24,92,,,Percent of total billed charges,92% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2592.63,90,,,percent of total billed charges,90% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2016.49,70,,,percent of total billed charges,70% of total billed charges,2592.63,90,,,percent of total billed charges,90% of total billed charges,2736.67,95,,,percent of total billed charges,95% of total billed charges,2736.67,95,,,percent of total billed charges,95% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2477.4,86,,,percent of total billed charges,86% of total billed charges,2304.56,80,,,percent of total billed charges,80% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2794.28,97,,,percent of total billed charges,97% of total billed charges,2592.63,90,,,percent of total billed charges,90% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2794.28,97,,,percent of total billed charges,97% of total billed charges,2679.05,93,,,percent of total billed charges,93% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2794.28,97,,,percent of total billed charges,97% of total billed charges,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2880.7,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2016.49,2880.7,
44615 - PF Intestinal Stricturoplasty w/wo Dilat Obstrc,4311783,CDM,960,RC,44615,HCPCS,Outpatient,,,2525.31,1262.66,,2272.78,90,,,percent of total billed charges,90% of total Billed charges,2146.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1063.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,613.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1648.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1063.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1653.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1063.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1859.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1859.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1682.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1682.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,867.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1063.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2127.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1985.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1422.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1648.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1063.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,3327.52,155,,,Fee Schedule,155% of CMS OPPS Rate,3327.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1063.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1008.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1063.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2190.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2190.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,613.42,3327.52,
44620 - PF Closure Enterostomy Lg/ Sm Intestine,4311784,CDM,960,RC,44620,HCPCS,Outpatient,,,2044.05,1022.03,,1839.65,90,,,percent of total billed charges,90% of total Billed charges,1729.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,860.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,440.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1334.33,155,,,Fee Schedule,155% of CMS OPPS Rate,860.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1491.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1491.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1342.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1342.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,701.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,860.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1721.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1584.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1114.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1334.33,155,,,Fee Schedule,155% of CMS OPPS Rate,860.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,2680.34,155,,,Fee Schedule,155% of CMS OPPS Rate,2680.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,860.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,802.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,860.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1763.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1763.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,440.5,2680.34,
44620-PF REPAIR BOWEL OPENING,3429946,CDM,510,RC,44620,HCPCS,Outpatient,,,2309.37,1154.69,,2078.43,90,,,percent of total billed charges,90% of total Billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1847.5,80,,,Percent of total Billed charges,80% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2078.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2240.09,97,,,Percent of total billed charges,97% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2124.62,92,,,Percent of total billed charges,92% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2078.43,90,,,percent of total billed charges,90% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1616.56,70,,,percent of total billed charges,70% of total billed charges,2078.43,90,,,percent of total billed charges,90% of total billed charges,2193.9,95,,,percent of total billed charges,95% of total billed charges,2193.9,95,,,percent of total billed charges,95% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1986.06,86,,,percent of total billed charges,86% of total billed charges,1847.5,80,,,percent of total billed charges,80% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2240.09,97,,,percent of total billed charges,97% of total billed charges,2078.43,90,,,percent of total billed charges,90% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2240.09,97,,,percent of total billed charges,97% of total billed charges,2147.71,93,,,percent of total billed charges,93% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2240.09,97,,,percent of total billed charges,97% of total billed charges,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2309.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1616.56,2309.37,
44625 - PF Clsr Ntrstm Lg/ Sm Resc & Anast Oth/Thn Clrct,4311785,CDM,960,RC,44625,HCPCS,Outpatient,,,2383.71,1191.86,,2145.34,90,,,percent of total billed charges,90% of total Billed charges,2018.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1003.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,515.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1556.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1003.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1501.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1003.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1689.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1689.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1567.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1567.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,820.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1003.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2007.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1849.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1286.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1556.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1003.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,3128.07,155,,,Fee Schedule,155% of CMS OPPS Rate,3128.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1003.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1003.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2077.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2077.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,515.5,3128.07,
44625 ? PF Repair Bowel Opening,3550406,CDM,510,RC,44625,HCPCS,Outpatient,,,2697.06,1348.53,,2427.35,90,,,percent of total billed charges,90% of total Billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2157.65,80,,,Percent of total Billed charges,80% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2427.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2616.15,97,,,Percent of total billed charges,97% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2481.3,92,,,Percent of total billed charges,92% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2427.35,90,,,percent of total billed charges,90% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.94,70,,,percent of total billed charges,70% of total billed charges,2427.35,90,,,percent of total billed charges,90% of total billed charges,2562.21,95,,,percent of total billed charges,95% of total billed charges,2562.21,95,,,percent of total billed charges,95% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2319.47,86,,,percent of total billed charges,86% of total billed charges,2157.65,80,,,percent of total billed charges,80% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2616.15,97,,,percent of total billed charges,97% of total billed charges,2427.35,90,,,percent of total billed charges,90% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2616.15,97,,,percent of total billed charges,97% of total billed charges,2508.27,93,,,percent of total billed charges,93% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2616.15,97,,,percent of total billed charges,97% of total billed charges,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2697.06,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.94,2697.06,
"44626 - (PF) Closure of enterostomy, large or small intestine; with resection and colorectal anas",3635068,CDM,510,RC,44626,HCPCS,Outpatient,,,4295.18,2147.59,,3865.66,90,,,percent of total billed charges,90% of total Billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3436.14,80,,,Percent of total Billed charges,80% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3865.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4166.32,97,,,Percent of total billed charges,97% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3951.57,92,,,Percent of total billed charges,92% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3865.66,90,,,percent of total billed charges,90% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3006.63,70,,,percent of total billed charges,70% of total billed charges,3865.66,90,,,percent of total billed charges,90% of total billed charges,4080.42,95,,,percent of total billed charges,95% of total billed charges,4080.42,95,,,percent of total billed charges,95% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3693.85,86,,,percent of total billed charges,86% of total billed charges,3436.14,80,,,percent of total billed charges,80% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4166.32,97,,,percent of total billed charges,97% of total billed charges,3865.66,90,,,percent of total billed charges,90% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4166.32,97,,,percent of total billed charges,97% of total billed charges,3994.52,93,,,percent of total billed charges,93% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4166.32,97,,,percent of total billed charges,97% of total billed charges,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4295.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3006.63,4295.18,
44626 - PF Clsr Ntrstm Lg/ Sm Resc & Colorectal Anastomosis,4311786,CDM,960,RC,44626,HCPCS,Outpatient,,,3787.24,1893.62,,3408.52,90,,,percent of total billed charges,90% of total Billed charges,3210.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,948.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2472.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2378.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1595.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2675.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2675.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2502.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2502.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1295.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3190.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2952.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2110.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2472.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4975.73,155,,,Fee Schedule,155% of CMS OPPS Rate,4975.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,948.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1520.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,3270.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3270.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,948.86,4975.73,
44640 - PF - Closure of intestinal cutaneous fistula,3640922,CDM,510,RC,44640,HCPCS,Outpatient,,,3760.05,1880.03,,3384.05,90,,,percent of total billed charges,90% of total Billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3008.04,80,,,Percent of total Billed charges,80% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3384.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3647.25,97,,,Percent of total billed charges,97% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3459.25,92,,,Percent of total billed charges,92% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3384.05,90,,,percent of total billed charges,90% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2632.04,70,,,percent of total billed charges,70% of total billed charges,3384.05,90,,,percent of total billed charges,90% of total billed charges,3572.05,95,,,percent of total billed charges,95% of total billed charges,3572.05,95,,,percent of total billed charges,95% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3233.64,86,,,percent of total billed charges,86% of total billed charges,3008.04,80,,,percent of total billed charges,80% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3647.25,97,,,percent of total billed charges,97% of total billed charges,3384.05,90,,,percent of total billed charges,90% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3647.25,97,,,percent of total billed charges,97% of total billed charges,3496.85,93,,,percent of total billed charges,93% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3647.25,97,,,percent of total billed charges,97% of total billed charges,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3760.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2632.04,3760.05,
44640 - PF Closure Intestinal Cutaneous Fistula,4311787,CDM,960,RC,44640,HCPCS,Outpatient,,,3314.97,1657.49,,2983.47,90,,,percent of total billed charges,90% of total Billed charges,2810.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2164,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2145,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1396.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2412.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2412.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2185.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2185.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1132.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2792.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2578.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1838.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2164,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4355.55,155,,,Fee Schedule,155% of CMS OPPS Rate,4355.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1176.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2856.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2856.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,4355.55,
44650 - Closure of enteroenteric or enterocolic fistula,3572791,CDM,983,RC,44650,HCPCS,Outpatient,,,3879.43,1939.72,,3491.49,90,,,percent of total billed charges,90% of total Billed charges,2898,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1439.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2230.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1439.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2217.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1439.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2493.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2493.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2257.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2257.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1167.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1439.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2878.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2664.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1892.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2230.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1439.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,4491.9,155,,,Fee Schedule,155% of CMS OPPS Rate,4491.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1439.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1378.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1439.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2948.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2948.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,4491.9,
44660- Closure of enterovesical fistula; without intestinal or bladder resection,3622986,CDM,510,RC,44660,HCPCS,Outpatient,,,3551.58,1775.79,,3196.42,90,,,percent of total billed charges,90% of total Billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2841.26,80,,,Percent of total Billed charges,80% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3196.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3445.03,97,,,Percent of total billed charges,97% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3267.45,92,,,Percent of total billed charges,92% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3196.42,90,,,percent of total billed charges,90% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.11,70,,,percent of total billed charges,70% of total billed charges,3196.42,90,,,percent of total billed charges,90% of total billed charges,3374,95,,,percent of total billed charges,95% of total billed charges,3374,95,,,percent of total billed charges,95% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3054.36,86,,,percent of total billed charges,86% of total billed charges,2841.26,80,,,percent of total billed charges,80% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3445.03,97,,,percent of total billed charges,97% of total billed charges,3196.42,90,,,percent of total billed charges,90% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3445.03,97,,,percent of total billed charges,97% of total billed charges,3302.97,93,,,percent of total billed charges,93% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3445.03,97,,,percent of total billed charges,97% of total billed charges,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3551.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2486.11,3551.58,
44661 PF - MA REPAIR BOWEL-BLADDER FISTULA,4135114,CDM,960,RC,44661,HCPCS,Outpatient,,,3702.52,1851.26,,3332.27,90,,,percent of total billed charges,90% of total Billed charges,3101.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1542.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2390.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1542.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2303.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1542.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2591.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2591.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2419.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2419.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1250.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1542.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3084.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2855.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2017.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2390.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1542.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4807.48,155,,,Fee Schedule,155% of CMS OPPS Rate,4807.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1542.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1491.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1542.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3153.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3153.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,4807.48,
44701 - PF Intraoperative colonic lavage (List separately in addition to code for primary procedure),3714936,CDM,510,RC,44701,HCPCS,Outpatient,,,461.8,230.90,,415.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,369.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,415.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,447.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,424.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,294.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,363.22,78.65,,,percent of total billed charges,78.65% of total billed charges,412.53,89.33,,,percent of total billed charges,89.33% of total billed charges,415.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,323.26,70,,,percent of total billed charges,70% of total billed charges,415.62,90,,,percent of total billed charges,90% of total billed charges,438.71,95,,,percent of total billed charges,95% of total billed charges,438.71,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.15,86,,,percent of total billed charges,86% of total billed charges,369.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,447.95,97,,,percent of total billed charges,97% of total billed charges,415.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,447.95,97,,,percent of total billed charges,97% of total billed charges,429.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.92,447.95,
44799 - PF Unlisted Px Sm Intestine,4311788,CDM,960,RC,44799,HCPCS,Outpatient,,,2374.4,1187.20,,2136.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,2136.96,
"44799- Unlisted procedure, small intestine",3623581,CDM,510,RC,44799,HCPCS,Outpatient,,,2659.33,1329.67,,2393.4,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2127.46,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2393.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2579.55,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2446.58,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2393.4,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1861.53,70,,,percent of total billed charges,70% of total billed charges,2393.4,90,,,percent of total billed charges,90% of total billed charges,2526.36,95,,,percent of total billed charges,95% of total billed charges,2526.36,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2287.02,86,,,percent of total billed charges,86% of total billed charges,2127.46,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2579.55,97,,,percent of total billed charges,97% of total billed charges,2393.4,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2579.55,97,,,percent of total billed charges,97% of total billed charges,2473.18,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2579.55,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4024.46,
44800 - PF Exc Meckel's Diverticulum/ Omphalomesenteric Duct,4311789,CDM,960,RC,44800,HCPCS,Outpatient,,,1832.21,916.11,,1648.99,90,,,percent of total billed charges,90% of total Billed charges,1545.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,482,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1196.06,155,,,Fee Schedule,155% of CMS OPPS Rate,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,771.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1326.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1188.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1188.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,618.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1402.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,992.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1196.06,155,,,Fee Schedule,155% of CMS OPPS Rate,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2395.68,155,,,Fee Schedule,155% of CMS OPPS Rate,2395.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,482,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,658.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1543.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1543.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,482,2395.68,
44880-EXCISION OF BOWEL POUCH,3429949,CDM,960,RC,44800,HCPCS,Outpatient,,,2058.21,1029.11,,1852.39,90,,,percent of total billed charges,90% of total Billed charges,1545.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,482,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1196.06,155,,,Fee Schedule,155% of CMS OPPS Rate,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,771.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1326.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1188.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1188.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,618.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1543.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1402.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,992.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1196.06,155,,,Fee Schedule,155% of CMS OPPS Rate,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2395.68,155,,,Fee Schedule,155% of CMS OPPS Rate,2395.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,482,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,658.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,771.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1543.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1543.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,482,2395.68,
44820 - Excision of lesion of mesentery (separate procedure,3783253,CDM,510,RC,44820,HCPCS,Outpatient,,,2299.47,1149.74,,2069.52,90,,,percent of total billed charges,90% of total Billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1839.58,80,,,Percent of total Billed charges,80% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2069.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2230.49,97,,,Percent of total billed charges,97% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2115.51,92,,,Percent of total billed charges,92% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2069.52,90,,,percent of total billed charges,90% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1609.63,70,,,percent of total billed charges,70% of total billed charges,2069.52,90,,,percent of total billed charges,90% of total billed charges,2184.5,95,,,percent of total billed charges,95% of total billed charges,2184.5,95,,,percent of total billed charges,95% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1977.54,86,,,percent of total billed charges,86% of total billed charges,1839.58,80,,,percent of total billed charges,80% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2230.49,97,,,percent of total billed charges,97% of total billed charges,2069.52,90,,,percent of total billed charges,90% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2230.49,97,,,percent of total billed charges,97% of total billed charges,2138.51,93,,,percent of total billed charges,93% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2230.49,97,,,percent of total billed charges,97% of total billed charges,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1609.63,2299.47,
44900 - PF I&D Appendiceal Abscess Open,4311790,CDM,960,RC,44900,HCPCS,Outpatient,,,1871.98,935.99,,1684.78,90,,,percent of total billed charges,90% of total Billed charges,1585.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,788.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,300.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1222,155,,,Fee Schedule,155% of CMS OPPS Rate,788.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1353.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1353.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1221.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1221.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,619.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1576.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1441.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1040.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1222,155,,,Fee Schedule,155% of CMS OPPS Rate,788.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,2456.81,155,,,Fee Schedule,155% of CMS OPPS Rate,2456.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,788.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,674.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,788.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1569.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1569.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,300.5,2456.81,
44950 - PF Appendectomy,4311791,CDM,960,RC,44950,HCPCS,Outpatient,,,1531.99,766.00,,1378.79,90,,,percent of total billed charges,90% of total Billed charges,1297.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,645.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.08,90,,,Percent of total Billed charges,90% of total billed charges,301.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1000.06,155,,,Fee Schedule,155% of CMS OPPS Rate,645.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,645.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1110.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1003.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1003.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,518.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1290.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1183.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,851,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1000.06,155,,,Fee Schedule,155% of CMS OPPS Rate,645.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,2010.38,155,,,Fee Schedule,155% of CMS OPPS Rate,2010.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,645.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,578.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,645.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1302.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301.5,2010.38,
44950- Appendectomy,3431235,CDM,510,RC,44950,HCPCS,Outpatient,,,1733.41,866.71,,1560.07,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1386.73,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1681.41,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.74,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1560.07,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.39,70,,,percent of total billed charges,70% of total billed charges,1560.07,90,,,percent of total billed charges,90% of total billed charges,1646.74,95,,,percent of total billed charges,95% of total billed charges,1646.74,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1490.73,86,,,percent of total billed charges,86% of total billed charges,1386.73,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1681.41,97,,,percent of total billed charges,97% of total billed charges,1560.07,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1681.41,97,,,percent of total billed charges,97% of total billed charges,1612.07,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1681.41,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1213.39,17267.34,
44955 - PF Appendec Indicated Purpose Oth Major Px Not Spx,4311792,CDM,960,RC,44955,HCPCS,Outpatient,,,199.95,99.98,,179.96,90,,,percent of total billed charges,90% of total Billed charges,168.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.53,155,,,Fee Schedule,155% of CMS OPPS Rate,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.53,155,,,Fee Schedule,155% of CMS OPPS Rate,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.41,155,,,Fee Schedule,155% of CMS OPPS Rate,261.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.9,261.41,
44955- Appendectomy w/ other major procedure,3431236,CDM,510,RC,44955,HCPCS,Outpatient,,,224.56,112.28,,202.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,179.65,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,202.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,206.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,143.41,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,176.62,78.65,,,percent of total billed charges,78.65% of total billed charges,200.6,89.33,,,percent of total billed charges,89.33% of total billed charges,202.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.19,70,,,percent of total billed charges,70% of total billed charges,202.1,90,,,percent of total billed charges,90% of total billed charges,213.33,95,,,percent of total billed charges,95% of total billed charges,213.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.12,86,,,percent of total billed charges,86% of total billed charges,179.65,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.82,97,,,percent of total billed charges,97% of total billed charges,202.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.82,97,,,percent of total billed charges,97% of total billed charges,208.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.41,217.82,
44960 - PF Appendec Rptd Appendix Absc/ Pritonitis,4311793,CDM,960,RC,44960,HCPCS,Outpatient,,,2093.01,1046.51,,1883.71,90,,,percent of total billed charges,90% of total Billed charges,1773.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,881.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1366.29,155,,,Fee Schedule,155% of CMS OPPS Rate,881.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1347.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,881.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1515.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1370.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1370.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,706.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,881.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1762.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1617.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1166.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1366.29,155,,,Fee Schedule,155% of CMS OPPS Rate,881.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,2749.48,155,,,Fee Schedule,155% of CMS OPPS Rate,2749.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,881.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,343,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,806.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,881.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1774.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1774.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,343,2749.48,
44960- Appendectomy/ruptured w/abscess/peritonitis,3431237,CDM,510,RC,44960,HCPCS,Outpatient,,,2373.13,1186.57,,2135.82,90,,,percent of total billed charges,90% of total Billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1898.5,80,,,Percent of total Billed charges,80% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2135.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2301.94,97,,,Percent of total billed charges,97% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2183.28,92,,,Percent of total billed charges,92% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2135.82,90,,,percent of total billed charges,90% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1661.19,70,,,percent of total billed charges,70% of total billed charges,2135.82,90,,,percent of total billed charges,90% of total billed charges,2254.47,95,,,percent of total billed charges,95% of total billed charges,2254.47,95,,,percent of total billed charges,95% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2040.89,86,,,percent of total billed charges,86% of total billed charges,1898.5,80,,,percent of total billed charges,80% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2301.94,97,,,percent of total billed charges,97% of total billed charges,2135.82,90,,,percent of total billed charges,90% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2301.94,97,,,percent of total billed charges,97% of total billed charges,2207.01,93,,,percent of total billed charges,93% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2301.94,97,,,percent of total billed charges,97% of total billed charges,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2373.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1661.19,2373.13,
44970 - PF Laparoscopic Appendectomy,4311794,CDM,960,RC,44970,HCPCS,Outpatient,,,1430.96,715.48,,1287.86,90,,,percent of total billed charges,90% of total Billed charges,1211.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,602.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,444.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,934.12,155,,,Fee Schedule,155% of CMS OPPS Rate,602.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,602.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1037,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,931.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,931.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,485.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1205.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1099.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,783.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,934.12,155,,,Fee Schedule,155% of CMS OPPS Rate,602.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1877.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1877.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,602.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,444.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,571.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,602.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1213.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1213.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,444.14,1877.1,
"44970-PF LAPAROSCOPY, APPENDECTOMY",3429957,CDM,510,RC,44970,HCPCS,Outpatient,,,1617.86,808.93,,1456.07,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1294.29,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1456.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1569.32,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.43,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1456.07,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.5,70,,,percent of total billed charges,70% of total billed charges,1456.07,90,,,percent of total billed charges,90% of total billed charges,1536.97,95,,,percent of total billed charges,95% of total billed charges,1536.97,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1391.36,86,,,percent of total billed charges,86% of total billed charges,1294.29,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1569.32,97,,,percent of total billed charges,97% of total billed charges,1456.07,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1569.32,97,,,percent of total billed charges,97% of total billed charges,1504.61,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1569.32,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1132.5,25409.89,
"44979 - (PF) Unlisted laparoscopy procedure, appendix",3635069,CDM,510,RC,44979,HCPCS,Outpatient,,,1613.96,806.98,,1452.56,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1291.17,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1452.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1565.54,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1484.84,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1452.56,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.77,70,,,percent of total billed charges,70% of total billed charges,1452.56,90,,,percent of total billed charges,90% of total billed charges,1533.26,95,,,percent of total billed charges,95% of total billed charges,1533.26,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1388.01,86,,,percent of total billed charges,86% of total billed charges,1291.17,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1565.54,97,,,percent of total billed charges,97% of total billed charges,1452.56,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.54,97,,,percent of total billed charges,97% of total billed charges,1500.98,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1565.54,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1129.77,25409.89,
44979 - PF Unlisted Laparoscopy Px Appendix,4311795,CDM,960,RC,44979,HCPCS,Outpatient,,,1424.64,712.32,,1282.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.39,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.39,1282.18,
45005- MSA DRAINAGE OF RECTAL ABSCESS,3514689,CDM,360,RC,45005,HCPCS,Outpatient,,,783.85,391.93,,705.47,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,627.08,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.47,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,760.33,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,721.14,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,705.47,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,548.7,70,,,percent of total billed charges,70% of total billed charges,705.47,90,,,percent of total billed charges,90% of total billed charges,744.66,95,,,percent of total billed charges,95% of total billed charges,744.66,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.11,86,,,percent of total billed charges,86% of total billed charges,627.08,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,760.33,97,,,percent of total billed charges,97% of total billed charges,705.47,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,760.33,97,,,percent of total billed charges,97% of total billed charges,728.98,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,760.33,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,5279.31,
45005-PF I&D SUBMUCOSAL ABSCESS RECTUM,4321635,CDM,981,RC,45005,HCPCS,Outpatient,,,325.22,162.61,,292.7,90,,,percent of total billed charges,90% of total Billed charges,468.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,252.03,155,,,Fee Schedule,155% of CMS OPPS Rate,162.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,278.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,286.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,193.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,252.03,155,,,Fee Schedule,155% of CMS OPPS Rate,162.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,725.9,155,,,Fee Schedule,155% of CMS OPPS Rate,725.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,522.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,725.9,
45020-PF I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC,4321634,CDM,981,RC,45020,HCPCS,Outpatient,,,1131.44,565.72,,1018.3,90,,,percent of total billed charges,90% of total Billed charges,1135.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,565.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,876.87,155,,,Fee Schedule,155% of CMS OPPS Rate,565.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,565.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,983.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,983.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,872.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,872.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,462.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,565.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1131.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1029.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,708.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,876.87,155,,,Fee Schedule,155% of CMS OPPS Rate,565.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1760.13,155,,,Fee Schedule,155% of CMS OPPS Rate,1760.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,565.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,460.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,565.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1145.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,150.5,1760.13,
45100- Biopsy of rectum,3431238,CDM,361,RC,45100,HCPCS,Outpatient,,,784.55,392.28,,706.1,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,627.64,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.1,90,,,Percent of total Billed charges,90% of total billed charges,165.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,761.01,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,721.79,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,706.1,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,549.19,70,,,percent of total billed charges,70% of total billed charges,706.1,90,,,percent of total billed charges,90% of total billed charges,745.32,95,,,percent of total billed charges,95% of total billed charges,745.32,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.71,86,,,percent of total billed charges,86% of total billed charges,627.64,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,761.01,97,,,percent of total billed charges,97% of total billed charges,706.1,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.01,97,,,percent of total billed charges,97% of total billed charges,729.63,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.01,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,150.5,12526.48,
"45110 - (PF) Proctectomy; complete, combined abdominoperineal, with colostomy",3635070,CDM,510,RC,45110,HCPCS,Outpatient,,,4830.35,2415.18,,4347.32,90,,,percent of total billed charges,90% of total Billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3864.28,80,,,Percent of total Billed charges,80% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4347.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4685.44,97,,,Percent of total billed charges,97% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4443.92,92,,,Percent of total billed charges,92% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4347.32,90,,,percent of total billed charges,90% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3381.25,70,,,percent of total billed charges,70% of total billed charges,4347.32,90,,,percent of total billed charges,90% of total billed charges,4588.83,95,,,percent of total billed charges,95% of total billed charges,4588.83,95,,,percent of total billed charges,95% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4154.1,86,,,percent of total billed charges,86% of total billed charges,3864.28,80,,,percent of total billed charges,80% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4685.44,97,,,percent of total billed charges,97% of total billed charges,4347.32,90,,,percent of total billed charges,90% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4685.44,97,,,percent of total billed charges,97% of total billed charges,4492.23,93,,,percent of total billed charges,93% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4685.44,97,,,percent of total billed charges,97% of total billed charges,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.35,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3381.25,4830.35,
"45111 - (PF) Proctectomy; partial resection of rectum, transabdominal approach",3635071,CDM,510,RC,45111,HCPCS,Outpatient,,,2893.57,1446.79,,2604.21,90,,,percent of total billed charges,90% of total Billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2314.86,80,,,Percent of total Billed charges,80% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2604.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2806.76,97,,,Percent of total billed charges,97% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2662.08,92,,,Percent of total billed charges,92% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2604.21,90,,,percent of total billed charges,90% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2025.5,70,,,percent of total billed charges,70% of total billed charges,2604.21,90,,,percent of total billed charges,90% of total billed charges,2748.89,95,,,percent of total billed charges,95% of total billed charges,2748.89,95,,,percent of total billed charges,95% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2488.47,86,,,percent of total billed charges,86% of total billed charges,2314.86,80,,,percent of total billed charges,80% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2806.76,97,,,percent of total billed charges,97% of total billed charges,2604.21,90,,,percent of total billed charges,90% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2806.76,97,,,percent of total billed charges,97% of total billed charges,2691.02,93,,,percent of total billed charges,93% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2806.76,97,,,percent of total billed charges,97% of total billed charges,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2893.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2025.5,2893.57,
"45119- Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), wi",3566788,CDM,510,RC,45119,HCPCS,Outpatient,,,4935.26,2467.63,,4441.73,90,,,percent of total billed charges,90% of total Billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3948.21,80,,,Percent of total Billed charges,80% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4441.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4787.2,97,,,Percent of total billed charges,97% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4540.44,92,,,Percent of total billed charges,92% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4441.73,90,,,percent of total billed charges,90% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3454.68,70,,,percent of total billed charges,70% of total billed charges,4441.73,90,,,percent of total billed charges,90% of total billed charges,4688.5,95,,,percent of total billed charges,95% of total billed charges,4688.5,95,,,percent of total billed charges,95% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4244.32,86,,,percent of total billed charges,86% of total billed charges,3948.21,80,,,percent of total billed charges,80% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4787.2,97,,,percent of total billed charges,97% of total billed charges,4441.73,90,,,percent of total billed charges,90% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4787.2,97,,,percent of total billed charges,97% of total billed charges,4589.79,93,,,percent of total billed charges,93% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4787.2,97,,,percent of total billed charges,97% of total billed charges,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4935.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3454.68,4935.26,
"45123 - Proctectomy, partial, without anastomosis, perineal approach",4037562,CDM,983,RC,45123,HCPCS,Outpatient,,,2953.2,1476.60,,2657.88,90,,,percent of total billed charges,90% of total Billed charges,2213.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1102.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,923.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1708.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1102.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1699.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1102.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1911.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1911.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1707.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1707.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,901.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2205.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2014.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1361.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1708.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1102.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,3430.23,155,,,Fee Schedule,155% of CMS OPPS Rate,3430.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1102.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1101.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1102.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2276.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2276.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,901.51,3430.23,
"45171 - (PF) Excision of rectal tumor, transanal approach; not including muscularis propria",3635072,CDM,510,RC,45171,HCPCS,Outpatient,,,1611.42,805.71,,1450.28,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.14,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1450.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1563.08,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1482.51,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1450.28,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1127.99,70,,,percent of total billed charges,70% of total billed charges,1450.28,90,,,percent of total billed charges,90% of total billed charges,1530.85,95,,,percent of total billed charges,95% of total billed charges,1530.85,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1385.82,86,,,percent of total billed charges,86% of total billed charges,1289.14,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1563.08,97,,,percent of total billed charges,97% of total billed charges,1450.28,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1563.08,97,,,percent of total billed charges,97% of total billed charges,1498.62,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1563.08,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1127.99,12526.48,
"45172 - PF Excision of rectal tumor, transanal approach; not including muscularis propria (ie, parti",3714941,CDM,510,RC,45172,HCPCS,Outpatient,,,2164.77,1082.39,,1948.29,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.82,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1948.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2099.83,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1991.59,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1948.29,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1515.34,70,,,percent of total billed charges,70% of total billed charges,1948.29,90,,,percent of total billed charges,90% of total billed charges,2056.53,95,,,percent of total billed charges,95% of total billed charges,2056.53,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1861.7,86,,,percent of total billed charges,86% of total billed charges,1731.82,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2099.83,97,,,percent of total billed charges,97% of total billed charges,1948.29,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2099.83,97,,,percent of total billed charges,97% of total billed charges,2013.24,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2099.83,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1515.34,12526.48,
45300 - PF Proctosgmdsc Rgd Dx w/ wo Coll Spec Br/ Wa Spx,4311796,CDM,960,RC,45300,HCPCS,Outpatient,,,111.88,55.94,,100.69,90,,,percent of total billed charges,90% of total Billed charges,159,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,90,,,Percent of total Billed charges,90% of total billed charges,24.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.04,155,,,Fee Schedule,155% of CMS OPPS Rate,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.04,155,,,Fee Schedule,155% of CMS OPPS Rate,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.45,155,,,Fee Schedule,155% of CMS OPPS Rate,246.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,238,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.37,259.78,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,510,RC,45300,HCPCS,Outpatient,,,321.06,160.53,,288.95,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,256.85,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.95,90,,,Percent of total Billed charges,90% of total billed charges,26.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,311.43,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,295.38,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,288.95,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,224.74,70,,,percent of total billed charges,70% of total billed charges,288.95,90,,,percent of total billed charges,90% of total billed charges,305.01,95,,,percent of total billed charges,95% of total billed charges,305.01,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,276.11,86,,,percent of total billed charges,86% of total billed charges,256.85,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,311.43,97,,,percent of total billed charges,97% of total billed charges,288.95,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,311.43,97,,,percent of total billed charges,97% of total billed charges,298.59,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,311.43,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.37,4051.42,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,510,RC,45303,HCPCS,Outpatient,,,2371.11,1185.56,,2134,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1896.89,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2134,90,,,Percent of total Billed charges,90% of total billed charges,31.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2299.98,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2181.42,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2134,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1659.78,70,,,percent of total billed charges,70% of total billed charges,2134,90,,,percent of total billed charges,90% of total billed charges,2252.55,95,,,percent of total billed charges,95% of total billed charges,2252.55,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2039.15,86,,,percent of total billed charges,86% of total billed charges,1896.89,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2299.98,97,,,percent of total billed charges,97% of total billed charges,2134,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2299.98,97,,,percent of total billed charges,97% of total billed charges,2205.13,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2299.98,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.31,5279.31,
45303 - PF Proctosgmdsc Rigid w/ Dilation,4311797,CDM,960,RC,45303,HCPCS,Outpatient,,,198.36,99.18,,178.52,90,,,percent of total billed charges,90% of total Billed charges,281.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.47,155,,,Fee Schedule,155% of CMS OPPS Rate,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.47,155,,,Fee Schedule,155% of CMS OPPS Rate,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.93,155,,,Fee Schedule,155% of CMS OPPS Rate,436.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1793.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1793.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.31,1793.84,
45305 - PF Proctosgmdsc Rigid w/ Bx Sngl/ Mult,4311798,CDM,960,RC,45305,HCPCS,Outpatient,,,168.62,84.31,,151.76,90,,,percent of total billed charges,90% of total Billed charges,239.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.07,155,,,Fee Schedule,155% of CMS OPPS Rate,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,87.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,110.07,155,,,Fee Schedule,155% of CMS OPPS Rate,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.43,155,,,Fee Schedule,155% of CMS OPPS Rate,371.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,157.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,377.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53,377.4,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,510,RC,45305,HCPCS,Outpatient,,,457.94,228.97,,412.15,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,366.35,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,412.15,90,,,Percent of total Billed charges,90% of total billed charges,58.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,444.2,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,421.3,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,412.15,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,320.56,70,,,percent of total billed charges,70% of total billed charges,412.15,90,,,percent of total billed charges,90% of total billed charges,435.04,95,,,percent of total billed charges,95% of total billed charges,435.04,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,393.83,86,,,percent of total billed charges,86% of total billed charges,366.35,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,444.2,97,,,percent of total billed charges,97% of total billed charges,412.15,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,444.2,97,,,percent of total billed charges,97% of total billed charges,425.88,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,444.2,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53,5279.31,
45307 - PF Proctosgmdsc Rigid w/ Rmvl Foreign Body,4311799,CDM,960,RC,45307,HCPCS,Outpatient,,,237.3,118.65,,213.57,90,,,percent of total billed charges,90% of total Billed charges,307.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.91,155,,,Fee Schedule,155% of CMS OPPS Rate,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.91,155,,,Fee Schedule,155% of CMS OPPS Rate,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.21,155,,,Fee Schedule,155% of CMS OPPS Rate,477.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,161.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.31,477.21,
45307-PF PROCTOSGMDSC RIGID W/RMVL FOREIGN BODY,4321468,CDM,981,RC,45307,HCPCS,Outpatient,,,199.88,99.94,,179.89,90,,,percent of total billed charges,90% of total Billed charges,299.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.91,155,,,Fee Schedule,155% of CMS OPPS Rate,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.91,155,,,Fee Schedule,155% of CMS OPPS Rate,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.72,155,,,Fee Schedule,155% of CMS OPPS Rate,464.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,161.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.31,464.72,
45330 - Diagnostic sigmoidoscopy,3431239,CDM,360,RC,45330,HCPCS,Outpatient,,,462.14,231.07,,415.93,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,369.71,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.93,90,,,Percent of total Billed charges,90% of total billed charges,58.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,448.28,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,425.17,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,415.93,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,323.5,70,,,percent of total billed charges,70% of total billed charges,415.93,90,,,percent of total billed charges,90% of total billed charges,439.03,95,,,percent of total billed charges,95% of total billed charges,439.03,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,397.44,86,,,percent of total billed charges,86% of total billed charges,369.71,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,448.28,97,,,percent of total billed charges,97% of total billed charges,415.93,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.28,97,,,percent of total billed charges,97% of total billed charges,429.79,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448.28,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.15,4051.42,
45330 - PF Sigmoidoscopy Flx Dx w/ Coll Spec Br/ Wa If Pfrmd,4311800,CDM,960,RC,45330,HCPCS,Outpatient,,,128.24,64.12,,115.42,90,,,percent of total billed charges,90% of total Billed charges,182.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,83.72,155,,,Fee Schedule,155% of CMS OPPS Rate,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,83.72,155,,,Fee Schedule,155% of CMS OPPS Rate,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.49,155,,,Fee Schedule,155% of CMS OPPS Rate,282.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,273.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.59,282.49,
45330-PF SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,4321633,CDM,981,RC,45330,HCPCS,Outpatient,,,108.02,54.01,,97.22,90,,,percent of total billed charges,90% of total Billed charges,162.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,83.72,155,,,Fee Schedule,155% of CMS OPPS Rate,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,83.72,155,,,Fee Schedule,155% of CMS OPPS Rate,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.15,155,,,Fee Schedule,155% of CMS OPPS Rate,251.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,273.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.59,273.36,
45331 - PF Sigmoidoscopy Flx w/ Bx Sngl/Mult,4311801,CDM,960,RC,45331,HCPCS,Outpatient,,,164.12,82.06,,147.71,90,,,percent of total billed charges,90% of total Billed charges,233.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.12,155,,,Fee Schedule,155% of CMS OPPS Rate,69.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,107.12,155,,,Fee Schedule,155% of CMS OPPS Rate,69.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.51,155,,,Fee Schedule,155% of CMS OPPS Rate,361.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,69.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.53,361.51,
45331 - Sigmoidoscopy and biopsy,3431240,CDM,360,RC,45331,HCPCS,Outpatient,,,716.67,358.34,,645,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,573.34,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,645,90,,,Percent of total Billed charges,90% of total billed charges,70.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,695.17,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,659.34,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,645,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,501.67,70,,,percent of total billed charges,70% of total billed charges,645,90,,,percent of total billed charges,90% of total billed charges,680.84,95,,,percent of total billed charges,95% of total billed charges,680.84,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,616.34,86,,,percent of total billed charges,86% of total billed charges,573.34,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,695.17,97,,,percent of total billed charges,97% of total billed charges,645,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.17,97,,,percent of total billed charges,97% of total billed charges,666.5,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,695.17,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.67,4051.42,
45332 - PF Sigmoidoscopy Flx w/ Rmvl Foreign Body,4311808,CDM,960,RC,45332,HCPCS,Outpatient,,,240.48,120.24,,216.43,90,,,percent of total billed charges,90% of total Billed charges,341.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,123.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.71,155,,,Fee Schedule,155% of CMS OPPS Rate,529.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,564.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,564.4,
45332 SIGMOIDOSCOPY W/FB REMOVAL,3429958,CDM,960,RC,45332,HCPCS,Outpatient,,,701.37,350.69,,631.23,90,,,percent of total billed charges,90% of total Billed charges,365,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,123.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.75,155,,,Fee Schedule,155% of CMS OPPS Rate,565.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,564.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,631.23,
45332-PF SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY,4321469,CDM,981,RC,45332,HCPCS,Outpatient,,,202.54,101.27,,182.29,90,,,percent of total billed charges,90% of total Billed charges,303.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,159.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,123.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.97,155,,,Fee Schedule,155% of CMS OPPS Rate,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,470.91,155,,,Fee Schedule,155% of CMS OPPS Rate,470.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,564.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,564.4,
45333 - PF Sigoidoscopy Flx w/ Rmvl Tumor By Hot Bx Forceps,4311809,CDM,960,RC,45333,HCPCS,Outpatient,,,215.95,107.98,,194.36,90,,,percent of total billed charges,90% of total Billed charges,306.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,140.97,155,,,Fee Schedule,155% of CMS OPPS Rate,90.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,140.97,155,,,Fee Schedule,155% of CMS OPPS Rate,90.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.7,155,,,Fee Schedule,155% of CMS OPPS Rate,475.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,90.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,90.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,572.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,572.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.37,572.56,
45333- Sigmoid/rmv tumor/polyp/hot bx for,3431241,CDM,510,RC,45333,HCPCS,Outpatient,,,830.16,415.08,,747.14,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,664.13,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.14,90,,,Percent of total Billed charges,90% of total billed charges,104.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,805.26,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,763.75,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,747.14,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,581.11,70,,,percent of total billed charges,70% of total billed charges,747.14,90,,,percent of total billed charges,90% of total billed charges,788.65,95,,,percent of total billed charges,95% of total billed charges,788.65,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,713.94,86,,,percent of total billed charges,86% of total billed charges,664.13,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,805.26,97,,,percent of total billed charges,97% of total billed charges,747.14,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,805.26,97,,,percent of total billed charges,97% of total billed charges,772.05,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,805.26,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94.64,4051.42,
45334 - PF Signoidoscopy Flx Control Bleeding,4311810,CDM,960,RC,45334,HCPCS,Outpatient,,,270.11,135.06,,243.1,90,,,percent of total billed charges,90% of total Billed charges,383.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,176.33,155,,,Fee Schedule,155% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,176.33,155,,,Fee Schedule,155% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,595,155,,,Fee Schedule,155% of CMS OPPS Rate,595,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,162.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,334.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,595,
45334- Sigmoidoscopy/control of bleeding,3431242,CDM,510,RC,45334,HCPCS,Outpatient,,,1246.96,623.48,,1122.26,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,997.57,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.26,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1209.55,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1147.2,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1122.26,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,872.87,70,,,percent of total billed charges,70% of total billed charges,1122.26,90,,,percent of total billed charges,90% of total billed charges,1184.61,95,,,percent of total billed charges,95% of total billed charges,1184.61,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1072.39,86,,,percent of total billed charges,86% of total billed charges,997.57,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1209.55,97,,,percent of total billed charges,97% of total billed charges,1122.26,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1209.55,97,,,percent of total billed charges,97% of total billed charges,1159.67,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1209.55,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,5279.31,
45335- Sigmoidoscopy/submucosal injection,3431243,CDM,510,RC,45335,HCPCS,Outpatient,,,727.99,364.00,,655.19,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,582.39,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.19,90,,,Percent of total Billed charges,90% of total billed charges,86.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,706.15,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,669.75,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,655.19,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,509.59,70,,,percent of total billed charges,70% of total billed charges,655.19,90,,,percent of total billed charges,90% of total billed charges,691.59,95,,,percent of total billed charges,95% of total billed charges,691.59,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,626.07,86,,,percent of total billed charges,86% of total billed charges,582.39,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,706.15,97,,,percent of total billed charges,97% of total billed charges,655.19,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.15,97,,,percent of total billed charges,97% of total billed charges,677.03,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,706.15,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.65,4051.42,
45337- Sigmoidoscopy/decompression,3431244,CDM,510,RC,45337,HCPCS,Outpatient,,,300.58,150.29,,270.52,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,240.46,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.52,90,,,Percent of total Billed charges,90% of total billed charges,135.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,291.56,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,276.53,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,270.52,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,210.41,70,,,percent of total billed charges,70% of total billed charges,270.52,90,,,percent of total billed charges,90% of total billed charges,285.55,95,,,percent of total billed charges,95% of total billed charges,285.55,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,258.5,86,,,percent of total billed charges,86% of total billed charges,240.46,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,291.56,97,,,percent of total billed charges,97% of total billed charges,270.52,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.56,97,,,percent of total billed charges,97% of total billed charges,279.54,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,291.56,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,122.97,4051.42,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,510,RC,45338,HCPCS,Outpatient,,,758.68,379.34,,682.81,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,606.94,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,682.81,90,,,Percent of total Billed charges,90% of total billed charges,134.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,735.92,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,697.99,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,682.81,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,531.08,70,,,percent of total billed charges,70% of total billed charges,682.81,90,,,percent of total billed charges,90% of total billed charges,720.75,95,,,percent of total billed charges,95% of total billed charges,720.75,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,652.46,86,,,percent of total billed charges,86% of total billed charges,606.94,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,735.92,97,,,percent of total billed charges,97% of total billed charges,682.81,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,735.92,97,,,percent of total billed charges,97% of total billed charges,705.57,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,735.92,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.95,5279.31,
45338 - PF Sgmdsc Flx Rmvl Tum Polyp/ Oth Les Snare Tq,4311811,CDM,960,RC,45338,HCPCS,Outpatient,,,275.85,137.93,,248.27,90,,,percent of total billed charges,90% of total Billed charges,392.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,180.06,155,,,Fee Schedule,155% of CMS OPPS Rate,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,180.06,155,,,Fee Schedule,155% of CMS OPPS Rate,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.63,155,,,Fee Schedule,155% of CMS OPPS Rate,607.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,376.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,620.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,101.39,620.84,
45340- Sigmoidoscop/transendo balloon dil,3431245,CDM,510,RC,45340,HCPCS,Outpatient,,,1151.91,575.96,,1036.72,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,921.53,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1036.72,90,,,Percent of total Billed charges,90% of total billed charges,109.36,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1117.35,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1059.76,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1036.72,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,806.34,70,,,percent of total billed charges,70% of total billed charges,1036.72,90,,,percent of total billed charges,90% of total billed charges,1094.31,95,,,percent of total billed charges,95% of total billed charges,1094.31,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,990.64,86,,,percent of total billed charges,86% of total billed charges,921.53,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1117.35,97,,,percent of total billed charges,97% of total billed charges,1036.72,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.35,97,,,percent of total billed charges,97% of total billed charges,1071.28,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1117.35,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99.42,5279.31,
45341 SIGMOIDOSCOPY W/ULTRASOUND,3429961,CDM,960,RC,45341,HCPCS,Outpatient,,,321.83,160.92,,289.65,90,,,percent of total billed charges,90% of total Billed charges,240.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,184.88,155,,,Fee Schedule,155% of CMS OPPS Rate,119.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,141.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,184.88,155,,,Fee Schedule,155% of CMS OPPS Rate,119.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.47,155,,,Fee Schedule,155% of CMS OPPS Rate,372.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,119.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,119.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,320.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.18,372.47,
45342 SIGMOIDOSCOPY W US GUIDE BX,3429962,CDM,960,RC,45342,HCPCS,Outpatient,,,440.92,220.46,,396.83,90,,,percent of total billed charges,90% of total Billed charges,331.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,199.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,257.19,155,,,Fee Schedule,155% of CMS OPPS Rate,165.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,230.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,256.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,256.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,302.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,193.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,257.19,155,,,Fee Schedule,155% of CMS OPPS Rate,165.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.17,155,,,Fee Schedule,155% of CMS OPPS Rate,514.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,165.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,234.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,165.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,490.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,165.93,514.17,
45346- Sigmoidoscopy/ablate tumor/polyps,3431246,CDM,510,RC,45346,HCPCS,Outpatient,,,5796.99,2898.50,,5217.29,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4637.59,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,5217.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5623.08,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5333.23,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5217.29,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4057.89,70,,,percent of total billed charges,70% of total billed charges,5217.29,90,,,percent of total billed charges,90% of total billed charges,5507.14,95,,,percent of total billed charges,95% of total billed charges,5507.14,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4985.41,86,,,percent of total billed charges,86% of total billed charges,4637.59,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5623.08,97,,,percent of total billed charges,97% of total billed charges,5217.29,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,5623.08,97,,,percent of total billed charges,97% of total billed charges,5391.2,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5623.08,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,836.02,5623.08,
45347- Sigmoidoscopy/endoscopic stent,3431247,CDM,510,RC,45347,HCPCS,Outpatient,,,401.37,200.69,,361.23,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,321.1,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,389.33,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,369.26,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,361.23,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,280.96,70,,,percent of total billed charges,70% of total billed charges,361.23,90,,,percent of total billed charges,90% of total billed charges,381.3,95,,,percent of total billed charges,95% of total billed charges,381.3,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,345.18,86,,,percent of total billed charges,86% of total billed charges,321.1,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,389.33,97,,,percent of total billed charges,97% of total billed charges,361.23,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.33,97,,,percent of total billed charges,97% of total billed charges,373.27,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,389.33,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,280.96,25549.17,
45349 SIGMOIDOSCOPY W/RESECTION,3429963,CDM,960,RC,45349,HCPCS,Outpatient,,,516.5,258.25,,464.85,90,,,percent of total billed charges,90% of total Billed charges,386.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,297.74,155,,,Fee Schedule,155% of CMS OPPS Rate,192.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,270.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,301.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,301.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,355.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,228.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,297.74,155,,,Fee Schedule,155% of CMS OPPS Rate,192.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.77,155,,,Fee Schedule,155% of CMS OPPS Rate,598.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.15,598.77,
45350 - SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S),3997185,CDM,960,RC,45350,HCPCS,Outpatient,,,1689.87,844.94,,1520.88,90,,,percent of total billed charges,90% of total Billed charges,732.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,150.75,155,,,Fee Schedule,155% of CMS OPPS Rate,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,150.75,155,,,Fee Schedule,155% of CMS OPPS Rate,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1135.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1135.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,612.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.15,1520.88,
45378 - PF Colonoscopy Flx Dx w/ Coll Spec When Pfrmd,4311812,CDM,960,RC,45378,HCPCS,Outpatient,,,371.08,185.54,,333.97,90,,,percent of total billed charges,90% of total Billed charges,506.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,712.03,90,,,Percent of total Billed charges,90% of total billed charges,180.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,277.74,155,,,Fee Schedule,155% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,282.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,282.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,277.74,155,,,Fee Schedule,155% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,784.81,155,,,Fee Schedule,155% of CMS OPPS Rate,784.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,775.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,155.38,784.81,
45378 - PF DIAGNOSTIC COLONSCOPY,3429964,CDM,960,RC,45378,HCPCS,Outpatient,,,371.08,185.54,,333.97,90,,,percent of total billed charges,90% of total Billed charges,506.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,712.03,90,,,Percent of total Billed charges,90% of total billed charges,180.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,277.74,155,,,Fee Schedule,155% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,282.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,282.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,216.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,277.74,155,,,Fee Schedule,155% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,784.81,155,,,Fee Schedule,155% of CMS OPPS Rate,784.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,775.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,155.38,784.81,
45379 - PF Colonoscopy Flx w/ Removal of Foreign Body(s),4311813,CDM,960,RC,45379,HCPCS,Outpatient,,,549.91,274.96,,494.92,90,,,percent of total billed charges,90% of total Billed charges,652.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,231.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,358.96,155,,,Fee Schedule,155% of CMS OPPS Rate,231.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,231.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,325.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,364.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,364.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,358.96,155,,,Fee Schedule,155% of CMS OPPS Rate,231.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1010.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,231.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,231.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,994.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,994.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.46,1010.85,
45379- Colonoscopy/remove foreign body,3431248,CDM,510,RC,45379,HCPCS,Outpatient,,,1118.44,559.22,,1006.6,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,894.75,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.6,90,,,Percent of total Billed charges,90% of total billed charges,260.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1084.89,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1028.96,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1006.6,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,782.91,70,,,percent of total billed charges,70% of total billed charges,1006.6,90,,,percent of total billed charges,90% of total billed charges,1062.52,95,,,percent of total billed charges,95% of total billed charges,1062.52,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,961.86,86,,,percent of total billed charges,86% of total billed charges,894.75,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1084.89,97,,,percent of total billed charges,97% of total billed charges,1006.6,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1084.89,97,,,percent of total billed charges,97% of total billed charges,1040.15,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1084.89,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,237.05,5279.31,
45380 - Colonoscopy and biopsy,3431249,CDM,360,RC,45380,HCPCS,Outpatient,,,1109.52,554.76,,998.57,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,887.62,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.57,90,,,Percent of total Billed charges,90% of total billed charges,247.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1076.23,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.76,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,998.57,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,776.66,70,,,percent of total billed charges,70% of total billed charges,998.57,90,,,percent of total billed charges,90% of total billed charges,1054.04,95,,,percent of total billed charges,95% of total billed charges,1054.04,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,954.19,86,,,percent of total billed charges,86% of total billed charges,887.62,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1076.23,97,,,percent of total billed charges,97% of total billed charges,998.57,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.23,97,,,percent of total billed charges,97% of total billed charges,1031.85,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1076.23,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.42,5279.31,
45380 - PF Colonoscopy w/ Bx Sngl/Mult,4311814,CDM,960,RC,45380,HCPCS,Outpatient,,,462.05,231.03,,415.85,90,,,percent of total billed charges,90% of total Billed charges,611.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,225.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,301.61,155,,,Fee Schedule,155% of CMS OPPS Rate,194.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,186.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,232.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,301.61,155,,,Fee Schedule,155% of CMS OPPS Rate,194.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,948.31,155,,,Fee Schedule,155% of CMS OPPS Rate,948.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,505.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,923.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,186.45,948.31,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,510,RC,45381,HCPCS,Outpatient,,,1130.85,565.43,,1017.77,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,904.68,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1017.77,90,,,Percent of total Billed charges,90% of total billed charges,234.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1096.92,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.38,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1017.77,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,791.6,70,,,percent of total billed charges,70% of total billed charges,1017.77,90,,,percent of total billed charges,90% of total billed charges,1074.31,95,,,percent of total billed charges,95% of total billed charges,1074.31,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,972.53,86,,,percent of total billed charges,86% of total billed charges,904.68,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1096.92,97,,,percent of total billed charges,97% of total billed charges,1017.77,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.92,97,,,percent of total billed charges,97% of total billed charges,1051.69,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1096.92,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,213.21,5279.31,
45382 COLONSCOPY/CONTROL BLEEDING,3429966,CDM,960,RC,45382,HCPCS,Outpatient,,,1703.6,851.80,,1533.24,90,,,percent of total billed charges,90% of total Billed charges,891.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,250.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,254,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,388.85,155,,,Fee Schedule,155% of CMS OPPS Rate,250.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,393.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,393.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,237.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,501.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,464.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,298.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,388.85,155,,,Fee Schedule,155% of CMS OPPS Rate,250.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1381.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,250.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,254,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,786.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,250.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1198.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1198.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,237.58,1533.24,
45384 - PF Colsc Flx w/ Removal Lesion By Hot Bx Forceps,4311815,CDM,960,RC,45384,HCPCS,Outpatient,,,528.04,264.02,,475.24,90,,,percent of total billed charges,90% of total Billed charges,693.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,344.7,155,,,Fee Schedule,155% of CMS OPPS Rate,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,349.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,349.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,412.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,344.7,155,,,Fee Schedule,155% of CMS OPPS Rate,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1075.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1075.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,627.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,923.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.7,1075.61,
45384 LESION REMOVE COLONSCOPY,3429968,CDM,960,RC,45384,HCPCS,Outpatient,,,1254,627.00,,1128.6,90,,,percent of total billed charges,90% of total Billed charges,693.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,344.7,155,,,Fee Schedule,155% of CMS OPPS Rate,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,349.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,349.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,412.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,344.7,155,,,Fee Schedule,155% of CMS OPPS Rate,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1075.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1075.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,627.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,923.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.7,1128.6,
45385 - PF Colsc Flx w/ Rmvl Of Tumor Polup Lesion Snare Tq,4311816,CDM,960,RC,45385,HCPCS,Outpatient,,,584.96,292.48,,526.46,90,,,percent of total billed charges,90% of total Billed charges,685.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,381.86,155,,,Fee Schedule,155% of CMS OPPS Rate,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,246.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,387.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,387.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,221.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,381.86,155,,,Fee Schedule,155% of CMS OPPS Rate,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1063.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1063.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1042.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1042.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221.04,1063.01,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,510,RC,45385,HCPCS,Outpatient,,,1168.64,584.32,,1051.78,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,934.91,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1051.78,90,,,Percent of total Billed charges,90% of total billed charges,294.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1133.58,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.15,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1051.78,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,818.05,70,,,percent of total billed charges,70% of total billed charges,1051.78,90,,,percent of total billed charges,90% of total billed charges,1110.21,95,,,percent of total billed charges,95% of total billed charges,1110.21,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1005.03,86,,,percent of total billed charges,86% of total billed charges,934.91,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1133.58,97,,,percent of total billed charges,97% of total billed charges,1051.78,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1133.58,97,,,percent of total billed charges,97% of total billed charges,1086.84,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1133.58,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,268.08,5279.31,
45386 COLONSOPE DILATE STICTURE,3429969,CDM,960,RC,45386,HCPCS,Outpatient,,,1555.39,777.70,,1399.85,90,,,percent of total billed charges,90% of total Billed charges,790.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,232.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,318.25,155,,,Fee Schedule,155% of CMS OPPS Rate,205.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,321.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,321.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,245.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,318.25,155,,,Fee Schedule,155% of CMS OPPS Rate,205.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1224.81,155,,,Fee Schedule,155% of CMS OPPS Rate,1224.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,205.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1199.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,205.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1281.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1281.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,190.83,1399.85,
45388 - PF Colonoscopy Flx Ablation Tumor Polyp/ Other Les,4311817,CDM,960,RC,45388,HCPCS,Outpatient,,,625.98,312.99,,563.38,90,,,percent of total billed charges,90% of total Billed charges,889.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,263.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,294.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,408.64,155,,,Fee Schedule,155% of CMS OPPS Rate,263.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,263.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,369.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,413.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,413.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,220.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,318.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,408.64,155,,,Fee Schedule,155% of CMS OPPS Rate,263.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1378.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1378.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,263.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3424.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,263.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.05,3424.21,
45388- Colonoscopy/w ablat tumor/polyps,3431251,CDM,510,RC,45388,HCPCS,Outpatient,,,6210.73,3105.37,,5589.66,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4968.58,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,5589.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6024.41,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,5713.87,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5589.66,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4347.51,70,,,percent of total billed charges,70% of total billed charges,5589.66,90,,,percent of total billed charges,90% of total billed charges,5900.19,95,,,percent of total billed charges,95% of total billed charges,5900.19,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5341.23,86,,,percent of total billed charges,86% of total billed charges,4968.58,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6024.41,97,,,percent of total billed charges,97% of total billed charges,5589.66,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,6024.41,97,,,percent of total billed charges,97% of total billed charges,5775.98,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6024.41,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,836.02,6024.41,
45389- Colonoscopy/w endoscopic stent,3431252,CDM,510,RC,45389,HCPCS,Outpatient,,,756.84,378.42,,681.16,90,,,percent of total billed charges,90% of total Billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,605.47,80,,,Percent of total Billed charges,80% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,734.13,97,,,Percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,696.29,92,,,Percent of total billed charges,92% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12652.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20170.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25549.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,681.16,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,529.79,70,,,percent of total billed charges,70% of total billed charges,681.16,90,,,percent of total billed charges,90% of total billed charges,719,95,,,percent of total billed charges,95% of total billed charges,719,95,,,percent of total billed charges,95% of total billed charges,4759.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9519.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,650.88,86,,,percent of total billed charges,86% of total billed charges,605.47,80,,,percent of total billed charges,80% of total billed charges,4942.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,734.13,97,,,percent of total billed charges,97% of total billed charges,681.16,90,,,percent of total billed charges,90% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.13,97,,,percent of total billed charges,97% of total billed charges,703.86,93,,,percent of total billed charges,93% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,734.13,97,,,percent of total billed charges,97% of total billed charges,4759.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4759.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4045.94,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,529.79,25549.17,
45390 - PF COLONOSCOPY W/RESECTION,3429970,CDM,960,RC,45390,HCPCS,Outpatient,,,667.21,333.61,,600.49,90,,,percent of total billed charges,90% of total Billed charges,648.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,499.52,155,,,Fee Schedule,155% of CMS OPPS Rate,322.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,504.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,504.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,269.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,595.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,380.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,499.52,155,,,Fee Schedule,155% of CMS OPPS Rate,322.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,382.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.5,1004.43,
45391 COLONOSCOPY W/ENDOSCOPE US,3429971,CDM,960,RC,45391,HCPCS,Outpatient,,,671.96,335.98,,604.76,90,,,percent of total billed charges,90% of total Billed charges,502.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,219.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,387.13,155,,,Fee Schedule,155% of CMS OPPS Rate,249.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,350.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,390.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,390.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,214.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,461.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,387.13,155,,,Fee Schedule,155% of CMS OPPS Rate,249.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,778.78,155,,,Fee Schedule,155% of CMS OPPS Rate,778.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,249.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,354.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,249.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,605.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,214.84,778.78,
45392 COLONSOPY W ENDOSCOPIC FNB,3429972,CDM,960,RC,45392,HCPCS,Outpatient,,,792.14,396.07,,712.93,90,,,percent of total billed charges,90% of total Billed charges,592.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,294.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,277.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,457.23,155,,,Fee Schedule,155% of CMS OPPS Rate,294.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,294.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,413.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,269.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,589.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,545.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,350.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,457.23,155,,,Fee Schedule,155% of CMS OPPS Rate,294.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,918.93,155,,,Fee Schedule,155% of CMS OPPS Rate,918.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,294.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,435.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,294.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,778.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,778.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,269.79,918.93,
45393- Colonoscopy w/decompression,3431253,CDM,510,RC,45393,HCPCS,Outpatient,,,664.25,332.13,,597.83,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,531.4,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,597.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,644.32,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,611.11,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,597.83,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,464.98,70,,,percent of total billed charges,70% of total billed charges,597.83,90,,,percent of total billed charges,90% of total billed charges,631.04,95,,,percent of total billed charges,95% of total billed charges,631.04,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,571.26,86,,,percent of total billed charges,86% of total billed charges,531.4,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,644.32,97,,,percent of total billed charges,97% of total billed charges,597.83,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.32,97,,,percent of total billed charges,97% of total billed charges,617.75,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,644.32,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,464.98,5279.31,
"45395 LAP, REMOVAL OF RECTUM",3429973,CDM,960,RC,45395,HCPCS,Outpatient,,,5168.3,2584.15,,4651.47,90,,,percent of total billed charges,90% of total Billed charges,3870.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1926.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2986.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1926.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2907.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1926.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3270.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3270.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3013.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3013.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1593.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3853.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3556.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2417.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2986.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1926.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,5999.12,155,,,Fee Schedule,155% of CMS OPPS Rate,5999.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1926.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1866.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1926.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,4051.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4051.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5999.12,
"45397 LAP, REMOVCE RECTUM W/POUCH",3429974,CDM,960,RC,45397,HCPCS,Outpatient,,,5613.52,2806.76,,5052.17,90,,,percent of total billed charges,90% of total Billed charges,4198.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2087.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3236.34,155,,,Fee Schedule,155% of CMS OPPS Rate,2087.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3162.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2087.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3556.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3556.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3275.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3275.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1733.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2087.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4175.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3865.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2603.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3236.34,155,,,Fee Schedule,155% of CMS OPPS Rate,2087.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,6508.2,155,,,Fee Schedule,155% of CMS OPPS Rate,6508.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2087.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2019.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2087.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,4383.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4383.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6508.2,
45398- Colonoscopy/flex/w band ligation,3431254,CDM,510,RC,45398,HCPCS,Outpatient,,,2106.1,1053.05,,1895.49,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.88,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1895.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2042.92,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1937.61,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1895.49,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.27,70,,,percent of total billed charges,70% of total billed charges,1895.49,90,,,percent of total billed charges,90% of total billed charges,2000.8,95,,,percent of total billed charges,95% of total billed charges,2000.8,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1811.25,86,,,percent of total billed charges,86% of total billed charges,1684.88,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2042.92,97,,,percent of total billed charges,97% of total billed charges,1895.49,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2042.92,97,,,percent of total billed charges,97% of total billed charges,1958.67,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2042.92,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,836.02,5279.31,
45399 - PF Unlisted Procedure Colon,4311818,CDM,960,RC,45399,HCPCS,Outpatient,,,593.6,296.80,,534.24,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.08,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.08,534.24,
45541-PF PROCTOPEXY PERINEAL APPROACH,4321632,CDM,981,RC,45541,HCPCS,Outpatient,,,1848.86,924.43,,1663.97,90,,,percent of total billed charges,90% of total Billed charges,1864.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,924.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1432.85,155,,,Fee Schedule,155% of CMS OPPS Rate,924.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1441.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,924.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1621.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1621.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1443.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1443.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,761.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1703.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1167.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1432.85,155,,,Fee Schedule,155% of CMS OPPS Rate,924.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2889.88,155,,,Fee Schedule,155% of CMS OPPS Rate,2889.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,924.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,932.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,924.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1884.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1884.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,2889.88,
45560- Rectocele repair,3431255,CDM,510,RC,45560,HCPCS,Outpatient,,,1824.04,912.02,,1641.64,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1459.23,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1641.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1769.32,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1678.12,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1641.64,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1276.83,70,,,percent of total billed charges,70% of total billed charges,1641.64,90,,,percent of total billed charges,90% of total billed charges,1732.84,95,,,percent of total billed charges,95% of total billed charges,1732.84,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1568.67,86,,,percent of total billed charges,86% of total billed charges,1459.23,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1769.32,97,,,percent of total billed charges,97% of total billed charges,1641.64,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1769.32,97,,,percent of total billed charges,97% of total billed charges,1696.36,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1769.32,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1276.83,12526.48,
45800- Closure of rectovesical fistula;,3566789,CDM,510,RC,45800,HCPCS,Outpatient,,,3431.2,1715.60,,3088.08,90,,,percent of total billed charges,90% of total Billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2744.96,80,,,Percent of total Billed charges,80% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3088.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3328.26,97,,,Percent of total billed charges,97% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3156.7,92,,,Percent of total billed charges,92% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3088.08,90,,,percent of total billed charges,90% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2401.84,70,,,percent of total billed charges,70% of total billed charges,3088.08,90,,,percent of total billed charges,90% of total billed charges,3259.64,95,,,percent of total billed charges,95% of total billed charges,3259.64,95,,,percent of total billed charges,95% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2950.83,86,,,percent of total billed charges,86% of total billed charges,2744.96,80,,,percent of total billed charges,80% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.26,97,,,percent of total billed charges,97% of total billed charges,3088.08,90,,,percent of total billed charges,90% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3328.26,97,,,percent of total billed charges,97% of total billed charges,3191.02,93,,,percent of total billed charges,93% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3328.26,97,,,percent of total billed charges,97% of total billed charges,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3431.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2401.84,3431.2,
45905 - (PF) Dilation of anal sphincter (separate procedure) under anesthesia other than,3635075,CDM,510,RC,45905,HCPCS,Outpatient,,,439.93,219.97,,395.94,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,351.94,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.94,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,426.73,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,404.74,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,395.94,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,307.95,70,,,percent of total billed charges,70% of total billed charges,395.94,90,,,percent of total billed charges,90% of total billed charges,417.93,95,,,percent of total billed charges,95% of total billed charges,417.93,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,378.34,86,,,percent of total billed charges,86% of total billed charges,351.94,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,426.73,97,,,percent of total billed charges,97% of total billed charges,395.94,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,426.73,97,,,percent of total billed charges,97% of total billed charges,409.13,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,426.73,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,5279.31,
45910 - (PF) Dilation of rectal stricture (separate procedure) under anesthesia other than,3635076,CDM,510,RC,45910,HCPCS,Outpatient,,,506.13,253.07,,455.52,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,404.9,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,455.52,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,490.95,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,465.64,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,455.52,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,354.29,70,,,percent of total billed charges,70% of total billed charges,455.52,90,,,percent of total billed charges,90% of total billed charges,480.82,95,,,percent of total billed charges,95% of total billed charges,480.82,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,435.27,86,,,percent of total billed charges,86% of total billed charges,404.9,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,490.95,97,,,percent of total billed charges,97% of total billed charges,455.52,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.95,97,,,percent of total billed charges,97% of total billed charges,470.7,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,490.95,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,5279.31,
45915- Removal of fecal impaction or foreign body (separate procedure) under anesthesia,3569402,CDM,510,RC,45915,HCPCS,Outpatient,,,902.82,451.41,,812.54,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,722.26,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.54,90,,,Percent of total Billed charges,90% of total billed charges,42.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,875.74,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,830.59,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,812.54,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,631.97,70,,,percent of total billed charges,70% of total billed charges,812.54,90,,,percent of total billed charges,90% of total billed charges,857.68,95,,,percent of total billed charges,95% of total billed charges,857.68,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,776.43,86,,,percent of total billed charges,86% of total billed charges,722.26,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,875.74,97,,,percent of total billed charges,97% of total billed charges,812.54,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,875.74,97,,,percent of total billed charges,97% of total billed charges,839.62,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,875.74,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.5,5279.31,
45990- Anorectal exam/surg/anesth/diag,3431256,CDM,510,RC,45990,HCPCS,Outpatient,,,278.01,139.01,,250.21,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,222.41,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,269.67,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,255.77,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,250.21,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,194.61,70,,,percent of total billed charges,70% of total billed charges,250.21,90,,,percent of total billed charges,90% of total billed charges,264.11,95,,,percent of total billed charges,95% of total billed charges,264.11,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,239.09,86,,,percent of total billed charges,86% of total billed charges,222.41,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,269.67,97,,,percent of total billed charges,97% of total billed charges,250.21,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.67,97,,,percent of total billed charges,97% of total billed charges,258.55,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,269.67,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,194.61,12526.48,
"45999 - PF Unlisted procedure, rectum",3714944,CDM,510,RC,45999,HCPCS,Outpatient,,,1034.74,517.37,,931.27,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,827.79,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,931.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1003.7,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,951.96,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,931.27,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,724.32,70,,,percent of total billed charges,70% of total billed charges,931.27,90,,,percent of total billed charges,90% of total billed charges,983,95,,,percent of total billed charges,95% of total billed charges,983,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,889.88,86,,,percent of total billed charges,86% of total billed charges,827.79,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1003.7,97,,,percent of total billed charges,97% of total billed charges,931.27,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1003.7,97,,,percent of total billed charges,97% of total billed charges,962.31,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1003.7,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,641.57,4051.42,
45999-PF UNLISTED PROCEDURE RECTUM,4321631,CDM,981,RC,45999,HCPCS,Outpatient,,,976.17,488.09,,878.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.85,878.55,
46020- Placement of seton,3566790,CDM,510,RC,46020,HCPCS,Outpatient,,,305,152.50,,274.5,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,244,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.5,90,,,Percent of total Billed charges,90% of total billed charges,192.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,295.85,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,280.6,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,274.5,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,213.5,70,,,percent of total billed charges,70% of total billed charges,274.5,90,,,percent of total billed charges,90% of total billed charges,289.75,95,,,percent of total billed charges,95% of total billed charges,289.75,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,262.3,86,,,percent of total billed charges,86% of total billed charges,244,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,295.85,97,,,percent of total billed charges,97% of total billed charges,274.5,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.85,97,,,percent of total billed charges,97% of total billed charges,283.65,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,295.85,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,174.71,12526.48,
"46030 - Removal of anal seton, other marker",3572806,CDM,960,RC,46030,HCPCS,Outpatient,,,644.65,322.33,,580.19,90,,,percent of total billed charges,90% of total Billed charges,328.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,133.21,155,,,Fee Schedule,155% of CMS OPPS Rate,85.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,158.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,133.21,155,,,Fee Schedule,155% of CMS OPPS Rate,85.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,508.93,155,,,Fee Schedule,155% of CMS OPPS Rate,508.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,274.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72,580.19,
46040-PF I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX,4321630,CDM,981,RC,46040,HCPCS,Outpatient,,,826.94,413.47,,744.25,90,,,percent of total billed charges,90% of total Billed charges,952.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,640.88,155,,,Fee Schedule,155% of CMS OPPS Rate,413.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,720.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,720.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,334.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,502.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,640.88,155,,,Fee Schedule,155% of CMS OPPS Rate,413.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1475.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1475.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,413.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,443.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,413.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1045.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,108.5,1475.65,
46045-PF I&D INTRAMURAL IM/ABSC TRANSANAL ANES,4321629,CDM,981,RC,46045,HCPCS,Outpatient,,,855,427.50,,769.5,90,,,percent of total billed charges,90% of total Billed charges,860.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,427.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,662.61,155,,,Fee Schedule,155% of CMS OPPS Rate,427.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,667.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,427.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,750.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,750.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,657.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,657.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,350.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,775.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,523.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,662.61,155,,,Fee Schedule,155% of CMS OPPS Rate,427.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1334.13,155,,,Fee Schedule,155% of CMS OPPS Rate,1334.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,427.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,130,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,371.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,427.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,866.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,866.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,130,1334.13,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,361,RC,46050,HCPCS,Outpatient,,,591.44,295.72,,532.3,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,473.15,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.3,90,,,Percent of total Billed charges,90% of total billed charges,83.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,573.7,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,544.12,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,532.3,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,414.01,70,,,percent of total billed charges,70% of total billed charges,532.3,90,,,percent of total billed charges,90% of total billed charges,561.87,95,,,percent of total billed charges,95% of total billed charges,561.87,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,508.64,86,,,percent of total billed charges,86% of total billed charges,473.15,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,573.7,97,,,percent of total billed charges,97% of total billed charges,532.3,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.7,97,,,percent of total billed charges,97% of total billed charges,550.04,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,573.7,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.66,4051.42,
46050-PF I&D PERIANAL ABSCESS SUPERFICIAL,4321628,CDM,981,RC,46050,HCPCS,Outpatient,,,195.84,97.92,,176.26,90,,,percent of total billed charges,90% of total Billed charges,293.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.76,155,,,Fee Schedule,155% of CMS OPPS Rate,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.76,155,,,Fee Schedule,155% of CMS OPPS Rate,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,455.31,155,,,Fee Schedule,155% of CMS OPPS Rate,455.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,387.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.66,455.31,
"46060 - PF Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulo",3714947,CDM,510,RC,46060,HCPCS,Outpatient,,,1266.05,633.03,,1139.45,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1012.84,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1139.45,90,,,Percent of total Billed charges,90% of total billed charges,250.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1228.07,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.77,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1139.45,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,886.24,70,,,percent of total billed charges,70% of total billed charges,1139.45,90,,,percent of total billed charges,90% of total billed charges,1202.75,95,,,percent of total billed charges,95% of total billed charges,1202.75,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1088.8,86,,,percent of total billed charges,86% of total billed charges,1012.84,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1228.07,97,,,percent of total billed charges,97% of total billed charges,1139.45,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1228.07,97,,,percent of total billed charges,97% of total billed charges,1177.43,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1228.07,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,227.5,12526.48,
46060-PF I&D ISCHIORCT/INTRAMURAL ABSC W/WO SETON,4321627,CDM,981,RC,46060,HCPCS,Outpatient,,,945.94,472.97,,851.35,90,,,percent of total billed charges,90% of total Billed charges,949.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,472.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1087,90,,,Percent of total Billed charges,90% of total billed charges,227.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,733.1,155,,,Fee Schedule,155% of CMS OPPS Rate,472.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,824.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,824.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,718.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,718.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,383.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,945.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,848.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,562.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,733.1,155,,,Fee Schedule,155% of CMS OPPS Rate,472.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1471.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,472.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,465.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,472.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,950.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,227.5,1471.03,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,510,RC,46080,HCPCS,Outpatient,,,737.92,368.96,,664.13,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,590.34,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,664.13,90,,,Percent of total Billed charges,90% of total billed charges,146.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,715.78,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,678.89,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,664.13,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,516.54,70,,,percent of total billed charges,70% of total billed charges,664.13,90,,,percent of total billed charges,90% of total billed charges,701.02,95,,,percent of total billed charges,95% of total billed charges,701.02,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,634.61,86,,,percent of total billed charges,86% of total billed charges,590.34,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,715.78,97,,,percent of total billed charges,97% of total billed charges,664.13,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,715.78,97,,,percent of total billed charges,97% of total billed charges,686.27,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,133,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,715.78,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133,12526.48,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,191.65,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,170.35,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.65,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,206.55,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.9,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,191.65,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,149.06,70,,,percent of total billed charges,70% of total billed charges,191.65,90,,,percent of total billed charges,90% of total billed charges,202.29,95,,,percent of total billed charges,95% of total billed charges,202.29,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,183.13,86,,,percent of total billed charges,86% of total billed charges,170.35,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,206.55,97,,,percent of total billed charges,97% of total billed charges,191.65,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.55,97,,,percent of total billed charges,97% of total billed charges,198.03,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.55,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,1047.51,
46083-PF INCISION THROMBOSED HEMORRHOID EXTERNAL,4321626,CDM,981,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,191.65,90,,,percent of total billed charges,90% of total Billed charges,305.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,165.03,155,,,Fee Schedule,155% of CMS OPPS Rate,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.03,155,,,Fee Schedule,155% of CMS OPPS Rate,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.7,155,,,Fee Schedule,155% of CMS OPPS Rate,473.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,220.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,340,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,340,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41,473.7,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,510,RC,46200,HCPCS,Outpatient,,,1198.61,599.31,,1078.75,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,958.89,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1078.75,90,,,Percent of total Billed charges,90% of total billed charges,200.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1162.65,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.72,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1078.75,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,839.03,70,,,percent of total billed charges,70% of total billed charges,1078.75,90,,,percent of total billed charges,90% of total billed charges,1138.68,95,,,percent of total billed charges,95% of total billed charges,1138.68,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1030.8,86,,,percent of total billed charges,86% of total billed charges,958.89,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1162.65,97,,,percent of total billed charges,97% of total billed charges,1078.75,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162.65,97,,,percent of total billed charges,97% of total billed charges,1114.71,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,182,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1162.65,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,182,12526.48,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,211.88,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,188.34,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.88,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.36,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,216.59,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,211.88,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,164.79,70,,,percent of total billed charges,70% of total billed charges,211.88,90,,,percent of total billed charges,90% of total billed charges,223.65,95,,,percent of total billed charges,95% of total billed charges,223.65,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.46,86,,,percent of total billed charges,86% of total billed charges,188.34,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.36,97,,,percent of total billed charges,97% of total billed charges,211.88,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.36,97,,,percent of total billed charges,97% of total billed charges,218.94,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.36,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,5279.31,
46220-PF EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS,4321625,CDM,981,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,211.88,90,,,percent of total billed charges,90% of total Billed charges,353.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,182.44,155,,,Fee Schedule,155% of CMS OPPS Rate,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,138.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,182.44,155,,,Fee Schedule,155% of CMS OPPS Rate,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,547.34,155,,,Fee Schedule,155% of CMS OPPS Rate,547.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,403.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,80,547.34,
46221 - PF Ligation of hemorroid(s),3700932,CDM,510,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,649.21,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,577.07,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.21,90,,,Percent of total Billed charges,90% of total billed charges,50.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,699.7,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,663.63,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,649.21,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,504.94,70,,,percent of total billed charges,70% of total billed charges,649.21,90,,,percent of total billed charges,90% of total billed charges,685.27,95,,,percent of total billed charges,95% of total billed charges,685.27,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,620.35,86,,,percent of total billed charges,86% of total billed charges,577.07,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,699.7,97,,,percent of total billed charges,97% of total billed charges,649.21,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.7,97,,,percent of total billed charges,97% of total billed charges,670.85,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.7,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46,4051.42,
46221-Ligation of hemorrhoid(s),3431259,CDM,361,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,649.21,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,577.07,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.21,90,,,Percent of total Billed charges,90% of total billed charges,50.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,699.7,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,663.63,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,649.21,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,504.94,70,,,percent of total billed charges,70% of total billed charges,649.21,90,,,percent of total billed charges,90% of total billed charges,685.27,95,,,percent of total billed charges,95% of total billed charges,685.27,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,620.35,86,,,percent of total billed charges,86% of total billed charges,577.07,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,699.7,97,,,percent of total billed charges,97% of total billed charges,649.21,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.7,97,,,percent of total billed charges,97% of total billed charges,670.85,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.7,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46,4051.42,
46221-PF Hemorrhoidectomy,4321624,CDM,981,RC,46221,HCPCS,Outpatient,,,368.34,184.17,,331.51,90,,,percent of total billed charges,90% of total Billed charges,455.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.79,90,,,Percent of total Billed charges,90% of total billed charges,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.87,155,,,Fee Schedule,155% of CMS OPPS Rate,705.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,527,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,527,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,705.87,
46230- Excision/mult/ext skin tags/anus,3431260,CDM,510,RC,46230,HCPCS,Outpatient,,,791.19,395.60,,712.07,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,632.95,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,712.07,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,767.45,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,727.89,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,712.07,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,553.83,70,,,percent of total billed charges,70% of total billed charges,712.07,90,,,percent of total billed charges,90% of total billed charges,751.63,95,,,percent of total billed charges,95% of total billed charges,751.63,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,680.42,86,,,percent of total billed charges,86% of total billed charges,632.95,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,767.45,97,,,percent of total billed charges,97% of total billed charges,712.07,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,767.45,97,,,percent of total billed charges,97% of total billed charges,735.81,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,767.45,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,12526.48,
"46250- Hemorrhoidectomy, external, 2 or more columns/groups",3569403,CDM,510,RC,46250,HCPCS,Outpatient,,,1224.58,612.29,,1102.12,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,979.66,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.12,90,,,Percent of total Billed charges,90% of total billed charges,142.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1187.84,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.61,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1102.12,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,857.21,70,,,percent of total billed charges,70% of total billed charges,1102.12,90,,,percent of total billed charges,90% of total billed charges,1163.35,95,,,percent of total billed charges,95% of total billed charges,1163.35,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1053.14,86,,,percent of total billed charges,86% of total billed charges,979.66,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1187.84,97,,,percent of total billed charges,97% of total billed charges,1102.12,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1187.84,97,,,percent of total billed charges,97% of total billed charges,1138.86,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1187.84,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129.5,12526.48,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,510,RC,46255,HCPCS,Outpatient,,,1339.94,669.97,,1205.95,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.95,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.95,90,,,Percent of total Billed charges,90% of total billed charges,288.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1299.74,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1232.74,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1205.95,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,937.96,70,,,percent of total billed charges,70% of total billed charges,1205.95,90,,,percent of total billed charges,90% of total billed charges,1272.94,95,,,percent of total billed charges,95% of total billed charges,1272.94,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1152.35,86,,,percent of total billed charges,86% of total billed charges,1071.95,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1299.74,97,,,percent of total billed charges,97% of total billed charges,1205.95,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1299.74,97,,,percent of total billed charges,97% of total billed charges,1246.14,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1299.74,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,262.5,12526.48,
46257 - HEMORRHOID NTRNL & XTRNL 1 COLUMN W/FISSURECTO,4037565,CDM,983,RC,46257,HCPCS,Outpatient,,,1076.6,538.30,,968.94,90,,,percent of total billed charges,90% of total Billed charges,806.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,401.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,280,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,622.54,155,,,Fee Schedule,155% of CMS OPPS Rate,401.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,401.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,732.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,732.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,640.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,640.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,339,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,755.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,504.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,622.54,155,,,Fee Schedule,155% of CMS OPPS Rate,401.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1250.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,401.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,280,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,462.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,401.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,845.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,845.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,280,1250.03,
46260 - HEMORRHOIDECTOMY INT & EXT 2 OR MORE COL,4311819,CDM,983,RC,46260,HCPCS,Outpatient,,,1120.26,560.13,,1008.23,90,,,percent of total billed charges,90% of total Billed charges,949.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,471.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1092.56,90,,,Percent of total Billed charges,90% of total billed charges,336,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,731.29,155,,,Fee Schedule,155% of CMS OPPS Rate,471.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,471.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,822.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,822.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,722.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,722.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,382.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,943.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,852.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,574.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,731.29,155,,,Fee Schedule,155% of CMS OPPS Rate,471.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.18,155,,,Fee Schedule,155% of CMS OPPS Rate,1471.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,471.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,336,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,563.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,471.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,951.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,951.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,336,1471.18,
"46260- Hemorrhoidectomy, internal and external, 2 or more co",3566915,CDM,510,RC,46260,HCPCS,Outpatient,,,1269.46,634.73,,1142.51,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1015.57,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1142.51,90,,,Percent of total Billed charges,90% of total billed charges,369.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1231.38,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.9,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1142.51,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,888.62,70,,,percent of total billed charges,70% of total billed charges,1142.51,90,,,percent of total billed charges,90% of total billed charges,1205.99,95,,,percent of total billed charges,95% of total billed charges,1205.99,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1091.74,86,,,percent of total billed charges,86% of total billed charges,1015.57,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1231.38,97,,,percent of total billed charges,97% of total billed charges,1142.51,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1231.38,97,,,percent of total billed charges,97% of total billed charges,1180.6,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,336,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1231.38,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,336,12526.48,
46270- Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous,3566791,CDM,510,RC,46270,HCPCS,Outpatient,,,1372.72,686.36,,1235.45,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1098.18,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.45,90,,,Percent of total Billed charges,90% of total billed charges,233.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1331.54,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1262.9,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1235.45,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,960.9,70,,,percent of total billed charges,70% of total billed charges,1235.45,90,,,percent of total billed charges,90% of total billed charges,1304.08,95,,,percent of total billed charges,95% of total billed charges,1304.08,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1180.54,86,,,percent of total billed charges,86% of total billed charges,1098.18,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1331.54,97,,,percent of total billed charges,97% of total billed charges,1235.45,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1331.54,97,,,percent of total billed charges,97% of total billed charges,1276.63,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1331.54,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.5,12526.48,
46280- Surgical tx of anal fistula,3431261,CDM,510,RC,46280,HCPCS,Outpatient,,,1251.32,625.66,,1126.19,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.06,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1126.19,90,,,Percent of total Billed charges,90% of total billed charges,337.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1213.78,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.21,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1126.19,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,875.92,70,,,percent of total billed charges,70% of total billed charges,1126.19,90,,,percent of total billed charges,90% of total billed charges,1188.75,95,,,percent of total billed charges,95% of total billed charges,1188.75,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1076.14,86,,,percent of total billed charges,86% of total billed charges,1001.06,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1213.78,97,,,percent of total billed charges,97% of total billed charges,1126.19,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1213.78,97,,,percent of total billed charges,97% of total billed charges,1163.73,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1213.78,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,306.5,12526.48,
46288 - PF Closure of anal fistula with rectal advancement flap,3715138,CDM,510,RC,46288,HCPCS,Outpatient,,,1455.08,727.54,,1309.57,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.06,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1309.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1411.43,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1338.67,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1309.57,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.56,70,,,percent of total billed charges,70% of total billed charges,1309.57,90,,,percent of total billed charges,90% of total billed charges,1382.33,95,,,percent of total billed charges,95% of total billed charges,1382.33,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1251.37,86,,,percent of total billed charges,86% of total billed charges,1164.06,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1411.43,97,,,percent of total billed charges,97% of total billed charges,1309.57,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1411.43,97,,,percent of total billed charges,97% of total billed charges,1353.22,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1411.43,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1018.56,12526.48,
46320 - PF Exc Thrombosed Hemorrhoid Xtrnl,4311820,CDM,960,RC,46320,HCPCS,Outpatient,,,261.18,130.59,,235.06,90,,,percent of total billed charges,90% of total Billed charges,313.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.47,90,,,Percent of total Billed charges,90% of total billed charges,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.38,155,,,Fee Schedule,155% of CMS OPPS Rate,485.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,359.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,485.38,
46320-PF EXC THROMBOSED HEMORRHOID XTRNL,4321470,CDM,981,RC,46320,HCPCS,Outpatient,,,220,110.00,,198,90,,,percent of total billed charges,90% of total Billed charges,313.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.47,90,,,Percent of total Billed charges,90% of total billed charges,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.38,155,,,Fee Schedule,155% of CMS OPPS Rate,485.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,359.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,485.38,
46320-Removal of hemorrhoid clot,3431262,CDM,361,RC,46320,HCPCS,Outpatient,,,540.29,270.15,,486.26,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,432.23,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.26,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,524.08,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,497.07,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,486.26,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,378.2,70,,,percent of total billed charges,70% of total billed charges,486.26,90,,,percent of total billed charges,90% of total billed charges,513.28,95,,,percent of total billed charges,95% of total billed charges,513.28,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,464.65,86,,,percent of total billed charges,86% of total billed charges,432.23,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,524.08,97,,,percent of total billed charges,97% of total billed charges,486.26,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.08,97,,,percent of total billed charges,97% of total billed charges,502.47,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,524.08,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,5279.31,
46505-Internal anal shincter Botox ing,3768906,CDM,983,RC,46505,HCPCS,Outpatient,,,809.2,404.60,,728.28,90,,,percent of total billed charges,90% of total Billed charges,546.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.26,155,,,Fee Schedule,155% of CMS OPPS Rate,242.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,242.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,415.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,415.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,360.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,360.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,484.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,375.26,155,,,Fee Schedule,155% of CMS OPPS Rate,242.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,846.9,155,,,Fee Schedule,155% of CMS OPPS Rate,846.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,242.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,242.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,567.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,191.87,846.9,
46600-Diagnostic anoscopy spx,3430923,CDM,361,RC,46600,HCPCS,Outpatient,,,299.02,149.51,,269.12,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,239.22,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.12,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,290.05,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,275.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,269.12,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,209.31,70,,,percent of total billed charges,70% of total billed charges,269.12,90,,,percent of total billed charges,90% of total billed charges,284.07,95,,,percent of total billed charges,95% of total billed charges,284.07,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,257.16,86,,,percent of total billed charges,86% of total billed charges,239.22,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,290.05,97,,,percent of total billed charges,97% of total billed charges,269.12,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.05,97,,,percent of total billed charges,97% of total billed charges,278.09,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,290.05,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,566.05,
46600-PF ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD,4321471,CDM,981,RC,46600,HCPCS,Outpatient,,,79.66,39.83,,71.69,90,,,percent of total billed charges,90% of total Billed charges,119.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.74,155,,,Fee Schedule,155% of CMS OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,60.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,60.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.74,155,,,Fee Schedule,155% of CMS OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.21,155,,,Fee Schedule,155% of CMS OPPS Rate,185.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,185.21,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,510,RC,46606,HCPCS,Outpatient,,,707.65,353.83,,636.89,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,566.12,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.89,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.42,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,651.04,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.89,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,495.36,70,,,percent of total billed charges,70% of total billed charges,636.89,90,,,percent of total billed charges,90% of total billed charges,672.27,95,,,percent of total billed charges,95% of total billed charges,672.27,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.58,86,,,percent of total billed charges,86% of total billed charges,566.12,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.42,97,,,percent of total billed charges,97% of total billed charges,636.89,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.42,97,,,percent of total billed charges,97% of total billed charges,658.11,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.42,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,5279.31,
46608-PF ANOSCOPY W/RMVL FOREIGN BODY,4321472,CDM,981,RC,46608,HCPCS,Outpatient,,,168.58,84.29,,151.72,90,,,percent of total billed charges,90% of total Billed charges,252.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.63,155,,,Fee Schedule,155% of CMS OPPS Rate,84.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.63,155,,,Fee Schedule,155% of CMS OPPS Rate,84.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.93,155,,,Fee Schedule,155% of CMS OPPS Rate,391.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,450.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.62,450.84,
"46610 - Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipo",3572808,CDM,983,RC,46610,HCPCS,Outpatient,,,701.24,350.62,,631.12,90,,,percent of total billed charges,90% of total Billed charges,342.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,122.7,155,,,Fee Schedule,155% of CMS OPPS Rate,79.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,100.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,122.7,155,,,Fee Schedule,155% of CMS OPPS Rate,79.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,531.42,155,,,Fee Schedule,155% of CMS OPPS Rate,531.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,79.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,439.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.78,631.12,
46611- Anoscopy/remove single tumor/snare,3431264,CDM,510,RC,46611,HCPCS,Outpatient,,,571.24,285.62,,514.12,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,456.99,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.12,90,,,Percent of total Billed charges,90% of total billed charges,80.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.1,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,525.54,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.12,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,399.87,70,,,percent of total billed charges,70% of total billed charges,514.12,90,,,percent of total billed charges,90% of total billed charges,542.68,95,,,percent of total billed charges,95% of total billed charges,542.68,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.27,86,,,percent of total billed charges,86% of total billed charges,456.99,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.1,97,,,percent of total billed charges,97% of total billed charges,514.12,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.1,97,,,percent of total billed charges,97% of total billed charges,531.25,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.1,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.53,4051.42,
46900 - PF Sstr Lesion Anus Simple Chemical,4309235,CDM,960,RC,46900,HCPCS,Outpatient,,,280.09,140.05,,252.08,90,,,percent of total billed charges,90% of total Billed charges,356.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,204.79,155,,,Fee Schedule,155% of CMS OPPS Rate,132.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,154.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,204.79,155,,,Fee Schedule,155% of CMS OPPS Rate,132.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.48,155,,,Fee Schedule,155% of CMS OPPS Rate,552.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,132.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,196.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,132.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,472.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47,552.48,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,281.6,140.80,,253.44,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,225.28,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,253.44,90,,,Percent of total Billed charges,90% of total billed charges,128.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,273.15,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,259.07,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,253.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,197.12,70,,,percent of total billed charges,70% of total billed charges,253.44,90,,,percent of total billed charges,90% of total billed charges,267.52,95,,,percent of total billed charges,95% of total billed charges,267.52,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,242.18,86,,,percent of total billed charges,86% of total billed charges,225.28,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,273.15,97,,,percent of total billed charges,97% of total billed charges,253.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.15,97,,,percent of total billed charges,97% of total billed charges,261.89,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.15,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.03,880.34,
46922-PF EXCISION OF ANAL LESION,3429981,CDM,510,RC,46922,HCPCS,Outpatient,,,789.69,394.85,,710.72,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,631.75,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.72,90,,,Percent of total Billed charges,90% of total billed charges,119.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,766,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,726.51,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,710.72,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,552.78,70,,,percent of total billed charges,70% of total billed charges,710.72,90,,,percent of total billed charges,90% of total billed charges,750.21,95,,,percent of total billed charges,95% of total billed charges,750.21,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,679.13,86,,,percent of total billed charges,86% of total billed charges,631.75,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,766,97,,,percent of total billed charges,97% of total billed charges,710.72,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,766,97,,,percent of total billed charges,97% of total billed charges,734.41,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,766,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,108.34,12526.48,
46924 - DSTRJ LESION ANUS EXTENSIVE,3997186,CDM,960,RC,46924,HCPCS,Outpatient,,,1367.72,683.86,,1230.95,90,,,percent of total billed charges,90% of total Billed charges,690.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,273.3,155,,,Fee Schedule,155% of CMS OPPS Rate,176.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,211.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,273.3,155,,,Fee Schedule,155% of CMS OPPS Rate,176.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1070.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1070.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,176.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,115,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,449.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1037,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115,1230.95,
46940 - PF Curettage/Cautery Anal Fissure w/Dilation of Anal Sphincter Initial,4327335,CDM,960,RC,46940,HCPCS,Outpatient,,,277.86,138.93,,250.07,90,,,percent of total billed charges,90% of total Billed charges,395.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,220.78,155,,,Fee Schedule,155% of CMS OPPS Rate,142.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,246.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,217.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,217.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,257.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,220.78,155,,,Fee Schedule,155% of CMS OPPS Rate,142.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.87,155,,,Fee Schedule,155% of CMS OPPS Rate,612.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,142.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,239.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,142.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,452.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,452.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,612.87,
"46945 - Hemorrhoidectomy, Internal by Ligation SNGL  w/o Ima",3896929,CDM,983,RC,46945,HCPCS,Outpatient,,,869.25,434.63,,782.33,90,,,percent of total billed charges,90% of total Billed charges,649.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,500.01,155,,,Fee Schedule,155% of CMS OPPS Rate,322.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,570.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,570.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,182.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,645.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,576.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,371.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,500.01,155,,,Fee Schedule,155% of CMS OPPS Rate,322.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1006.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,219.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,593.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,1006.65,
"46947- Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling",3566792,CDM,510,RC,46947,HCPCS,Outpatient,,,1026.29,513.15,,923.66,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,821.03,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.66,90,,,Percent of total Billed charges,90% of total billed charges,276.36,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,995.5,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,944.19,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,923.66,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,718.4,70,,,percent of total billed charges,70% of total billed charges,923.66,90,,,percent of total billed charges,90% of total billed charges,974.98,95,,,percent of total billed charges,95% of total billed charges,974.98,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,882.61,86,,,percent of total billed charges,86% of total billed charges,821.03,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,995.5,97,,,percent of total billed charges,97% of total billed charges,923.66,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,995.5,97,,,percent of total billed charges,97% of total billed charges,954.45,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,995.5,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.24,12526.48,
"46999 - PF Unlisted procedure, anus",3641212,CDM,510,RC,46999,HCPCS,Outpatient,,,664.83,332.42,,598.35,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,531.86,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,644.89,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,611.64,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,598.35,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,465.38,70,,,percent of total billed charges,70% of total billed charges,598.35,90,,,percent of total billed charges,90% of total billed charges,631.59,95,,,percent of total billed charges,95% of total billed charges,631.59,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,571.75,86,,,percent of total billed charges,86% of total billed charges,531.86,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,644.89,97,,,percent of total billed charges,97% of total billed charges,598.35,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.89,97,,,percent of total billed charges,97% of total billed charges,618.29,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,644.89,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,465.38,4051.42,
47000 - PF Bx Liver Needle Percutaneous,4311821,CDM,960,RC,47000,HCPCS,Outpatient,,,203.37,101.69,,183.03,90,,,percent of total billed charges,90% of total Billed charges,289.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.27,90,,,Percent of total Billed charges,90% of total billed charges,89.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,158.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,447.97,155,,,Fee Schedule,155% of CMS OPPS Rate,447.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,656.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,698.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.03,698.36,
CT add Needle Bx Liver,645138,CDM,360,RC,47000,HCPCS,Outpatient,,,729.74,364.87,,656.77,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,583.79,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,656.77,90,,,Percent of total Billed charges,90% of total billed charges,98.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,707.85,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,671.36,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,656.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,510.82,70,,,percent of total billed charges,70% of total billed charges,656.77,90,,,percent of total billed charges,90% of total billed charges,693.25,95,,,percent of total billed charges,95% of total billed charges,693.25,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,627.58,86,,,percent of total billed charges,86% of total billed charges,583.79,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,707.85,97,,,percent of total billed charges,97% of total billed charges,656.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.85,97,,,percent of total billed charges,97% of total billed charges,678.66,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,707.85,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.65,7310.49,
Read,4181198,CDM,972,RC,47000,HCPCS,Outpatient,,,291.89,145.95,,262.7,90,,,percent of total billed charges,90% of total Billed charges,368.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.27,90,,,Percent of total Billed charges,90% of total billed charges,89.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,158.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,132.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,570.8,155,,,Fee Schedule,155% of CMS OPPS Rate,570.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,656.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,698.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,698.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.03,698.36,
47001 - PF Bx Lvr Ndl Done Purpose Tm Oth Major Px,4311822,CDM,960,RC,47001,HCPCS,Outpatient,,,248.86,124.43,,223.97,90,,,percent of total billed charges,90% of total Billed charges,210.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.46,155,,,Fee Schedule,155% of CMS OPPS Rate,104.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.46,155,,,Fee Schedule,155% of CMS OPPS Rate,104.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.95,155,,,Fee Schedule,155% of CMS OPPS Rate,325.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,100.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,84.42,325.95,
"47001-MA NEEDLE BIOPSY, LIVER ADD ON",3429982,CDM,510,RC,47001,HCPCS,Outpatient,,,280.54,140.27,,252.49,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,224.43,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,252.49,90,,,Percent of total Billed charges,90% of total billed charges,101.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,272.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,258.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,179.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,220.65,78.65,,,percent of total billed charges,78.65% of total billed charges,250.61,89.33,,,percent of total billed charges,89.33% of total billed charges,252.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.38,70,,,percent of total billed charges,70% of total billed charges,252.49,90,,,percent of total billed charges,90% of total billed charges,266.51,95,,,percent of total billed charges,95% of total billed charges,266.51,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.26,86,,,percent of total billed charges,86% of total billed charges,224.43,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,272.12,97,,,percent of total billed charges,97% of total billed charges,252.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,272.12,97,,,percent of total billed charges,97% of total billed charges,260.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.38,272.12,
47100 - PF Bx Liver Wedge,4311823,CDM,960,RC,47100,HCPCS,Outpatient,,,2005.32,1002.66,,1804.79,90,,,percent of total billed charges,90% of total Billed charges,1699.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1309.05,155,,,Fee Schedule,155% of CMS OPPS Rate,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,844.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1460.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1306.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1306.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,682.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1689.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1542.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1092.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1309.05,155,,,Fee Schedule,155% of CMS OPPS Rate,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2633.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2633.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,770.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1702.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1702.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,243.5,2633.53,
47100-PF WEDGE BIOPSY OF LIVER,3429984,CDM,510,RC,47100,HCPCS,Outpatient,,,2272.42,1136.21,,2045.18,90,,,percent of total billed charges,90% of total Billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1817.94,80,,,Percent of total Billed charges,80% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2204.25,97,,,Percent of total billed charges,97% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2090.63,92,,,Percent of total billed charges,92% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2045.18,90,,,percent of total billed charges,90% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1590.69,70,,,percent of total billed charges,70% of total billed charges,2045.18,90,,,percent of total billed charges,90% of total billed charges,2158.8,95,,,percent of total billed charges,95% of total billed charges,2158.8,95,,,percent of total billed charges,95% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1954.28,86,,,percent of total billed charges,86% of total billed charges,1817.94,80,,,percent of total billed charges,80% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.25,97,,,percent of total billed charges,97% of total billed charges,2045.18,90,,,percent of total billed charges,90% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.25,97,,,percent of total billed charges,97% of total billed charges,2113.35,93,,,percent of total billed charges,93% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2204.25,97,,,percent of total billed charges,97% of total billed charges,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1590.69,2272.42,
"47120 - Hepatectomy, resection of liver; partial lobectomy",3800924,CDM,983,RC,47120,HCPCS,Outpatient,,,6291.35,3145.68,,5662.22,90,,,percent of total billed charges,90% of total Billed charges,4709.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2343.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,710.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3633.01,155,,,Fee Schedule,155% of CMS OPPS Rate,2343.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3585.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2343.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4032.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4032.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3651,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3651,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1884.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4687.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4308.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3108.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3633.01,155,,,Fee Schedule,155% of CMS OPPS Rate,2343.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,7299.96,155,,,Fee Schedule,155% of CMS OPPS Rate,7299.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2343.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2180.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2343.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,4715.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4715.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,710.5,7299.96,
47350 - PF Mgmt Lvr Hemrrg Smpl Sutr Lvr Wnd/ Inj,4311824,CDM,960,RC,47350,HCPCS,Outpatient,,,3251.43,1625.72,,2926.29,90,,,percent of total billed charges,90% of total Billed charges,2754.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1369.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,528,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2122.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1369.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1369.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2133.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2133.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1105.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1369.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2738.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2517.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1802.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2122.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1369.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,4269.21,155,,,Fee Schedule,155% of CMS OPPS Rate,4269.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1369.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,528,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1307.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1369.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2777.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2777.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,528,4269.21,
47379 - PF Unlisted Laparoscopic Px Liver,4311825,CDM,960,RC,47379,HCPCS,Outpatient,,,2374.4,1187.20,,2136.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,712.32,2136.96,
"47399 - Unlisted procedure, liver",3783262,CDM,510,RC,47399,HCPCS,Outpatient,,,1939.31,969.66,,1745.38,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1551.45,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1745.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1881.13,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1784.17,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1745.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.52,70,,,percent of total billed charges,70% of total billed charges,1745.38,90,,,percent of total billed charges,90% of total billed charges,1842.34,95,,,percent of total billed charges,95% of total billed charges,1842.34,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1667.81,86,,,percent of total billed charges,86% of total billed charges,1551.45,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1881.13,97,,,percent of total billed charges,97% of total billed charges,1745.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1881.13,97,,,percent of total billed charges,97% of total billed charges,1803.56,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1881.13,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.01,3163.8,
47531 - PF Njx Cholangio Prq w/ Img Gid RS&I Existing Access,4311826,CDM,960,RC,47531,HCPCS,Outpatient,,,160.41,80.21,,144.37,90,,,percent of total billed charges,90% of total Billed charges,227.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.72,155,,,Fee Schedule,155% of CMS OPPS Rate,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.72,155,,,Fee Schedule,155% of CMS OPPS Rate,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.35,155,,,Fee Schedule,155% of CMS OPPS Rate,353.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,392.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.56,392.05,
Read,601985,CDM,972,RC,47531,HCPCS,Outpatient,,,405.56,202.78,,365,90,,,percent of total billed charges,90% of total Billed charges,466.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.72,155,,,Fee Schedule,155% of CMS OPPS Rate,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.72,155,,,Fee Schedule,155% of CMS OPPS Rate,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.66,155,,,Fee Schedule,155% of CMS OPPS Rate,723.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,392.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.56,723.66,
47532 - PF Njx Cholangio Prq w/ Img Gid RS&I New Access,4311827,CDM,960,RC,47532,HCPCS,Outpatient,,,487.11,243.56,,438.4,90,,,percent of total billed charges,90% of total Billed charges,692.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,317.98,155,,,Fee Schedule,155% of CMS OPPS Rate,205.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,442.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,327.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,327.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,386.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,245.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,317.98,155,,,Fee Schedule,155% of CMS OPPS Rate,205.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1073,155,,,Fee Schedule,155% of CMS OPPS Rate,1073,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,205.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,863.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,205.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.22,1073,
47533 - PF Prq Plmt Biliary Drg Cath w/ Img Gid RS&I External,4311828,CDM,960,RC,47533,HCPCS,Outpatient,,,611.39,305.70,,550.25,90,,,percent of total billed charges,90% of total Billed charges,868.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,399.11,155,,,Fee Schedule,155% of CMS OPPS Rate,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,457.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,409.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,409.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,483.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,306.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,399.11,155,,,Fee Schedule,155% of CMS OPPS Rate,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1346.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1346.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1406.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.68,1406.78,
Read,1449180,CDM,972,RC,47533,HCPCS,Outpatient,,,1124.62,562.31,,1012.16,90,,,percent of total billed charges,90% of total Billed charges,1362.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,399.11,155,,,Fee Schedule,155% of CMS OPPS Rate,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,457.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,409.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,409.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,514.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,483.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,306.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,399.11,155,,,Fee Schedule,155% of CMS OPPS Rate,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2112.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1406.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,257.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.68,2112.46,
47534 - PF Prq Pmt Biliary Drg Cath w/ Img GID RS&I Int-Ext,4311829,CDM,960,RC,47534,HCPCS,Outpatient,,,854.67,427.34,,769.2,90,,,percent of total billed charges,90% of total Billed charges,1214.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,331.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,557.92,155,,,Fee Schedule,155% of CMS OPPS Rate,359.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,567.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,359.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,638.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,638.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,572,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,572,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,353.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,719.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,674.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,424.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,557.92,155,,,Fee Schedule,155% of CMS OPPS Rate,359.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1882.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,359.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1735.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,359.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.35,1882.66,
47535 - PF Conv Ext Bil Drg Cath To Int-Ext Bil Drg Cath,4311830,CDM,960,RC,47535,HCPCS,Outpatient,,,452.68,226.34,,407.41,90,,,percent of total billed charges,90% of total Billed charges,643.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,190.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,295.49,155,,,Fee Schedule,155% of CMS OPPS Rate,190.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,336.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,336.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,301.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,301.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,355.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,224.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,295.49,155,,,Fee Schedule,155% of CMS OPPS Rate,190.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,997.15,155,,,Fee Schedule,155% of CMS OPPS Rate,997.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,190.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1161.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,190.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.53,1161.36,
47536 - PF Exchange Biliary Drg Cath Prq w/ Img GID RS&I,4311831,CDM,960,RC,47536,HCPCS,Outpatient,,,302.93,151.47,,272.64,90,,,percent of total billed charges,90% of total Billed charges,430.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,197.73,155,,,Fee Schedule,155% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,203.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,203.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,240.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,151.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,197.73,155,,,Fee Schedule,155% of CMS OPPS Rate,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,667.28,155,,,Fee Schedule,155% of CMS OPPS Rate,667.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,855.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.18,855.14,
47537 - PF Removal Biliary Drg Cath Req Fluor Gid RS&I,4311832,CDM,960,RC,47537,HCPCS,Outpatient,,,222.08,111.04,,199.87,90,,,percent of total billed charges,90% of total Billed charges,315.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,144.96,155,,,Fee Schedule,155% of CMS OPPS Rate,93.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,108.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,144.96,155,,,Fee Schedule,155% of CMS OPPS Rate,93.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,489.18,155,,,Fee Schedule,155% of CMS OPPS Rate,489.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,93.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,424.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.02,489.18,
47538 - PF Plmt Bile Duct Stent Prq Existing Access,4311833,CDM,960,RC,47538,HCPCS,Outpatient,,,540.79,270.40,,486.71,90,,,percent of total billed charges,90% of total Billed charges,768.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,227.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,353.01,155,,,Fee Schedule,155% of CMS OPPS Rate,227.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,407.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,364.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,364.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,234.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,455.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,429.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,271.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,353.01,155,,,Fee Schedule,155% of CMS OPPS Rate,227.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1191.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,227.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4690.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,227.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.75,4690.09,
47539 - PF Plmt Bile Duct Stent Prq New Access w/o Sep Cath,4311834,CDM,960,RC,47539,HCPCS,Outpatient,,,985.24,492.62,,886.72,90,,,percent of total billed charges,90% of total Billed charges,1400.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,414.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,643.16,155,,,Fee Schedule,155% of CMS OPPS Rate,414.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,414.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,730.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,385.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,774.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,491.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,643.16,155,,,Fee Schedule,155% of CMS OPPS Rate,414.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,2170.28,155,,,Fee Schedule,155% of CMS OPPS Rate,2170.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,414.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5131.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,414.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.14,5131.9,
47540 - PF Plmt Bile Duct Stent Prq New Access w/ Sep Cath,4311835,CDM,960,RC,47540,HCPCS,Outpatient,,,1015.1,507.55,,913.59,90,,,percent of total billed charges,90% of total Billed charges,1442.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,427.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,433.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,662.64,155,,,Fee Schedule,155% of CMS OPPS Rate,427.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,427.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,758.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,758.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,680.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,680.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,460.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,855.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,802.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,507.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,662.64,155,,,Fee Schedule,155% of CMS OPPS Rate,427.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,2236.05,155,,,Fee Schedule,155% of CMS OPPS Rate,2236.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,427.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,433.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5340.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,427.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.51,5340.72,
47541 - PF Plmt Access Thru Biliary Tree Into Sm Bwl New,4311836,CDM,960,RC,47541,HCPCS,Outpatient,,,371.02,185.51,,333.92,90,,,percent of total billed charges,90% of total Billed charges,698.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,507.21,155,,,Fee Schedule,155% of CMS OPPS Rate,327.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,571.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,571.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,512.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,512.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,267.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,382.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,507.21,155,,,Fee Schedule,155% of CMS OPPS Rate,327.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1082.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1082.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,327.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1242.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,327.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.54,1242.81,
47562 - PF Laparoscopy Surg Cholecystectomy,4311837,CDM,960,RC,47562,HCPCS,Outpatient,,,1568.91,784.46,,1412.02,90,,,percent of total billed charges,90% of total Billed charges,1329.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1024.16,155,,,Fee Schedule,155% of CMS OPPS Rate,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,660.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1137.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1024.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1024.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,531.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1208.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,866.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1024.16,155,,,Fee Schedule,155% of CMS OPPS Rate,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2060.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2060.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,844.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1515.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1515.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,531.59,2060.91,
47562- Cholecystectomy/laparoscopy,3431265,CDM,510,RC,47562,HCPCS,Outpatient,,,1778.76,889.38,,1600.88,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.01,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1600.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1725.4,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1636.46,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1600.88,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.13,70,,,percent of total billed charges,70% of total billed charges,1600.88,90,,,percent of total billed charges,90% of total billed charges,1689.82,95,,,percent of total billed charges,95% of total billed charges,1689.82,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1529.73,86,,,percent of total billed charges,86% of total billed charges,1423.01,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1725.4,97,,,percent of total billed charges,97% of total billed charges,1600.88,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1725.4,97,,,percent of total billed charges,97% of total billed charges,1654.25,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1725.4,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1245.13,25409.89,
47563 - PF Laps urg Cholecystectomy w/ Cholagniography,4311838,CDM,960,RC,47563,HCPCS,Outpatient,,,1712.15,856.08,,1540.94,90,,,percent of total billed charges,90% of total Billed charges,1449.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,721.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,633.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1117.69,155,,,Fee Schedule,155% of CMS OPPS Rate,721.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1101.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,721.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1238.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1115.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1115.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,577.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1442.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1316.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,945.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1117.69,155,,,Fee Schedule,155% of CMS OPPS Rate,721.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2246.51,155,,,Fee Schedule,155% of CMS OPPS Rate,2246.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,721.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,633.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,862.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,721.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1530.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1530.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,577.35,2246.51,
47563- Lapchol w/cholangiography,3431266,CDM,510,RC,47563,HCPCS,Outpatient,,,1936.74,968.37,,1743.07,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.39,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1743.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1878.64,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.8,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1743.07,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.72,70,,,percent of total billed charges,70% of total billed charges,1743.07,90,,,percent of total billed charges,90% of total billed charges,1839.9,95,,,percent of total billed charges,95% of total billed charges,1839.9,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1665.6,86,,,percent of total billed charges,86% of total billed charges,1549.39,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1878.64,97,,,percent of total billed charges,97% of total billed charges,1743.07,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1878.64,97,,,percent of total billed charges,97% of total billed charges,1801.17,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1878.64,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1355.72,25409.89,
47564 - PF Laps Surg Cholecstc w/ Expl Common Duct,4311839,CDM,960,RC,47564,HCPCS,Outpatient,,,2660.75,1330.38,,2394.68,90,,,percent of total billed charges,90% of total Billed charges,2251.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1120.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,740.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1736.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1120.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1712.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1120.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1925.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1925.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1736.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1736.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,899.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2241.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2049.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1473.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1736.91,155,,,Fee Schedule,155% of CMS OPPS Rate,1120.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,3490.49,155,,,Fee Schedule,155% of CMS OPPS Rate,3490.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1120.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,740.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1043.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1120.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1750.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1750.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,740.52,3490.49,
47564- Lap/surg/chol w/explor common duct,3431267,CDM,510,RC,47564,HCPCS,Outpatient,,,3008.6,1504.30,,2707.74,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2406.88,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2707.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2918.34,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2767.91,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2707.74,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.02,70,,,percent of total billed charges,70% of total billed charges,2707.74,90,,,percent of total billed charges,90% of total billed charges,2858.17,95,,,percent of total billed charges,95% of total billed charges,2858.17,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2587.4,86,,,percent of total billed charges,86% of total billed charges,2406.88,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2918.34,97,,,percent of total billed charges,97% of total billed charges,2707.74,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2918.34,97,,,percent of total billed charges,97% of total billed charges,2798,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2918.34,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2106.02,25409.89,
47570 - PF Laparoscopy Surg Cholecystoeneterostomy,4311840,CDM,960,RC,47570,HCPCS,Outpatient,,,1854.58,927.29,,1669.12,90,,,percent of total billed charges,90% of total Billed charges,1569.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,781.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,658.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1210.64,155,,,Fee Schedule,155% of CMS OPPS Rate,781.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,781.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1341.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1341.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1211.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1211.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,628.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1429.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1032.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1210.64,155,,,Fee Schedule,155% of CMS OPPS Rate,781.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,2433.41,155,,,Fee Schedule,155% of CMS OPPS Rate,2433.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,781.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1291.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,781.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1568.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1568.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,628.1,2433.41,
47579 - PF Unlisted Laparoscopy Px Biliary Tract,4311841,CDM,960,RC,47579,HCPCS,Outpatient,,,1662.08,831.04,,1495.87,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.62,1495.87,
47600 - PF Cholecystectomy,4311842,CDM,960,RC,47600,HCPCS,Outpatient,,,2547.69,1273.85,,2292.92,90,,,percent of total billed charges,90% of total Billed charges,2157.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1072.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,474,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1663.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1072.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1643.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1072.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1848.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1848.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1668.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1668.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,862.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1072.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1968.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1415.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1663.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1072.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,3343.46,155,,,Fee Schedule,155% of CMS OPPS Rate,3343.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1072.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,474,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1072.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,2195.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2195.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,474,3343.46,
47600- Cholecystectomy,3431268,CDM,510,RC,47600,HCPCS,Outpatient,,,2882.95,1441.48,,2594.66,90,,,percent of total billed charges,90% of total Billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2306.36,80,,,Percent of total Billed charges,80% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2594.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2796.46,97,,,Percent of total billed charges,97% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2652.31,92,,,Percent of total billed charges,92% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2594.66,90,,,percent of total billed charges,90% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2018.07,70,,,percent of total billed charges,70% of total billed charges,2594.66,90,,,percent of total billed charges,90% of total billed charges,2738.8,95,,,percent of total billed charges,95% of total billed charges,2738.8,95,,,percent of total billed charges,95% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2479.34,86,,,percent of total billed charges,86% of total billed charges,2306.36,80,,,percent of total billed charges,80% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2796.46,97,,,percent of total billed charges,97% of total billed charges,2594.66,90,,,percent of total billed charges,90% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2796.46,97,,,percent of total billed charges,97% of total billed charges,2681.14,93,,,percent of total billed charges,93% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2796.46,97,,,percent of total billed charges,97% of total billed charges,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2882.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2018.07,2882.95,
47605 - PF Cholecystectomy w/ Cholangiography,4311843,CDM,960,RC,47605,HCPCS,Outpatient,,,2690.5,1345.25,,2421.45,90,,,percent of total billed charges,90% of total Billed charges,2278.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,2657.24,90,,,Percent of total Billed charges,90% of total billed charges,522,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1756.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1729.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1133.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1944.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1757.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1757.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,908.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2073.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1494.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1756.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,3531.4,155,,,Fee Schedule,155% of CMS OPPS Rate,3531.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,522,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,912.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,1989.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1989.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,522,3531.4,
47605- Cholecystectomy; with cholangiography,3622764,CDM,510,RC,47605,HCPCS,Outpatient,,,3045.49,1522.75,,2740.94,90,,,percent of total billed charges,90% of total Billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2436.39,80,,,Percent of total Billed charges,80% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2740.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2954.13,97,,,Percent of total billed charges,97% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.85,92,,,Percent of total billed charges,92% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2740.94,90,,,percent of total billed charges,90% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.84,70,,,percent of total billed charges,70% of total billed charges,2740.94,90,,,percent of total billed charges,90% of total billed charges,2893.22,95,,,percent of total billed charges,95% of total billed charges,2893.22,95,,,percent of total billed charges,95% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2619.12,86,,,percent of total billed charges,86% of total billed charges,2436.39,80,,,percent of total billed charges,80% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.13,97,,,percent of total billed charges,97% of total billed charges,2740.94,90,,,percent of total billed charges,90% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.13,97,,,percent of total billed charges,97% of total billed charges,2832.31,93,,,percent of total billed charges,93% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2954.13,97,,,percent of total billed charges,97% of total billed charges,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.84,3045.49,
47610 - PF Cholecystectomy w/ Exploration Common Duct,4311844,CDM,960,RC,47610,HCPCS,Outpatient,,,2993.62,1496.81,,2694.26,90,,,percent of total billed charges,90% of total Billed charges,2537.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1260.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1954.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1260.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1930.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1260.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2171.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2171.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1966.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1966.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1014.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1260.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2320.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1678.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1954.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1260.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,3932.95,155,,,Fee Schedule,155% of CMS OPPS Rate,3932.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1260.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,566.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1045.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1260.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,2543.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2543.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,566.5,3932.95,
47610- Cholecystectomy/explor common duct,3431269,CDM,510,RC,47610,HCPCS,Outpatient,,,3394.93,1697.47,,3055.44,90,,,percent of total billed charges,90% of total Billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2715.94,80,,,Percent of total Billed charges,80% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3055.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3293.08,97,,,Percent of total billed charges,97% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3123.34,92,,,Percent of total billed charges,92% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3055.44,90,,,percent of total billed charges,90% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2376.45,70,,,percent of total billed charges,70% of total billed charges,3055.44,90,,,percent of total billed charges,90% of total billed charges,3225.18,95,,,percent of total billed charges,95% of total billed charges,3225.18,95,,,percent of total billed charges,95% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2919.64,86,,,percent of total billed charges,86% of total billed charges,2715.94,80,,,percent of total billed charges,80% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3293.08,97,,,percent of total billed charges,97% of total billed charges,3055.44,90,,,percent of total billed charges,90% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3293.08,97,,,percent of total billed charges,97% of total billed charges,3157.28,93,,,percent of total billed charges,93% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3293.08,97,,,percent of total billed charges,97% of total billed charges,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3394.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2376.45,3394.93,
47612 - PF Cholecystectomy Expl Duct Choledochoenterostomy,4311845,CDM,960,RC,47612,HCPCS,Outpatient,,,3044.65,1522.33,,2740.19,90,,,percent of total billed charges,90% of total Billed charges,2580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1282.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,945,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1987.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1282.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1903.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1282.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2141.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2141.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2000.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2000.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1024.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1282.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2564.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2360.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1712.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1987.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1282.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,4000.3,155,,,Fee Schedule,155% of CMS OPPS Rate,4000.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1282.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,945,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1282.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1282.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2571.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2571.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,945,4000.3,
47620 - PF Cholecstc Expl Dux Sphntrotomy/ Sphnctrop,4311846,CDM,960,RC,47620,HCPCS,Outpatient,,,3290.61,1645.31,,2961.55,90,,,percent of total billed charges,90% of total Billed charges,2788.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1385.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2148.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1385.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2054.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1385.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2311.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2311.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2161.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2161.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1107.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1385.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2771.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2550.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1851.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2148.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1385.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4322.59,155,,,Fee Schedule,155% of CMS OPPS Rate,4322.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1385.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1178.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1385.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2796.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2796.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,4322.59,
47711- Bile duct tumor exc/extrahepatic,3431270,CDM,510,RC,47711,HCPCS,Outpatient,,,4204.59,2102.30,,3784.13,90,,,percent of total billed charges,90% of total Billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3363.67,80,,,Percent of total Billed charges,80% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3784.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4078.45,97,,,Percent of total billed charges,97% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3868.22,92,,,Percent of total billed charges,92% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3784.13,90,,,percent of total billed charges,90% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2943.21,70,,,percent of total billed charges,70% of total billed charges,3784.13,90,,,percent of total billed charges,90% of total billed charges,3994.36,95,,,percent of total billed charges,95% of total billed charges,3994.36,95,,,percent of total billed charges,95% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3615.95,86,,,percent of total billed charges,86% of total billed charges,3363.67,80,,,percent of total billed charges,80% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.45,97,,,percent of total billed charges,97% of total billed charges,3784.13,90,,,percent of total billed charges,90% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4078.45,97,,,percent of total billed charges,97% of total billed charges,3910.27,93,,,percent of total billed charges,93% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4078.45,97,,,percent of total billed charges,97% of total billed charges,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4204.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2943.21,4204.59,
47720 - PF Cholecystoenterostomy Direct,4311847,CDM,960,RC,47720,HCPCS,Outpatient,,,2751.07,1375.54,,2475.96,90,,,percent of total billed charges,90% of total Billed charges,2331.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1158.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1795.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1158.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1723.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1158.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1938.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1938.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1800.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1800.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,922.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2317.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2124.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1528.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1795.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1158.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,3613.14,155,,,Fee Schedule,155% of CMS OPPS Rate,3613.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1158.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1287.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1158.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2318.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2318.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,3613.14,
47721- PF Cholecystoenterostomy w/ Gastroenterostomy,4311848,CDM,960,RC,47721,HCPCS,Outpatient,,,3231.89,1615.95,,2908.7,90,,,percent of total billed charges,90% of total Billed charges,2738.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1361.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2109.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1361.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2021.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1361.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2273.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2273.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2117.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2117.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1092.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1361.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2722.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2499.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1804.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2109.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1361.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,4245.16,155,,,Fee Schedule,155% of CMS OPPS Rate,4245.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1361.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1190.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1361.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,2742.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2742.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,598.5,4245.16,
47740 - PF Cholecystoenterostomy Roux-En-Y,4311849,CDM,960,RC,47740,HCPCS,Outpatient,,,3129.98,1564.99,,2816.98,90,,,percent of total billed charges,90% of total Billed charges,2653.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1318.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2043.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1960.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1318.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2204.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2204.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2052.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2052.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1057,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1318.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2636.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2421.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1747.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2043.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4113.59,155,,,Fee Schedule,155% of CMS OPPS Rate,4113.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1318.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1061.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1318.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2656.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2656.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,4113.59,
47741 - PF Cholecstontrstm Roux-En-Y w/ Gastrontrstm,4311850,CDM,960,RC,47741,HCPCS,Outpatient,,,3522.28,1761.14,,3170.05,90,,,percent of total billed charges,90% of total Billed charges,2986.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1483.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2299.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1483.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2203.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1483.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2478,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2478,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2310.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2310.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1172.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1483.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2966.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2726.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1972.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2299.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1483.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,4628.61,155,,,Fee Schedule,155% of CMS OPPS Rate,4628.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1483.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1483.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2990.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2990.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4628.61,
47760 - PF Anast Xtrhepatc Biliary Ducts & GI Tract,4311852,CDM,960,RC,47760,HCPCS,Outpatient,,,5376.28,2688.14,,4838.65,90,,,percent of total billed charges,90% of total Billed charges,4553.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2264.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,781,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3509.6,155,,,Fee Schedule,155% of CMS OPPS Rate,2264.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3357.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2264.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3776.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3776.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3534.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3534.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1821.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2264.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4528.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4171.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3019.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3509.6,155,,,Fee Schedule,155% of CMS OPPS Rate,2264.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,7058.08,155,,,Fee Schedule,155% of CMS OPPS Rate,7058.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2264.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,781,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2095.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2264.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4579.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4579.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,781,7058.08,
47760- Anastamo/extrahep bil duct/gi trac,3431271,CDM,510,RC,47760,HCPCS,Outpatient,,,6088.1,3044.05,,5479.29,90,,,percent of total billed charges,90% of total Billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4870.48,80,,,Percent of total Billed charges,80% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5479.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5905.46,97,,,Percent of total billed charges,97% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5601.05,92,,,Percent of total billed charges,92% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5479.29,90,,,percent of total billed charges,90% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4261.67,70,,,percent of total billed charges,70% of total billed charges,5479.29,90,,,percent of total billed charges,90% of total billed charges,5783.7,95,,,percent of total billed charges,95% of total billed charges,5783.7,95,,,percent of total billed charges,95% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5235.77,86,,,percent of total billed charges,86% of total billed charges,4870.48,80,,,percent of total billed charges,80% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5905.46,97,,,percent of total billed charges,97% of total billed charges,5479.29,90,,,percent of total billed charges,90% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5905.46,97,,,percent of total billed charges,97% of total billed charges,5661.93,93,,,percent of total billed charges,93% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5905.46,97,,,percent of total billed charges,97% of total billed charges,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6088.1,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4261.67,6088.1,
47765 - PF Anast Intrahepatc Ducts & GI Tract,4311853,CDM,960,RC,47765,HCPCS,Outpatient,,,7044.42,3522.21,,6339.98,90,,,percent of total billed charges,90% of total Billed charges,6062.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2966.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,784,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,4598.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2966.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4538.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2966.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5104.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5104.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,4792.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,4792.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2458.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2966.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5933.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5655.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,4134.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,4598.56,155,,,Fee Schedule,155% of CMS OPPS Rate,2966.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,9397.19,155,,,Fee Schedule,155% of CMS OPPS Rate,9397.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2966.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,784,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2744.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2966.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,6175.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,6175.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,784,9397.19,
47780 - PF Anast Roux-En-Y Xtrhepatc Biliary Ducts & GI,4311854,CDM,960,RC,47780,HCPCS,Outpatient,,,5914.54,2957.27,,5323.09,90,,,percent of total billed charges,90% of total Billed charges,5006.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2490.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,825.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3860.99,155,,,Fee Schedule,155% of CMS OPPS Rate,2490.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3688.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2490.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4148.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4148.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3885.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3885.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2000.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2490.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4981.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4584.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3323.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3860.99,155,,,Fee Schedule,155% of CMS OPPS Rate,2490.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,7760.26,155,,,Fee Schedule,155% of CMS OPPS Rate,7760.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2490.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,825.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2289.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2490.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,5021.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,5021.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,825.5,7760.26,
47780- Anastamo/Roux-en-Y/extrahep bil/gi,3431272,CDM,510,RC,47780,HCPCS,Outpatient,,,6689.99,3345.00,,6020.99,90,,,percent of total billed charges,90% of total Billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5351.99,80,,,Percent of total Billed charges,80% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6020.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6489.29,97,,,Percent of total billed charges,97% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6154.79,92,,,Percent of total billed charges,92% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6020.99,90,,,percent of total billed charges,90% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.99,70,,,percent of total billed charges,70% of total billed charges,6020.99,90,,,percent of total billed charges,90% of total billed charges,6355.49,95,,,percent of total billed charges,95% of total billed charges,6355.49,95,,,percent of total billed charges,95% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5753.39,86,,,percent of total billed charges,86% of total billed charges,5351.99,80,,,percent of total billed charges,80% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6489.29,97,,,percent of total billed charges,97% of total billed charges,6020.99,90,,,percent of total billed charges,90% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6489.29,97,,,percent of total billed charges,97% of total billed charges,6221.69,93,,,percent of total billed charges,93% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6489.29,97,,,percent of total billed charges,97% of total billed charges,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6689.99,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.99,6689.99,
47785 - PF Anast Roux-En-Y Intrahepatc Biliary Ducts & GI,4311855,CDM,960,RC,47785,HCPCS,Outpatient,,,7746.96,3873.48,,6972.26,90,,,percent of total billed charges,90% of total Billed charges,6545.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3262.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,5057.19,155,,,Fee Schedule,155% of CMS OPPS Rate,3262.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4848.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3262.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5452.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5452.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5118.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5118.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2621.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3262.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6525.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6039.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,4398.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,5057.19,155,,,Fee Schedule,155% of CMS OPPS Rate,3262.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,10145.6,155,,,Fee Schedule,155% of CMS OPPS Rate,10145.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,3262.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2979.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3262.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,6594.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,6594.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,10145.6,
Read,4181204,CDM,972,RC,48102,HCPCS,Outpatient,,,509.47,254.74,,458.52,90,,,percent of total billed charges,90% of total Billed charges,724.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.95,155,,,Fee Schedule,155% of CMS OPPS Rate,230.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,410.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,366.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,366.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,431.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,356.95,155,,,Fee Schedule,155% of CMS OPPS Rate,230.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1122.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1043.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,192.44,1122.77,
"48140 - (PF) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticoj",3635077,CDM,510,RC,48140,HCPCS,Outpatient,,,4222.05,2111.03,,3799.85,90,,,percent of total billed charges,90% of total Billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.64,80,,,Percent of total Billed charges,80% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3799.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4095.39,97,,,Percent of total billed charges,97% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3884.29,92,,,Percent of total billed charges,92% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3799.85,90,,,percent of total billed charges,90% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2955.44,70,,,percent of total billed charges,70% of total billed charges,3799.85,90,,,percent of total billed charges,90% of total billed charges,4010.95,95,,,percent of total billed charges,95% of total billed charges,4010.95,95,,,percent of total billed charges,95% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3630.96,86,,,percent of total billed charges,86% of total billed charges,3377.64,80,,,percent of total billed charges,80% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4095.39,97,,,percent of total billed charges,97% of total billed charges,3799.85,90,,,percent of total billed charges,90% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4095.39,97,,,percent of total billed charges,97% of total billed charges,3926.51,93,,,percent of total billed charges,93% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4095.39,97,,,percent of total billed charges,97% of total billed charges,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4222.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2955.44,4222.05,
48153- Pancreatectomy,3431273,CDM,510,RC,48153,HCPCS,Outpatient,,,8401.14,4200.57,,7561.03,90,,,percent of total billed charges,90% of total Billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6720.91,80,,,Percent of total Billed charges,80% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7561.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8149.11,97,,,Percent of total billed charges,97% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7729.05,92,,,Percent of total billed charges,92% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7561.03,90,,,percent of total billed charges,90% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5880.8,70,,,percent of total billed charges,70% of total billed charges,7561.03,90,,,percent of total billed charges,90% of total billed charges,7981.08,95,,,percent of total billed charges,95% of total billed charges,7981.08,95,,,percent of total billed charges,95% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7224.98,86,,,percent of total billed charges,86% of total billed charges,6720.91,80,,,percent of total billed charges,80% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8149.11,97,,,percent of total billed charges,97% of total billed charges,7561.03,90,,,percent of total billed charges,90% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8149.11,97,,,percent of total billed charges,97% of total billed charges,7813.06,93,,,percent of total billed charges,93% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,8149.11,97,,,percent of total billed charges,97% of total billed charges,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,8401.14,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5880.8,8401.14,
49000 - PF Exploratory Laparotomy Celiotomy w/ wo Bx Spx,4311856,CDM,960,RC,49000,HCPCS,Outpatient,,,1824.44,912.22,,1642,90,,,percent of total billed charges,90% of total Billed charges,1545.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,768.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1806.99,90,,,Percent of total Billed charges,90% of total billed charges,333,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1190.97,155,,,Fee Schedule,155% of CMS OPPS Rate,768.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1179.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,768.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1326.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1326.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1195.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1195.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,621.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1536.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1410.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1004.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1190.97,155,,,Fee Schedule,155% of CMS OPPS Rate,768.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2394.77,155,,,Fee Schedule,155% of CMS OPPS Rate,2394.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,768.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,333,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,722.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,768.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1558.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1558.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,333,2394.77,
49000-PF EXPLORATION OF ABDOMEN,3430004,CDM,510,RC,49000,HCPCS,Outpatient,,,2065.34,1032.67,,1858.81,90,,,percent of total billed charges,90% of total Billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1652.27,80,,,Percent of total Billed charges,80% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1858.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2003.38,97,,,Percent of total billed charges,97% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1900.11,92,,,Percent of total billed charges,92% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1858.81,90,,,percent of total billed charges,90% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1445.74,70,,,percent of total billed charges,70% of total billed charges,1858.81,90,,,percent of total billed charges,90% of total billed charges,1962.07,95,,,percent of total billed charges,95% of total billed charges,1962.07,95,,,percent of total billed charges,95% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1776.19,86,,,percent of total billed charges,86% of total billed charges,1652.27,80,,,percent of total billed charges,80% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2003.38,97,,,percent of total billed charges,97% of total billed charges,1858.81,90,,,percent of total billed charges,90% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2003.38,97,,,percent of total billed charges,97% of total billed charges,1920.77,93,,,percent of total billed charges,93% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2003.38,97,,,percent of total billed charges,97% of total billed charges,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2065.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1445.74,2065.34,
49002 - PF Reopening of recent laparotomy,3715139,CDM,510,RC,49002,HCPCS,Outpatient,,,2813.09,1406.55,,2531.78,90,,,percent of total billed charges,90% of total Billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2250.47,80,,,Percent of total Billed charges,80% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2531.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2728.7,97,,,Percent of total billed charges,97% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2588.04,92,,,Percent of total billed charges,92% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2531.78,90,,,percent of total billed charges,90% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1969.16,70,,,percent of total billed charges,70% of total billed charges,2531.78,90,,,percent of total billed charges,90% of total billed charges,2672.44,95,,,percent of total billed charges,95% of total billed charges,2672.44,95,,,percent of total billed charges,95% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2419.26,86,,,percent of total billed charges,86% of total billed charges,2250.47,80,,,percent of total billed charges,80% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2728.7,97,,,percent of total billed charges,97% of total billed charges,2531.78,90,,,percent of total billed charges,90% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2728.7,97,,,percent of total billed charges,97% of total billed charges,2616.17,93,,,percent of total billed charges,93% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2728.7,97,,,percent of total billed charges,97% of total billed charges,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2813.09,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1969.16,2813.09,
49002 - PF Reopening Recent Lapartomy,4311857,CDM,960,RC,49002,HCPCS,Outpatient,,,2484.17,1242.09,,2235.75,90,,,percent of total billed charges,90% of total Billed charges,2104.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1046.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,333,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1621.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1046.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1604.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1046.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1804.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1804.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1633.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1633.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,844.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1046.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2092.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1927.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1382.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1621.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1046.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,3261.25,155,,,Fee Schedule,155% of CMS OPPS Rate,3261.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1046.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,333,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,939.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1046.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2122.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2122.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,333,3261.25,
49010 - PF Expl Retroperitoneum w/ wo Bx Spx,4311858,CDM,960,RC,49010,HCPCS,Outpatient,,,2199.52,1099.76,,1979.57,90,,,percent of total billed charges,90% of total Billed charges,1864.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,926.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,424.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1435.84,155,,,Fee Schedule,155% of CMS OPPS Rate,926.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1417.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,926.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1594.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1594.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1444.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1444.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,753.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1852.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1704.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1216.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1435.84,155,,,Fee Schedule,155% of CMS OPPS Rate,926.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2889.6,155,,,Fee Schedule,155% of CMS OPPS Rate,2889.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,926.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,890.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,926.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1912.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1912.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,424.5,2889.6,
49010- Retroperitoneal exploration,3431274,CDM,510,RC,49010,HCPCS,Outpatient,,,2494.23,1247.12,,2244.81,90,,,percent of total billed charges,90% of total Billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1995.38,80,,,Percent of total Billed charges,80% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2419.4,97,,,Percent of total billed charges,97% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2294.69,92,,,Percent of total billed charges,92% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2244.81,90,,,percent of total billed charges,90% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1745.96,70,,,percent of total billed charges,70% of total billed charges,2244.81,90,,,percent of total billed charges,90% of total billed charges,2369.52,95,,,percent of total billed charges,95% of total billed charges,2369.52,95,,,percent of total billed charges,95% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2145.04,86,,,percent of total billed charges,86% of total billed charges,1995.38,80,,,percent of total billed charges,80% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2419.4,97,,,percent of total billed charges,97% of total billed charges,2244.81,90,,,percent of total billed charges,90% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2419.4,97,,,percent of total billed charges,97% of total billed charges,2319.63,93,,,percent of total billed charges,93% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2419.4,97,,,percent of total billed charges,97% of total billed charges,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2494.23,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1745.96,2494.23,
"49020 - Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, o",3783250,CDM,510,RC,49020,HCPCS,Outpatient,,,4288.59,2144.30,,3859.73,90,,,percent of total billed charges,90% of total Billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3430.87,80,,,Percent of total Billed charges,80% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3859.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4159.93,97,,,Percent of total billed charges,97% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3945.5,92,,,Percent of total billed charges,92% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3859.73,90,,,percent of total billed charges,90% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.01,70,,,percent of total billed charges,70% of total billed charges,3859.73,90,,,percent of total billed charges,90% of total billed charges,4074.16,95,,,percent of total billed charges,95% of total billed charges,4074.16,95,,,percent of total billed charges,95% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3688.19,86,,,percent of total billed charges,86% of total billed charges,3430.87,80,,,percent of total billed charges,80% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4159.93,97,,,percent of total billed charges,97% of total billed charges,3859.73,90,,,percent of total billed charges,90% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4159.93,97,,,percent of total billed charges,97% of total billed charges,3988.39,93,,,percent of total billed charges,93% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4159.93,97,,,percent of total billed charges,97% of total billed charges,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4288.59,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3002.01,4288.59,
49020 - PF Drainage Periton Abscess/ Local Peritonitis Open,4311859,CDM,960,RC,49020,HCPCS,Outpatient,,,3785.18,1892.59,,3406.66,90,,,percent of total billed charges,90% of total Billed charges,3206.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1594.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,259.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2470.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1594.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2369.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1594.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2665.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2665.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2482.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2482.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1285.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1594.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3188.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2929.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2091.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2470.95,155,,,Fee Schedule,155% of CMS OPPS Rate,1594.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,4970.57,155,,,Fee Schedule,155% of CMS OPPS Rate,4970.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1594.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1479.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1594.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,3225.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3225.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,259.5,4970.57,
"49060 - (PF) Drainage of retroperitoneal abscess, open",3635078,CDM,510,RC,49060,HCPCS,Outpatient,,,2954.19,1477.10,,2658.77,90,,,percent of total billed charges,90% of total Billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.35,80,,,Percent of total Billed charges,80% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2658.77,90,,,Percent of total Billed charges,90% of total billed charges,293.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2865.56,97,,,Percent of total billed charges,97% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2717.85,92,,,Percent of total billed charges,92% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2658.77,90,,,percent of total billed charges,90% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2067.93,70,,,percent of total billed charges,70% of total billed charges,2658.77,90,,,percent of total billed charges,90% of total billed charges,2806.48,95,,,percent of total billed charges,95% of total billed charges,2806.48,95,,,percent of total billed charges,95% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2540.6,86,,,percent of total billed charges,86% of total billed charges,2363.35,80,,,percent of total billed charges,80% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2865.56,97,,,percent of total billed charges,97% of total billed charges,2658.77,90,,,percent of total billed charges,90% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2865.56,97,,,percent of total billed charges,97% of total billed charges,2747.4,93,,,percent of total billed charges,93% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,266.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2865.56,97,,,percent of total billed charges,97% of total billed charges,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,266.5,2954.19,
49082 - PF Abd Paracentesis Dx/ Ther w/o Imaging Guid,4311860,CDM,960,RC,49082,HCPCS,Outpatient,,,169.65,84.83,,152.69,90,,,percent of total billed charges,90% of total Billed charges,241.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.69,155,,,Fee Schedule,155% of CMS OPPS Rate,373.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.53,373.69,
49082- Abd paracentesis/w/o image guide,3431275,CDM,510,RC,49082,HCPCS,Outpatient,,,533.82,266.91,,480.44,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,427.06,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.44,90,,,Percent of total Billed charges,90% of total billed charges,59.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,517.81,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,491.11,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,480.44,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,373.67,70,,,percent of total billed charges,70% of total billed charges,480.44,90,,,percent of total billed charges,90% of total billed charges,507.13,95,,,percent of total billed charges,95% of total billed charges,507.13,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.09,86,,,percent of total billed charges,86% of total billed charges,427.06,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,517.81,97,,,percent of total billed charges,97% of total billed charges,480.44,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.81,97,,,percent of total billed charges,97% of total billed charges,496.45,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,517.81,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.53,4024.46,
49082-PF ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,4321473,CDM,981,RC,49082,HCPCS,Outpatient,,,142.9,71.45,,128.61,90,,,percent of total billed charges,90% of total Billed charges,214.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.23,155,,,Fee Schedule,155% of CMS OPPS Rate,332.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.53,332.23,
PHY-ABDOMINAL PARACENTESIS W/O IMG GUIDE,3428504,CDM,981,RC,49082,HCPCS,Outpatient,,,533.82,266.91,,480.44,90,,,percent of total billed charges,90% of total Billed charges,272.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,110.73,155,,,Fee Schedule,155% of CMS OPPS Rate,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,421.86,155,,,Fee Schedule,155% of CMS OPPS Rate,421.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.53,480.44,
49083- Abd paracentesis/w image guide,3431276,CDM,360,RC,49083,HCPCS,Outpatient,,,740.36,370.18,,666.32,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,592.29,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.32,90,,,Percent of total Billed charges,90% of total billed charges,92.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,718.15,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,681.13,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,666.32,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,518.25,70,,,percent of total billed charges,70% of total billed charges,666.32,90,,,percent of total billed charges,90% of total billed charges,703.34,95,,,percent of total billed charges,95% of total billed charges,703.34,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,636.71,86,,,percent of total billed charges,86% of total billed charges,592.29,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,718.15,97,,,percent of total billed charges,97% of total billed charges,666.32,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,718.15,97,,,percent of total billed charges,97% of total billed charges,688.53,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,718.15,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,84.33,4024.46,
49083-PF ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE,4321623,CDM,981,RC,49083,HCPCS,Outpatient,,,206.06,103.03,,185.45,90,,,percent of total billed charges,90% of total Billed charges,309.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,121.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,479.07,155,,,Fee Schedule,155% of CMS OPPS Rate,479.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.33,479.07,
CT add Paracentesis,645112,CDM,360,RC,49083,HCPCS,Outpatient,,,715.55,357.78,,644,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,572.44,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,644,90,,,Percent of total Billed charges,90% of total billed charges,92.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,694.08,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,658.31,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,644,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,500.89,70,,,percent of total billed charges,70% of total billed charges,644,90,,,percent of total billed charges,90% of total billed charges,679.77,95,,,percent of total billed charges,95% of total billed charges,679.77,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,615.37,86,,,percent of total billed charges,86% of total billed charges,572.44,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,694.08,97,,,percent of total billed charges,97% of total billed charges,644,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.08,97,,,percent of total billed charges,97% of total billed charges,665.46,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,694.08,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,84.33,4024.46,
Read,2964107,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,257.6,90,,,percent of total billed charges,90% of total Billed charges,381.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,121.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.2,155,,,Fee Schedule,155% of CMS OPPS Rate,591.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.33,591.2,
Read,3318437,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,257.6,90,,,percent of total billed charges,90% of total Billed charges,381.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,121.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.2,155,,,Fee Schedule,155% of CMS OPPS Rate,591.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.33,591.2,
Read,3318471,CDM,972,RC,49083,HCPCS,Outpatient,,,286.22,143.11,,257.6,90,,,percent of total billed charges,90% of total Billed charges,381.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,121.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.68,155,,,Fee Schedule,155% of CMS OPPS Rate,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.2,155,,,Fee Schedule,155% of CMS OPPS Rate,591.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.33,591.2,
US add Paracentesis,645148,CDM,360,RC,49083,HCPCS,Outpatient,,,715.55,357.78,,644,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,572.44,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,644,90,,,Percent of total Billed charges,90% of total billed charges,92.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,694.08,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,658.31,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,644,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,500.89,70,,,percent of total billed charges,70% of total billed charges,644,90,,,percent of total billed charges,90% of total billed charges,679.77,95,,,percent of total billed charges,95% of total billed charges,679.77,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,615.37,86,,,percent of total billed charges,86% of total billed charges,572.44,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,694.08,97,,,percent of total billed charges,97% of total billed charges,644,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.08,97,,,percent of total billed charges,97% of total billed charges,665.46,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,694.08,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,84.33,4024.46,
"49084 - (PF) Peritoneal lavage, including imaging guidance, when performed",3635079,CDM,510,RC,49084,HCPCS,Outpatient,,,288.8,144.40,,259.92,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,231.04,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.92,90,,,Percent of total Billed charges,90% of total billed charges,85.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,280.14,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,265.7,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,259.92,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,202.16,70,,,percent of total billed charges,70% of total billed charges,259.92,90,,,percent of total billed charges,90% of total billed charges,274.36,95,,,percent of total billed charges,95% of total billed charges,274.36,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,248.37,86,,,percent of total billed charges,86% of total billed charges,231.04,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,280.14,97,,,percent of total billed charges,97% of total billed charges,259.92,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.14,97,,,percent of total billed charges,97% of total billed charges,268.58,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.14,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77.62,4024.46,
49084-PF PERITONEAL LAVAGE W/WO IMAGING GUIDANCE,4321474,CDM,981,RC,49084,HCPCS,Outpatient,,,216.44,108.22,,194.8,90,,,percent of total billed charges,90% of total Billed charges,216.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,167.73,155,,,Fee Schedule,155% of CMS OPPS Rate,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,145.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.73,155,,,Fee Schedule,155% of CMS OPPS Rate,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,336.04,155,,,Fee Schedule,155% of CMS OPPS Rate,336.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.62,336.04,
CT add Needle Bx Abdominal Mass,645126,CDM,360,RC,49180,HCPCS,Outpatient,,,433.75,216.88,,390.38,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,347,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.38,90,,,Percent of total Billed charges,90% of total billed charges,89.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,420.74,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,399.05,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,390.38,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,303.63,70,,,percent of total billed charges,70% of total billed charges,390.38,90,,,percent of total billed charges,90% of total billed charges,412.06,95,,,percent of total billed charges,95% of total billed charges,412.06,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,373.03,86,,,percent of total billed charges,86% of total billed charges,347,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,420.74,97,,,percent of total billed charges,97% of total billed charges,390.38,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.74,97,,,percent of total billed charges,97% of total billed charges,403.39,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,420.74,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.97,7310.49,
Read,4181190,CDM,972,RC,49180,HCPCS,Outpatient,,,173.5,86.75,,156.15,90,,,percent of total billed charges,90% of total Billed charges,247.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,94.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,383.19,155,,,Fee Schedule,155% of CMS OPPS Rate,383.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,621.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,307.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.95,621.37,
49203-PF EXC ABD TUM 5CM OR LESS,3430008,CDM,510,RC,49203,HCPCS,Outpatient,,,3207.18,1603.59,,2886.46,90,,,percent of total billed charges,90% of total Billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2565.74,80,,,Percent of total Billed charges,80% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2886.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3110.96,97,,,Percent of total billed charges,97% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2950.61,92,,,Percent of total billed charges,92% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2886.46,90,,,percent of total billed charges,90% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2245.03,70,,,percent of total billed charges,70% of total billed charges,2886.46,90,,,percent of total billed charges,90% of total billed charges,3046.82,95,,,percent of total billed charges,95% of total billed charges,3046.82,95,,,percent of total billed charges,95% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2758.17,86,,,percent of total billed charges,86% of total billed charges,2565.74,80,,,percent of total billed charges,80% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3110.96,97,,,percent of total billed charges,97% of total billed charges,2886.46,90,,,percent of total billed charges,90% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3110.96,97,,,percent of total billed charges,97% of total billed charges,2982.68,93,,,percent of total billed charges,93% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3110.96,97,,,percent of total billed charges,97% of total billed charges,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3207.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2245.03,3207.18,
49204 - PF EXC ABD TUM OVER 5 CM,3527860,CDM,960,RC,49204,HCPCS,Outpatient,,,4079.6,2039.80,,3671.64,90,,,percent of total billed charges,90% of total Billed charges,3056.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1522.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1039.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2359.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1522.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2330.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1522.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2621.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2621.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2365.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2365.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1237.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1522.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3044.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2791.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1966.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2359.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1522.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,4737.48,155,,,Fee Schedule,155% of CMS OPPS Rate,4737.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1522.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1446.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1522.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,3083.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3083.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1039.94,4737.48,
49205-PF EXC ABD TUM OVER 10CM,3430010,CDM,510,RC,49205,HCPCS,Outpatient,,,4682.57,2341.29,,4214.31,90,,,percent of total billed charges,90% of total Billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3746.06,80,,,Percent of total Billed charges,80% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4214.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4542.09,97,,,Percent of total billed charges,97% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4307.96,92,,,Percent of total billed charges,92% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4214.31,90,,,percent of total billed charges,90% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3277.8,70,,,percent of total billed charges,70% of total billed charges,4214.31,90,,,percent of total billed charges,90% of total billed charges,4448.44,95,,,percent of total billed charges,95% of total billed charges,4448.44,95,,,percent of total billed charges,95% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4027.01,86,,,percent of total billed charges,86% of total billed charges,3746.06,80,,,percent of total billed charges,80% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4542.09,97,,,percent of total billed charges,97% of total billed charges,4214.31,90,,,percent of total billed charges,90% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4542.09,97,,,percent of total billed charges,97% of total billed charges,4354.79,93,,,percent of total billed charges,93% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4542.09,97,,,percent of total billed charges,97% of total billed charges,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4682.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3277.8,4682.57,
49250-PF EXCISION OF UMBILICUS,3430012,CDM,510,RC,49250,HCPCS,Outpatient,,,1580.44,790.22,,1422.4,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1264.35,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1422.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1533.03,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1454,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1422.4,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1106.31,70,,,percent of total billed charges,70% of total billed charges,1422.4,90,,,percent of total billed charges,90% of total billed charges,1501.42,95,,,percent of total billed charges,95% of total billed charges,1501.42,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1359.18,86,,,percent of total billed charges,86% of total billed charges,1264.35,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1533.03,97,,,percent of total billed charges,97% of total billed charges,1422.4,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1533.03,97,,,percent of total billed charges,97% of total billed charges,1469.81,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1533.03,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1106.31,17267.34,
"49255 - (PF) Omentectomy, epiploectomy, resection of omentum (separate proc",3635080,CDM,510,RC,49255,HCPCS,Outpatient,,,2105.96,1052.98,,1895.36,90,,,percent of total billed charges,90% of total Billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1684.77,80,,,Percent of total Billed charges,80% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1895.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2042.78,97,,,Percent of total billed charges,97% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1937.48,92,,,Percent of total billed charges,92% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1895.36,90,,,percent of total billed charges,90% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1474.17,70,,,percent of total billed charges,70% of total billed charges,1895.36,90,,,percent of total billed charges,90% of total billed charges,2000.66,95,,,percent of total billed charges,95% of total billed charges,2000.66,95,,,percent of total billed charges,95% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1811.13,86,,,percent of total billed charges,86% of total billed charges,1684.77,80,,,percent of total billed charges,80% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2042.78,97,,,percent of total billed charges,97% of total billed charges,1895.36,90,,,percent of total billed charges,90% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2042.78,97,,,percent of total billed charges,97% of total billed charges,1958.54,93,,,percent of total billed charges,93% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2042.78,97,,,percent of total billed charges,97% of total billed charges,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2105.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1474.17,2105.96,
49320 - PF Laps Abd Prtm & Omentum Dx w/ wo Spec Br/Wa Spx,4311861,CDM,960,RC,49320,HCPCS,Outpatient,,,777.35,388.68,,699.62,90,,,percent of total billed charges,90% of total Billed charges,657.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.74,90,,,Percent of total Billed charges,90% of total billed charges,281.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,507.44,155,,,Fee Schedule,155% of CMS OPPS Rate,327.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,565.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,506.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,506.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,262.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,597.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,421.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,507.44,155,,,Fee Schedule,155% of CMS OPPS Rate,327.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1018.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1018.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,327.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,336.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,327.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,660.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,262.28,1018.66,
49320-PF DIAG LAPARO,3430014,CDM,510,RC,49320,HCPCS,Outpatient,,,877.13,438.57,,789.42,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,701.7,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,789.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,850.82,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,806.96,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,789.42,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,613.99,70,,,percent of total billed charges,70% of total billed charges,789.42,90,,,percent of total billed charges,90% of total billed charges,833.27,95,,,percent of total billed charges,95% of total billed charges,833.27,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,754.33,86,,,percent of total billed charges,86% of total billed charges,701.7,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,850.82,97,,,percent of total billed charges,97% of total billed charges,789.42,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,850.82,97,,,percent of total billed charges,97% of total billed charges,815.73,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,850.82,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,613.99,25409.89,
49321 - PF Laparoscopy Surg w/ Bx Sngl/Mult,4311862,CDM,960,RC,49321,HCPCS,Outpatient,,,813.9,406.95,,732.51,90,,,percent of total billed charges,90% of total Billed charges,688.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.22,90,,,Percent of total Billed charges,90% of total billed charges,294.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,531.31,155,,,Fee Schedule,155% of CMS OPPS Rate,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,594.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,531.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,531.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,278.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,531.31,155,,,Fee Schedule,155% of CMS OPPS Rate,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1066.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,701.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,701.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.08,1066.82,
"49321-PF LAPAROSCOPY, BIOPSY",3430016,CDM,510,RC,49321,HCPCS,Outpatient,,,918.78,459.39,,826.9,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,735.02,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,826.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,891.22,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,845.28,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,826.9,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,643.15,70,,,percent of total billed charges,70% of total billed charges,826.9,90,,,percent of total billed charges,90% of total billed charges,872.84,95,,,percent of total billed charges,95% of total billed charges,872.84,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,790.15,86,,,percent of total billed charges,86% of total billed charges,735.02,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,891.22,97,,,percent of total billed charges,97% of total billed charges,826.9,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,891.22,97,,,percent of total billed charges,97% of total billed charges,854.47,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,891.22,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,643.15,25409.89,
49322 - PF Laps Surg w/ Aspir Cavity/Cyst Sngl/Mult,4311863,CDM,960,RC,49322,HCPCS,Outpatient,,,889.21,444.61,,800.29,90,,,percent of total billed charges,90% of total Billed charges,752.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,374.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,872.62,90,,,Percent of total Billed charges,90% of total billed charges,323.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,580.46,155,,,Fee Schedule,155% of CMS OPPS Rate,374.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,374.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,643.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,577.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,577.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,296.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,748.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,681,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,479.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,580.46,155,,,Fee Schedule,155% of CMS OPPS Rate,374.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1165.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1165.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,374.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,374.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,750.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,296.98,1165.76,
"49322-PF LAPAROSCOPY, ASPIRATION",3430018,CDM,510,RC,49322,HCPCS,Outpatient,,,1004.19,502.10,,903.77,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,803.35,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,903.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,974.06,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,923.85,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,903.77,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,702.93,70,,,percent of total billed charges,70% of total billed charges,903.77,90,,,percent of total billed charges,90% of total billed charges,953.98,95,,,percent of total billed charges,95% of total billed charges,953.98,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,863.6,86,,,percent of total billed charges,86% of total billed charges,803.35,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,974.06,97,,,percent of total billed charges,97% of total billed charges,903.77,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.06,97,,,percent of total billed charges,97% of total billed charges,933.9,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,974.06,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,702.93,25409.89,
"49323 - Laparoscopy, surgical; w/ drainage of lymophocele to",4241829,CDM,960,RC,49323,HCPCS,Outpatient,,,1346.37,673.19,,1211.73,90,,,percent of total billed charges,90% of total Billed charges,1272.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,501.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.36,155,,,Fee Schedule,155% of CMS OPPS Rate,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1105.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1105.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,992.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,992.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1170.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,828.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.36,155,,,Fee Schedule,155% of CMS OPPS Rate,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1972.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1972.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,501.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,833.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1309,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1309,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,501.17,1972.22,
49323 - PF Laps Surg w/ Drg Lymohocele Prtl Cavity,4311864,CDM,960,RC,49323,HCPCS,Outpatient,,,1507.93,753.97,,1357.14,90,,,percent of total billed charges,90% of total Billed charges,1272.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,501.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.36,155,,,Fee Schedule,155% of CMS OPPS Rate,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,982.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1105.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1105.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,992.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,992.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1170.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,828.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.36,155,,,Fee Schedule,155% of CMS OPPS Rate,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1972.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1972.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,501.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,833.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,635.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1309,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1309,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,501.17,1972.22,
"49324 - Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter",3572809,CDM,960,RC,49324,HCPCS,Outpatient,,,1044.66,522.33,,940.19,90,,,percent of total billed charges,90% of total Billed charges,781.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,388.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,265.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,602.83,155,,,Fee Schedule,155% of CMS OPPS Rate,388.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,388.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,672.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,606.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,606.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,314.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,777.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,715.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,514.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,602.83,155,,,Fee Schedule,155% of CMS OPPS Rate,388.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,388.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,391.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,388.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,799.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,799.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,265.29,1211.71,
49325-PF LAP REVISION PERM IP CATH,3430020,CDM,510,RC,49325,HCPCS,Outpatient,,,1117.95,558.98,,1006.16,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,894.36,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1084.41,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1028.51,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1006.16,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,782.57,70,,,percent of total billed charges,70% of total billed charges,1006.16,90,,,percent of total billed charges,90% of total billed charges,1062.05,95,,,percent of total billed charges,95% of total billed charges,1062.05,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,961.44,86,,,percent of total billed charges,86% of total billed charges,894.36,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1084.41,97,,,percent of total billed charges,97% of total billed charges,1006.16,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1084.41,97,,,percent of total billed charges,97% of total billed charges,1039.69,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1084.41,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,782.57,25409.89,
"49326 - (PF) Laparoscopy, surgical; with omentopexy (omental tacking procedure)",3635081,CDM,510,RC,49326,HCPCS,Outpatient,,,516.55,258.28,,464.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,413.24,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,464.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,501.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,475.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,329.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,406.28,78.65,,,percent of total billed charges,78.65% of total billed charges,461.44,89.33,,,percent of total billed charges,89.33% of total billed charges,464.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,361.59,70,,,percent of total billed charges,70% of total billed charges,464.9,90,,,percent of total billed charges,90% of total billed charges,490.72,95,,,percent of total billed charges,95% of total billed charges,490.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.23,86,,,percent of total billed charges,86% of total billed charges,413.24,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,501.05,97,,,percent of total billed charges,97% of total billed charges,464.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,501.05,97,,,percent of total billed charges,97% of total billed charges,480.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.88,501.05,
49329 - PF Unlisted Laparoscopy Px Abd Pertoneum & Omentum,4311865,CDM,960,RC,49329,HCPCS,Outpatient,,,1068.48,534.24,,961.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,961.63,
"49329-MA AST UNLISTED LAP ABD,PERIT,OMENT",3430021,CDM,510,RC,49329,HCPCS,Outpatient,,,461.21,230.61,,415.09,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,368.97,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,415.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,447.37,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,424.31,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,415.09,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,322.85,70,,,percent of total billed charges,70% of total billed charges,415.09,90,,,percent of total billed charges,90% of total billed charges,438.15,95,,,percent of total billed charges,95% of total billed charges,438.15,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,396.64,86,,,percent of total billed charges,86% of total billed charges,368.97,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,447.37,97,,,percent of total billed charges,97% of total billed charges,415.09,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,447.37,97,,,percent of total billed charges,97% of total billed charges,428.93,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,447.37,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,322.85,25409.89,
Periotoneal Port Rad inj/sup,3402664,CDM,320,RC,49400,HCPCS,Outpatient,,,377.68,188.84,,339.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,302.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,339.91,90,,,Percent of total Billed charges,90% of total billed charges,52.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,366.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,347.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,241.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,297.05,78.65,,,percent of total billed charges,78.65% of total billed charges,337.39,89.33,,,percent of total billed charges,89.33% of total billed charges,339.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,264.38,70,,,percent of total billed charges,70% of total billed charges,339.91,90,,,percent of total billed charges,90% of total billed charges,358.8,95,,,percent of total billed charges,95% of total billed charges,358.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.8,86,,,percent of total billed charges,86% of total billed charges,302.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,366.35,97,,,percent of total billed charges,97% of total billed charges,339.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,366.35,97,,,percent of total billed charges,97% of total billed charges,351.24,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48,366.35,
49402- Removal peritoneal FB from peritoneal cavity,3569395,CDM,510,RC,49402,HCPCS,Outpatient,,,2297.42,1148.71,,2067.68,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1837.94,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2067.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2228.5,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,2113.63,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2067.68,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1608.19,70,,,percent of total billed charges,70% of total billed charges,2067.68,90,,,percent of total billed charges,90% of total billed charges,2182.55,95,,,percent of total billed charges,95% of total billed charges,2182.55,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1975.78,86,,,percent of total billed charges,86% of total billed charges,1837.94,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2228.5,97,,,percent of total billed charges,97% of total billed charges,2067.68,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2228.5,97,,,percent of total billed charges,97% of total billed charges,2136.6,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2228.5,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1608.19,17267.34,
"49411 - Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, do",3760998,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.80,,1086.83,90,,,percent of total billed charges,90% of total Billed charges,633.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,982.64,155,,,Fee Schedule,155% of CMS OPPS Rate,982.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,501.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1044.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.13,1086.83,
49411-Fiducial Placement -Pelvic,3916937,CDM,510,RC,49411,HCPCS,Outpatient,,,1207.59,603.80,,1086.83,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,966.07,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1086.83,90,,,Percent of total Billed charges,90% of total billed charges,173.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1171.36,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1110.98,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1086.83,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,845.31,70,,,percent of total billed charges,70% of total billed charges,1086.83,90,,,percent of total billed charges,90% of total billed charges,1147.21,95,,,percent of total billed charges,95% of total billed charges,1147.21,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1038.53,86,,,percent of total billed charges,86% of total billed charges,966.07,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1171.36,97,,,percent of total billed charges,97% of total billed charges,1086.83,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1171.36,97,,,percent of total billed charges,97% of total billed charges,1123.06,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1171.36,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,158.12,6535.92,
49411-INS MARK ABD/PEL FOR RT PERQ Profee,3565265,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.80,,1086.83,90,,,percent of total billed charges,90% of total Billed charges,633.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,982.64,155,,,Fee Schedule,155% of CMS OPPS Rate,982.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,501.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1044.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.13,1086.83,
49411-PELVIC FIDUCIAL,3435787,CDM,333,RC,49411,HCPCS,Outpatient,,,1178.65,589.33,,1060.79,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,942.92,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1060.79,90,,,Percent of total Billed charges,90% of total billed charges,173.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1143.29,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.36,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1060.79,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,825.06,70,,,percent of total billed charges,70% of total billed charges,1060.79,90,,,percent of total billed charges,90% of total billed charges,1119.72,95,,,percent of total billed charges,95% of total billed charges,1119.72,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1013.64,86,,,percent of total billed charges,86% of total billed charges,942.92,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1143.29,97,,,percent of total billed charges,97% of total billed charges,1060.79,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1143.29,97,,,percent of total billed charges,97% of total billed charges,1096.14,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1143.29,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,158.12,6535.92,
49411-PELVIC FIDUCIAL Profee,3565262,CDM,983,RC,49411,HCPCS,Outpatient,,,1207.59,603.80,,1086.83,90,,,percent of total billed charges,90% of total Billed charges,633.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,982.64,155,,,Fee Schedule,155% of CMS OPPS Rate,982.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,501.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1044.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.13,1086.83,
CT fiducial Marker abd/pelvis,3642894,CDM,350,RC,49411,HCPCS,Outpatient,,,1178.65,589.33,,1060.79,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,942.92,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1060.79,90,,,Percent of total Billed charges,90% of total billed charges,173.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1143.29,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.36,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1060.79,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,825.06,70,,,percent of total billed charges,70% of total billed charges,1060.79,90,,,percent of total billed charges,90% of total billed charges,1119.72,95,,,percent of total billed charges,95% of total billed charges,1119.72,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1013.64,86,,,percent of total billed charges,86% of total billed charges,942.92,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1143.29,97,,,percent of total billed charges,97% of total billed charges,1060.79,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1143.29,97,,,percent of total billed charges,97% of total billed charges,1096.14,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1143.29,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,158.12,6535.92,
Read,4181188,CDM,972,RC,49411,HCPCS,Outpatient,,,471.46,235.73,,424.31,90,,,percent of total billed charges,90% of total Billed charges,633.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,207.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,278.78,155,,,Fee Schedule,155% of CMS OPPS Rate,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,982.64,155,,,Fee Schedule,155% of CMS OPPS Rate,982.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,501.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1044.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.13,1044.48,
49419-MA INSERT ABDOM CATH,3430023,CDM,510,RC,49419,HCPCS,Outpatient,,,1133.9,566.95,,1020.51,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,907.12,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.51,90,,,Percent of total Billed charges,90% of total billed charges,381.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1099.88,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.19,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1020.51,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,793.73,70,,,percent of total billed charges,70% of total billed charges,1020.51,90,,,percent of total billed charges,90% of total billed charges,1077.21,95,,,percent of total billed charges,95% of total billed charges,1077.21,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,975.15,86,,,percent of total billed charges,86% of total billed charges,907.12,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1099.88,97,,,percent of total billed charges,97% of total billed charges,1020.51,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1099.88,97,,,percent of total billed charges,97% of total billed charges,1054.53,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,347,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1099.88,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,347,25056.97,
"49421- Insertion of tunneled intraperitoneal catheter for dialysis, open",3621513,CDM,510,RC,49421,HCPCS,Outpatient,,,616.62,308.31,,554.96,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,493.3,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,598.12,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,567.29,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,554.96,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,431.63,70,,,percent of total billed charges,70% of total billed charges,554.96,90,,,percent of total billed charges,90% of total billed charges,585.79,95,,,percent of total billed charges,95% of total billed charges,585.79,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,530.29,86,,,percent of total billed charges,86% of total billed charges,493.3,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,598.12,97,,,percent of total billed charges,97% of total billed charges,554.96,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.12,97,,,percent of total billed charges,97% of total billed charges,573.46,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,598.12,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,431.63,17267.34,
49422-MA REMOVE PERM CANNUAL/CATH,3430024,CDM,510,RC,49422,HCPCS,Outpatient,,,600.45,300.23,,540.41,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,480.36,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,540.41,90,,,Percent of total Billed charges,90% of total billed charges,368.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,582.44,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,552.41,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,540.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,420.32,70,,,percent of total billed charges,70% of total billed charges,540.41,90,,,percent of total billed charges,90% of total billed charges,570.43,95,,,percent of total billed charges,95% of total billed charges,570.43,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,516.39,86,,,percent of total billed charges,86% of total billed charges,480.36,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,582.44,97,,,percent of total billed charges,97% of total billed charges,540.41,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.44,97,,,percent of total billed charges,97% of total billed charges,558.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,582.44,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,334.92,14522.85,
49440 - PF Insert Gastrostomy Tube Perq,4311866,CDM,960,RC,49440,HCPCS,Outpatient,,,469.4,234.70,,422.46,90,,,percent of total billed charges,90% of total Billed charges,667.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,306.4,155,,,Fee Schedule,155% of CMS OPPS Rate,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,279.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,313.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,313.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,171.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,369.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,234.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,306.4,155,,,Fee Schedule,155% of CMS OPPS Rate,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1033.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1033.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2932.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,2018.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2018.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,171.46,2932.57,
49440-PF Insertion of Gastrostomy Tube,4321622,CDM,981,RC,49440,HCPCS,Outpatient,,,395.38,197.69,,355.84,90,,,percent of total billed charges,90% of total Billed charges,593.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,306.4,155,,,Fee Schedule,155% of CMS OPPS Rate,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,279.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,313.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,313.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,171.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,395.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,369.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,234.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,306.4,155,,,Fee Schedule,155% of CMS OPPS Rate,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,919.24,155,,,Fee Schedule,155% of CMS OPPS Rate,919.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2932.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,2018.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2018.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,171.46,2932.57,
49441 - PF Insert Duodenostomy/ Jejunostomy Tube Perq,4311867,CDM,960,RC,49441,HCPCS,Outpatient,,,555.25,277.63,,499.73,90,,,percent of total billed charges,90% of total Billed charges,789.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,192.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,362.47,155,,,Fee Schedule,155% of CMS OPPS Rate,233.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,329.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,371.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,371.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,286.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,362.47,155,,,Fee Schedule,155% of CMS OPPS Rate,233.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1223.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1223.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,233.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1165.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,233.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,2277.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2277.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,192.24,2277.32,
49442 - PF Insert Cecostomy/ Other Colonic Tube Perq,4311868,CDM,960,RC,49442,HCPCS,Outpatient,,,471.01,235.51,,423.91,90,,,percent of total billed charges,90% of total Billed charges,669.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,159.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,307.47,155,,,Fee Schedule,155% of CMS OPPS Rate,198.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,313.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,313.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,370.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,229.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,307.47,155,,,Fee Schedule,155% of CMS OPPS Rate,198.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1037.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,957.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1772.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1772.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,159.5,1772.08,
49446 - PF Convert Gastrostomy-Gastro-Jejunostomy Tube Perq,4311869,CDM,960,RC,49446,HCPCS,Outpatient,,,340.75,170.38,,306.68,90,,,percent of total billed charges,90% of total Billed charges,484.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,143.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,222.44,155,,,Fee Schedule,155% of CMS OPPS Rate,143.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,171.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,222.44,155,,,Fee Schedule,155% of CMS OPPS Rate,143.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.6,155,,,Fee Schedule,155% of CMS OPPS Rate,750.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,143.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3978.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,143.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1889.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1889.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,121.38,3978.59,
"49446- Conv gastrostomy tube to GJ tube, perct",3569401,CDM,510,RC,49446,HCPCS,Outpatient,,,2001.46,1000.73,,1801.31,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1601.17,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1801.31,90,,,Percent of total Billed charges,90% of total billed charges,138.42,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1941.42,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1841.34,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1801.31,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1401.02,70,,,percent of total billed charges,70% of total billed charges,1801.31,90,,,percent of total billed charges,90% of total billed charges,1901.39,95,,,percent of total billed charges,95% of total billed charges,1901.39,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1721.26,86,,,percent of total billed charges,86% of total billed charges,1601.17,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1941.42,97,,,percent of total billed charges,97% of total billed charges,1801.31,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1941.42,97,,,percent of total billed charges,97% of total billed charges,1861.36,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1941.42,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.84,8490.45,
49450 - PF Replace Gastrostomy/ Cecostomy Tube Perq,4311875,CDM,960,RC,49450,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,221.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.7,155,,,Fee Schedule,155% of CMS OPPS Rate,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.7,155,,,Fee Schedule,155% of CMS OPPS Rate,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.2,155,,,Fee Schedule,155% of CMS OPPS Rate,343.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4793.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1261.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1261.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.1,4793.57,
49450-PF REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS,4321475,CDM,981,RC,49450,HCPCS,Outpatient,,,131.24,65.62,,118.12,90,,,percent of total billed charges,90% of total Billed charges,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.7,155,,,Fee Schedule,155% of CMS OPPS Rate,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.7,155,,,Fee Schedule,155% of CMS OPPS Rate,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.12,155,,,Fee Schedule,155% of CMS OPPS Rate,305.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4793.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1261.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1261.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.1,4793.57,
49451 - PF Replace Duodenostomy/ Jejunostomy Tube Perq,4311876,CDM,960,RC,49451,HCPCS,Outpatient,,,206.15,103.08,,185.54,90,,,percent of total billed charges,90% of total Billed charges,292.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,134.57,155,,,Fee Schedule,155% of CMS OPPS Rate,86.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,139.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,139.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,134.57,155,,,Fee Schedule,155% of CMS OPPS Rate,86.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.1,155,,,Fee Schedule,155% of CMS OPPS Rate,454.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,86.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3926.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,86.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1378.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1378.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.33,3926.21,
"49451 - Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance i",3783266,CDM,510,RC,49451,HCPCS,Outpatient,,,1602.89,801.45,,1442.6,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1282.31,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1442.6,90,,,Percent of total Billed charges,90% of total billed charges,77.36,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1554.8,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1474.66,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1442.6,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1122.02,70,,,percent of total billed charges,70% of total billed charges,1442.6,90,,,percent of total billed charges,90% of total billed charges,1522.75,95,,,percent of total billed charges,95% of total billed charges,1522.75,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1378.49,86,,,percent of total billed charges,86% of total billed charges,1282.31,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1554.8,97,,,percent of total billed charges,97% of total billed charges,1442.6,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.8,97,,,percent of total billed charges,97% of total billed charges,1490.69,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1554.8,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.33,4024.46,
49452 - PF Replace Gastro-Jejunostomy Tube Perq,4311877,CDM,960,RC,49452,HCPCS,Outpatient,,,318.48,159.24,,286.63,90,,,percent of total billed charges,90% of total Billed charges,452.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,109.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.9,155,,,Fee Schedule,155% of CMS OPPS Rate,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,160.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,207.9,155,,,Fee Schedule,155% of CMS OPPS Rate,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,701.55,155,,,Fee Schedule,155% of CMS OPPS Rate,701.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3774.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1698.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1698.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.78,3774.1,
49452 - Replace G-J Tube Perc,4189307,CDM,960,RC,49452,HCPCS,Outpatient,,,1739.44,869.72,,1565.5,90,,,percent of total billed charges,90% of total Billed charges,866.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,109.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.9,155,,,Fee Schedule,155% of CMS OPPS Rate,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,160.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,207.9,155,,,Fee Schedule,155% of CMS OPPS Rate,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1343.39,155,,,Fee Schedule,155% of CMS OPPS Rate,1343.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3774.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1698.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1698.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.78,3774.1,
49460 - PF Obstructive Material Rmvl From GI Tube,4311878,CDM,960,RC,49460,HCPCS,Outpatient,,,115.75,57.88,,104.18,90,,,percent of total billed charges,90% of total Billed charges,164.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.56,155,,,Fee Schedule,155% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,75.56,155,,,Fee Schedule,155% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.98,155,,,Fee Schedule,155% of CMS OPPS Rate,254.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,721.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1395.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.96,1395.36,
49505 - PF Rpr 1st Inguin Hrna Age 5 yrs/> Reducible,4311879,CDM,960,RC,49505,HCPCS,Outpatient,,,1241.1,620.55,,1116.99,90,,,percent of total billed charges,90% of total Billed charges,1050.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,522.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.62,90,,,Percent of total Billed charges,90% of total billed charges,317.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,810.19,155,,,Fee Schedule,155% of CMS OPPS Rate,522.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,522.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,899.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,805.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,805.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,420.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1045.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,950.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,675.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,810.19,155,,,Fee Schedule,155% of CMS OPPS Rate,522.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1627.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1627.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,522.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,539.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,522.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1048.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1048.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,317.5,1627.64,
"49505- Repair initial inguinal hernia, age 5 years or older; reducible",3566793,CDM,510,RC,49505,HCPCS,Outpatient,,,1402.5,701.25,,1262.25,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1122,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1262.25,90,,,Percent of total Billed charges,90% of total billed charges,349.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1360.43,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.3,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1262.25,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,981.75,70,,,percent of total billed charges,70% of total billed charges,1262.25,90,,,percent of total billed charges,90% of total billed charges,1332.38,95,,,percent of total billed charges,95% of total billed charges,1332.38,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1206.15,86,,,percent of total billed charges,86% of total billed charges,1122,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1360.43,97,,,percent of total billed charges,97% of total billed charges,1262.25,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.43,97,,,percent of total billed charges,97% of total billed charges,1304.33,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1360.43,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,317.5,17267.34,
49507 - PF Rpr 1st Inguin Hrna Age 5 yrs/> Incarcerated,4311880,CDM,960,RC,49507,HCPCS,Outpatient,,,1397.6,698.80,,1257.84,90,,,percent of total billed charges,90% of total Billed charges,1181.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,588.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,442.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,912.33,155,,,Fee Schedule,155% of CMS OPPS Rate,588.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,899.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,588.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1012.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1012.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,908.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,908.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,472.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1177.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1071.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,764.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,912.33,155,,,Fee Schedule,155% of CMS OPPS Rate,588.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1831.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1831.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,588.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,590.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,588.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1287.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1287.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,442.7,1831.31,
"49507- Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated",3566794,CDM,510,RC,49507,HCPCS,Outpatient,,,1576.72,788.36,,1419.05,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.38,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1419.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1529.42,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1450.58,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1419.05,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.7,70,,,percent of total billed charges,70% of total billed charges,1419.05,90,,,percent of total billed charges,90% of total billed charges,1497.88,95,,,percent of total billed charges,95% of total billed charges,1497.88,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1355.98,86,,,percent of total billed charges,86% of total billed charges,1261.38,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1529.42,97,,,percent of total billed charges,97% of total billed charges,1419.05,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.42,97,,,percent of total billed charges,97% of total billed charges,1466.35,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1529.42,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1103.7,17267.34,
49520 - PF Rpr Recrt Inguinal Hrna Any Age Reducible,4311881,CDM,960,RC,49520,HCPCS,Outpatient,,,1507.65,753.83,,1356.89,90,,,percent of total billed charges,90% of total Billed charges,1276.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,432,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.17,155,,,Fee Schedule,155% of CMS OPPS Rate,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,969.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,634.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1090.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1090.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,981,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,981,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,510.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1157.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,828.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.17,155,,,Fee Schedule,155% of CMS OPPS Rate,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1978.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1978.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,432,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1275.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,432,1978.71,
"49520- Repair recurrent inguinal hernia, any age; reducible",3622240,CDM,510,RC,49520,HCPCS,Outpatient,,,1706.37,853.19,,1535.73,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1365.1,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1535.73,90,,,Percent of total Billed charges,90% of total billed charges,475.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1655.18,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.86,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1535.73,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.46,70,,,percent of total billed charges,70% of total billed charges,1535.73,90,,,percent of total billed charges,90% of total billed charges,1621.05,95,,,percent of total billed charges,95% of total billed charges,1621.05,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1467.48,86,,,percent of total billed charges,86% of total billed charges,1365.1,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1655.18,97,,,percent of total billed charges,97% of total billed charges,1535.73,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1655.18,97,,,percent of total billed charges,97% of total billed charges,1586.92,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,432,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1655.18,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,432,17267.34,
"49521 - (50) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3699536,CDM,510,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,1737.91,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1544.81,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1737.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1873.08,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1776.53,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1737.91,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.71,70,,,percent of total billed charges,70% of total billed charges,1737.91,90,,,percent of total billed charges,90% of total billed charges,1834.46,95,,,percent of total billed charges,95% of total billed charges,1834.46,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1660.67,86,,,percent of total billed charges,86% of total billed charges,1544.81,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1873.08,97,,,percent of total billed charges,97% of total billed charges,1737.91,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1873.08,97,,,percent of total billed charges,97% of total billed charges,1795.84,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1873.08,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1351.71,17267.34,
"49521 - (PF) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3635082,CDM,510,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,1737.91,90,,,percent of total billed charges,90% of total Billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1544.81,80,,,Percent of total Billed charges,80% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1737.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1873.08,97,,,Percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1776.53,92,,,Percent of total billed charges,92% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,8551.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13632.29,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17267.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1737.91,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.71,70,,,percent of total billed charges,70% of total billed charges,1737.91,90,,,percent of total billed charges,90% of total billed charges,1834.46,95,,,percent of total billed charges,95% of total billed charges,1834.46,95,,,percent of total billed charges,95% of total billed charges,3216.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6433.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1660.67,86,,,percent of total billed charges,86% of total billed charges,1544.81,80,,,percent of total billed charges,80% of total billed charges,3214.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1873.08,97,,,percent of total billed charges,97% of total billed charges,1737.91,90,,,percent of total billed charges,90% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1873.08,97,,,percent of total billed charges,97% of total billed charges,1795.84,93,,,percent of total billed charges,93% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1873.08,97,,,percent of total billed charges,97% of total billed charges,3216.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,3216.99,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2734.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1351.71,17267.34,
49521 - PF Rpr Recrt Inguin Hrna Any Age Incarcerated,4311882,CDM,960,RC,49521,HCPCS,Outpatient,,,1709.19,854.60,,1538.27,90,,,percent of total billed charges,90% of total Billed charges,1445.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,510.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1115.74,155,,,Fee Schedule,155% of CMS OPPS Rate,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1101.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,719.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1238.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1115.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1115.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,578.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1439.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1316.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,945.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1115.74,155,,,Fee Schedule,155% of CMS OPPS Rate,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2241.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2241.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,701.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1547,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1547,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,510.07,2241.24,
49525 - PF Rpr Inguin Hrna Sliding Any Age,4311883,CDM,960,RC,49525,HCPCS,Outpatient,,,1365.09,682.55,,1228.58,90,,,percent of total billed charges,90% of total Billed charges,1154.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,317.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,891.13,155,,,Fee Schedule,155% of CMS OPPS Rate,574.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,574.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,990.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,990.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,889.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,889.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,462.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1149.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1049.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,749.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,891.13,155,,,Fee Schedule,155% of CMS OPPS Rate,574.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1789.92,155,,,Fee Schedule,155% of CMS OPPS Rate,1789.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,574.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,518.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,574.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1155.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,317.5,1789.92,
49550 - PF 1st Fem Hrna Hany Age Reducible,4311884,CDM,960,RC,49550,HCPCS,Outpatient,,,1375.37,687.69,,1237.83,90,,,percent of total billed charges,90% of total Billed charges,1161.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,306.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,897.84,155,,,Fee Schedule,155% of CMS OPPS Rate,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,579.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,994.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,893.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,893.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,464.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1053.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,751.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,897.84,155,,,Fee Schedule,155% of CMS OPPS Rate,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1800.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1800.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,531.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1162.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,306.5,1800.77,
49550 - RPR Rem Hernia Init Reduc,4189308,CDM,960,RC,49550,HCPCS,Outpatient,,,1383.2,691.60,,1244.88,90,,,percent of total billed charges,90% of total Billed charges,1161.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,306.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,897.84,155,,,Fee Schedule,155% of CMS OPPS Rate,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,884.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,579.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,994.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,994.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,893.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,893.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,464.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1158.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1053.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,751.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,897.84,155,,,Fee Schedule,155% of CMS OPPS Rate,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1800.77,155,,,Fee Schedule,155% of CMS OPPS Rate,1800.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,531.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,579.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1162.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,306.5,1800.77,
49553 - PF Rpr 1st Fem Hrna Any Age Incarcerated,4311885,CDM,960,RC,49553,HCPCS,Outpatient,,,1506.2,753.10,,1355.58,90,,,percent of total billed charges,90% of total Billed charges,1274.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,406.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,983.23,155,,,Fee Schedule,155% of CMS OPPS Rate,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,968.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,634.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1089.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1089.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,979.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,979.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,509.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1155.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,825.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,983.23,155,,,Fee Schedule,155% of CMS OPPS Rate,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1975.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1975.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,581.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1275,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,406.81,1975.6,
49553 - RPR 1ST FEM HERNIA ANY AGE INCARCERATED,3997189,CDM,960,RC,49553,HCPCS,Outpatient,,,1702.61,851.31,,1532.35,90,,,percent of total billed charges,90% of total Billed charges,1274.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,406.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,983.23,155,,,Fee Schedule,155% of CMS OPPS Rate,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,968.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,634.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1089.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1089.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,979.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,979.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,509.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1268.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1155.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,825.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,983.23,155,,,Fee Schedule,155% of CMS OPPS Rate,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1975.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1975.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,581.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,634.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1275,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,406.81,1975.6,
49555 - PF Rpr Recrt Fem Hrna Reducible,4311886,CDM,960,RC,49555,HCPCS,Outpatient,,,1440.19,720.10,,1296.17,90,,,percent of total billed charges,90% of total Billed charges,1218.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,606.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,365,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,940.14,155,,,Fee Schedule,155% of CMS OPPS Rate,606.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,606.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1039.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,933.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,933.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,482.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1213.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1102.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,787.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,940.14,155,,,Fee Schedule,155% of CMS OPPS Rate,606.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1889.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1889.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,606.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,365,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,586.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,606.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1206.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1206.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365,1889.26,
49557 - PF Rpr Recrt Fem Hrna Incarcerated,4311887,CDM,960,RC,49557,HCPCS,Outpatient,,,1726.92,863.46,,1554.23,90,,,percent of total billed charges,90% of total Billed charges,1462.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,522.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1127.32,155,,,Fee Schedule,155% of CMS OPPS Rate,727.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,727.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1249.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1249.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1125.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1125.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,585.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1454.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1328.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,952.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1127.32,155,,,Fee Schedule,155% of CMS OPPS Rate,727.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2266.3,155,,,Fee Schedule,155% of CMS OPPS Rate,2266.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,727.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,645.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,727.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1464.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1464.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,522.84,2266.3,
49591 - PF Rpr AA Hrna 1st < 3 cm Reducible,4311888,CDM,960,RC,49591,HCPCS,Outpatient,,,820.31,410.16,,738.28,90,,,percent of total billed charges,90% of total Billed charges,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,535.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.09,738.28,
49591- RPR AA HERNIA 1ST < 3 CM REDUCIBLE,4199249,CDM,983,RC,49591,HCPCS,Outpatient,,,800.31,400.16,,720.28,90,,,percent of total billed charges,90% of total Billed charges,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,535.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.09,720.28,
49591-PF Rpr AA Hrn 1st <3 cm RDC,4322111,CDM,960,RC,49591,HCPCS,Outpatient,,,678.44,339.22,,610.6,90,,,percent of total billed charges,90% of total Billed charges,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.53,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.49,155,,,Fee Schedule,155% of CMS OPPS Rate,535.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.53,690.96,
49592 - PF Rpr AA Hrna 1st < 3 cm NCRC8/ Strangulated,4311889,CDM,960,RC,49592,HCPCS,Outpatient,,,1145.15,572.58,,1030.64,90,,,percent of total billed charges,90% of total Billed charges,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.55,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,747.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.55,1030.64,
49592- RPR AA HERNIA 1ST < 3 CM NCRC8/STRANGULATED,4199250,CDM,983,RC,49592,HCPCS,Outpatient,,,1117.23,558.62,,1005.51,90,,,percent of total billed charges,90% of total Billed charges,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.17,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.55,155,,,Fee Schedule,155% of CMS OPPS Rate,747.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.17,1005.51,
49593 - PF Rpr AA Hrna 1st 3-10 cm Reducible,4311890,CDM,960,RC,49593,HCPCS,Outpatient,,,1379.17,689.59,,1241.25,90,,,percent of total billed charges,90% of total Billed charges,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.75,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1161.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,900.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.75,1241.25,
49593- RPR AA HERNIA 1ST 3-10 CM REDUCIBLE,4199251,CDM,983,RC,49593,HCPCS,Outpatient,,,1344.53,672.27,,1210.08,90,,,percent of total billed charges,90% of total Billed charges,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1161.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,900.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.36,1210.08,
49593-PF Rpr AA Hrn 1st 3-10 RDC,4322112,CDM,960,RC,49593,HCPCS,Outpatient,,,1139.82,569.91,,1025.84,90,,,percent of total billed charges,90% of total Billed charges,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1161.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,900.3,155,,,Fee Schedule,155% of CMS OPPS Rate,900.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.95,1161.68,
49594 - PF Rpr AA Hrna 1st 3-10 cm NCRC8/ Strangulated,4311891,CDM,960,RC,49594,HCPCS,Outpatient,,,1798.72,899.36,,1618.85,90,,,percent of total billed charges,90% of total Billed charges,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1174.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.62,1618.85,
49594- RPR AA HERNIA 1ST 3-10 CM NCRC8/STRANGULATED,4199252,CDM,983,RC,49594,HCPCS,Outpatient,,,1754.87,877.44,,1579.38,90,,,percent of total billed charges,90% of total Billed charges,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.46,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1174.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.46,1579.38,
49595 - PF Rpr AA Hrna 1st > 10 cm Reducible,4311892,CDM,960,RC,49595,HCPCS,Outpatient,,,1855.27,927.64,,1669.74,90,,,percent of total billed charges,90% of total Billed charges,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.58,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.58,1669.74,
49595- RPR AA HERNIA 1ST > 10 CM REDUCIBLE,4199253,CDM,983,RC,49595,HCPCS,Outpatient,,,1810.02,905.01,,1629.02,90,,,percent of total billed charges,90% of total Billed charges,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.01,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.01,1629.02,
49595-PF Rpr AA Hrn 1st >10 cm RDC,4322113,CDM,960,RC,49595,HCPCS,Outpatient,,,1534.72,767.36,,1381.25,90,,,percent of total billed charges,90% of total Billed charges,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.42,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1562.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1211.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.42,1562.72,
49596 - PF Rpr AA Hrna 1st > 10 cm NCRC8/ Strangulated,4311893,CDM,960,RC,49596,HCPCS,Outpatient,,,2464.89,1232.45,,2218.4,90,,,percent of total billed charges,90% of total Billed charges,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.47,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2076.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1609.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.47,2218.4,
49596- RPR AA HERNIA 1ST > 10 CM NCRC8/STRANGULATED,4199254,CDM,983,RC,49596,HCPCS,Outpatient,,,2404.77,1202.39,,2164.29,90,,,percent of total billed charges,90% of total Billed charges,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.43,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2076.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1609.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1609.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,721.43,2164.29,
49600 - PF Rpr Small Omphalocele w/ Primary Closure,4311894,CDM,960,RC,49600,HCPCS,Outpatient,,,1750.31,875.16,,1575.28,90,,,percent of total billed charges,90% of total Billed charges,1482.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,737.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,317,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1142.58,155,,,Fee Schedule,155% of CMS OPPS Rate,737.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,737.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1267.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1267.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1140.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1140.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,524.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,737.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1474.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1345.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,967.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1142.58,155,,,Fee Schedule,155% of CMS OPPS Rate,737.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2298.14,155,,,Fee Schedule,155% of CMS OPPS Rate,2298.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,737.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,317,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,654.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,737.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1474.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,317,2298.14,
49605 - PF Rpr Lg Omphalocele/ Gastroschisis w/ wo Prosth,4311895,CDM,960,RC,49605,HCPCS,Outpatient,,,11811.07,5905.54,,10629.96,90,,,percent of total billed charges,90% of total Billed charges,10008.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4974.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,483,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,7710.23,155,,,Fee Schedule,155% of CMS OPPS Rate,4974.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7392.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4974.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8314.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8314.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,7843.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,7843.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3999.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4974.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9948.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9255.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,6836.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,7710.23,155,,,Fee Schedule,155% of CMS OPPS Rate,4974.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,15512.8,155,,,Fee Schedule,155% of CMS OPPS Rate,15512.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,4974.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,483,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4232.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,4974.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,10043.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,10043.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,483,15512.8,
49606 - PF Prp Lg Omphalocele/ Gastroschisis Rmvl Prosth,4311896,CDM,960,RC,49606,HCPCS,Outpatient,,,2718.76,1359.38,,2446.88,90,,,percent of total billed charges,90% of total Billed charges,2302.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1145.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,483,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1774.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1145.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1744.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1145.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1962.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1962.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1780.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1780.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,916.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1145.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2290.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2100.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1526.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1774.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1145.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,3568.88,155,,,Fee Schedule,155% of CMS OPPS Rate,3568.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1145.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,483,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1093.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1145.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,2295.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2295.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,483,3568.88,
49610 - PF Rpr Omphalocele Gross Typ Opration 1st Stg,4311897,CDM,960,RC,49610,HCPCS,Outpatient,,,1654.48,827.24,,1489.03,90,,,percent of total billed charges,90% of total Billed charges,1400.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,696.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,400,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1080.02,155,,,Fee Schedule,155% of CMS OPPS Rate,696.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1061.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,696.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1193.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1193.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1074.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1074.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,521.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1393.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1267.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,910.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1080.02,155,,,Fee Schedule,155% of CMS OPPS Rate,696.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,2171.19,155,,,Fee Schedule,155% of CMS OPPS Rate,2171.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,696.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,698.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,696.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1387.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1387.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,400,2171.19,
49611 - PF Rpr Omphalocele Gross Typ Opration 2nd Stg,4311898,CDM,960,RC,49611,HCPCS,Outpatient,,,1453.13,726.57,,1307.82,90,,,percent of total billed charges,90% of total Billed charges,1229.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,611.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,400,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,948.58,155,,,Fee Schedule,155% of CMS OPPS Rate,611.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,611.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1018.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,942.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,942.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,448.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1223.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1111.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,795.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,948.58,155,,,Fee Schedule,155% of CMS OPPS Rate,611.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1905.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1905.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,611.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,753.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,611.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,1088,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1088,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,400,1905.99,
49613 - PF Rpr AA Hrna Recr < 3 cm Reducible,4311899,CDM,960,RC,49613,HCPCS,Outpatient,,,1011.21,505.61,,910.09,90,,,percent of total billed charges,90% of total Billed charges,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,660.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.36,910.09,
49613 - RPR AA HERNIA RECR < 3 CM REDUCIBLE,4199261,CDM,983,RC,49613,HCPCS,Outpatient,,,986.54,493.27,,887.89,90,,,percent of total billed charges,90% of total Billed charges,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.96,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,660.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.96,887.89,
49613- RPR AA HERNIA RECR < 3 CM REDUCIBLE,4199255,CDM,983,RC,49613,HCPCS,Outpatient,,,986.54,493.27,,887.89,90,,,percent of total billed charges,90% of total Billed charges,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.96,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,660.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.96,887.89,
49613-PF Rpr AA Hrn RCR <3 RDC,4322114,CDM,960,RC,49613,HCPCS,Outpatient,,,836.18,418.09,,752.56,90,,,percent of total billed charges,90% of total Billed charges,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.11,155,,,Fee Schedule,155% of CMS OPPS Rate,660.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.85,851.76,
49614 - PF Rpr AA Hrna Recr < 3 cm NCRC8/ Strangulated,4311900,CDM,960,RC,49614,HCPCS,Outpatient,,,1376.29,688.15,,1238.66,90,,,percent of total billed charges,90% of total Billed charges,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1159.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,898.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.89,1238.66,
49614- RPR AA HERNIA RECR < 3 CM NCRC8/STRANGULATED,4199256,CDM,983,RC,49614,HCPCS,Outpatient,,,1341.73,670.87,,1207.56,90,,,percent of total billed charges,90% of total Billed charges,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1159.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.43,155,,,Fee Schedule,155% of CMS OPPS Rate,898.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,579.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.52,1207.56,
49615 - PF Rpr AA Hrna Recr 3-10 cm Reducible,4311901,CDM,960,RC,49615,HCPCS,Outpatient,,,1539.18,769.59,,1385.26,90,,,percent of total billed charges,90% of total Billed charges,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.75,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.75,1385.26,
49615 - RPR AA HERNIA RECR 3-10 CM REDUCIBLE,4199262,CDM,983,RC,49615,HCPCS,Outpatient,,,1501.64,750.82,,1351.48,90,,,percent of total billed charges,90% of total Billed charges,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.49,1351.48,
49615- RPR AA HERNIA RECR 3-10 CM REDUCIBLE,4199257,CDM,983,RC,49615,HCPCS,Outpatient,,,1501.64,750.82,,1351.48,90,,,percent of total billed charges,90% of total Billed charges,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.49,1351.48,
49615-PF Rpr AA Hrn RCR 3-10 RDC,4322115,CDM,960,RC,49615,HCPCS,Outpatient,,,1270.2,635.10,,1143.18,90,,,percent of total billed charges,90% of total Billed charges,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.06,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1296.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,648.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.06,1296.46,
49616 - PF Rpr AA Hrna Recr 3-10 cm NCRC8/ Strangulated,4311902,CDM,960,RC,49616,HCPCS,Outpatient,,,2070.78,1035.39,,1863.7,90,,,percent of total billed charges,90% of total Billed charges,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.23,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1744.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1351.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.23,1863.7,
49616- RPR AA HERNIA RECR 3-10 CM NCRC8/STRANGULATED,4199258,CDM,983,RC,49616,HCPCS,Outpatient,,,2020.29,1010.15,,1818.26,90,,,percent of total billed charges,90% of total Billed charges,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1744.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1351.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,872.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.09,1818.26,
49617 - PF Rpr AA Hrna Recr > 10 cm Reducible,4311903,CDM,960,RC,49617,HCPCS,Outpatient,,,2065.37,1032.69,,1858.83,90,,,percent of total billed charges,90% of total Billed charges,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1793.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.61,1858.83,
49617 - RPR AA HERNIA RECR > 10 CM REDUCIBLE,4199263,CDM,983,RC,49617,HCPCS,Outpatient,,,2077.53,1038.77,,1869.78,90,,,percent of total billed charges,90% of total Billed charges,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.26,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1793.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.26,1869.78,
49617- RPR AA HERNIA RECR > 10 CM REDUCIBLE,4199259,CDM,983,RC,49617,HCPCS,Outpatient,,,2077.53,1038.77,,1869.78,90,,,percent of total billed charges,90% of total Billed charges,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.26,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1793.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.26,1869.78,
49617-PF Rpr AA Hrn RCR >10 RDC,4322116,CDM,960,RC,49617,HCPCS,Outpatient,,,1759.12,879.56,,1583.21,90,,,percent of total billed charges,90% of total Billed charges,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.74,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1793.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.74,1793.68,
49618 - PF Rpr AA Hrna Recr > 10 cm NCRC8/ Strangulated,4311904,CDM,960,RC,49618,HCPCS,Outpatient,,,2988.97,1494.49,,2690.07,90,,,percent of total billed charges,90% of total Billed charges,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.69,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2517.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1951.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.69,2690.07,
49618- RPR AA HERNIA RECR > 10 CM NCRC8/STRANGULATED,4199260,CDM,983,RC,49618,HCPCS,Outpatient,,,2916.06,1458.03,,2624.45,90,,,percent of total billed charges,90% of total Billed charges,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2517.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1951.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1258.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.82,2624.45,
49621 - RPR PARASTOMAL HERNIA 1ST/RECR REDUCIBLE,4249119,CDM,983,RC,49621,HCPCS,Outpatient,,,1986.6,993.30,,1787.94,90,,,percent of total billed charges,90% of total Billed charges,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161.96,155,,,Fee Schedule,155% of CMS OPPS Rate,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.98,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1161.96,155,,,Fee Schedule,155% of CMS OPPS Rate,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1161.96,155,,,Fee Schedule,155% of CMS OPPS Rate,1161.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.98,1787.94,
49622PF Rpr Parastomal Hrna 1st/Rec NCRC/Strangulated,4281206,CDM,960,RC,49622,HCPCS,Outpatient,,,1962.31,981.16,,1766.08,90,,,percent of total billed charges,90% of total Billed charges,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.71,155,,,Fee Schedule,155% of CMS OPPS Rate,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.69,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1851.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1434.71,155,,,Fee Schedule,155% of CMS OPPS Rate,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1434.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1434.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,588.69,1851.24,
49623 - PF Rmvl NonInfct Mesh/Prosth AA/Parastomal Hra Rpr PF,4305373,CDM,960,RC,49623,HCPCS,Outpatient,,,424.04,212.02,,381.64,90,,,percent of total billed charges,90% of total Billed charges,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.03,155,,,Fee Schedule,155% of CMS OPPS Rate,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.21,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,400.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.03,155,,,Fee Schedule,155% of CMS OPPS Rate,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.03,155,,,Fee Schedule,155% of CMS OPPS Rate,310.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.21,400.04,
"49650 - PF - Laparoscopy, surgical; repair initial inguinal hernia",3640923,CDM,510,RC,49650,HCPCS,Outpatient,,,1154.79,577.40,,1039.31,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,923.83,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1120.15,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1062.41,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1039.31,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,808.35,70,,,percent of total billed charges,70% of total billed charges,1039.31,90,,,percent of total billed charges,90% of total billed charges,1097.05,95,,,percent of total billed charges,95% of total billed charges,1097.05,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,993.12,86,,,percent of total billed charges,86% of total billed charges,923.83,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1120.15,97,,,percent of total billed charges,97% of total billed charges,1039.31,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1120.15,97,,,percent of total billed charges,97% of total billed charges,1073.95,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1120.15,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,808.35,25409.89,
49650 - PF Laparoscopy Surg Rpr Init Inguinal Hrna,4311905,CDM,960,RC,49650,HCPCS,Outpatient,,,1022.18,511.09,,919.96,90,,,percent of total billed charges,90% of total Billed charges,864.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,341.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,667.26,155,,,Fee Schedule,155% of CMS OPPS Rate,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,430.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,661.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,661.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,780.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,551.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,667.26,155,,,Fee Schedule,155% of CMS OPPS Rate,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1340.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1340.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,502.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,860.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,341.4,1340.32,
"49651 - Laparoscopy, surgical; repair recurrent inguinal hernia",3572810,CDM,960,RC,49651,HCPCS,Outpatient,,,1509.83,754.92,,1358.85,90,,,percent of total billed charges,90% of total Billed charges,1130.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,872.99,155,,,Fee Schedule,155% of CMS OPPS Rate,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,965.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,861.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,861.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,449.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1017.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,720,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,872.99,155,,,Fee Schedule,155% of CMS OPPS Rate,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1752.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1752.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,561.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1122.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.54,1752.99,
49651 - PF Laps Surg Rpr Recurrent Inguinal Hrna,4311906,CDM,960,RC,49651,HCPCS,Outpatient,,,1337.31,668.66,,1203.58,90,,,percent of total billed charges,90% of total Billed charges,1130.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,872.99,155,,,Fee Schedule,155% of CMS OPPS Rate,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,965.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,965.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,861.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,861.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,449.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1126.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1017.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,720,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,872.99,155,,,Fee Schedule,155% of CMS OPPS Rate,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1752.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1752.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,561.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,563.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1122.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.54,1752.99,
49659 - Laparo Proc Hernia Repair,4189309,CDM,960,RC,49659,HCPCS,Outpatient,,,2611.84,1305.92,,2350.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.55,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.55,2350.66,
49659 - PF Unlisted Laps Px Hrnap Herniorrhaphy Herniotomy,4311907,CDM,960,RC,49659,HCPCS,Outpatient,,,1068.48,534.24,,961.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,961.63,
49905-PF OMENTAL FLAP INTRA-ABD,3430038,CDM,510,RC,49905,HCPCS,Outpatient,,,954.24,477.12,,858.82,90,,,percent of total billed charges,90% of total Billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,763.39,80,,,Percent of total Billed charges,80% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,858.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,925.61,97,,,Percent of total billed charges,97% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,877.9,92,,,Percent of total billed charges,92% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,858.82,90,,,percent of total billed charges,90% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,667.97,70,,,percent of total billed charges,70% of total billed charges,858.82,90,,,percent of total billed charges,90% of total billed charges,906.53,95,,,percent of total billed charges,95% of total billed charges,906.53,95,,,percent of total billed charges,95% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,820.65,86,,,percent of total billed charges,86% of total billed charges,763.39,80,,,percent of total billed charges,80% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,925.61,97,,,percent of total billed charges,97% of total billed charges,858.82,90,,,percent of total billed charges,90% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,925.61,97,,,percent of total billed charges,97% of total billed charges,887.44,93,,,percent of total billed charges,93% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,925.61,97,,,percent of total billed charges,97% of total billed charges,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,954.24,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,667.97,954.24,
"49999 - PF Unlisted procedure, abdomen, peritoneum and omentum",3641213,CDM,510,RC,49999,HCPCS,Outpatient,,,3723.06,1861.53,,3350.75,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2978.45,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3350.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3611.37,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3425.22,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3350.75,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2606.14,70,,,percent of total billed charges,70% of total billed charges,3350.75,90,,,percent of total billed charges,90% of total billed charges,3536.91,95,,,percent of total billed charges,95% of total billed charges,3536.91,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3201.83,86,,,percent of total billed charges,86% of total billed charges,2978.45,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3611.37,97,,,percent of total billed charges,97% of total billed charges,3350.75,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3611.37,97,,,percent of total billed charges,97% of total billed charges,3462.45,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3611.37,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4024.46,
49999 - PF Unlisted Px Abd Peritoneum & Omentum,4311908,CDM,960,RC,49999,HCPCS,Outpatient,,,1068.48,534.24,,961.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.54,961.63,
49999-PF UNLISTED PROCEDURE ABDOMEN PERITONEUM & OMENTUM,4321621,CDM,981,RC,49999,HCPCS,Outpatient,,,3512.32,1756.16,,3161.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.7,3161.09,
"50080 - Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, l",3572811,CDM,510,RC,50080,HCPCS,Outpatient,,,2266.36,1133.18,,2039.72,90,,,percent of total billed charges,90% of total Billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1813.09,80,,,Percent of total Billed charges,80% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2039.72,90,,,Percent of total Billed charges,90% of total billed charges,853.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2198.37,97,,,Percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,2085.05,92,,,Percent of total billed charges,92% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20660.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32936.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,41719.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2039.72,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1586.45,70,,,percent of total billed charges,70% of total billed charges,2039.72,90,,,percent of total billed charges,90% of total billed charges,2153.04,95,,,percent of total billed charges,95% of total billed charges,2153.04,95,,,percent of total billed charges,95% of total billed charges,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15544.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1949.07,86,,,percent of total billed charges,86% of total billed charges,1813.09,80,,,percent of total billed charges,80% of total billed charges,8341.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2198.37,97,,,percent of total billed charges,97% of total billed charges,2039.72,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2198.37,97,,,percent of total billed charges,97% of total billed charges,2107.71,93,,,percent of total billed charges,93% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,776,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2198.37,97,,,percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,7772.46,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6606.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,776,41719.04,
50080PF - Percutaneous nephrostolithotomy or pyelostolithoto,4263691,CDM,975,RC,50080,HCPCS,Outpatient,,,1610.46,805.23,,1449.41,90,,,percent of total billed charges,90% of total Billed charges,1530.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,776,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1051.3,155,,,Fee Schedule,155% of CMS OPPS Rate,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1322.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,678.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1487.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1323.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1323.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,692.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1562.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1009.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1051.3,155,,,Fee Schedule,155% of CMS OPPS Rate,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2372.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,776,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1098.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1734.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1734.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,678.26,2372.24,
50081PF-Percutaneous/rmv kidney stone,4263689,CDM,975,RC,50081,HCPCS,Outpatient,,,2607.68,1303.84,,2346.91,90,,,percent of total billed charges,90% of total Billed charges,2354.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1098.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1702.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1098.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1945.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1098.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2187.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2187.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1951.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1951.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1016.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2196.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2302.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1491.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1702.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1098.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3649.34,155,,,Fee Schedule,155% of CMS OPPS Rate,3649.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1098.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1477.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1098.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2552.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2552.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1016.08,3649.34,
CT add Needle Bx Renal,645130,CDM,360,RC,50200,HCPCS,Outpatient,,,1239.99,620.00,,1115.99,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,991.99,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1115.99,90,,,Percent of total Billed charges,90% of total billed charges,150.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1202.79,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.79,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1115.99,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,867.99,70,,,percent of total billed charges,70% of total billed charges,1115.99,90,,,percent of total billed charges,90% of total billed charges,1177.99,95,,,percent of total billed charges,95% of total billed charges,1177.99,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1066.39,86,,,percent of total billed charges,86% of total billed charges,991.99,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1202.79,97,,,percent of total billed charges,97% of total billed charges,1115.99,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.79,97,,,percent of total billed charges,97% of total billed charges,1153.19,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1202.79,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.11,7310.49,
Read,4181206,CDM,972,RC,50200,HCPCS,Outpatient,,,496,248.00,,446.4,90,,,percent of total billed charges,90% of total Billed charges,609.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.98,155,,,Fee Schedule,155% of CMS OPPS Rate,122.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,194.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,194.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,229.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,145.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.98,155,,,Fee Schedule,155% of CMS OPPS Rate,122.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.25,155,,,Fee Schedule,155% of CMS OPPS Rate,945.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,122.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,564.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1158.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106.83,1158.72,
50220 - Nephrectomy w/PRTL Ureterectomy w/Open Rib Resc,3899049,CDM,983,RC,50220,HCPCS,Outpatient,,,2775.57,1387.79,,2498.01,90,,,percent of total billed charges,90% of total Billed charges,2078.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1035.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,621,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1604.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1035.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1597.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1035.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1797.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1797.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1606.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1606.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,835.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1035.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2070.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1895.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1259.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1604.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1035.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,3222.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3222.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1035.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,621,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1201.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1035.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,2091.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2091.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,621,3222.28,
50230PF- Nephrect/rad/lymphadenec/vc thromb,4263690,CDM,975,RC,50230,HCPCS,Outpatient,,,2975.08,1487.54,,2677.57,90,,,percent of total billed charges,90% of total Billed charges,2517.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1252.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,753,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1942.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1252.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1952.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1252.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2196.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2196.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1965,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1965,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1021.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1252.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2505.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2318.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1518.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1942.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1252.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,3901.61,155,,,Fee Schedule,155% of CMS OPPS Rate,3901.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1252.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,753,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1580.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1252.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,2564.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2564.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,753,3901.61,
50234PF Nephrectomy w/Total Ureterectomy and Bladder Cuff Same Incision,4263108,CDM,975,RC,50234,HCPCS,Outpatient,,,3025.56,1512.78,,2723,90,,,percent of total billed charges,90% of total Billed charges,2561.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1274.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,777.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1975.07,155,,,Fee Schedule,155% of CMS OPPS Rate,1274.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1983.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1274.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2230.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2230.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1993.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1993.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1036.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1274.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2548.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2352.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1535.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1975.07,155,,,Fee Schedule,155% of CMS OPPS Rate,1274.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3970,155,,,Fee Schedule,155% of CMS OPPS Rate,3970,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1274.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,777.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1528.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1274.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2603.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2603.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,777.5,3970,
50384 - PF Removal Indwelling Ureteral Stent Prq,4301623,CDM,960,RC,50384,HCPCS,Outpatient,,,472.89,236.45,,425.6,90,,,percent of total billed charges,90% of total Billed charges,695.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,223.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.74,155,,,Fee Schedule,155% of CMS OPPS Rate,223.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,223.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,394.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,354.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,354.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,418.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,266.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.74,155,,,Fee Schedule,155% of CMS OPPS Rate,223.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1078.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1078.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,223.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1443.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,223.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1863.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1863.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193.43,1863.88,
50386 - PF Remove Int Dwell Ureteral Stent Transurethral,4301620,CDM,960,RC,50386,HCPCS,Outpatient,,,334.03,167.02,,300.63,90,,,percent of total billed charges,90% of total Billed charges,491.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.22,155,,,Fee Schedule,155% of CMS OPPS Rate,157.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,247.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,247.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,292.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,189.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,244.22,155,,,Fee Schedule,155% of CMS OPPS Rate,157.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.96,155,,,Fee Schedule,155% of CMS OPPS Rate,761.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,157.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,761.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1473.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1473.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135.61,1473.56,
"50389 - (50) Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwe",3699539,CDM,510,RC,50389,HCPCS,Outpatient,,,1042.44,521.22,,938.2,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,833.95,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1011.17,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,959.04,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,938.2,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,729.71,70,,,percent of total billed charges,70% of total billed charges,938.2,90,,,percent of total billed charges,90% of total billed charges,990.32,95,,,percent of total billed charges,95% of total billed charges,990.32,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,896.5,86,,,percent of total billed charges,86% of total billed charges,833.95,80,,,percent of total billed charges,80% of total billed charges,575.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1011.17,97,,,percent of total billed charges,97% of total billed charges,938.2,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.17,97,,,percent of total billed charges,97% of total billed charges,969.47,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1011.17,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,482.77,3048.61,
"50389 - PF Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwell",3699538,CDM,510,RC,50389,HCPCS,Outpatient,,,1042.44,521.22,,938.2,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,833.95,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1011.17,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,959.04,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,938.2,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,729.71,70,,,percent of total billed charges,70% of total billed charges,938.2,90,,,percent of total billed charges,90% of total billed charges,990.32,95,,,percent of total billed charges,95% of total billed charges,990.32,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,896.5,86,,,percent of total billed charges,86% of total billed charges,833.95,80,,,percent of total billed charges,80% of total billed charges,575.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1011.17,97,,,percent of total billed charges,97% of total billed charges,938.2,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.17,97,,,percent of total billed charges,97% of total billed charges,969.47,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1011.17,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,482.77,3048.61,
CT add Renal drainage/asp,654538,CDM,360,RC,50390,HCPCS,Outpatient,,,245.5,122.75,,220.95,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,196.4,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.95,90,,,Percent of total Billed charges,90% of total billed charges,100.71,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,238.14,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,225.86,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.95,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,171.85,70,,,percent of total billed charges,70% of total billed charges,220.95,90,,,percent of total billed charges,90% of total billed charges,233.23,95,,,percent of total billed charges,95% of total billed charges,233.23,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,211.13,86,,,percent of total billed charges,86% of total billed charges,196.4,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,238.14,97,,,percent of total billed charges,97% of total billed charges,220.95,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.14,97,,,percent of total billed charges,97% of total billed charges,228.32,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.14,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.55,3163.8,
DR Nephrostogram Injection Procedure,646389,CDM,361,RC,50430,HCPCS,Outpatient,,,1519.38,759.69,,1367.44,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.5,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1367.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1473.8,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.83,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1367.44,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.57,70,,,percent of total billed charges,70% of total billed charges,1367.44,90,,,percent of total billed charges,90% of total billed charges,1443.41,95,,,percent of total billed charges,95% of total billed charges,1443.41,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1306.67,86,,,percent of total billed charges,86% of total billed charges,1215.5,80,,,percent of total billed charges,80% of total billed charges,575.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1473.8,97,,,percent of total billed charges,97% of total billed charges,1367.44,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1473.8,97,,,percent of total billed charges,97% of total billed charges,1413.02,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1473.8,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,482.77,3048.61,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,510,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR INTRODUCTION OF NEPHRO CATH BI,3431933,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR INTRODUCTION OF NEPHRO CATH LT,3431934,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR INTRODUCTION OF NEPHRO CATH RT,3431935,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR NEPHROSTOMY PERCUTANEOUS LT,3431936,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR NEPHROSTOMY PERCUTANEOUS RT,3431937,CDM,360,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-IR- Nephrostomy Tube Insertion Bilateral,4061203,CDM,481,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1819.94,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2047.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2206.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2092.94,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1592.45,70,,,percent of total billed charges,70% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,2161.18,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1956.44,86,,,percent of total billed charges,86% of total billed charges,1819.94,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2206.68,97,,,percent of total billed charges,97% of total billed charges,2047.44,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2206.68,97,,,percent of total billed charges,97% of total billed charges,2115.68,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2206.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
50432-PF IR INTRODUCTION OF NEPHRO CATH BI,3580889,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF IR INTRODUCTION OF NEPHRO CATH LT,3580890,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF IR INTRODUCTION OF NEPHRO CATH RT,3580891,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF IR NEPHROSTOMY PERCUTANEOUS LT,3580892,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF IR NEPHROSTOMY PERCUTANEOUS RT,3580893,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF IR Nephrostomy Tube Insertion Bilateral,4061206,CDM,960,RC,50432,HCPCS,Outpatient,,,2274.93,1137.47,,2047.44,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,2047.44,
50432-PF PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I,4321476,CDM,981,RC,50432,HCPCS,Outpatient,,,397.52,198.76,,357.77,90,,,percent of total billed charges,90% of total Billed charges,596.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.22,155,,,Fee Schedule,155% of CMS OPPS Rate,924.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,924.22,
CT Nephrostomy Percutaneous Bilat,3349765,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
CT Nephrostomy Percutaneous LT,3349767,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
CT Nephrostomy Percutaneous RT,3349769,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
IR Introduction of Nephro Catheter Bilat,603513,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
IR Introduction of Nephro Catheter Lt,603503,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
IR Introduction of Nephro Catheter Rt,603508,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
IR Ureteral Stent Placement Lt,603505,CDM,360,RC,50432,HCPCS,Outpatient,,,2184.02,1092.01,,1965.62,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.22,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1965.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2118.5,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2009.3,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.81,70,,,percent of total billed charges,70% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,2074.82,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1878.26,86,,,percent of total billed charges,86% of total billed charges,1747.22,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2118.5,97,,,percent of total billed charges,97% of total billed charges,1965.62,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.5,97,,,percent of total billed charges,97% of total billed charges,2031.14,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2118.5,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1431.99,9042.77,
Read,596947,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
Read,596950,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
Read,596953,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
Read,4181214,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
Read,4181216,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
Read,4181218,CDM,972,RC,50432,HCPCS,Outpatient,,,873.61,436.81,,786.25,90,,,percent of total billed charges,90% of total Billed charges,1054.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1634.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1634.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1634.01,
"50433-PF Placement of nephroureteral catheter, new access",4271250,CDM,960,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,1960.22,90,,,percent of total billed charges,90% of total Billed charges,1313.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.18,155,,,Fee Schedule,155% of CMS OPPS Rate,247.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,438.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,391.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,391.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,462.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,291.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,383.18,155,,,Fee Schedule,155% of CMS OPPS Rate,247.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2036.03,155,,,Fee Schedule,155% of CMS OPPS Rate,2036.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,247.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1196.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,247.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.17,2036.03,
"50433-Placement of nephroureteral catheter, new access",4271249,CDM,481,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,1960.22,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.42,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2112.68,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.78,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1960.22,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.61,70,,,percent of total billed charges,70% of total billed charges,1960.22,90,,,percent of total billed charges,90% of total billed charges,2069.12,95,,,percent of total billed charges,95% of total billed charges,2069.12,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1873.1,86,,,percent of total billed charges,86% of total billed charges,1742.42,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2112.68,97,,,percent of total billed charges,97% of total billed charges,1960.22,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.68,97,,,percent of total billed charges,97% of total billed charges,2025.56,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2112.68,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1524.61,15625.36,
"Placement of nephroureteral catheter, new access",4271251,CDM,761,RC,50433,HCPCS,Outpatient,,,2178.02,1089.01,,1960.22,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.42,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2112.68,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.78,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1960.22,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.61,70,,,percent of total billed charges,70% of total billed charges,1960.22,90,,,percent of total billed charges,90% of total billed charges,2069.12,95,,,percent of total billed charges,95% of total billed charges,2069.12,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1873.1,86,,,percent of total billed charges,86% of total billed charges,1742.42,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2112.68,97,,,percent of total billed charges,97% of total billed charges,1960.22,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.68,97,,,percent of total billed charges,97% of total billed charges,2025.56,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2112.68,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1524.61,15625.36,
50435-IR NEPHROSTOMY TUBE CHANGE BILAT,3431938,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
50435-IR- Nephrostomy Tube Change Left,4061204,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
50435-Nephrostomy Tube Change RT,3560655,CDM,481,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
50435-PF EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I,4321620,CDM,981,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
50435-PF IR NEPHROSTOMY TUBE CHANGE BILAT,3580894,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
50435-PF IR Nephrostomy Tube Change Left,4061207,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
50435-PF Nephrostomy Tube Change RT,3580895,CDM,960,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
CT Nephrostomy Tube Change Bilat,3349761,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
CT Nephrostomy Tube Change LT,3349763,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
CT Nephrostomy Tube Change RT,3349759,CDM,761,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,154.16,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.92,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,177.28,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,134.89,70,,,percent of total billed charges,70% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,183.07,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,165.72,86,,,percent of total billed charges,86% of total billed charges,154.16,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,186.92,97,,,percent of total billed charges,97% of total billed charges,173.43,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.92,97,,,percent of total billed charges,97% of total billed charges,179.21,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,186.92,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.89,9042.77,
Read,630444,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
Read,630446,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
Read,630448,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
Read,4181220,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
Read,4181222,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
Read,4181224,CDM,972,RC,50435,HCPCS,Outpatient,,,192.7,96.35,,173.43,90,,,percent of total billed charges,90% of total Billed charges,289.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.01,155,,,Fee Schedule,155% of CMS OPPS Rate,448.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.09,495.7,
50541PF Lap Surgical Ablation of Renal Cysts,4263109,CDM,975,RC,50541,HCPCS,Outpatient,,,2126.56,1063.28,,1913.9,90,,,percent of total billed charges,90% of total Billed charges,1797.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,895.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,724.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1388.2,155,,,Fee Schedule,155% of CMS OPPS Rate,895.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1396.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,895.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1571.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1571.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1401.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1401.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,731.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,895.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1791.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1653.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1071.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1388.2,155,,,Fee Schedule,155% of CMS OPPS Rate,895.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,2786.48,155,,,Fee Schedule,155% of CMS OPPS Rate,2786.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,895.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,895.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1840.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1840.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,724.61,2786.48,
50543PF Lap Surgical Partial Nephrectomy,4263110,CDM,975,RC,50543,HCPCS,Outpatient,,,3445.68,1722.84,,3101.11,90,,,percent of total billed charges,90% of total Billed charges,2916.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1451.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2249.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1451.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2266.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1451.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2549.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2549.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2273.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2273.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1184.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1451.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2902.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2683.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1737.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2249.33,155,,,Fee Schedule,155% of CMS OPPS Rate,1451.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,4520,155,,,Fee Schedule,155% of CMS OPPS Rate,4520,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1451.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1602.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1451.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2977.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2977.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1184.47,4520,
50544PF Laparoscopy Surgical Pyeloplasty,4263111,CDM,975,RC,50544,HCPCS,Outpatient,,,2878.35,1439.18,,2590.52,90,,,percent of total billed charges,90% of total Billed charges,2436.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1212.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,997.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1878.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1212.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1895.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1212.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2132.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2132.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1906.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1906.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,992.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2424.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2249.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1461.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1878.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1212.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,3776.27,155,,,Fee Schedule,155% of CMS OPPS Rate,3776.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1212.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,997.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1338.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1212.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2496.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2496.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,992.14,3776.27,
50545PF Lap Surgical Radical Nephrectomy,4263112,CDM,975,RC,50545,HCPCS,Outpatient,,,3093.11,1546.56,,2783.8,90,,,percent of total billed charges,90% of total Billed charges,2617.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1302.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2019.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1302.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2037.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1302.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2049.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2049.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1066.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1302.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2418.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1572.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2019.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1302.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,4057.42,155,,,Fee Schedule,155% of CMS OPPS Rate,4057.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1302.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1567.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1302.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2688.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2688.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4057.42,
50546PF Lap Surgical Nephrectomy w/Partial Ureterectomy,4263113,CDM,975,RC,50546,HCPCS,Outpatient,,,2792.12,1396.06,,2512.91,90,,,percent of total billed charges,90% of total Billed charges,2361.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1175.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,926.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1822.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1833.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1175.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2062.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2062.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1840.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1840.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,959.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2351.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2172.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1420.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1822.69,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3660.33,155,,,Fee Schedule,155% of CMS OPPS Rate,3660.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1175.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,926.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1175.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2403.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2403.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,926.65,3660.33,
50548PF Lap Surgical Nephrectomy w/Total Ureterectomy,4263114,CDM,975,RC,50548,HCPCS,Outpatient,,,3112.01,1556.01,,2800.81,90,,,percent of total billed charges,90% of total Billed charges,2634,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1310.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2031.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1310.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2049.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1310.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2305.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2305.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2062.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2062.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1072.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1310.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2621.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2433.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1582.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2031.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1310.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,4082.7,155,,,Fee Schedule,155% of CMS OPPS Rate,4082.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1310.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1532.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1310.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2699.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2699.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4082.7,
50549PF Unlisted Lap Procedure Renal,4263115,CDM,975,RC,50549,HCPCS,Outpatient,,,3988.99,1994.50,,3590.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.7,3590.09,
50555PF Renal endoscopy/biopsy,4263116,CDM,975,RC,50555,HCPCS,Outpatient,,,788.13,394.07,,709.32,90,,,percent of total billed charges,90% of total Billed charges,731.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,514.48,155,,,Fee Schedule,155% of CMS OPPS Rate,331.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,584.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,584.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,523.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,523.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,271.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,663.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,618.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,402.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,514.48,155,,,Fee Schedule,155% of CMS OPPS Rate,331.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1134.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1134.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,331.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,331.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,809.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,809.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,271.84,1134.58,
50590PF Lithotripsy Extracorporeal Shock Wave,4263117,CDM,975,RC,50590,HCPCS,Outpatient,,,1314.99,657.50,,1183.49,90,,,percent of total billed charges,90% of total Billed charges,1268.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1817.14,90,,,Percent of total Billed charges,90% of total billed charges,249.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,858.41,155,,,Fee Schedule,155% of CMS OPPS Rate,553.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,553.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,973.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,973.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,861.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,861.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,452.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1016.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,653.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,858.41,155,,,Fee Schedule,155% of CMS OPPS Rate,553.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1966.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1966.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,553.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,986.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,553.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1491.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1491.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,249.5,1966.19,
"50605 - Ureterotomy for insertion of indwelling stent, all types",3760902,CDM,983,RC,50605,HCPCS,Outpatient,,,2689.8,1344.90,,2420.82,90,,,percent of total billed charges,90% of total Billed charges,2016.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1004.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1557.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1521.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1004.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1711.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1711.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1541.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1541.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,792.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1004.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2009.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1818.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1276.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1557.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1004.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,3124.97,155,,,Fee Schedule,155% of CMS OPPS Rate,3124.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1004.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,964.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1004.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1959.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1959.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,792.2,3124.97,
50693: IR Nephroureteral Stent Placement,3654904,CDM,481,RC,50693,HCPCS,Outpatient,,,2490.76,1245.38,,2241.68,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.61,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2241.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2416.04,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2291.5,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2241.68,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1743.53,70,,,percent of total billed charges,70% of total billed charges,2241.68,90,,,percent of total billed charges,90% of total billed charges,2366.22,95,,,percent of total billed charges,95% of total billed charges,2366.22,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2142.05,86,,,percent of total billed charges,86% of total billed charges,1992.61,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2416.04,97,,,percent of total billed charges,97% of total billed charges,2241.68,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2416.04,97,,,percent of total billed charges,97% of total billed charges,2316.41,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2416.04,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1743.53,15625.36,
50693-IR PF Nephroureteral Stent Placement,3654906,CDM,960,RC,50693,HCPCS,Outpatient,,,2490.76,1245.38,,2241.68,90,,,percent of total billed charges,90% of total Billed charges,1133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.09,155,,,Fee Schedule,155% of CMS OPPS Rate,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,312.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,312.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,189.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,368.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,231.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.09,155,,,Fee Schedule,155% of CMS OPPS Rate,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1756.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1756.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1111.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.47,2241.68,
Read,4183196,CDM,972,RC,50693,HCPCS,Outpatient,,,954.05,477.03,,858.65,90,,,percent of total billed charges,90% of total Billed charges,1133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.09,155,,,Fee Schedule,155% of CMS OPPS Rate,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,351,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,312.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,312.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,189.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,368.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,231.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.09,155,,,Fee Schedule,155% of CMS OPPS Rate,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1756.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1756.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1111.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.47,1756.83,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,2798.94,1399.47,,2519.05,90,,,percent of total billed charges,90% of total Billed charges,1310.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,244.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,485.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,305.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2031.83,155,,,Fee Schedule,155% of CMS OPPS Rate,2031.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.83,2519.05,
50715 - Ureterolysis w/wo RPSG Ureter Retroperitoneal Fibrosis,4169590,CDM,983,RC,50715,HCPCS,Outpatient,,,2838.02,1419.01,,2554.22,90,,,percent of total billed charges,90% of total Billed charges,2385.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1190.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1844.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1190.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1832.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1190.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2060.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2060.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1842.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1842.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,981.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2380.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2174.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1469.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1844.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1190.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,3697.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3697.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1190.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1187.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1190.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2395.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2395.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,981.78,3697.28,
50760PF Ureteroureterostomy,4263118,CDM,975,RC,50760,HCPCS,Outpatient,,,2650.4,1325.20,,2385.36,90,,,percent of total billed charges,90% of total Billed charges,2245.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1116.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,697.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1730.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1116.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1722.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1116.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1937.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1937.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1735.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1735.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,899.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2232.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2047.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1372.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1730.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1116.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3480.18,155,,,Fee Schedule,155% of CMS OPPS Rate,3480.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1116.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1288.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1116.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,2265.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2265.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,697.5,3480.18,
50780-REIMPLANT URETER IN BLADDER,3430053,CDM,510,RC,50780,HCPCS,Outpatient,,,2916.75,1458.38,,2625.08,90,,,percent of total billed charges,90% of total Billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2333.4,80,,,Percent of total Billed charges,80% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2829.25,97,,,Percent of total billed charges,97% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2683.41,92,,,Percent of total billed charges,92% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.08,90,,,percent of total billed charges,90% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2041.73,70,,,percent of total billed charges,70% of total billed charges,2625.08,90,,,percent of total billed charges,90% of total billed charges,2770.91,95,,,percent of total billed charges,95% of total billed charges,2770.91,95,,,percent of total billed charges,95% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2508.41,86,,,percent of total billed charges,86% of total billed charges,2333.4,80,,,percent of total billed charges,80% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2829.25,97,,,percent of total billed charges,97% of total billed charges,2625.08,90,,,percent of total billed charges,90% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2829.25,97,,,percent of total billed charges,97% of total billed charges,2712.58,93,,,percent of total billed charges,93% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2829.25,97,,,percent of total billed charges,97% of total billed charges,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2916.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2041.73,2916.75,
50945 - PF Laparoscopy Urtrolithotomy,4327331,CDM,960,RC,50945,HCPCS,Outpatient,,,1858.56,929.28,,1672.7,90,,,percent of total billed charges,90% of total Billed charges,1902.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,946.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,765.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1466.97,155,,,Fee Schedule,155% of CMS OPPS Rate,946.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1479.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,946.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1664.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1664.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1484.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1484.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,778.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,946.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1892.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1751.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1133.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1466.97,155,,,Fee Schedule,155% of CMS OPPS Rate,946.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2948.61,155,,,Fee Schedule,155% of CMS OPPS Rate,2948.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,946.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1080.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,946.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1944.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1944.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,765.9,2948.61,
50949PF Unlisted Laparoscopy Procedure Ureter,4263119,CDM,975,RC,50949,HCPCS,Outpatient,,,3988.99,1994.50,,3590.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1196.7,3590.09,
51040PF Cystostomy/Cystotomy w/Drainage,4263120,CDM,975,RC,51040,HCPCS,Outpatient,,,666.09,333.05,,599.48,90,,,percent of total billed charges,90% of total Billed charges,562.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,263.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,434.81,155,,,Fee Schedule,155% of CMS OPPS Rate,280.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,280.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,494.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,432.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,432.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,231.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,510.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,324.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,434.81,155,,,Fee Schedule,155% of CMS OPPS Rate,280.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,872.53,155,,,Fee Schedule,155% of CMS OPPS Rate,872.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,280.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,405.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,280.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,570.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,570.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,231.34,872.53,
51100-PF Aspiration of Bladder; by Needle,4321619,CDM,981,RC,51100,HCPCS,Outpatient,,,77.18,38.59,,69.46,90,,,percent of total billed charges,90% of total Billed charges,108.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,59.81,155,,,Fee Schedule,155% of CMS OPPS Rate,38.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,59.81,155,,,Fee Schedule,155% of CMS OPPS Rate,38.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.18,155,,,Fee Schedule,155% of CMS OPPS Rate,168.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,38.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,123.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.98,168.18,
51102-PF ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER,4321477,CDM,981,RC,51102,HCPCS,Outpatient,,,279.84,139.92,,251.86,90,,,percent of total billed charges,90% of total Billed charges,371.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,216.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,222.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,222.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,216.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.47,155,,,Fee Schedule,155% of CMS OPPS Rate,575.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,440.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139.92,575.47,
51102PF Aspiration of Bladder w/Insertion Suprapubic Catheter,4263121,CDM,975,RC,51102,HCPCS,Outpatient,,,538.44,269.22,,484.6,90,,,percent of total billed charges,90% of total Billed charges,371.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,216.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,222.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,222.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,216.88,155,,,Fee Schedule,155% of CMS OPPS Rate,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.47,155,,,Fee Schedule,155% of CMS OPPS Rate,575.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,440.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139.92,575.47,
51500PF Excision Urachal Cyst/Sinus w/wo Umbilical Hernia Repair,4263122,CDM,975,RC,51500,HCPCS,Outpatient,,,1470.94,735.47,,1323.85,90,,,percent of total billed charges,90% of total Billed charges,1243.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,429,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,960.23,155,,,Fee Schedule,155% of CMS OPPS Rate,619.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,968.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,619.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1089.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1089.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,964.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,964.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,508.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1137.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,731.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,960.23,155,,,Fee Schedule,155% of CMS OPPS Rate,619.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1928.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1928.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,619.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,429,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,707.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,619.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1363.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1363.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,429,1928.17,
"51550 - Cystectomy, partial; simple",4169593,CDM,983,RC,51550,HCPCS,Outpatient,,,2254.97,1127.49,,2029.47,90,,,percent of total billed charges,90% of total Billed charges,1891.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,941.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1459.26,155,,,Fee Schedule,155% of CMS OPPS Rate,941.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1466.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,941.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1649.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1649.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1471.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1471.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,770.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,941.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1882.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1735.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1139,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1459.26,155,,,Fee Schedule,155% of CMS OPPS Rate,941.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2931.28,155,,,Fee Schedule,155% of CMS OPPS Rate,2931.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,941.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1047.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,941.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1941.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1941.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544,2931.28,
51555PF Cystectomy Partial Complicated,4263123,CDM,975,RC,51555,HCPCS,Outpatient,,,2919.96,1459.98,,2627.96,90,,,percent of total billed charges,90% of total Billed charges,2474.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1229.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1906.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1229.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1869.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1229.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2103.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2103.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1937.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1937.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1010.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1229.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2459.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2286.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1495.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1906.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1229.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3834.82,155,,,Fee Schedule,155% of CMS OPPS Rate,3834.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1229.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1326.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1229.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2547.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2547.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544,3834.82,
51575PF Cystectomy w/Bilat Pelvic Lymphadenectomy w/External Iliac/Hypogastric/Obturator Nodes,4263124,CDM,975,RC,51575,HCPCS,Outpatient,,,4215.77,2107.89,,3794.19,90,,,percent of total billed charges,90% of total Billed charges,3569.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1775.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2752.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1775.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2691.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1775.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3027.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3027.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2791.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2791.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1450.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1775.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3551,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3293.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2140.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2752.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1775.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,5533.22,155,,,Fee Schedule,155% of CMS OPPS Rate,5533.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1775.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2131.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1775.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,3644.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3644.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5533.22,
51600PF Injection Procedure Cystography or Voiding Urethrocystography,4263125,CDM,975,RC,51600,HCPCS,Outpatient,,,102.46,51.23,,92.21,90,,,percent of total billed charges,90% of total Billed charges,145.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,66.87,155,,,Fee Schedule,155% of CMS OPPS Rate,43.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,35.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,51.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,66.87,155,,,Fee Schedule,155% of CMS OPPS Rate,43.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.68,155,,,Fee Schedule,155% of CMS OPPS Rate,225.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,43.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,351.56,
51610PF Injection Procedure for Retrograde Urethrocystography,4263126,CDM,975,RC,51610,HCPCS,Outpatient,,,146.52,73.26,,131.87,90,,,percent of total billed charges,90% of total Billed charges,183.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,95.65,155,,,Fee Schedule,155% of CMS OPPS Rate,61.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,96.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,95.65,155,,,Fee Schedule,155% of CMS OPPS Rate,61.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.67,155,,,Fee Schedule,155% of CMS OPPS Rate,284.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,61.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,604.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,604.21,
51700PF Bladder Irrigation Simple Lavage/Instillation,4263127,CDM,975,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,63.86,90,,,percent of total billed charges,90% of total Billed charges,100.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,38.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.29,155,,,Fee Schedule,155% of CMS OPPS Rate,156.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.7,159.8,
51700-PF BLDR IRRIGATION SMPL LAVAGE &/INSTLJ,4321618,CDM,981,RC,51700,HCPCS,Outpatient,,,59.76,29.88,,53.78,90,,,percent of total billed charges,90% of total Billed charges,89.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,38.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.94,155,,,Fee Schedule,155% of CMS OPPS Rate,138.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.7,159.8,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,63.86,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.76,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.86,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.82,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,65.27,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.86,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,49.67,70,,,percent of total billed charges,70% of total billed charges,63.86,90,,,percent of total billed charges,90% of total billed charges,67.4,95,,,percent of total billed charges,95% of total billed charges,67.4,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.02,86,,,percent of total billed charges,86% of total billed charges,56.76,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.82,97,,,percent of total billed charges,97% of total billed charges,63.86,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.82,97,,,percent of total billed charges,97% of total billed charges,65.98,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.82,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1047.51,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,63.86,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.76,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.86,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.82,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,65.27,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.86,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,49.67,70,,,percent of total billed charges,70% of total billed charges,63.86,90,,,percent of total billed charges,90% of total billed charges,67.4,95,,,percent of total billed charges,95% of total billed charges,67.4,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.02,86,,,percent of total billed charges,86% of total billed charges,56.76,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.82,97,,,percent of total billed charges,97% of total billed charges,63.86,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.82,97,,,percent of total billed charges,97% of total billed charges,65.98,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.82,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1047.51,
51701PF Insertion Non-Indwelling Bladder Catheter,4263128,CDM,975,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,53.84,90,,,percent of total billed charges,90% of total Billed charges,68.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.51,155,,,Fee Schedule,155% of CMS OPPS Rate,105.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,105.51,
51701-PF INSJ NON-NDWELLG BLADDER CATHETER,4321617,CDM,981,RC,51701,HCPCS,Outpatient,,,50.38,25.19,,45.34,90,,,percent of total billed charges,90% of total Billed charges,68.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.51,155,,,Fee Schedule,155% of CMS OPPS Rate,105.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,105.51,
51702PF Insertion Temporary Indwelling Bladder Catheter Simple,4263129,CDM,975,RC,51702,HCPCS,Outpatient,,,58.79,29.40,,52.91,90,,,percent of total billed charges,90% of total Billed charges,82.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.6,155,,,Fee Schedule,155% of CMS OPPS Rate,128.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,134.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.09,134.64,
51702-PF INSJ NON-NDWELLG BLADDER CATHETER,4321616,CDM,981,RC,51702,HCPCS,Outpatient,,,49.52,24.76,,44.57,90,,,percent of total billed charges,90% of total Billed charges,74.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.13,155,,,Fee Schedule,155% of CMS OPPS Rate,115.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,134.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.09,134.64,
51703PF Insertion Temporary Indwelling Bladder Catheter Complicated,4263130,CDM,975,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,160.31,90,,,percent of total billed charges,90% of total Billed charges,218.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.04,155,,,Fee Schedule,155% of CMS OPPS Rate,338.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.88,338.04,
51703-PF INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED,4321615,CDM,981,RC,51703,HCPCS,Outpatient,,,150.04,75.02,,135.04,90,,,percent of total billed charges,90% of total Billed charges,218.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.04,155,,,Fee Schedule,155% of CMS OPPS Rate,338.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.88,338.04,
CATH TEMP DWELL COMPLICATED,3428403,CDM,761,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,160.31,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,142.5,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.31,90,,,Percent of total Billed charges,90% of total billed charges,82.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,172.78,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,163.87,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,160.31,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,124.68,70,,,percent of total billed charges,70% of total billed charges,160.31,90,,,percent of total billed charges,90% of total billed charges,169.21,95,,,percent of total billed charges,95% of total billed charges,169.21,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,153.18,86,,,percent of total billed charges,86% of total billed charges,142.5,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,172.78,97,,,percent of total billed charges,97% of total billed charges,160.31,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.78,97,,,percent of total billed charges,97% of total billed charges,165.65,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.78,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,74.61,708.98,
Cath Temp Dwell Simple,3428404,CDM,761,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,160.31,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,142.5,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.31,90,,,Percent of total Billed charges,90% of total billed charges,82.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,172.78,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,163.87,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,160.31,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,124.68,70,,,percent of total billed charges,70% of total billed charges,160.31,90,,,percent of total billed charges,90% of total billed charges,169.21,95,,,percent of total billed charges,95% of total billed charges,169.21,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,153.18,86,,,percent of total billed charges,86% of total billed charges,142.5,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,172.78,97,,,percent of total billed charges,97% of total billed charges,160.31,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.78,97,,,percent of total billed charges,97% of total billed charges,165.65,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.78,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,74.61,708.98,
51705PF Change Cystostomy Tube Simple,4263131,CDM,975,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,107.02,90,,,percent of total billed charges,90% of total Billed charges,141.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.03,155,,,Fee Schedule,155% of CMS OPPS Rate,219.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,203.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,219.03,
51705-PF CHANGE CYSTOSTOMY TUBE SIMPLE,4321614,CDM,981,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,107.02,90,,,percent of total billed charges,90% of total Billed charges,141.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.03,155,,,Fee Schedule,155% of CMS OPPS Rate,219.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,203.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,219.03,
51710PF Change Cystostomy Tube Complicated,4263132,CDM,975,RC,51710,HCPCS,Outpatient,,,184.4,92.20,,165.96,90,,,percent of total billed charges,90% of total Billed charges,206.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.36,155,,,Fee Schedule,155% of CMS OPPS Rate,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,119.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,119.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.36,155,,,Fee Schedule,155% of CMS OPPS Rate,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.59,155,,,Fee Schedule,155% of CMS OPPS Rate,320.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,280.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,320.59,
51715PF Endoscopic Injection Implant Material Submucosal Tissues Urethra/Bladder Neck,4263133,CDM,975,RC,51715,HCPCS,Outpatient,,,465.55,232.78,,419,90,,,percent of total billed charges,90% of total Billed charges,553.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,303.91,155,,,Fee Schedule,155% of CMS OPPS Rate,196.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,343.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,307.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,307.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,239.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,303.91,155,,,Fee Schedule,155% of CMS OPPS Rate,196.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.8,155,,,Fee Schedule,155% of CMS OPPS Rate,857.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,196.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,563.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,158.93,857.8,
51720PF Bladder Instillation Anticarcinogenic Agentc,4263134,CDM,975,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,92.4,90,,,percent of total billed charges,90% of total Billed charges,125.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.65,155,,,Fee Schedule,155% of CMS OPPS Rate,194.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.23,212.16,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,497.91,248.96,,448.12,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,398.33,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.12,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,482.97,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,458.08,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,448.12,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,348.54,70,,,percent of total billed charges,70% of total billed charges,448.12,90,,,percent of total billed charges,90% of total billed charges,473.01,95,,,percent of total billed charges,95% of total billed charges,473.01,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,428.2,86,,,percent of total billed charges,86% of total billed charges,398.33,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,482.97,97,,,percent of total billed charges,97% of total billed charges,448.12,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.97,97,,,percent of total billed charges,97% of total billed charges,463.06,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,482.97,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1047.51,
51726PF Complex Cystometrogram,4263135,CDM,975,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,585.91,90,,,percent of total billed charges,90% of total Billed charges,389.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,669,90,,,Percent of total Billed charges,90% of total billed charges,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.3,155,,,Fee Schedule,155% of CMS OPPS Rate,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,487.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,265.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.3,155,,,Fee Schedule,155% of CMS OPPS Rate,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.17,155,,,Fee Schedule,155% of CMS OPPS Rate,603.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,514.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,669,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,585.91,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,520.81,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.91,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,631.48,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,598.93,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,585.91,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,455.71,70,,,percent of total billed charges,70% of total billed charges,585.91,90,,,percent of total billed charges,90% of total billed charges,618.46,95,,,percent of total billed charges,95% of total billed charges,618.46,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,559.87,86,,,percent of total billed charges,86% of total billed charges,520.81,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,631.48,97,,,percent of total billed charges,97% of total billed charges,585.91,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.48,97,,,percent of total billed charges,97% of total billed charges,605.44,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,631.48,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1047.51,
51728PF Complex Cystometrogram w/Voiding Pressure Studies Any Technique,4263136,CDM,975,RC,51728,HCPCS,Outpatient,,,787.63,393.82,,708.87,90,,,percent of total billed charges,90% of total Billed charges,470.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,225.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,357.28,155,,,Fee Schedule,155% of CMS OPPS Rate,230.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,592.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,484.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,484.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,251.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,382.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.28,155,,,Fee Schedule,155% of CMS OPPS Rate,230.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,728.58,155,,,Fee Schedule,155% of CMS OPPS Rate,728.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,285.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,225.65,728.58,
51729PF Complex Cystometrogram w/Voiding Pressure and Urethral Pressure Profile Studies,4263137,CDM,975,RC,51729,HCPCS,Outpatient,,,838.74,419.37,,754.87,90,,,percent of total billed charges,90% of total Billed charges,469.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,247.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.83,155,,,Fee Schedule,155% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,632.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,520.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,520.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,271.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,384.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,155,,,Fee Schedule,155% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,727.66,155,,,Fee Schedule,155% of CMS OPPS Rate,727.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,275.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,665.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,230.21,754.87,
51741PF Complex Uroflowmetry,4263138,CDM,975,RC,51741,HCPCS,Outpatient,,,31.96,15.98,,28.76,90,,,percent of total billed charges,90% of total Billed charges,9.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.22,90,,,Percent of total Billed charges,90% of total billed charges,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,7.89,155,,,Fee Schedule,155% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,155,,,Fee Schedule,155% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.42,155,,,Fee Schedule,155% of CMS OPPS Rate,15.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.09,111.49,
51797PF Addon Voiding Pressure Studies Intra-Abdominal,4263139,CDM,975,RC,51797,HCPCS,Outpatient,,,411.58,205.79,,370.42,90,,,percent of total billed charges,90% of total Billed charges,275.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,208.23,155,,,Fee Schedule,155% of CMS OPPS Rate,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,273.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,221.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,221.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.23,155,,,Fee Schedule,155% of CMS OPPS Rate,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.29,155,,,Fee Schedule,155% of CMS OPPS Rate,427.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,427.29,
51798-PF MEAS POST-VOIDING RESIDUAL URINE&/BLADDER CAP,4321613,CDM,981,RC,51798,HCPCS,Outpatient,,,18.92,9.46,,17.03,90,,,percent of total billed charges,90% of total Billed charges,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.11,155,,,Fee Schedule,155% of CMS OPPS Rate,29.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,34.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.46,34.68,
51798PF Measurement Post-Voiding Residual Urine/Bladder Capacity Ultrasound Non-Imaging,4263140,CDM,975,RC,51798,HCPCS,Outpatient,,,22.46,11.23,,20.21,90,,,percent of total billed charges,90% of total Billed charges,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.11,155,,,Fee Schedule,155% of CMS OPPS Rate,29.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,34.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.46,34.68,
51800 - CSTOPLASTY/CSTOURTP PLSTC ANY,3997196,CDM,960,RC,51800,HCPCS,Outpatient,,,2709.94,1354.97,,2438.95,90,,,percent of total billed charges,90% of total Billed charges,2030.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1011.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,621,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1567.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1011.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1539.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1011.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1731.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1731.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1591.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1591.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,833.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2022.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1877.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1219.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1567.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1011.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,3147.04,155,,,Fee Schedule,155% of CMS OPPS Rate,3147.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1011.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,621,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1198.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1011.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,2089.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2089.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,621,3147.04,
51845- Abdomino-vag vesical neck suspens,3431682,CDM,360,RC,51845,HCPCS,Outpatient,,,1518.84,759.42,,1366.96,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.07,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1473.27,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1397.33,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1366.96,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.19,70,,,percent of total billed charges,70% of total billed charges,1366.96,90,,,percent of total billed charges,90% of total billed charges,1442.9,95,,,percent of total billed charges,95% of total billed charges,1442.9,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1306.2,86,,,percent of total billed charges,86% of total billed charges,1215.07,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1473.27,97,,,percent of total billed charges,97% of total billed charges,1366.96,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1473.27,97,,,percent of total billed charges,97% of total billed charges,1412.52,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1473.27,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1063.19,22596.74,
51860-MA AST REPAIR OF BLADDER WD,3430084,CDM,510,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,1763.83,90,,,percent of total billed charges,90% of total Billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.85,80,,,Percent of total Billed charges,80% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1763.83,90,,,Percent of total Billed charges,90% of total billed charges,457.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1901.02,97,,,Percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.03,92,,,Percent of total billed charges,92% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20660.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32936.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,41719.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1763.83,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1371.87,70,,,percent of total billed charges,70% of total billed charges,1763.83,90,,,percent of total billed charges,90% of total billed charges,1861.82,95,,,percent of total billed charges,95% of total billed charges,1861.82,95,,,percent of total billed charges,95% of total billed charges,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15544.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1685.44,86,,,percent of total billed charges,86% of total billed charges,1567.85,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1901.02,97,,,percent of total billed charges,97% of total billed charges,1763.83,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1901.02,97,,,percent of total billed charges,97% of total billed charges,1822.62,93,,,percent of total billed charges,93% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,416,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1901.02,97,,,percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,7772.46,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6606.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,416,41719.04,
51860-PF REPAIR OF BLADDER WOUND,3430085,CDM,510,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,1763.83,90,,,percent of total billed charges,90% of total Billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.85,80,,,Percent of total Billed charges,80% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1763.83,90,,,Percent of total Billed charges,90% of total billed charges,457.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1901.02,97,,,Percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.03,92,,,Percent of total billed charges,92% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20660.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32936.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,41719.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1763.83,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,1371.87,70,,,percent of total billed charges,70% of total billed charges,1763.83,90,,,percent of total billed charges,90% of total billed charges,1861.82,95,,,percent of total billed charges,95% of total billed charges,1861.82,95,,,percent of total billed charges,95% of total billed charges,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15544.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1685.44,86,,,percent of total billed charges,86% of total billed charges,1567.85,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1901.02,97,,,percent of total billed charges,97% of total billed charges,1763.83,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1901.02,97,,,percent of total billed charges,97% of total billed charges,1822.62,93,,,percent of total billed charges,93% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,416,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1901.02,97,,,percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,7772.46,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6606.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,416,41719.04,
"51865PF Cystorrhaphy, suture of bladder wound, injury or rup",4272098,CDM,975,RC,51865,HCPCS,Outpatient,,,2080.93,1040.47,,1872.84,90,,,percent of total billed charges,90% of total Billed charges,1761.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,876.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,467,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1358.4,155,,,Fee Schedule,155% of CMS OPPS Rate,876.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1327.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1493.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1493.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1371.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1371.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,714.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1752.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1618.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1065.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1358.4,155,,,Fee Schedule,155% of CMS OPPS Rate,876.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,2731.02,155,,,Fee Schedule,155% of CMS OPPS Rate,2731.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,876.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,467,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1047.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,876.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1797.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1797.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,467,2731.02,
51800PF Cystoplasty/Cystourethroplasty Plastic,4263141,CDM,975,RC,51880,HCPCS,Outpatient,,,1073.11,536.56,,965.8,90,,,percent of total billed charges,90% of total Billed charges,908.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,451.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,233.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,700.51,155,,,Fee Schedule,155% of CMS OPPS Rate,451.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,797.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,797.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,706.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,706.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,373.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,903.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,833.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,541.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,700.51,155,,,Fee Schedule,155% of CMS OPPS Rate,451.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1408.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1408.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,451.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,511.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,451.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,940.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,940.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,233.5,1408.55,
"51900 - Closure of vesicovaginal fistula, abdominal approach",3783524,CDM,510,RC,51900,HCPCS,Outpatient,,,2148.28,1074.14,,1933.45,90,,,percent of total billed charges,90% of total Billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.62,80,,,Percent of total Billed charges,80% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2083.83,97,,,Percent of total billed charges,97% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1976.42,92,,,Percent of total billed charges,92% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.45,90,,,percent of total billed charges,90% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.8,70,,,percent of total billed charges,70% of total billed charges,1933.45,90,,,percent of total billed charges,90% of total billed charges,2040.87,95,,,percent of total billed charges,95% of total billed charges,2040.87,95,,,percent of total billed charges,95% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1847.52,86,,,percent of total billed charges,86% of total billed charges,1718.62,80,,,percent of total billed charges,80% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2083.83,97,,,percent of total billed charges,97% of total billed charges,1933.45,90,,,percent of total billed charges,90% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2083.83,97,,,percent of total billed charges,97% of total billed charges,1997.9,93,,,percent of total billed charges,93% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2083.83,97,,,percent of total billed charges,97% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.8,2148.28,
51900-MA REPAIR BLADDER/VAGINA LESION,3430088,CDM,510,RC,51900,HCPCS,Outpatient,,,2148.28,1074.14,,1933.45,90,,,percent of total billed charges,90% of total Billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.62,80,,,Percent of total Billed charges,80% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2083.83,97,,,Percent of total billed charges,97% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1976.42,92,,,Percent of total billed charges,92% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.45,90,,,percent of total billed charges,90% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.8,70,,,percent of total billed charges,70% of total billed charges,1933.45,90,,,percent of total billed charges,90% of total billed charges,2040.87,95,,,percent of total billed charges,95% of total billed charges,2040.87,95,,,percent of total billed charges,95% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1847.52,86,,,percent of total billed charges,86% of total billed charges,1718.62,80,,,percent of total billed charges,80% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2083.83,97,,,percent of total billed charges,97% of total billed charges,1933.45,90,,,percent of total billed charges,90% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2083.83,97,,,percent of total billed charges,97% of total billed charges,1997.9,93,,,percent of total billed charges,93% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2083.83,97,,,percent of total billed charges,97% of total billed charges,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2148.28,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1503.8,2148.28,
"51999 - PF Unlisted Laparoscipy Procedure, Bladder",4309238,CDM,960,RC,51999,HCPCS,Outpatient,,,1699.84,849.92,,1529.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.95,1529.86,
52000PF Cystourethroscopy,4263142,CDM,975,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,168.08,90,,,percent of total billed charges,90% of total Billed charges,265.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.15,90,,,Percent of total Billed charges,90% of total billed charges,75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.91,155,,,Fee Schedule,155% of CMS OPPS Rate,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,95.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.91,155,,,Fee Schedule,155% of CMS OPPS Rate,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.37,155,,,Fee Schedule,155% of CMS OPPS Rate,411.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75,493.15,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,168.08,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,149.4,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.08,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,181.15,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,171.81,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,168.08,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,130.73,70,,,percent of total billed charges,70% of total billed charges,168.08,90,,,percent of total billed charges,90% of total billed charges,177.41,95,,,percent of total billed charges,95% of total billed charges,177.41,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,160.61,86,,,percent of total billed charges,86% of total billed charges,149.4,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,181.15,97,,,percent of total billed charges,97% of total billed charges,168.08,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.15,97,,,percent of total billed charges,97% of total billed charges,173.68,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.15,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,3048.61,
52001PF Cystourethroscopy w/Irrigation and Evacuation Multiple Obstructing Clots,4263143,CDM,975,RC,52001,HCPCS,Outpatient,,,662.38,331.19,,596.14,90,,,percent of total billed charges,90% of total Billed charges,704.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,240.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,278.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,490.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,229.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,557.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,336,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,432.39,155,,,Fee Schedule,155% of CMS OPPS Rate,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1091.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1091.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,278.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,724.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,229.07,1091.79,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,510,RC,52005,HCPCS,Outpatient,,,723.54,361.77,,651.19,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,578.83,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,651.19,90,,,Percent of total Billed charges,90% of total billed charges,127.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,701.83,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,665.66,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,651.19,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,506.48,70,,,percent of total billed charges,70% of total billed charges,651.19,90,,,percent of total billed charges,90% of total billed charges,687.36,95,,,percent of total billed charges,95% of total billed charges,687.36,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,622.24,86,,,percent of total billed charges,86% of total billed charges,578.83,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,701.83,97,,,percent of total billed charges,97% of total billed charges,651.19,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,701.83,97,,,percent of total billed charges,97% of total billed charges,672.89,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,701.83,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116,9042.77,
52005-PF CYSTO BLADDER W/URETERAL CATHETERIZATION,4321478,CDM,981,RC,52005,HCPCS,Outpatient,,,255.48,127.74,,229.93,90,,,percent of total billed charges,90% of total Billed charges,383.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.76,90,,,Percent of total Billed charges,90% of total billed charges,116,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,225.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,152.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.99,155,,,Fee Schedule,155% of CMS OPPS Rate,593.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1087.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,523.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106.51,1087.01,
52005PF Cystourethroscopy w/Ureteral Catheterization w/wo Irrigation/Instillation,4263144,CDM,975,RC,52005,HCPCS,Outpatient,,,303.31,151.66,,272.98,90,,,percent of total billed charges,90% of total Billed charges,416.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.76,90,,,Percent of total Billed charges,90% of total billed charges,116,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,225.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,152.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.02,155,,,Fee Schedule,155% of CMS OPPS Rate,645.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1087.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,523.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106.51,1087.01,
52204- Cystourethroscopy with biopsy,3430089,CDM,510,RC,52204,HCPCS,Outpatient,,,324.06,162.03,,291.65,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,259.25,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.65,90,,,Percent of total Billed charges,90% of total billed charges,135.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,314.34,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,298.14,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,291.65,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,226.84,70,,,percent of total billed charges,70% of total billed charges,291.65,90,,,percent of total billed charges,90% of total billed charges,307.86,95,,,percent of total billed charges,95% of total billed charges,307.86,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,278.69,86,,,percent of total billed charges,86% of total billed charges,259.25,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,314.34,97,,,percent of total billed charges,97% of total billed charges,291.65,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.34,97,,,percent of total billed charges,97% of total billed charges,301.38,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,314.34,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,123.5,9042.77,
"52214 - Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bla",3572812,CDM,983,RC,52214,HCPCS,Outpatient,,,1875.47,937.74,,1687.92,90,,,percent of total billed charges,90% of total Billed charges,876.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,181.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,265.96,155,,,Fee Schedule,155% of CMS OPPS Rate,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,265.96,155,,,Fee Schedule,155% of CMS OPPS Rate,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1359.07,155,,,Fee Schedule,155% of CMS OPPS Rate,1359.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1216.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1216.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,152.39,1687.92,
52214PF Cystourethroscopy w/Destruction of Lesions,4263145,CDM,975,RC,52214,HCPCS,Outpatient,,,407.44,203.72,,366.7,90,,,percent of total billed charges,90% of total Billed charges,579.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,181.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,265.96,155,,,Fee Schedule,155% of CMS OPPS Rate,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,265.96,155,,,Fee Schedule,155% of CMS OPPS Rate,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,897.5,155,,,Fee Schedule,155% of CMS OPPS Rate,897.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1216.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1216.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,152.39,1216.52,
52224PF Cystourethroscopy w/Removal Small Lesion Less Than 0.5cm w/wo Bx,4263146,CDM,975,RC,52224,HCPCS,Outpatient,,,471.95,235.98,,424.76,90,,,percent of total billed charges,90% of total Billed charges,670.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,153.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,308.09,155,,,Fee Schedule,155% of CMS OPPS Rate,198.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,349.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,242.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.09,155,,,Fee Schedule,155% of CMS OPPS Rate,198.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1039.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1670.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1127.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1127.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.5,1670.12,
52234PF Cystourethroscopy w/Fulguration/Resection Small Tumor 0.5cm-2.0cm,4263147,CDM,975,RC,52234,HCPCS,Outpatient,,,566.85,283.43,,510.17,90,,,percent of total billed charges,90% of total Billed charges,479.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,216,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,370.03,155,,,Fee Schedule,155% of CMS OPPS Rate,238.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,419.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,375.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,375.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,196.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,370.03,155,,,Fee Schedule,155% of CMS OPPS Rate,238.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,743.57,155,,,Fee Schedule,155% of CMS OPPS Rate,743.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,238.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,216,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,441.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,238.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,492.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,196.37,743.57,
52235PF Cystourethroscopy w/Fulguration/Resection Medium Tumor 2.0cm-5.0cm,4263148,CDM,975,RC,52235,HCPCS,Outpatient,,,665.16,332.58,,598.64,90,,,percent of total billed charges,90% of total Billed charges,562.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,270.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,434.2,155,,,Fee Schedule,155% of CMS OPPS Rate,280.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,280.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,492.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,440.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,440.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,230.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,520.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,434.2,155,,,Fee Schedule,155% of CMS OPPS Rate,280.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,871.77,155,,,Fee Schedule,155% of CMS OPPS Rate,871.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,280.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,552.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,280.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,578,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,578,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,230.2,871.77,
52240PF Cystourethroscopy w/Fulguration/Resection Large Tumor Greater Than 5.0cm,4263149,CDM,975,RC,52240,HCPCS,Outpatient,,,904.82,452.41,,814.34,90,,,percent of total billed charges,90% of total Billed charges,765.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,450.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,590.64,155,,,Fee Schedule,155% of CMS OPPS Rate,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,381.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,670.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,600.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,600.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,374.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,460.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,590.64,155,,,Fee Schedule,155% of CMS OPPS Rate,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1186.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1186.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,876.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1010.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,374.19,1186.99,
52260PF Cystourethroscopy w/Dilation Bladder General/Conduction Anesthesia,4263150,CDM,975,RC,52260,HCPCS,Outpatient,,,487.32,243.66,,438.59,90,,,percent of total billed charges,90% of total Billed charges,412.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,318.12,155,,,Fee Schedule,155% of CMS OPPS Rate,205.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,360.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,322.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,322.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,249.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,318.12,155,,,Fee Schedule,155% of CMS OPPS Rate,205.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.68,155,,,Fee Schedule,155% of CMS OPPS Rate,638.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,205.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,301.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,205.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,421.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,421.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,638.68,
52276PF Cystourethroscopy w/Direct Vision Internal Urethrotomy,4263151,CDM,975,RC,52276,HCPCS,Outpatient,,,608.99,304.50,,548.09,90,,,percent of total billed charges,90% of total Billed charges,515.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,247.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,397.54,155,,,Fee Schedule,155% of CMS OPPS Rate,256.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,404.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,404.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,211.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,309.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,397.54,155,,,Fee Schedule,155% of CMS OPPS Rate,256.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,799.03,155,,,Fee Schedule,155% of CMS OPPS Rate,799.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,256.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,681.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,256.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,532.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,211.2,799.03,
52281-PF CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS,4321479,CDM,981,RC,52281,HCPCS,Outpatient,,,294.82,147.41,,265.34,90,,,percent of total billed charges,90% of total Billed charges,442.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.05,90,,,Percent of total Billed charges,90% of total billed charges,107.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,259.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,685.46,155,,,Fee Schedule,155% of CMS OPPS Rate,685.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,614.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.5,761.05,
52281PF Cystourethroscopy w/Calibration/Dilation Urethral Stricture/Stenosis Male/Female,4263152,CDM,960,RC,52281,HCPCS,Outpatient,,,312.51,156.26,,281.26,90,,,percent of total billed charges,90% of total Billed charges,458.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.05,90,,,Percent of total Billed charges,90% of total billed charges,107.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,259.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.61,155,,,Fee Schedule,155% of CMS OPPS Rate,710.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,614.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.5,761.05,
52284 - PF Optilume/cystourethroscopoy for stricture,4339430,CDM,960,RC,52284,HCPCS,Outpatient,,,314.08,157.04,,282.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,282.67,
52287PF Cystourethroscopy w/Injection Chemodenervation Bladder,4263153,CDM,975,RC,52287,HCPCS,Outpatient,,,392.66,196.33,,353.39,90,,,percent of total billed charges,90% of total Billed charges,535.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.32,155,,,Fee Schedule,155% of CMS OPPS Rate,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,289.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,259.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,259.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,306.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,200.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.32,155,,,Fee Schedule,155% of CMS OPPS Rate,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.6,155,,,Fee Schedule,155% of CMS OPPS Rate,830.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.74,830.6,
"52300 - Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or",3760999,CDM,983,RC,52300,HCPCS,Outpatient,,,728.25,364.13,,655.43,90,,,percent of total billed charges,90% of total Billed charges,546.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,195,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,422.78,155,,,Fee Schedule,155% of CMS OPPS Rate,272.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,477.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,427.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,427.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,545.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,504.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,327.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,422.78,155,,,Fee Schedule,155% of CMS OPPS Rate,272.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,847.23,155,,,Fee Schedule,155% of CMS OPPS Rate,847.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,272.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,195,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,418.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,272.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,571.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,571.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,195,847.23,
52310-PF CYSTO W/SIMPLE REMOVAL STONE & STENT,4321612,CDM,981,RC,52310,HCPCS,Outpatient,,,294.5,147.25,,265.05,90,,,percent of total billed charges,90% of total Billed charges,441.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.68,90,,,Percent of total Billed charges,90% of total billed charges,129,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,684.71,155,,,Fee Schedule,155% of CMS OPPS Rate,684.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.97,691.68,
52310PF Cystourethroscopy w/Removal FB/Calculus/Ureteral Stent Urethra/Bladder Simple,4263154,CDM,975,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,314.67,90,,,percent of total billed charges,90% of total Billed charges,450.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.68,90,,,Percent of total Billed charges,90% of total billed charges,129,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.66,155,,,Fee Schedule,155% of CMS OPPS Rate,697.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.97,697.66,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,314.67,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,279.7,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.67,90,,,Percent of total Billed charges,90% of total billed charges,141.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,339.14,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,321.66,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.67,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,244.74,70,,,percent of total billed charges,70% of total billed charges,314.67,90,,,percent of total billed charges,90% of total billed charges,332.15,95,,,percent of total billed charges,95% of total billed charges,332.15,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.68,86,,,percent of total billed charges,86% of total billed charges,279.7,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.14,97,,,percent of total billed charges,97% of total billed charges,314.67,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.14,97,,,percent of total billed charges,97% of total billed charges,325.16,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.14,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129,9042.77,
52317PF Litholapaxy Crushing/Fragmentation and Removal Calculus Simple/Small Less Than 2.5cm,4263155,CDM,975,RC,52317,HCPCS,Outpatient,,,800.98,400.49,,720.88,90,,,percent of total billed charges,90% of total Billed charges,1138.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,337.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,256,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,522.86,155,,,Fee Schedule,155% of CMS OPPS Rate,337.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,595.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,595.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,534.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,534.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,276.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,630.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,411.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,522.86,155,,,Fee Schedule,155% of CMS OPPS Rate,337.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1764.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1764.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,337.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,256,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1302.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,337.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1527.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1527.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,256,1764.38,
52318PF Litholapaxy Crushing/Fragmentation and Removal Calculus Comp/Large Greater Than 2.5cm,4263156,CDM,975,RC,52318,HCPCS,Outpatient,,,1094.27,547.14,,984.84,90,,,percent of total billed charges,90% of total Billed charges,925.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,460.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,272,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,714.32,155,,,Fee Schedule,155% of CMS OPPS Rate,460.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,460.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,726.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,726.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,921.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,857.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,558.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,714.32,155,,,Fee Schedule,155% of CMS OPPS Rate,460.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1435.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1435.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,460.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,272,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,588.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,460.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,950.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,272,1435.08,
"52330 - Cystourethroscopy (including ureteral catheterization); with manipulation, without removal o",3572813,CDM,983,RC,52330,HCPCS,Outpatient,,,1532.65,766.33,,1379.39,90,,,percent of total billed charges,90% of total Billed charges,832.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,212,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,396.47,155,,,Fee Schedule,155% of CMS OPPS Rate,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,403.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,403.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,210.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,396.47,155,,,Fee Schedule,155% of CMS OPPS Rate,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1289.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1289.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,212,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,914.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,941.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,941.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.29,1379.39,
52330PF Cystourethroscopy w/Manipulation w/o Removal Ureteral Calculus,4263157,CDM,975,RC,52330,HCPCS,Outpatient,,,607.37,303.69,,546.63,90,,,percent of total billed charges,90% of total Billed charges,832.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,212,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,396.47,155,,,Fee Schedule,155% of CMS OPPS Rate,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,403.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,403.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,210.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,511.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,396.47,155,,,Fee Schedule,155% of CMS OPPS Rate,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1289.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1289.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,212,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,914.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,255.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,941.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,941.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,210.29,1289.79,
52332PF Cystourethroscopy w/Insertion Indwelling Ureteral Stent,4263158,CDM,975,RC,52332,HCPCS,Outpatient,,,358.04,179.02,,322.24,90,,,percent of total billed charges,90% of total Billed charges,508.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1057.35,90,,,Percent of total Billed charges,90% of total billed charges,143.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,233.72,155,,,Fee Schedule,155% of CMS OPPS Rate,150.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,264.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,235.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,235.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,179.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,233.72,155,,,Fee Schedule,155% of CMS OPPS Rate,150.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.69,155,,,Fee Schedule,155% of CMS OPPS Rate,788.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,766.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,927.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,927.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.37,1057.35,
"52341- Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electro",3621519,CDM,510,RC,52341,HCPCS,Outpatient,,,739,369.50,,665.1,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,591.2,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,716.83,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,679.88,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,665.1,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,517.3,70,,,percent of total billed charges,70% of total billed charges,665.1,90,,,percent of total billed charges,90% of total billed charges,702.05,95,,,percent of total billed charges,95% of total billed charges,702.05,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,635.54,86,,,percent of total billed charges,86% of total billed charges,591.2,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,716.83,97,,,percent of total billed charges,97% of total billed charges,665.1,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.83,97,,,percent of total billed charges,97% of total billed charges,687.27,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,716.83,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,517.3,15625.36,
52344PF Cystourethroscopy w/Ureteroscopy w/Tx Ureteral Stricture,4263159,CDM,975,RC,52344,HCPCS,Outpatient,,,850.4,425.20,,765.36,90,,,percent of total billed charges,90% of total Billed charges,720.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,358.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,360.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,555.13,155,,,Fee Schedule,155% of CMS OPPS Rate,358.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,630.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,630.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,564.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,564.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,309.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,716.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,666,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,431.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,555.13,155,,,Fee Schedule,155% of CMS OPPS Rate,358.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1117.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,358.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,358.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,759.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,759.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,309.18,1117.22,
"52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, b",3621659,CDM,510,RC,52345,HCPCS,Outpatient,,,1028.58,514.29,,925.72,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,822.86,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,925.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,997.72,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,946.29,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,925.72,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,720.01,70,,,percent of total billed charges,70% of total billed charges,925.72,90,,,percent of total billed charges,90% of total billed charges,977.15,95,,,percent of total billed charges,95% of total billed charges,977.15,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,884.58,86,,,percent of total billed charges,86% of total billed charges,822.86,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,997.72,97,,,percent of total billed charges,97% of total billed charges,925.72,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,997.72,97,,,percent of total billed charges,97% of total billed charges,956.58,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,997.72,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,720.01,15625.36,
52351PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy Diagnostic,4263160,CDM,975,RC,52351,HCPCS,Outpatient,,,696.98,348.49,,627.28,90,,,percent of total billed charges,90% of total Billed charges,589.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,287.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,454.97,155,,,Fee Schedule,155% of CMS OPPS Rate,293.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,516.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,241.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,545.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,352.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,454.97,155,,,Fee Schedule,155% of CMS OPPS Rate,293.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,914.31,155,,,Fee Schedule,155% of CMS OPPS Rate,914.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,293.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,293.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,628.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,628.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,241.41,914.31,
52352PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Removal/Manipulation Calculus,4263161,CDM,975,RC,52352,HCPCS,Outpatient,,,816.98,408.49,,735.28,90,,,percent of total billed charges,90% of total Billed charges,690.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,344.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,533.31,155,,,Fee Schedule,155% of CMS OPPS Rate,344.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,606.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,543.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,543.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,282.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,688.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,641.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,417.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,533.31,155,,,Fee Schedule,155% of CMS OPPS Rate,344.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1070.85,155,,,Fee Schedule,155% of CMS OPPS Rate,1070.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,344.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,344.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,737.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,737.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,282.06,1070.85,
52353PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Lithotripsy,4263162,CDM,975,RC,52353,HCPCS,Outpatient,,,904.82,452.41,,814.34,90,,,percent of total billed charges,90% of total Billed charges,765.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,396.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,590.64,155,,,Fee Schedule,155% of CMS OPPS Rate,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,381.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,670.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,600.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,600.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,314.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,460.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,590.64,155,,,Fee Schedule,155% of CMS OPPS Rate,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,1186.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1186.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,381.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,847.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,847.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,314.31,1186.99,
52354PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Bx/Fulguration Renal Pelvic Lesion,4263163,CDM,975,RC,52354,HCPCS,Outpatient,,,961.9,480.95,,865.71,90,,,percent of total billed charges,90% of total Billed charges,814.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,405.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,361.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,627.92,155,,,Fee Schedule,155% of CMS OPPS Rate,405.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,713.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,713.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,639.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,639.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,810.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,754.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,490.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,627.92,155,,,Fee Schedule,155% of CMS OPPS Rate,405.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1262.13,155,,,Fee Schedule,155% of CMS OPPS Rate,1262.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,405.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,405.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,784.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,784.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,332.36,1262.13,
52355 - PF Cystourethroscopy w/Ureteroscopy/Pyeloscopy w/Resection Ureteral/Renal Pelvic Tumor,4327196,CDM,960,RC,52355,HCPCS,Outpatient,,,892.34,446.17,,803.11,90,,,percent of total billed charges,90% of total Billed charges,912.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,453.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.56,155,,,Fee Schedule,155% of CMS OPPS Rate,453.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,453.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,799.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,716.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,716.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,372.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,845.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,550.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,703.56,155,,,Fee Schedule,155% of CMS OPPS Rate,453.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1413.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1413.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,453.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,549.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,453.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,935,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,935,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,372.52,1413.66,
"52356 - (50) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including inse",3699540,CDM,510,RC,52356,HCPCS,Outpatient,,,959.14,479.57,,863.23,90,,,percent of total billed charges,90% of total Billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,767.31,80,,,Percent of total Billed charges,80% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,930.37,97,,,Percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,882.41,92,,,Percent of total billed charges,92% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11352.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18097.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22923.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,863.23,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,671.4,70,,,percent of total billed charges,70% of total billed charges,863.23,90,,,percent of total billed charges,90% of total billed charges,911.18,95,,,percent of total billed charges,95% of total billed charges,911.18,95,,,percent of total billed charges,95% of total billed charges,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8541.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,824.86,86,,,percent of total billed charges,86% of total billed charges,767.31,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,930.37,97,,,percent of total billed charges,97% of total billed charges,863.23,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.37,97,,,percent of total billed charges,97% of total billed charges,892,93,,,percent of total billed charges,93% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,930.37,97,,,percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4270.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3630.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,671.4,22923.72,
52356PF Cystourethroscopy w/Ureteroscopy w/Lithotripsy w/Insert Indwelling Ureteral Stent,4263165,CDM,975,RC,52356,HCPCS,Outpatient,,,959.14,479.57,,863.23,90,,,percent of total billed charges,90% of total Billed charges,811.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,403.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.11,155,,,Fee Schedule,155% of CMS OPPS Rate,403.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,403.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,710.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,710.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,636.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,636.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,337.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,807.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,751.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,487.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,626.11,155,,,Fee Schedule,155% of CMS OPPS Rate,403.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1258.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1258.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,403.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,458.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,403.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337.38,1258.48,
"52400 - PF Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethr",3699541,CDM,510,RC,52400,HCPCS,Outpatient,,,1246.03,623.02,,1121.43,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,996.82,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1121.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1208.65,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.35,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1121.43,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,872.22,70,,,percent of total billed charges,70% of total billed charges,1121.43,90,,,percent of total billed charges,90% of total billed charges,1183.73,95,,,percent of total billed charges,95% of total billed charges,1183.73,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1071.59,86,,,percent of total billed charges,86% of total billed charges,996.82,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1208.65,97,,,percent of total billed charges,97% of total billed charges,1121.43,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1208.65,97,,,percent of total billed charges,97% of total billed charges,1158.81,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1208.65,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,872.22,15625.36,
"52400PF Cystourethroscopy with incision, fulguration, or res",4272095,CDM,975,RC,52400,HCPCS,Outpatient,,,1103.08,551.54,,992.77,90,,,percent of total billed charges,90% of total Billed charges,933.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,464.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,493.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,720.07,155,,,Fee Schedule,155% of CMS OPPS Rate,464.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,726.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,464.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,817.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,817.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,727.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,727.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,404.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,858.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,555.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,720.07,155,,,Fee Schedule,155% of CMS OPPS Rate,464.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1446.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1446.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,464.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,655.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,464.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,953.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,953.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,404.68,1446.32,
52441PF Cystourethro w/Implant,4263166,CDM,975,RC,52441,HCPCS,Outpatient,,,483.9,241.95,,435.51,90,,,percent of total billed charges,90% of total Billed charges,687.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,203.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.87,155,,,Fee Schedule,155% of CMS OPPS Rate,203.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,203.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,338.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,322.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,322.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,202.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,407.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,247.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,315.87,155,,,Fee Schedule,155% of CMS OPPS Rate,203.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1065.92,155,,,Fee Schedule,155% of CMS OPPS Rate,1065.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,203.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1288.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,203.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.74,1288.91,
52442PF Cystourethro w/Addl Implant,4263167,CDM,975,RC,52442,HCPCS,Outpatient,,,117.7,58.85,,105.93,90,,,percent of total billed charges,90% of total Billed charges,167.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.83,155,,,Fee Schedule,155% of CMS OPPS Rate,49.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,59.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.83,155,,,Fee Schedule,155% of CMS OPPS Rate,49.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.27,155,,,Fee Schedule,155% of CMS OPPS Rate,259.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,978.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,978.86,
52450 - PF Transurethral Incision Prostate,4301621,CDM,960,RC,52450,HCPCS,Outpatient,,,971.62,485.81,,874.46,90,,,percent of total billed charges,90% of total Billed charges,920.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,458.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,315,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,710.37,155,,,Fee Schedule,155% of CMS OPPS Rate,458.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,458.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,709.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,709.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,374.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,535.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,710.37,155,,,Fee Schedule,155% of CMS OPPS Rate,458.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1426.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,458.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,315,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,522.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,458.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,930.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,315,1426.02,
52500 - Revision of bladder neck,4241830,CDM,960,RC,52500,HCPCS,Outpatient,,,1010.35,505.18,,909.32,90,,,percent of total billed charges,90% of total Billed charges,955.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,738.68,155,,,Fee Schedule,155% of CMS OPPS Rate,476.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,476.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,836,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,836,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,736.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,736.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,400.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,869.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,555.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,738.68,155,,,Fee Schedule,155% of CMS OPPS Rate,476.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1480.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1480.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,476.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,368,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,638.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,476.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,966.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,966.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,368,1480.45,
52601PF Transurethral Electrosurgical Resection Prostate w/Control Postop Bleed Complete,4263168,CDM,975,RC,52601,HCPCS,Outpatient,,,1684.18,842.09,,1515.76,90,,,percent of total billed charges,90% of total Billed charges,1424.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1865,90,,,Percent of total Billed charges,90% of total billed charges,601.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1099.42,155,,,Fee Schedule,155% of CMS OPPS Rate,709.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1042.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,709.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1172.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1172.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1110.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1110.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,673.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1309.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,845.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1099.42,155,,,Fee Schedule,155% of CMS OPPS Rate,709.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2207.74,155,,,Fee Schedule,155% of CMS OPPS Rate,2207.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,709.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,986.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,709.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1686.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1686.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,601.5,2207.74,
52630 - PF TrnsUrthrl Rsctn Rsdl/Rgrwth Obstr Prstate Tiss,4349187,CDM,960,RC,52630,HCPCS,Outpatient,,,772.26,386.13,,695.03,90,,,percent of total billed charges,90% of total Billed charges,785.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,391.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,399.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,607.31,155,,,Fee Schedule,155% of CMS OPPS Rate,391.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,391.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,646.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,604.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,604.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,336.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,783.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,713.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,607.31,155,,,Fee Schedule,155% of CMS OPPS Rate,391.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1217.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,391.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,648.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,391.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,884.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,336.54,1217.06,
52648PF Laser Vaporization Prostate w/Control Postoperative Bleeding Complete,4263169,CDM,975,RC,52648,HCPCS,Outpatient,,,1598.61,799.31,,1438.75,90,,,percent of total billed charges,90% of total Billed charges,2206.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,673.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,619.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1043.57,155,,,Fee Schedule,155% of CMS OPPS Rate,673.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,987.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,673.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1110.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1048.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1048.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1237.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,796.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1043.57,155,,,Fee Schedule,155% of CMS OPPS Rate,673.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3420.06,155,,,Fee Schedule,155% of CMS OPPS Rate,3420.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,673.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7187.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,673.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3455.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3455.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,549.57,7187.12,
53020PF Meatotomy/Cutting of Meatus Except Infant,4263164,CDM,975,RC,53020,HCPCS,Outpatient,,,1088.11,544.06,,979.3,90,,,percent of total billed charges,90% of total Billed charges,188.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,145.99,155,,,Fee Schedule,155% of CMS OPPS Rate,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,113.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,145.99,155,,,Fee Schedule,155% of CMS OPPS Rate,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.62,155,,,Fee Schedule,155% of CMS OPPS Rate,292.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,221.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,194.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45,979.3,
53200 Biopsy of urethra,3621304,CDM,510,RC,53200,HCPCS,Outpatient,,,410.55,205.28,,369.5,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,328.44,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,369.5,90,,,Percent of total Billed charges,90% of total billed charges,70.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,398.23,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,377.71,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,369.5,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,287.39,70,,,percent of total billed charges,70% of total billed charges,369.5,90,,,percent of total billed charges,90% of total billed charges,390.02,95,,,percent of total billed charges,95% of total billed charges,390.02,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,353.07,86,,,percent of total billed charges,86% of total billed charges,328.44,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,398.23,97,,,percent of total billed charges,97% of total billed charges,369.5,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.23,97,,,percent of total billed charges,97% of total billed charges,381.81,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,398.23,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,64,9042.77,
53200-PF BIOPSY URETHRA,4321480,CDM,981,RC,53200,HCPCS,Outpatient,,,276.98,138.49,,249.28,90,,,percent of total billed charges,90% of total Billed charges,292.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,214.66,155,,,Fee Schedule,155% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,242.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,216.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,216.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,214.66,155,,,Fee Schedule,155% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.95,155,,,Fee Schedule,155% of CMS OPPS Rate,453.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64,453.95,
53220PF Excision/Fulguration Carcinoma Urethra,4263170,CDM,975,RC,53220,HCPCS,Outpatient,,,1041.53,520.77,,937.38,90,,,percent of total billed charges,90% of total Billed charges,879.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,438.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,679.91,155,,,Fee Schedule,155% of CMS OPPS Rate,438.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,438.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,772.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,772.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,681.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,681.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,365.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,877.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,804.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,515.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,679.91,155,,,Fee Schedule,155% of CMS OPPS Rate,438.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1363.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1363.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,438.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,323,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,500.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,438.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,903.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,903.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,323,1363.32,
53265 - Excision or fulgration; urethral caruncle,4241831,CDM,960,RC,53265,HCPCS,Outpatient,,,467.31,233.66,,420.58,90,,,percent of total billed charges,90% of total Billed charges,406.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,286.55,155,,,Fee Schedule,155% of CMS OPPS Rate,184.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,335.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,286.55,155,,,Fee Schedule,155% of CMS OPPS Rate,184.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,629.92,155,,,Fee Schedule,155% of CMS OPPS Rate,629.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,184.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,115,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,349.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,428.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,428.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115,629.92,
"53450 - Urethromeatoplasty, with mucosal advancement",3997201,CDM,960,RC,53450,HCPCS,Outpatient,,,1060.73,530.37,,954.66,90,,,percent of total billed charges,90% of total Billed charges,795.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,396.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,614.31,155,,,Fee Schedule,155% of CMS OPPS Rate,396.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,622.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,699.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,699.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,616.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,616.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,466.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,614.31,155,,,Fee Schedule,155% of CMS OPPS Rate,396.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1232.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1232.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,396.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,415.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,396.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,808.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,138.5,1232.54,
"53505 - PF Urethrorrhaphy, suture of urethral wound or injury; penile",3641188,CDM,510,RC,53505,HCPCS,Outpatient,,,1263.34,631.67,,1137.01,90,,,percent of total billed charges,90% of total Billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1010.67,80,,,Percent of total Billed charges,80% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1137.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1225.44,97,,,Percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1162.27,92,,,Percent of total billed charges,92% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11352.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18097.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22923.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1137.01,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,884.34,70,,,percent of total billed charges,70% of total billed charges,1137.01,90,,,percent of total billed charges,90% of total billed charges,1200.17,95,,,percent of total billed charges,95% of total billed charges,1200.17,95,,,percent of total billed charges,95% of total billed charges,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8541.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1086.47,86,,,percent of total billed charges,86% of total billed charges,1010.67,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1225.44,97,,,percent of total billed charges,97% of total billed charges,1137.01,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1225.44,97,,,percent of total billed charges,97% of total billed charges,1174.91,93,,,percent of total billed charges,93% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1225.44,97,,,percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4270.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3630.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,884.34,22923.72,
"53510 - Urethrorrhaphy, suture of urethral wound or injury; perineal",3783527,CDM,510,RC,53510,HCPCS,Outpatient,,,1647.05,823.53,,1482.35,90,,,percent of total billed charges,90% of total Billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1317.64,80,,,Percent of total Billed charges,80% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1482.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1597.64,97,,,Percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1515.29,92,,,Percent of total billed charges,92% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11352.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18097.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22923.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1482.35,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1152.94,70,,,percent of total billed charges,70% of total billed charges,1482.35,90,,,percent of total billed charges,90% of total billed charges,1564.7,95,,,percent of total billed charges,95% of total billed charges,1564.7,95,,,percent of total billed charges,95% of total billed charges,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8541.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1416.46,86,,,percent of total billed charges,86% of total billed charges,1317.64,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1597.64,97,,,percent of total billed charges,97% of total billed charges,1482.35,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1597.64,97,,,percent of total billed charges,97% of total billed charges,1531.76,93,,,percent of total billed charges,93% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1597.64,97,,,percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4270.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3630.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1152.94,22923.72,
53600-PF DILAT URETHRAL STRIX DILATOR MALE 1ST,4321611,CDM,981,RC,53600,HCPCS,Outpatient,,,126.32,63.16,,113.69,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.76,155,,,Fee Schedule,155% of CMS OPPS Rate,229.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,229.76,
53600PF Dilation Urethral Stricture Passage of Sound/Urethral Dilator Male Initial,4263171,CDM,975,RC,53600,HCPCS,Outpatient,,,149.97,74.99,,134.97,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.76,155,,,Fee Schedule,155% of CMS OPPS Rate,229.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,229.76,
53605PF Dilation Urethral Stricture/Vesical Neck Passage Urethral Dilator Male w/Anesthesia,4263172,CDM,975,RC,53605,HCPCS,Outpatient,,,150.75,75.38,,135.68,90,,,percent of total billed charges,90% of total Billed charges,126.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,98.41,155,,,Fee Schedule,155% of CMS OPPS Rate,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,98.41,155,,,Fee Schedule,155% of CMS OPPS Rate,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.84,155,,,Fee Schedule,155% of CMS OPPS Rate,195.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,129.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,195.84,
53620-PF DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST,4321610,CDM,981,RC,53620,HCPCS,Outpatient,,,169.22,84.61,,152.3,90,,,percent of total billed charges,90% of total Billed charges,248.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.6,155,,,Fee Schedule,155% of CMS OPPS Rate,384.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,384.6,
53620PF Dilation Urethral Stricture Passage Filiform and Follower Male Initial,4263173,CDM,975,RC,53620,HCPCS,Outpatient,,,200.9,100.45,,180.81,90,,,percent of total billed charges,90% of total Billed charges,248.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.6,155,,,Fee Schedule,155% of CMS OPPS Rate,384.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,384.6,
53621PF Dilation Urethral Stricture Passage Filiform and Follower Male Subsequent,4263174,CDM,975,RC,53621,HCPCS,Outpatient,,,166.78,83.39,,150.1,90,,,percent of total billed charges,90% of total Billed charges,224.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,108.86,155,,,Fee Schedule,155% of CMS OPPS Rate,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,108.86,155,,,Fee Schedule,155% of CMS OPPS Rate,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.66,155,,,Fee Schedule,155% of CMS OPPS Rate,348.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,348.66,
53660PF Dilation Female Urethra Suppository/Instillation Initial,4263175,CDM,975,RC,53660,HCPCS,Outpatient,,,96.38,48.19,,86.74,90,,,percent of total billed charges,90% of total Billed charges,111.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,63.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,63.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.59,155,,,Fee Schedule,155% of CMS OPPS Rate,172.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,172.59,
53661PF Dilation Female Urethra w/Suppository/Instillation Subsequent,4263176,CDM,975,RC,53661,HCPCS,Outpatient,,,94.4,47.20,,84.96,90,,,percent of total billed charges,90% of total Billed charges,109.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.63,155,,,Fee Schedule,155% of CMS OPPS Rate,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,61.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,61.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,47.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.63,155,,,Fee Schedule,155% of CMS OPPS Rate,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.54,155,,,Fee Schedule,155% of CMS OPPS Rate,169.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,133.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,169.54,
"53899 - Unlisted procedure, urinary system",3899055,CDM,983,RC,53899,HCPCS,Outpatient,,,2389.88,1194.94,,2150.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.96,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.96,2150.89,
54001 - Slitting Prepuce Dorsal/Lat SPX XCP Newborn,3899058,CDM,983,RC,54001,HCPCS,Outpatient,,,500.6,250.30,,450.54,90,,,percent of total billed charges,90% of total Billed charges,323.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,210.13,155,,,Fee Schedule,155% of CMS OPPS Rate,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,223.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,210.13,155,,,Fee Schedule,155% of CMS OPPS Rate,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,501.91,155,,,Fee Schedule,155% of CMS OPPS Rate,501.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,312.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,358.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48,501.91,
54001PF Slitting Prepuce Dorsal/Lateral Except Newborn,4265108,CDM,960,RC,54001,HCPCS,Outpatient,,,321.92,160.96,,289.73,90,,,percent of total billed charges,90% of total Billed charges,323.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,210.13,155,,,Fee Schedule,155% of CMS OPPS Rate,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,223.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,210.13,155,,,Fee Schedule,155% of CMS OPPS Rate,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,501.91,155,,,Fee Schedule,155% of CMS OPPS Rate,501.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,312.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,358.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48,501.91,
54055PF Destruction Lesion Penis Simple Electrodesiccation,4265109,CDM,960,RC,54055,HCPCS,Outpatient,,,217.54,108.77,,195.79,90,,,percent of total billed charges,90% of total Billed charges,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142,155,,,Fee Schedule,155% of CMS OPPS Rate,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142,155,,,Fee Schedule,155% of CMS OPPS Rate,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.24,155,,,Fee Schedule,155% of CMS OPPS Rate,338.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,278.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,230.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.5,338.24,
54056PF Cryosurgery/penis lesion (s),4265110,CDM,960,RC,54056,HCPCS,Outpatient,,,219.19,109.60,,197.27,90,,,percent of total billed charges,90% of total Billed charges,237.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.44,155,,,Fee Schedule,155% of CMS OPPS Rate,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.44,155,,,Fee Schedule,155% of CMS OPPS Rate,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.2,155,,,Fee Schedule,155% of CMS OPPS Rate,368.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,284.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,368.2,
54057 - Laser Surg Penis Lesion(s),4189310,CDM,960,RC,54057,HCPCS,Outpatient,,,313.65,156.83,,282.29,90,,,percent of total billed charges,90% of total Billed charges,225.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,145,155,,,Fee Schedule,155% of CMS OPPS Rate,93.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,145,155,,,Fee Schedule,155% of CMS OPPS Rate,93.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.74,155,,,Fee Schedule,155% of CMS OPPS Rate,349.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,93.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,349.74,
54060PF Destruction Lesion Penis Simple Surgical Excision,4265111,CDM,960,RC,54060,HCPCS,Outpatient,,,298.98,149.49,,269.08,90,,,percent of total billed charges,90% of total Billed charges,310.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,195.18,155,,,Fee Schedule,155% of CMS OPPS Rate,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.18,155,,,Fee Schedule,155% of CMS OPPS Rate,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.02,155,,,Fee Schedule,155% of CMS OPPS Rate,482.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,348.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.5,482.02,
54065 - Dstr lesion penis extensive,4241824,CDM,510,RC,54065,HCPCS,Outpatient,,,442.68,221.34,,398.41,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,354.14,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.41,90,,,Percent of total Billed charges,90% of total billed charges,149.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,429.4,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,407.27,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,398.41,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,309.88,70,,,percent of total billed charges,70% of total billed charges,398.41,90,,,percent of total billed charges,90% of total billed charges,420.55,95,,,percent of total billed charges,95% of total billed charges,420.55,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,380.7,86,,,percent of total billed charges,86% of total billed charges,354.14,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,429.4,97,,,percent of total billed charges,97% of total billed charges,398.41,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.4,97,,,percent of total billed charges,97% of total billed charges,411.69,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,429.4,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.89,8413.78,
54100PF Bx Penis Separate Procedure,4265112,CDM,960,RC,54100,HCPCS,Outpatient,,,242.27,121.14,,218.04,90,,,percent of total billed charges,90% of total Billed charges,306.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,179.94,155,,,Fee Schedule,155% of CMS OPPS Rate,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,181.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,181.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,179.94,155,,,Fee Schedule,155% of CMS OPPS Rate,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.11,155,,,Fee Schedule,155% of CMS OPPS Rate,475.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,196.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,475.11,
54120PF Amputation Penis Partial,4265113,CDM,960,RC,54120,HCPCS,Outpatient,,,1459.43,729.72,,1313.49,90,,,percent of total billed charges,90% of total Billed charges,1234.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,614.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,310.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,952.69,155,,,Fee Schedule,155% of CMS OPPS Rate,614.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,902.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,614.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1015.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1015.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,957.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,957.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,503.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1229.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1130.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,727.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,952.69,155,,,Fee Schedule,155% of CMS OPPS Rate,614.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1913.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,614.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,614.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1257.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1257.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,310.5,1913.6,
54150PF Circumcision w/Clamp/Other Device w/Regional Dorsal,4267330,CDM,960,RC,54150,HCPCS,Outpatient,,,226.78,113.39,,204.1,90,,,percent of total billed charges,90% of total Billed charges,239.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.52,90,,,Percent of total Billed charges,90% of total billed charges,79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.04,155,,,Fee Schedule,155% of CMS OPPS Rate,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,158.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.04,155,,,Fee Schedule,155% of CMS OPPS Rate,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.48,155,,,Fee Schedule,155% of CMS OPPS Rate,370.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,336.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,303.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,303.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.9,376.52,
Circumcision,634068,CDM,723,RC,54150,HCPCS,Outpatient,,,375.91,187.96,,338.32,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,300.73,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.32,90,,,Percent of total Billed charges,90% of total billed charges,86.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,364.63,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,345.84,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,338.32,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,263.14,70,,,percent of total billed charges,70% of total billed charges,338.32,90,,,percent of total billed charges,90% of total billed charges,357.11,95,,,percent of total billed charges,95% of total billed charges,357.11,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,323.28,86,,,percent of total billed charges,86% of total billed charges,300.73,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,364.63,97,,,percent of total billed charges,97% of total billed charges,338.32,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.63,97,,,percent of total billed charges,97% of total billed charges,349.6,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,364.63,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79,9042.77,
Circumcision procedure date/time,636296,CDM,723,RC,54150,HCPCS,Outpatient,,,381.66,190.83,,343.49,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,305.33,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.49,90,,,Percent of total Billed charges,90% of total billed charges,86.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,370.21,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,351.13,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,343.49,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,267.16,70,,,percent of total billed charges,70% of total billed charges,343.49,90,,,percent of total billed charges,90% of total billed charges,362.58,95,,,percent of total billed charges,95% of total billed charges,362.58,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,328.23,86,,,percent of total billed charges,86% of total billed charges,305.33,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,370.21,97,,,percent of total billed charges,97% of total billed charges,343.49,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.21,97,,,percent of total billed charges,97% of total billed charges,354.94,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.21,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79,9042.77,
54160PF Circumcision Surg Exc Other Than Clamp/Device/Dorsal,4267335,CDM,960,RC,54160,HCPCS,Outpatient,,,335.86,167.93,,302.27,90,,,percent of total billed charges,90% of total Billed charges,351.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.23,155,,,Fee Schedule,155% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,165.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.23,155,,,Fee Schedule,155% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,544.31,155,,,Fee Schedule,155% of CMS OPPS Rate,544.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.79,544.31,
54161PF Circumcision Surg Exc Other Than Clamp/Device/Dorsal,4267336,CDM,960,RC,54161,HCPCS,Outpatient,,,454.58,227.29,,409.12,90,,,percent of total billed charges,90% of total Billed charges,384.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.72,90,,,Percent of total Billed charges,90% of total billed charges,128,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.73,155,,,Fee Schedule,155% of CMS OPPS Rate,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.73,155,,,Fee Schedule,155% of CMS OPPS Rate,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.32,155,,,Fee Schedule,155% of CMS OPPS Rate,595.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128,595.32,
54162PF Lysis/Excision Penile Post-Circumcision Adhesions,4265114,CDM,960,RC,54162,HCPCS,Outpatient,,,461.49,230.75,,415.34,90,,,percent of total billed charges,90% of total Billed charges,442.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,301.26,155,,,Fee Schedule,155% of CMS OPPS Rate,194.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,320.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,300.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,300.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,354.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,227.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,301.26,155,,,Fee Schedule,155% of CMS OPPS Rate,194.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,685.44,155,,,Fee Schedule,155% of CMS OPPS Rate,685.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,500.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,500.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,154.75,685.44,
54163PF Repair Incomplete Circumcision,4265115,CDM,960,RC,54163,HCPCS,Outpatient,,,499.55,249.78,,449.6,90,,,percent of total billed charges,90% of total Billed charges,421.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,210.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,326.1,155,,,Fee Schedule,155% of CMS OPPS Rate,210.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,210.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,349.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,324.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,324.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,420.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,243.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,326.1,155,,,Fee Schedule,155% of CMS OPPS Rate,210.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,652.77,155,,,Fee Schedule,155% of CMS OPPS Rate,652.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,210.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,210.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,432.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,148.46,652.77,
54164PF Frenulotomy of Penis,4265116,CDM,960,RC,54164,HCPCS,Outpatient,,,440.76,220.38,,396.68,90,,,percent of total billed charges,90% of total Billed charges,372.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,287.71,155,,,Fee Schedule,155% of CMS OPPS Rate,185.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,308.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,285.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,285.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,337.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.71,155,,,Fee Schedule,155% of CMS OPPS Rate,185.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,576.79,155,,,Fee Schedule,155% of CMS OPPS Rate,576.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,380.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.35,576.79,
54200PF Injection Procedure Peyronie Disease,4267337,CDM,960,RC,54200,HCPCS,Outpatient,,,194.91,97.46,,175.42,90,,,percent of total billed charges,90% of total Billed charges,189.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.33,155,,,Fee Schedule,155% of CMS OPPS Rate,294.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.03,294.33,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,510,RC,54200,HCPCS,Outpatient,,,286.73,143.37,,258.06,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,229.38,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,278.13,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,263.79,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,258.06,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,200.71,70,,,percent of total billed charges,70% of total billed charges,258.06,90,,,percent of total billed charges,90% of total billed charges,272.39,95,,,percent of total billed charges,95% of total billed charges,272.39,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,246.59,86,,,percent of total billed charges,86% of total billed charges,229.38,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,278.13,97,,,percent of total billed charges,97% of total billed charges,258.06,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.13,97,,,percent of total billed charges,97% of total billed charges,266.66,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.13,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,1047.51,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,510,RC,54200,HCPCS,Outpatient,,,286.73,143.37,,258.06,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,229.38,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,278.13,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,263.79,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,258.06,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,200.71,70,,,percent of total billed charges,70% of total billed charges,258.06,90,,,percent of total billed charges,90% of total billed charges,272.39,95,,,percent of total billed charges,95% of total billed charges,272.39,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,246.59,86,,,percent of total billed charges,86% of total billed charges,229.38,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,278.13,97,,,percent of total billed charges,97% of total billed charges,258.06,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.13,97,,,percent of total billed charges,97% of total billed charges,266.66,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.13,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,1047.51,
54220PF Irrigation Corpora Cavernosa Priapism,4265117,CDM,960,RC,54220,HCPCS,Outpatient,,,311.97,155.99,,280.77,90,,,percent of total billed charges,90% of total Billed charges,341.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.89,155,,,Fee Schedule,155% of CMS OPPS Rate,528.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.1,528.89,
54220-PF Irrigation Corpora Cavernosa Priapism,4321609,CDM,981,RC,54220,HCPCS,Outpatient,,,262.78,131.39,,236.5,90,,,percent of total billed charges,90% of total Billed charges,341.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.89,155,,,Fee Schedule,155% of CMS OPPS Rate,528.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.1,528.89,
Irrigation/Aspiration/Injection Treatment for Priapism,3428472,CDM,981,RC,54220,HCPCS,Outpatient,,,558.03,279.02,,502.23,90,,,percent of total billed charges,90% of total Billed charges,341.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.65,155,,,Fee Schedule,155% of CMS OPPS Rate,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.89,155,,,Fee Schedule,155% of CMS OPPS Rate,528.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.1,528.89,
54230 - PF Injection Corpora Cavernosography,4333234,CDM,960,RC,54230,HCPCS,Outpatient,,,151.4,75.70,,136.26,90,,,percent of total billed charges,90% of total Billed charges,178.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,119.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,119.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.52,155,,,Fee Schedule,155% of CMS OPPS Rate,276.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,187.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63.56,276.52,
54235PF Injection Corpora Cavernosa w/Pharmacologic Agent,4265118,CDM,960,RC,54235,HCPCS,Outpatient,,,170.5,85.25,,153.45,90,,,percent of total billed charges,90% of total Billed charges,155.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.29,155,,,Fee Schedule,155% of CMS OPPS Rate,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,81.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.29,155,,,Fee Schedule,155% of CMS OPPS Rate,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.27,155,,,Fee Schedule,155% of CMS OPPS Rate,241.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.64,241.27,
54360 Plastic operation on penis to correct angulation,3622376,CDM,510,RC,54360,HCPCS,Outpatient,,,1881.45,940.73,,1693.31,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.16,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1693.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1825.01,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1730.93,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1693.31,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1317.02,70,,,percent of total billed charges,70% of total billed charges,1693.31,90,,,percent of total billed charges,90% of total billed charges,1787.38,95,,,percent of total billed charges,95% of total billed charges,1787.38,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1618.05,86,,,percent of total billed charges,86% of total billed charges,1505.16,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1825.01,97,,,percent of total billed charges,97% of total billed charges,1693.31,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1825.01,97,,,percent of total billed charges,97% of total billed charges,1749.75,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1825.01,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1317.02,15625.36,
54400PF Insertion Penile Prosthesis Non-Inflatable Semi-Rigi,4265119,CDM,960,RC,54400,HCPCS,Outpatient,,,1228.39,614.20,,1105.55,90,,,percent of total billed charges,90% of total Billed charges,1038.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.88,155,,,Fee Schedule,155% of CMS OPPS Rate,517.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,759.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,517.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,804.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,804.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,421.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1034.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,949.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,609.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,801.88,155,,,Fee Schedule,155% of CMS OPPS Rate,517.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1610.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1610.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,517.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,837.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,517.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1051.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1051.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,421.83,1610.02,
54405PF Insertion Multi-Component Inflatable Penile Prosthes,4265120,CDM,960,RC,54405,HCPCS,Outpatient,,,1870.43,935.22,,1683.39,90,,,percent of total billed charges,90% of total Billed charges,1581.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,787.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1221,155,,,Fee Schedule,155% of CMS OPPS Rate,787.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1157.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,787.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1301.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1301.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1231.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1231.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,643.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1453.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,938.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1221,155,,,Fee Schedule,155% of CMS OPPS Rate,787.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2451.39,155,,,Fee Schedule,155% of CMS OPPS Rate,2451.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,787.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1246.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,787.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1613.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1613.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,643.85,2451.39,
"54406 - (PF) Removal of all components of a multi-component, inflatable penile prosthesis without",3635228,CDM,510,RC,54406,HCPCS,Outpatient,,,1907.19,953.60,,1716.47,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1525.75,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1716.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1849.97,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1754.61,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1716.47,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1335.03,70,,,percent of total billed charges,70% of total billed charges,1716.47,90,,,percent of total billed charges,90% of total billed charges,1811.83,95,,,percent of total billed charges,95% of total billed charges,1811.83,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1640.18,86,,,percent of total billed charges,86% of total billed charges,1525.75,80,,,percent of total billed charges,80% of total billed charges,3120.79,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1849.97,97,,,percent of total billed charges,97% of total billed charges,1716.47,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1849.97,97,,,percent of total billed charges,97% of total billed charges,1773.69,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1849.97,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1335.03,15625.36,
"54408 - PF - Repair of component(s) of a multi-component, inflatable penile prosthesis",3640924,CDM,510,RC,54408,HCPCS,Outpatient,,,2061.67,1030.84,,1855.5,90,,,percent of total billed charges,90% of total Billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1649.34,80,,,Percent of total Billed charges,80% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1855.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1999.82,97,,,Percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1896.74,92,,,Percent of total billed charges,92% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11352.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18097.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22923.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1855.5,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1443.17,70,,,percent of total billed charges,70% of total billed charges,1855.5,90,,,percent of total billed charges,90% of total billed charges,1958.59,95,,,percent of total billed charges,95% of total billed charges,1958.59,95,,,percent of total billed charges,95% of total billed charges,4270.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8541.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1773.04,86,,,percent of total billed charges,86% of total billed charges,1649.34,80,,,percent of total billed charges,80% of total billed charges,4374.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1999.82,97,,,percent of total billed charges,97% of total billed charges,1855.5,90,,,percent of total billed charges,90% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1999.82,97,,,percent of total billed charges,97% of total billed charges,1917.35,93,,,percent of total billed charges,93% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1999.82,97,,,percent of total billed charges,97% of total billed charges,4270.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4270.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3630.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1443.17,22923.72,
54410 - Rmvl & Rplcmt Infaltable Penile Prosth Same Sess,4169596,CDM,983,RC,54410,HCPCS,Outpatient,,,2008.55,1004.28,,1807.7,90,,,percent of total billed charges,90% of total Billed charges,1684.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,839.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1300.53,155,,,Fee Schedule,155% of CMS OPPS Rate,839.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1230.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,839.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1384.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1384.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1306.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1306.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,839.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1678.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1542.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,992.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1300.53,155,,,Fee Schedule,155% of CMS OPPS Rate,839.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2611.69,155,,,Fee Schedule,155% of CMS OPPS Rate,2611.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,839.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,849.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,839.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1712.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1712.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,684.79,2611.69,
54415 - PF Rmvl Non-Nfltbl/Nfltbl Penile Prosth w/o Rplcmnt,4128290,CDM,960,RC,54415,HCPCS,Outpatient,,,1017.7,508.85,,915.93,90,,,percent of total billed charges,90% of total Billed charges,1033.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,515.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.45,155,,,Fee Schedule,155% of CMS OPPS Rate,515.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,515.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,850.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,798.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,798.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,421.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1030.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,604.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,798.45,155,,,Fee Schedule,155% of CMS OPPS Rate,515.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1602.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1602.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,515.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,503.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,515.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1047.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1047.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,421.77,1602.45,
54417 - PF Remove/Replace Non-Inflatable/Inflatable Penile Prosthesis Infected Field Same Session,4333237,CDM,960,RC,54417,HCPCS,Outpatient,,,1721.1,860.55,,1548.99,90,,,percent of total billed charges,90% of total Billed charges,1758.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,875.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1357.49,155,,,Fee Schedule,155% of CMS OPPS Rate,875.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,875.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1445.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1445.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1368.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1368.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,715.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,875.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1751.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1614.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1041.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1357.49,155,,,Fee Schedule,155% of CMS OPPS Rate,875.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2725.71,155,,,Fee Schedule,155% of CMS OPPS Rate,2725.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,875.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,819.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,875.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1791.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1791.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,715.9,2725.71,
"54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or",3621664,CDM,510,RC,54435,HCPCS,Outpatient,,,1071.52,535.76,,964.37,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,857.22,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,964.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1039.37,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,985.8,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,964.37,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,750.06,70,,,percent of total billed charges,70% of total billed charges,964.37,90,,,percent of total billed charges,90% of total billed charges,1017.94,95,,,percent of total billed charges,95% of total billed charges,1017.94,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,921.51,86,,,percent of total billed charges,86% of total billed charges,857.22,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1039.37,97,,,percent of total billed charges,97% of total billed charges,964.37,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.37,97,,,percent of total billed charges,97% of total billed charges,996.51,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1039.37,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,750.06,15625.36,
54437 - PF Repair of traumatic corporeal tear(s),4333235,CDM,960,RC,54437,HCPCS,Outpatient,,,1296.46,648.23,,1166.81,90,,,percent of total billed charges,90% of total Billed charges,1319.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,546.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1019.25,155,,,Fee Schedule,155% of CMS OPPS Rate,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1084.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1084.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1019.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1019.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,591.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1203.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,771.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1019.25,155,,,Fee Schedule,155% of CMS OPPS Rate,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2045.38,155,,,Fee Schedule,155% of CMS OPPS Rate,2045.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,752.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.78,2045.38,
54440 - Plastic operation penis injury,4241832,CDM,960,RC,54440,HCPCS,Outpatient,,,4059.8,2029.90,,3653.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,901.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,901.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1606.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1606.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,553.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1046.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323,3653.82,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,510,RC,54450,HCPCS,Outpatient,,,175.51,87.76,,157.96,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,140.41,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,170.24,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,161.47,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,157.96,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,122.86,70,,,percent of total billed charges,70% of total billed charges,157.96,90,,,percent of total billed charges,90% of total billed charges,166.73,95,,,percent of total billed charges,95% of total billed charges,166.73,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,150.94,86,,,percent of total billed charges,86% of total billed charges,140.41,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,170.24,97,,,percent of total billed charges,97% of total billed charges,157.96,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.24,97,,,percent of total billed charges,97% of total billed charges,163.22,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,170.24,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,122.86,1047.51,
54450-PF FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING,4321481,CDM,981,RC,54450,HCPCS,Outpatient,,,112.4,56.20,,101.16,90,,,percent of total billed charges,90% of total Billed charges,122.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.39,155,,,Fee Schedule,155% of CMS OPPS Rate,189.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,137.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.95,189.39,
54512 Excision of extraparenchymal lesion of testis,3622072,CDM,510,RC,54512,HCPCS,Outpatient,,,1399.81,699.91,,1259.83,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1119.85,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1259.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1357.82,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.83,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1259.83,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,979.87,70,,,percent of total billed charges,70% of total billed charges,1259.83,90,,,percent of total billed charges,90% of total billed charges,1329.82,95,,,percent of total billed charges,95% of total billed charges,1329.82,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1203.84,86,,,percent of total billed charges,86% of total billed charges,1119.85,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1357.82,97,,,percent of total billed charges,97% of total billed charges,1259.83,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1357.82,97,,,percent of total billed charges,97% of total billed charges,1301.82,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1357.82,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,979.87,15625.36,
54520PF Orchiectomy Simple w/woTesticular Prosthesis Scrotal,4265121,CDM,960,RC,54520,HCPCS,Outpatient,,,755.54,377.77,,679.99,90,,,percent of total billed charges,90% of total Billed charges,638.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,208,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,493.19,155,,,Fee Schedule,155% of CMS OPPS Rate,318.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,523.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,490.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,490.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,260.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,636.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,579.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,373.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,493.19,155,,,Fee Schedule,155% of CMS OPPS Rate,318.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,989.99,155,,,Fee Schedule,155% of CMS OPPS Rate,989.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,318.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,208,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,429.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,318.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,650.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,208,989.99,
"54522 - (50) Orchiectomy, partial",3715148,CDM,510,RC,54522,HCPCS,Outpatient,,,1531.53,765.77,,1378.38,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1225.22,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1378.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1485.58,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.01,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1378.38,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.07,70,,,percent of total billed charges,70% of total billed charges,1378.38,90,,,percent of total billed charges,90% of total billed charges,1454.95,95,,,percent of total billed charges,95% of total billed charges,1454.95,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1317.12,86,,,percent of total billed charges,86% of total billed charges,1225.22,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1485.58,97,,,percent of total billed charges,97% of total billed charges,1378.38,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.58,97,,,percent of total billed charges,97% of total billed charges,1424.32,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1485.58,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1072.07,15625.36,
"54522 - PF Orchiectomy, partial",3715145,CDM,510,RC,54522,HCPCS,Outpatient,,,1531.53,765.77,,1378.38,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1225.22,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1378.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1485.58,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.01,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1378.38,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.07,70,,,percent of total billed charges,70% of total billed charges,1378.38,90,,,percent of total billed charges,90% of total billed charges,1454.95,95,,,percent of total billed charges,95% of total billed charges,1454.95,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1317.12,86,,,percent of total billed charges,86% of total billed charges,1225.22,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1485.58,97,,,percent of total billed charges,97% of total billed charges,1378.38,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.58,97,,,percent of total billed charges,97% of total billed charges,1424.32,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1485.58,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1072.07,15625.36,
54530PF Orchiectomy Radical Tumor Inguinal Approach,4281200,CDM,960,RC,54530,HCPCS,Outpatient,,,1047.7,523.85,,942.93,90,,,percent of total billed charges,90% of total Billed charges,990.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,494.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,765.99,155,,,Fee Schedule,155% of CMS OPPS Rate,494.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,494.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,814.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,814.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,765.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,765.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,403.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,494.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,988.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,903.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,580.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,765.99,155,,,Fee Schedule,155% of CMS OPPS Rate,494.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1535.59,155,,,Fee Schedule,155% of CMS OPPS Rate,1535.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,494.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,653.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,494.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1003.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1003.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,403.08,1535.59,
"54535 - Orchiectomy, radical, for tumor; with abdominal exploration",4037641,CDM,983,RC,54535,HCPCS,Outpatient,,,1939.85,969.93,,1745.87,90,,,percent of total billed charges,90% of total Billed charges,1453.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,724.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122.68,155,,,Fee Schedule,155% of CMS OPPS Rate,724.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,724.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1196.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1196.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1130.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1130.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,599.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1334.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,858.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1122.68,155,,,Fee Schedule,155% of CMS OPPS Rate,724.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,2253.33,155,,,Fee Schedule,155% of CMS OPPS Rate,2253.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,724.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,840.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,724.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1481.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1481.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,599.53,2253.33,
54600 - PF Rdct Torsion Testis w/wo Fix Clat Testis,4301624,CDM,960,RC,54600,HCPCS,Outpatient,,,931.89,465.95,,838.7,90,,,percent of total billed charges,90% of total Billed charges,881.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,439.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,281,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,681.33,155,,,Fee Schedule,155% of CMS OPPS Rate,439.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,439.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,727.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,683.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,683.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,363.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,879.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,806.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,516.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,681.33,155,,,Fee Schedule,155% of CMS OPPS Rate,439.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1366.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,439.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,281,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,477.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,439.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,898.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,281,1366.65,
54640PF Orchiopexy Inguinal/Scrotal Approach,4265122,CDM,960,RC,54640,HCPCS,Outpatient,,,1002.04,501.02,,901.84,90,,,percent of total billed charges,90% of total Billed charges,848.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1112.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,654.13,155,,,Fee Schedule,155% of CMS OPPS Rate,422.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,699,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,699,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,662.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,662.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,382.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,844.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,781.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,509.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,654.13,155,,,Fee Schedule,155% of CMS OPPS Rate,422.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1314.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1314.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,612.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,955.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,955.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,382.08,1314.8,
54690 - PF Laparoscopy Surgical Orchiectomy,4315549,CDM,960,RC,54690,HCPCS,Outpatient,,,1352.81,676.41,,1217.53,90,,,percent of total billed charges,90% of total Billed charges,1282.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,638.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,579.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,989.07,155,,,Fee Schedule,155% of CMS OPPS Rate,638.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,638.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1054.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,526.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1276.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1176.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,757.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,989.07,155,,,Fee Schedule,155% of CMS OPPS Rate,638.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1987.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1987.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,638.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,579.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,677.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,638.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1400.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1400.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,526.65,1987.35,
54699PF Unlisted laparoscopy proc/testis,4265123,CDM,960,RC,54699,HCPCS,Outpatient,,,489.41,244.71,,440.47,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.82,440.47,
54700-PF I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE,4321608,CDM,981,RC,54700,HCPCS,Outpatient,,,412.24,206.12,,371.02,90,,,percent of total billed charges,90% of total Billed charges,414.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,319.47,155,,,Fee Schedule,155% of CMS OPPS Rate,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,323.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,323.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,249.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.47,155,,,Fee Schedule,155% of CMS OPPS Rate,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.75,155,,,Fee Schedule,155% of CMS OPPS Rate,641.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.5,641.75,
54700PF Incision/Drainage Epididymis/Testis/Scrotal Space,4265124,CDM,960,RC,54700,HCPCS,Outpatient,,,489.41,244.71,,440.47,90,,,percent of total billed charges,90% of total Billed charges,414.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,319.47,155,,,Fee Schedule,155% of CMS OPPS Rate,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,323.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,323.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,381.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,249.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.47,155,,,Fee Schedule,155% of CMS OPPS Rate,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.75,155,,,Fee Schedule,155% of CMS OPPS Rate,641.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,437.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.5,641.75,
54840PF Excision Spermatocele w/wo Epididymectomy,4265125,CDM,960,RC,54840,HCPCS,Outpatient,,,742.81,371.41,,668.53,90,,,percent of total billed charges,90% of total Billed charges,626.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.9,155,,,Fee Schedule,155% of CMS OPPS Rate,312.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,312.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,516.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,483.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,483.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,256.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,570.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,364.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,484.9,155,,,Fee Schedule,155% of CMS OPPS Rate,312.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,971.71,155,,,Fee Schedule,155% of CMS OPPS Rate,971.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,312.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,412.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,312.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,636.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,256.39,971.71,
54860 - PF Epididymectomy; unilateral,3715149,CDM,510,RC,54860,HCPCS,Outpatient,,,1088.33,544.17,,979.5,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,870.66,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,979.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1055.68,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.26,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,979.5,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,761.83,70,,,percent of total billed charges,70% of total billed charges,979.5,90,,,percent of total billed charges,90% of total billed charges,1033.91,95,,,percent of total billed charges,95% of total billed charges,1033.91,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,935.96,86,,,percent of total billed charges,86% of total billed charges,870.66,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1055.68,97,,,percent of total billed charges,97% of total billed charges,979.5,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1055.68,97,,,percent of total billed charges,97% of total billed charges,1012.15,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1055.68,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,761.83,15625.36,
55000PF Bx Testis Needle Separate Procedure,4265126,CDM,960,RC,55000,HCPCS,Outpatient,,,194.3,97.15,,174.87,90,,,percent of total billed charges,90% of total Billed charges,197.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,126.82,155,,,Fee Schedule,155% of CMS OPPS Rate,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,126.82,155,,,Fee Schedule,155% of CMS OPPS Rate,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.94,155,,,Fee Schedule,155% of CMS OPPS Rate,305.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,162.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,227.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,305.94,
55040PF Excision Hydrocele Unilateral,4265127,CDM,960,RC,55040,HCPCS,Outpatient,,,777.33,388.67,,699.6,90,,,percent of total billed charges,90% of total Billed charges,657.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,507.42,155,,,Fee Schedule,155% of CMS OPPS Rate,327.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,506.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,506.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,270.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,327.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,597.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,382.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,507.42,155,,,Fee Schedule,155% of CMS OPPS Rate,327.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1019.25,155,,,Fee Schedule,155% of CMS OPPS Rate,1019.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,327.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,423.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,327.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,672.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,672.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,243.5,1019.25,
55041PF Excision Hydrocele Bilateral,4265128,CDM,960,RC,55041,HCPCS,Outpatient,,,1178.87,589.44,,1060.98,90,,,percent of total billed charges,90% of total Billed charges,996.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,496.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,392,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,769.56,155,,,Fee Schedule,155% of CMS OPPS Rate,496.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,821.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,821.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,771.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,771.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,407.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,910.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,586.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,769.56,155,,,Fee Schedule,155% of CMS OPPS Rate,496.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1545.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1545.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,496.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,392,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,624.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,496.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1015.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1015.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,392,1545.29,
55100PF Drainage of scrotal wall abscess,4267405,CDM,960,RC,55100,HCPCS,Outpatient,,,383.64,191.82,,345.28,90,,,percent of total billed charges,90% of total Billed charges,381.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,267.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,190.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.65,155,,,Fee Schedule,155% of CMS OPPS Rate,591.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,591.65,
55100-PF DRAINAGE SCROTAL WALL ABSCESS,4321482,CDM,981,RC,55100,HCPCS,Outpatient,,,323.14,161.57,,290.83,90,,,percent of total billed charges,90% of total Billed charges,381.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,267.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,190.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.65,155,,,Fee Schedule,155% of CMS OPPS Rate,591.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,591.65,
55110 - PF Scrotal exploration,3700900,CDM,510,RC,55110,HCPCS,Outpatient,,,1011.21,505.61,,910.09,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,808.97,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,910.09,90,,,Percent of total Billed charges,90% of total billed charges,138.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.87,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,930.31,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,910.09,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,707.85,70,,,percent of total billed charges,70% of total billed charges,910.09,90,,,percent of total billed charges,90% of total billed charges,960.65,95,,,percent of total billed charges,95% of total billed charges,960.65,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.64,86,,,percent of total billed charges,86% of total billed charges,808.97,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.87,97,,,percent of total billed charges,97% of total billed charges,910.09,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.87,97,,,percent of total billed charges,97% of total billed charges,940.43,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,126,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.87,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,126,15625.36,
55150 - PF Resection of scrotum,3715150,CDM,510,RC,55150,HCPCS,Outpatient,,,1287.33,643.67,,1158.6,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.86,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1248.71,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1184.34,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1158.6,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,901.13,70,,,percent of total billed charges,70% of total billed charges,1158.6,90,,,percent of total billed charges,90% of total billed charges,1222.96,95,,,percent of total billed charges,95% of total billed charges,1222.96,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1107.1,86,,,percent of total billed charges,86% of total billed charges,1029.86,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1248.71,97,,,percent of total billed charges,97% of total billed charges,1158.6,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.71,97,,,percent of total billed charges,97% of total billed charges,1197.22,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1248.71,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,901.13,15625.36,
"55200 - PF Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separat",3715237,CDM,510,RC,55200,HCPCS,Outpatient,,,981.55,490.78,,883.4,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,785.24,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,883.4,90,,,Percent of total Billed charges,90% of total billed charges,126.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,952.1,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,903.03,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,883.4,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,687.09,70,,,percent of total billed charges,70% of total billed charges,883.4,90,,,percent of total billed charges,90% of total billed charges,932.47,95,,,percent of total billed charges,95% of total billed charges,932.47,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,844.13,86,,,percent of total billed charges,86% of total billed charges,785.24,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,952.1,97,,,percent of total billed charges,97% of total billed charges,883.4,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,952.1,97,,,percent of total billed charges,97% of total billed charges,912.84,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,115,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.1,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,115,15625.36,
55250PF Vasectomy Unilateral/Bilateral Separate Procedure w/,4265129,CDM,960,RC,55250,HCPCS,Outpatient,,,521.56,260.78,,469.4,90,,,percent of total billed charges,90% of total Billed charges,538.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.01,90,,,Percent of total Billed charges,90% of total billed charges,148.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,340.47,155,,,Fee Schedule,155% of CMS OPPS Rate,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,364.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,338.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,338.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,182.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,399.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,340.47,155,,,Fee Schedule,155% of CMS OPPS Rate,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,834.12,155,,,Fee Schedule,155% of CMS OPPS Rate,834.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,605.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,148.5,862.01,
55400PF Vasovasostomy/Vasovasorrhaphy,4265130,CDM,960,RC,55400,HCPCS,Outpatient,,,1153.04,576.52,,1037.74,90,,,percent of total billed charges,90% of total Billed charges,974.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,485.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,752.7,155,,,Fee Schedule,155% of CMS OPPS Rate,485.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,714.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,485.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,803.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,756.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,756.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.91,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,971.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,892.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,573.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,752.7,155,,,Fee Schedule,155% of CMS OPPS Rate,485.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1510.65,155,,,Fee Schedule,155% of CMS OPPS Rate,1510.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,485.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2519.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,485.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,990.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,990.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,345.91,2519.35,
55500PF Excision Hydrocele Spermatic Cord Unilateral Separat,4265143,CDM,960,RC,55500,HCPCS,Outpatient,,,908.02,454.01,,817.22,90,,,percent of total billed charges,90% of total Billed charges,768.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,382.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.74,155,,,Fee Schedule,155% of CMS OPPS Rate,382.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,632.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,593.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,593.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,317.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,764.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,700.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,460.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,592.74,155,,,Fee Schedule,155% of CMS OPPS Rate,382.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1190.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1190.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,382.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,405.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,382.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,799,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,799,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,317.08,1190.93,
55520PF Excision Lesion Spermatic Cord,4265132,CDM,960,RC,55520,HCPCS,Outpatient,,,1078.43,539.22,,970.59,90,,,percent of total billed charges,90% of total Billed charges,912.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,454.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,195,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,703.98,155,,,Fee Schedule,155% of CMS OPPS Rate,454.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,454.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,735.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,695.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,695.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,365.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,908.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,821.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,574.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,703.98,155,,,Fee Schedule,155% of CMS OPPS Rate,454.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1414.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1414.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,454.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,195,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,454.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,909.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,195,1414.58,
55530- Exc varicocele/ligate spermat vein,3431674,CDM,510,RC,55530,HCPCS,Outpatient,,,917.6,458.80,,825.84,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,734.08,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,825.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,890.07,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,844.19,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,825.84,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,642.32,70,,,percent of total billed charges,70% of total billed charges,825.84,90,,,percent of total billed charges,90% of total billed charges,871.72,95,,,percent of total billed charges,95% of total billed charges,871.72,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,789.14,86,,,percent of total billed charges,86% of total billed charges,734.08,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,890.07,97,,,percent of total billed charges,97% of total billed charges,825.84,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,890.07,97,,,percent of total billed charges,97% of total billed charges,853.37,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,890.07,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,642.32,15625.36,
55530PF Exc variocele/ligate spermat vein,4265133,CDM,960,RC,55530,HCPCS,Outpatient,,,811.07,405.54,,729.96,90,,,percent of total billed charges,90% of total Billed charges,686.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,529.46,155,,,Fee Schedule,155% of CMS OPPS Rate,341.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,564.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,528.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,528.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,683.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,623.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,397.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,529.46,155,,,Fee Schedule,155% of CMS OPPS Rate,341.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1064.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1064.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,341.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,438.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,341.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,703.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,703.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,280.81,1064.28,
55700PF Bx Prostate Needle/Punch Single/Multiple Any Approac,4265134,CDM,960,RC,55700,HCPCS,Outpatient,,,301.59,150.80,,271.43,90,,,percent of total billed charges,90% of total Billed charges,357.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.04,90,,,Percent of total Billed charges,90% of total billed charges,89.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.49,155,,,Fee Schedule,155% of CMS OPPS Rate,553.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,420.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.5,595.04,
Read,3575337,CDM,972,RC,55700,HCPCS,Outpatient,,,301.59,150.80,,271.43,90,,,percent of total billed charges,90% of total Billed charges,357.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.04,90,,,Percent of total Billed charges,90% of total billed charges,89.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.49,155,,,Fee Schedule,155% of CMS OPPS Rate,553.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,420.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.5,595.04,
US add Needle Bx Prostate,645154,CDM,320,RC,55700,HCPCS,Outpatient,,,599.2,299.60,,539.28,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,479.36,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.28,90,,,Percent of total Billed charges,90% of total billed charges,98.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,581.22,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,551.26,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,539.28,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,419.44,70,,,percent of total billed charges,70% of total billed charges,539.28,90,,,percent of total billed charges,90% of total billed charges,569.24,95,,,percent of total billed charges,95% of total billed charges,569.24,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,515.31,86,,,percent of total billed charges,86% of total billed charges,479.36,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,581.22,97,,,percent of total billed charges,97% of total billed charges,539.28,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.22,97,,,percent of total billed charges,97% of total billed charges,557.26,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,581.22,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.5,9042.77,
"55706- Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling,",3569411,CDM,510,RC,55706,HCPCS,Outpatient,,,974.28,487.14,,876.85,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,779.42,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,945.05,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,896.34,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,876.85,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,682,70,,,percent of total billed charges,70% of total billed charges,876.85,90,,,percent of total billed charges,90% of total billed charges,925.57,95,,,percent of total billed charges,95% of total billed charges,925.57,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,837.88,86,,,percent of total billed charges,86% of total billed charges,779.42,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,945.05,97,,,percent of total billed charges,97% of total billed charges,876.85,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.05,97,,,percent of total billed charges,97% of total billed charges,906.08,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,945.05,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,682,15625.36,
55706PF Bx Prostate Needle Transperineal Stereotactic Guided,4265142,CDM,960,RC,55706,HCPCS,Outpatient,,,864.07,432.04,,777.66,90,,,percent of total billed charges,90% of total Billed charges,730.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,363.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.05,155,,,Fee Schedule,155% of CMS OPPS Rate,363.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,598.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,598.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,561.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,561.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,662.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,421.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,564.05,155,,,Fee Schedule,155% of CMS OPPS Rate,363.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1131.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1131.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,363.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,413.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,363.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,728.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,728.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,297.83,1131.89,
"55725 Prostatotomy, external drainage of prostatic abscess, any approach; complicated",3622080,CDM,510,RC,55725,HCPCS,Outpatient,,,1546.74,773.37,,1392.07,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1237.39,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1392.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1500.34,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1423,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1392.07,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.72,70,,,percent of total billed charges,70% of total billed charges,1392.07,90,,,percent of total billed charges,90% of total billed charges,1469.4,95,,,percent of total billed charges,95% of total billed charges,1469.4,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1330.2,86,,,percent of total billed charges,86% of total billed charges,1237.39,80,,,percent of total billed charges,80% of total billed charges,3120.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1500.34,97,,,percent of total billed charges,97% of total billed charges,1392.07,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1500.34,97,,,percent of total billed charges,97% of total billed charges,1438.47,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1500.34,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1082.72,15625.36,
55821PF Prostatectomy Suprapubic Subtotal 1 or 2 Stages,4265135,CDM,960,RC,55821,HCPCS,Outpatient,,,1940.02,970.01,,1746.02,90,,,percent of total billed charges,90% of total Billed charges,1673.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,817.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,621,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1266.43,155,,,Fee Schedule,155% of CMS OPPS Rate,817.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1249.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,817.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1405.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1405.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1331.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1331.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,695.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,817.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1634.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1571.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1015.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1266.43,155,,,Fee Schedule,155% of CMS OPPS Rate,817.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2594.42,155,,,Fee Schedule,155% of CMS OPPS Rate,2594.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,817.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,621,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1207.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,817.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1744.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1744.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,621,2594.42,
55845PF Prostatectomy Retropubic Radical w/wo Nerve Sparing,4265136,CDM,960,RC,55845,HCPCS,Outpatient,,,3150.19,1575.10,,2835.17,90,,,percent of total billed charges,90% of total Billed charges,2665.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1326.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,969.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2056.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1326.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1950.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1326.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2193.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2193.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2083.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2083.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1198.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2653.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2458.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1594.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2056.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1326.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,4130.84,155,,,Fee Schedule,155% of CMS OPPS Rate,4130.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1326.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2063.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1326.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,3275.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3275.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,969.5,4130.84,
55866PF Laparoscopy Surgical Prostatectomy Retropubic Radica,4265137,CDM,960,RC,55866,HCPCS,Outpatient,,,2774.91,1387.46,,2497.42,90,,,percent of total billed charges,90% of total Billed charges,2586.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1168.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1811.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2197.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1168.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2471.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2471.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2206.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2206.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1273.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2337.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2604.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1688.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1811.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1168.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,4009.09,155,,,Fee Schedule,155% of CMS OPPS Rate,4009.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1168.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3010.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1168.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3477.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3477.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4009.09,
55867 - PF Laparoscopy Surgical Prostatectomy Simple Subtotal Includes Robot Assist,4327195,CDM,960,RC,55867,HCPCS,Outpatient,,,2011.74,1005.87,,1810.57,90,,,percent of total billed charges,90% of total Billed charges,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1588.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1024.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1024.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2049.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1588.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1588.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1588.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1024.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.52,2049.86,
55874PF Transperineal Placement Biodegradable Material Peri-,4265141,CDM,960,RC,55874,HCPCS,Outpatient,,,378.14,189.07,,340.33,90,,,percent of total billed charges,90% of total Billed charges,537.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,159.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.85,155,,,Fee Schedule,155% of CMS OPPS Rate,159.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,265.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,265.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,250.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,250.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.44,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,295.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,246.85,155,,,Fee Schedule,155% of CMS OPPS Rate,159.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,832.97,155,,,Fee Schedule,155% of CMS OPPS Rate,832.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,159.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3917.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,159.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.44,3917.62,
55875PF Transperineal needle/cath/prostate/interstit radioel,4265138,CDM,960,RC,55875,HCPCS,Outpatient,,,1789.94,894.97,,1610.95,90,,,percent of total billed charges,90% of total Billed charges,1510.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,559.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1168.47,155,,,Fee Schedule,155% of CMS OPPS Rate,753.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,753.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1276.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1276.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1163.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1163.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,607.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,753.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1507.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1372.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,872.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1168.47,155,,,Fee Schedule,155% of CMS OPPS Rate,753.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,2340.78,155,,,Fee Schedule,155% of CMS OPPS Rate,2340.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,753.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,850.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,753.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1517.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,559.16,2340.78,
55876PF Placement Interstitial Device Radiation Therapy Guid,4265139,CDM,960,RC,55876,HCPCS,Outpatient,,,116.64,58.32,,104.98,90,,,percent of total billed charges,90% of total Billed charges,214.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.08,155,,,Fee Schedule,155% of CMS OPPS Rate,333.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.99,333.08,
55876-PROSTATE FIDUCIAL,3565264,CDM,360,RC,55876,HCPCS,Outpatient,,,377.76,188.88,,339.98,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,302.21,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,366.43,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,347.54,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,339.98,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,264.43,70,,,percent of total billed charges,70% of total billed charges,339.98,90,,,percent of total billed charges,90% of total billed charges,358.87,95,,,percent of total billed charges,95% of total billed charges,358.87,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,324.87,86,,,percent of total billed charges,86% of total billed charges,302.21,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,366.43,97,,,percent of total billed charges,97% of total billed charges,339.98,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.43,97,,,percent of total billed charges,97% of total billed charges,351.32,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,366.43,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,264.43,6535.92,
55876-PROSTATE FIDUCIAL Profee,3565261,CDM,983,RC,55876,HCPCS,Outpatient,,,382.3,191.15,,344.07,90,,,percent of total billed charges,90% of total Billed charges,242,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.1,155,,,Fee Schedule,155% of CMS OPPS Rate,375.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.99,375.1,
Read,3575343,CDM,972,RC,55876,HCPCS,Outpatient,,,233.28,116.64,,209.95,90,,,percent of total billed charges,90% of total Billed charges,242,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.1,155,,,Fee Schedule,155% of CMS OPPS Rate,375.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.99,375.1,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,510,RC,55899,HCPCS,Outpatient,,,5318.66,2659.33,,4786.79,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4254.93,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4786.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5159.1,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,4893.17,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4786.79,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,3723.06,70,,,percent of total billed charges,70% of total billed charges,4786.79,90,,,percent of total billed charges,90% of total billed charges,5052.73,95,,,percent of total billed charges,95% of total billed charges,5052.73,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4574.05,86,,,percent of total billed charges,86% of total billed charges,4254.93,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5159.1,97,,,percent of total billed charges,97% of total billed charges,4786.79,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,5159.1,97,,,percent of total billed charges,97% of total billed charges,4946.35,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5159.1,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,5159.1,
55899PF Unlisted Procedure Male Genital System,4265140,CDM,960,RC,55899,HCPCS,Outpatient,,,3343.24,1671.62,,3008.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.97,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.97,3008.92,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,360,RC,56405,HCPCS,Outpatient,,,380.26,190.13,,342.23,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,304.21,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.23,90,,,Percent of total Billed charges,90% of total billed charges,103.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,368.85,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,349.84,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,342.23,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,266.18,70,,,percent of total billed charges,70% of total billed charges,342.23,90,,,percent of total billed charges,90% of total billed charges,361.25,95,,,percent of total billed charges,95% of total billed charges,361.25,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,327.02,86,,,percent of total billed charges,86% of total billed charges,304.21,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,368.85,97,,,percent of total billed charges,97% of total billed charges,342.23,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.85,97,,,percent of total billed charges,97% of total billed charges,353.64,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,368.85,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.81,1423.33,
56405-PF I&D VULVA/PERINEAL ABSCESS,4321607,CDM,981,RC,56405,HCPCS,Outpatient,,,244.26,122.13,,219.83,90,,,percent of total billed charges,90% of total Billed charges,265.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.29,155,,,Fee Schedule,155% of CMS OPPS Rate,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.29,155,,,Fee Schedule,155% of CMS OPPS Rate,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.91,155,,,Fee Schedule,155% of CMS OPPS Rate,410.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,220.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.81,410.91,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,256.2,128.10,,230.58,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,204.96,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.58,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,248.51,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,235.7,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.58,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,179.34,70,,,percent of total billed charges,70% of total billed charges,230.58,90,,,percent of total billed charges,90% of total billed charges,243.39,95,,,percent of total billed charges,95% of total billed charges,243.39,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,220.33,86,,,percent of total billed charges,86% of total billed charges,204.96,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.51,97,,,percent of total billed charges,97% of total billed charges,230.58,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.51,97,,,percent of total billed charges,97% of total billed charges,238.27,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.51,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,868.4,
56420-PF I&D OF BARTHOLINS GLAND ABSCESS,4321606,CDM,981,RC,56420,HCPCS,Outpatient,,,215.8,107.90,,194.22,90,,,percent of total billed charges,90% of total Billed charges,285.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.34,155,,,Fee Schedule,155% of CMS OPPS Rate,442.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,241.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.5,442.34,
56420PF Incision/Drainage Bartholin's Gland Abscess,4265144,CDM,960,RC,56420,HCPCS,Outpatient,,,256.2,128.10,,230.58,90,,,percent of total billed charges,90% of total Billed charges,285.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.34,155,,,Fee Schedule,155% of CMS OPPS Rate,442.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,241.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.5,442.34,
56440PF Bartholin gland cyst/marsupializat,4165145,CDM,960,RC,56440,HCPCS,Outpatient,,,423.64,211.82,,381.28,90,,,percent of total billed charges,90% of total Billed charges,356.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.55,155,,,Fee Schedule,155% of CMS OPPS Rate,178.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,275.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,275.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,176.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,325.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,217.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,276.55,155,,,Fee Schedule,155% of CMS OPPS Rate,178.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.98,155,,,Fee Schedule,155% of CMS OPPS Rate,552.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,178.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,163,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,247.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,163,552.98,
56441-MA LYSIS OF LABIAL LESION(S),3430121,CDM,510,RC,56441,HCPCS,Outpatient,,,473.56,236.78,,426.2,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,378.85,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,426.2,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,459.35,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,435.68,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,426.2,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,331.49,70,,,percent of total billed charges,70% of total billed charges,426.2,90,,,percent of total billed charges,90% of total billed charges,449.88,95,,,percent of total billed charges,95% of total billed charges,449.88,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,407.26,86,,,percent of total billed charges,86% of total billed charges,378.85,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,459.35,97,,,percent of total billed charges,97% of total billed charges,426.2,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,459.35,97,,,percent of total billed charges,97% of total billed charges,440.41,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,459.35,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,13784.12,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,265.32,132.66,,238.79,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,212.26,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.79,90,,,Percent of total Billed charges,90% of total billed charges,69.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,257.36,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,244.09,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,238.79,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,185.72,70,,,percent of total billed charges,70% of total billed charges,238.79,90,,,percent of total billed charges,90% of total billed charges,252.05,95,,,percent of total billed charges,95% of total billed charges,252.05,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,228.18,86,,,percent of total billed charges,86% of total billed charges,212.26,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,257.36,97,,,percent of total billed charges,97% of total billed charges,238.79,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.36,97,,,percent of total billed charges,97% of total billed charges,246.75,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.36,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.5,8413.78,
56515- Lesion destruction/vulva/extensive,3431356,CDM,510,RC,56515,HCPCS,Outpatient,,,716.79,358.40,,645.11,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,573.43,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.11,90,,,Percent of total Billed charges,90% of total billed charges,128.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,695.29,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,659.45,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,645.11,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,70,,,percent of total billed charges,70% of total billed charges,645.11,90,,,percent of total billed charges,90% of total billed charges,680.95,95,,,percent of total billed charges,95% of total billed charges,680.95,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,616.44,86,,,percent of total billed charges,86% of total billed charges,573.43,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,695.29,97,,,percent of total billed charges,97% of total billed charges,645.11,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.29,97,,,percent of total billed charges,97% of total billed charges,666.61,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,695.29,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116.5,8413.78,
56605- BX vulva or perineum/1 lesion,3431357,CDM,360,RC,56605,HCPCS,Outpatient,,,248.99,124.50,,224.09,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,199.19,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.09,90,,,Percent of total Billed charges,90% of total billed charges,61.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,241.52,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,229.07,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,224.09,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,174.29,70,,,percent of total billed charges,70% of total billed charges,224.09,90,,,percent of total billed charges,90% of total billed charges,236.54,95,,,percent of total billed charges,95% of total billed charges,236.54,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,214.13,86,,,percent of total billed charges,86% of total billed charges,199.19,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,241.52,97,,,percent of total billed charges,97% of total billed charges,224.09,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.52,97,,,percent of total billed charges,97% of total billed charges,231.56,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,241.52,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55.51,3429.49,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,360,RC,56606,HCPCS,Outpatient,,,100.02,50.01,,90.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,80.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,90.02,90,,,Percent of total Billed charges,90% of total billed charges,30.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,97.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,92.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,63.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,78.67,78.65,,,percent of total billed charges,78.65% of total billed charges,89.35,89.33,,,percent of total billed charges,89.33% of total billed charges,90.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,70.01,70,,,percent of total billed charges,70% of total billed charges,90.02,90,,,percent of total billed charges,90% of total billed charges,95.02,95,,,percent of total billed charges,95% of total billed charges,95.02,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.02,86,,,percent of total billed charges,86% of total billed charges,80.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,97.02,97,,,percent of total billed charges,97% of total billed charges,90.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,97.02,97,,,percent of total billed charges,97% of total billed charges,93.02,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.4,97.02,
56620- Vulvectomy/simple/partial,3431359,CDM,510,RC,56620,HCPCS,Outpatient,,,1519.81,759.91,,1367.83,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.85,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1367.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1474.22,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1398.23,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1367.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.87,70,,,percent of total billed charges,70% of total billed charges,1367.83,90,,,percent of total billed charges,90% of total billed charges,1443.82,95,,,percent of total billed charges,95% of total billed charges,1443.82,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1307.04,86,,,percent of total billed charges,86% of total billed charges,1215.85,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1474.22,97,,,percent of total billed charges,97% of total billed charges,1367.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474.22,97,,,percent of total billed charges,97% of total billed charges,1413.42,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1474.22,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1063.87,13784.12,
56625-PF COMPLETE REMOVAL OF VULVA,3430126,CDM,510,RC,56625,HCPCS,Outpatient,,,1749.47,874.74,,1574.52,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1399.58,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1574.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1696.99,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1609.51,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1574.52,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.63,70,,,percent of total billed charges,70% of total billed charges,1574.52,90,,,percent of total billed charges,90% of total billed charges,1662,95,,,percent of total billed charges,95% of total billed charges,1662,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1504.54,86,,,percent of total billed charges,86% of total billed charges,1399.58,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1696.99,97,,,percent of total billed charges,97% of total billed charges,1574.52,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1696.99,97,,,percent of total billed charges,97% of total billed charges,1627.01,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1696.99,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1224.63,13784.12,
56630-MA AST EXTENSIVE VULVA SURGERY,3430127,CDM,510,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,2273.42,90,,,percent of total billed charges,90% of total Billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2020.82,80,,,Percent of total Billed charges,80% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2273.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2450.24,97,,,Percent of total billed charges,97% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2323.94,92,,,Percent of total billed charges,92% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2273.42,90,,,percent of total billed charges,90% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1768.21,70,,,percent of total billed charges,70% of total billed charges,2273.42,90,,,percent of total billed charges,90% of total billed charges,2399.72,95,,,percent of total billed charges,95% of total billed charges,2399.72,95,,,percent of total billed charges,95% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2172.38,86,,,percent of total billed charges,86% of total billed charges,2020.82,80,,,percent of total billed charges,80% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2450.24,97,,,percent of total billed charges,97% of total billed charges,2273.42,90,,,percent of total billed charges,90% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2450.24,97,,,percent of total billed charges,97% of total billed charges,2349.2,93,,,percent of total billed charges,93% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2450.24,97,,,percent of total billed charges,97% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1768.21,2526.02,
56630-PF EXTENSIVE VULVA SURG,3430128,CDM,510,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,2273.42,90,,,percent of total billed charges,90% of total Billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2020.82,80,,,Percent of total Billed charges,80% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2273.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2450.24,97,,,Percent of total billed charges,97% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2323.94,92,,,Percent of total billed charges,92% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2273.42,90,,,percent of total billed charges,90% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1768.21,70,,,percent of total billed charges,70% of total billed charges,2273.42,90,,,percent of total billed charges,90% of total billed charges,2399.72,95,,,percent of total billed charges,95% of total billed charges,2399.72,95,,,percent of total billed charges,95% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2172.38,86,,,percent of total billed charges,86% of total billed charges,2020.82,80,,,percent of total billed charges,80% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2450.24,97,,,percent of total billed charges,97% of total billed charges,2273.42,90,,,percent of total billed charges,90% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2450.24,97,,,percent of total billed charges,97% of total billed charges,2349.2,93,,,percent of total billed charges,93% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2450.24,97,,,percent of total billed charges,97% of total billed charges,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2526.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1768.21,2526.02,
MA AST EXTENSIVE VULVA SURGERY,3527846,CDM,960,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,2273.42,90,,,percent of total billed charges,90% of total Billed charges,1893.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1462.92,155,,,Fee Schedule,155% of CMS OPPS Rate,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,943.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1400.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1420.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1420.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,822.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1887.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1676.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1116.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1462.92,155,,,Fee Schedule,155% of CMS OPPS Rate,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2935.2,155,,,Fee Schedule,155% of CMS OPPS Rate,2935.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1114.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1821.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1821.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.5,2935.2,
"56631 - PF Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy",3641189,CDM,510,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,2812.7,90,,,percent of total billed charges,90% of total Billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2500.18,80,,,Percent of total Billed charges,80% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2812.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3031.46,97,,,Percent of total billed charges,97% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2875.2,92,,,Percent of total billed charges,92% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2812.7,90,,,percent of total billed charges,90% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2187.65,70,,,percent of total billed charges,70% of total billed charges,2812.7,90,,,percent of total billed charges,90% of total billed charges,2968.96,95,,,percent of total billed charges,95% of total billed charges,2968.96,95,,,percent of total billed charges,95% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2687.69,86,,,percent of total billed charges,86% of total billed charges,2500.18,80,,,percent of total billed charges,80% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3031.46,97,,,percent of total billed charges,97% of total billed charges,2812.7,90,,,percent of total billed charges,90% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3031.46,97,,,percent of total billed charges,97% of total billed charges,2906.45,93,,,percent of total billed charges,93% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3031.46,97,,,percent of total billed charges,97% of total billed charges,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3125.22,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2187.65,3125.22,
MA EXTENSIVE VULVA SURGERY,3527835,CDM,960,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,2812.7,90,,,percent of total billed charges,90% of total Billed charges,2342.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1809.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1555.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1167.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1749.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1051.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2334.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2100.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1402.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1809.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3631.09,155,,,Fee Schedule,155% of CMS OPPS Rate,3631.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1545.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2307.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2307.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.5,3631.09,
56632 - PF EXTENSIVE VULVA SURGERY,3430130,CDM,510,RC,56632,HCPCS,Outpatient,,,3765.84,1882.92,,3389.26,90,,,percent of total billed charges,90% of total Billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3012.67,80,,,Percent of total Billed charges,80% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3652.86,97,,,Percent of total billed charges,97% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3464.57,92,,,Percent of total billed charges,92% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.26,90,,,percent of total billed charges,90% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2636.09,70,,,percent of total billed charges,70% of total billed charges,3389.26,90,,,percent of total billed charges,90% of total billed charges,3577.55,95,,,percent of total billed charges,95% of total billed charges,3577.55,95,,,percent of total billed charges,95% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3238.62,86,,,percent of total billed charges,86% of total billed charges,3012.67,80,,,percent of total billed charges,80% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3652.86,97,,,percent of total billed charges,97% of total billed charges,3389.26,90,,,percent of total billed charges,90% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3652.86,97,,,percent of total billed charges,97% of total billed charges,3502.23,93,,,percent of total billed charges,93% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3652.86,97,,,percent of total billed charges,97% of total billed charges,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3765.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2636.09,3765.84,
56633-PF EXTENSIVE VULVA SURGERY,3430132,CDM,510,RC,56633,HCPCS,Outpatient,,,3243.18,1621.59,,2918.86,90,,,percent of total billed charges,90% of total Billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2594.54,80,,,Percent of total Billed charges,80% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2918.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3145.88,97,,,Percent of total billed charges,97% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2983.73,92,,,Percent of total billed charges,92% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2918.86,90,,,percent of total billed charges,90% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2270.23,70,,,percent of total billed charges,70% of total billed charges,2918.86,90,,,percent of total billed charges,90% of total billed charges,3081.02,95,,,percent of total billed charges,95% of total billed charges,3081.02,95,,,percent of total billed charges,95% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2789.13,86,,,percent of total billed charges,86% of total billed charges,2594.54,80,,,percent of total billed charges,80% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3145.88,97,,,percent of total billed charges,97% of total billed charges,2918.86,90,,,percent of total billed charges,90% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3145.88,97,,,percent of total billed charges,97% of total billed charges,3016.16,93,,,percent of total billed charges,93% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3145.88,97,,,percent of total billed charges,97% of total billed charges,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3243.18,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2270.23,3243.18,
"56634 - PF Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy",3696903,CDM,510,RC,56634,HCPCS,Outpatient,,,3408.96,1704.48,,3068.06,90,,,percent of total billed charges,90% of total Billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2727.17,80,,,Percent of total Billed charges,80% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3306.69,97,,,Percent of total billed charges,97% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3136.24,92,,,Percent of total billed charges,92% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3068.06,90,,,percent of total billed charges,90% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2386.27,70,,,percent of total billed charges,70% of total billed charges,3068.06,90,,,percent of total billed charges,90% of total billed charges,3238.51,95,,,percent of total billed charges,95% of total billed charges,3238.51,95,,,percent of total billed charges,95% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2931.71,86,,,percent of total billed charges,86% of total billed charges,2727.17,80,,,percent of total billed charges,80% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.69,97,,,percent of total billed charges,97% of total billed charges,3068.06,90,,,percent of total billed charges,90% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3306.69,97,,,percent of total billed charges,97% of total billed charges,3170.33,93,,,percent of total billed charges,93% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3306.69,97,,,percent of total billed charges,97% of total billed charges,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3408.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2386.27,3408.96,
"56637 - PF Vulvectomy, radical, complete; with bilateral inguinofemoral lymphadenectomy",3696906,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3601.94,90,,,percent of total billed charges,90% of total Billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3201.73,80,,,Percent of total Billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3882.1,97,,,Percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3681.99,92,,,Percent of total billed charges,92% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,70,,,percent of total billed charges,70% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3441.86,86,,,percent of total billed charges,86% of total billed charges,3201.73,80,,,percent of total billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3722.01,93,,,percent of total billed charges,93% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3882.1,97,,,percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,4002.16,
56637-MA AST EXTENSIVE VULVA SURGERY,3430133,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3601.94,90,,,percent of total billed charges,90% of total Billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3201.73,80,,,Percent of total Billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3882.1,97,,,Percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3681.99,92,,,Percent of total billed charges,92% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,70,,,percent of total billed charges,70% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3441.86,86,,,percent of total billed charges,86% of total billed charges,3201.73,80,,,percent of total billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3722.01,93,,,percent of total billed charges,93% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3882.1,97,,,percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,4002.16,
56637-PF EXTENSIVE VULVA SURGERY,3430134,CDM,510,RC,56637,HCPCS,Outpatient,,,4002.16,2001.08,,3601.94,90,,,percent of total billed charges,90% of total Billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3201.73,80,,,Percent of total Billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3882.1,97,,,Percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3681.99,92,,,Percent of total billed charges,92% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,70,,,percent of total billed charges,70% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,3802.05,95,,,percent of total billed charges,95% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3441.86,86,,,percent of total billed charges,86% of total billed charges,3201.73,80,,,percent of total billed charges,80% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3601.94,90,,,percent of total billed charges,90% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3882.1,97,,,percent of total billed charges,97% of total billed charges,3722.01,93,,,percent of total billed charges,93% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3882.1,97,,,percent of total billed charges,97% of total billed charges,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2801.51,4002.16,
56700- Part hymenectomy/revi hymenal ring,3431360,CDM,510,RC,56700,HCPCS,Outpatient,,,530.49,265.25,,477.44,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,424.39,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.44,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,514.58,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,488.05,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,477.44,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,371.34,70,,,percent of total billed charges,70% of total billed charges,477.44,90,,,percent of total billed charges,90% of total billed charges,503.97,95,,,percent of total billed charges,95% of total billed charges,503.97,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,456.22,86,,,percent of total billed charges,86% of total billed charges,424.39,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,514.58,97,,,percent of total billed charges,97% of total billed charges,477.44,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.58,97,,,percent of total billed charges,97% of total billed charges,493.36,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,514.58,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,13784.12,
56740-MA REMOVE VAGINA GLAND LESION,3430137,CDM,510,RC,56740,HCPCS,Outpatient,,,835.46,417.73,,751.91,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,668.37,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,751.91,90,,,Percent of total Billed charges,90% of total billed charges,172.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,810.4,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,768.62,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,751.91,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,584.82,70,,,percent of total billed charges,70% of total billed charges,751.91,90,,,percent of total billed charges,90% of total billed charges,793.69,95,,,percent of total billed charges,95% of total billed charges,793.69,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,718.5,86,,,percent of total billed charges,86% of total billed charges,668.37,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,810.4,97,,,percent of total billed charges,97% of total billed charges,751.91,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.4,97,,,percent of total billed charges,97% of total billed charges,776.98,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,810.4,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157,13784.12,
56740-PF EXC BARTHOLINS GLAND/CYST,4321605,CDM,981,RC,56740,HCPCS,Outpatient,,,621.42,310.71,,559.28,90,,,percent of total billed charges,90% of total Billed charges,624.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,481.59,155,,,Fee Schedule,155% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,310.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,468.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,468.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,285.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,621.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,552.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,369.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,481.59,155,,,Fee Schedule,155% of CMS OPPS Rate,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,968.52,155,,,Fee Schedule,155% of CMS OPPS Rate,968.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,320.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,310.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,609.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,609.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157,968.52,
56800- Plastic repair/introitus,3431361,CDM,510,RC,56800,HCPCS,Outpatient,,,665.34,332.67,,598.81,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,532.27,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,645.38,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,612.11,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,598.81,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,465.74,70,,,percent of total billed charges,70% of total billed charges,598.81,90,,,percent of total billed charges,90% of total billed charges,632.07,95,,,percent of total billed charges,95% of total billed charges,632.07,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,572.19,86,,,percent of total billed charges,86% of total billed charges,532.27,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,645.38,97,,,percent of total billed charges,97% of total billed charges,598.81,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.38,97,,,percent of total billed charges,97% of total billed charges,618.77,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,645.38,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,465.74,13784.12,
56810- Perineoplasy/non-OB,3431362,CDM,510,RC,56810,HCPCS,Outpatient,,,716.93,358.47,,645.24,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,573.54,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,695.42,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,659.58,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,645.24,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,501.85,70,,,percent of total billed charges,70% of total billed charges,645.24,90,,,percent of total billed charges,90% of total billed charges,681.08,95,,,percent of total billed charges,95% of total billed charges,681.08,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,616.56,86,,,percent of total billed charges,86% of total billed charges,573.54,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,695.42,97,,,percent of total billed charges,97% of total billed charges,645.24,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.42,97,,,percent of total billed charges,97% of total billed charges,666.74,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,695.42,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.85,13784.12,
56820 Exam of vulva w/scope,3428323,CDM,983,RC,56820,HCPCS,Outpatient,,,322.74,161.37,,290.47,90,,,percent of total billed charges,90% of total Billed charges,205.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.18,155,,,Fee Schedule,155% of CMS OPPS Rate,83.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,104.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.18,155,,,Fee Schedule,155% of CMS OPPS Rate,83.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.29,155,,,Fee Schedule,155% of CMS OPPS Rate,318.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,222.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.24,318.29,
56821 Exam/biopsy of vulva w/scope,3428324,CDM,983,RC,56821,HCPCS,Outpatient,,,433.02,216.51,,389.72,90,,,percent of total billed charges,90% of total Billed charges,275.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,175.21,155,,,Fee Schedule,155% of CMS OPPS Rate,113.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.21,155,,,Fee Schedule,155% of CMS OPPS Rate,113.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.6,155,,,Fee Schedule,155% of CMS OPPS Rate,427.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,173.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,294.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,105.72,427.6,
MA EXPLORATION OF VAGINA,3527839,CDM,960,RC,57000,HCPCS,Outpatient,,,532.02,266.01,,478.82,90,,,percent of total billed charges,90% of total Billed charges,398.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,119.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,307.95,155,,,Fee Schedule,155% of CMS OPPS Rate,198.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,294.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,183.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,232.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,307.95,155,,,Fee Schedule,155% of CMS OPPS Rate,198.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.05,155,,,Fee Schedule,155% of CMS OPPS Rate,618.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,386.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,119.5,618.05,
57022 - I&D Vaginal Hematoma Obstetrical/Postpartum,4113117,CDM,983,RC,57022,HCPCS,Outpatient,,,425.99,213.00,,383.39,90,,,percent of total billed charges,90% of total Billed charges,357.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.09,155,,,Fee Schedule,155% of CMS OPPS Rate,178.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,263.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,209.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,276.09,155,,,Fee Schedule,155% of CMS OPPS Rate,178.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.16,155,,,Fee Schedule,155% of CMS OPPS Rate,554.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,178.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,344.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,344.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139.14,554.16,
57023 - I&D VAGINAL HEMATOMA NON-OBSTETRICAL,3997202,CDM,960,RC,57023,HCPCS,Outpatient,,,848.67,424.34,,763.8,90,,,percent of total billed charges,90% of total Billed charges,635.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,316.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,490.31,155,,,Fee Schedule,155% of CMS OPPS Rate,316.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,482.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,482.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,297.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,568.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,379.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,490.31,155,,,Fee Schedule,155% of CMS OPPS Rate,316.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,984.96,155,,,Fee Schedule,155% of CMS OPPS Rate,984.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,316.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,286.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,316.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,637.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,637.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,139.14,984.96,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,229.09,114.55,,206.18,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,183.27,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.18,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.22,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,210.76,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.18,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,160.36,70,,,percent of total billed charges,70% of total billed charges,206.18,90,,,percent of total billed charges,90% of total billed charges,217.64,95,,,percent of total billed charges,95% of total billed charges,217.64,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.02,86,,,percent of total billed charges,86% of total billed charges,183.27,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.22,97,,,percent of total billed charges,97% of total billed charges,206.18,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.22,97,,,percent of total billed charges,97% of total billed charges,213.05,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.22,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,13784.12,
57065-MA DESTROY VAG LESIONS COMPLEX,3430143,CDM,510,RC,57065,HCPCS,Outpatient,,,636.95,318.48,,573.26,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,509.56,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.26,90,,,Percent of total Billed charges,90% of total billed charges,169.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,617.84,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,585.99,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,573.26,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,445.87,70,,,percent of total billed charges,70% of total billed charges,573.26,90,,,percent of total billed charges,90% of total billed charges,605.1,95,,,percent of total billed charges,95% of total billed charges,605.1,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,547.78,86,,,percent of total billed charges,86% of total billed charges,509.56,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,617.84,97,,,percent of total billed charges,97% of total billed charges,573.26,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,617.84,97,,,percent of total billed charges,97% of total billed charges,592.36,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,617.84,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.44,13784.12,
57100PF Bx Vaginal Mucosa Simple Separate Procedure,4265146,CDM,960,RC,57100,HCPCS,Outpatient,,,153.95,76.98,,138.56,90,,,percent of total billed charges,90% of total Billed charges,165.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,100.5,155,,,Fee Schedule,155% of CMS OPPS Rate,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.5,155,,,Fee Schedule,155% of CMS OPPS Rate,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.95,155,,,Fee Schedule,155% of CMS OPPS Rate,255.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.99,255.95,
57105PF Bx Vaginal Mucosa Extensive Requiring Suture,4265147,CDM,960,RC,57105,HCPCS,Outpatient,,,333.58,166.79,,300.22,90,,,percent of total billed charges,90% of total Billed charges,310.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,217.76,155,,,Fee Schedule,155% of CMS OPPS Rate,140.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,203.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,203.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,201.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,201.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,280.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,237.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,217.76,155,,,Fee Schedule,155% of CMS OPPS Rate,140.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,481.69,155,,,Fee Schedule,155% of CMS OPPS Rate,481.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,140.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,140.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70,481.69,
57106- Vaginectomy/part rmv vaginal wall,3431365,CDM,510,RC,57106,HCPCS,Outpatient,,,1404.47,702.24,,1264.02,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.58,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1362.34,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1292.11,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1264.02,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,983.13,70,,,percent of total billed charges,70% of total billed charges,1264.02,90,,,percent of total billed charges,90% of total billed charges,1334.25,95,,,percent of total billed charges,95% of total billed charges,1334.25,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1207.84,86,,,percent of total billed charges,86% of total billed charges,1123.58,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1362.34,97,,,percent of total billed charges,97% of total billed charges,1264.02,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1362.34,97,,,percent of total billed charges,97% of total billed charges,1306.16,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1362.34,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,983.13,13784.12,
"57107-PF REMOVE VAGINA TISSUE, PART",3430147,CDM,510,RC,57107,HCPCS,Outpatient,,,3859.8,1929.90,,3473.82,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3087.84,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3473.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3744.01,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3551.02,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3473.82,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2701.86,70,,,percent of total billed charges,70% of total billed charges,3473.82,90,,,percent of total billed charges,90% of total billed charges,3666.81,95,,,percent of total billed charges,95% of total billed charges,3666.81,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3319.43,86,,,percent of total billed charges,86% of total billed charges,3087.84,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3744.01,97,,,percent of total billed charges,97% of total billed charges,3473.82,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3744.01,97,,,percent of total billed charges,97% of total billed charges,3589.61,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3744.01,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2182.83,13784.12,
"57110 - PF  Vaginectomy, complete removal vaginal wall",4301616,CDM,960,RC,57110,HCPCS,Outpatient,,,1903.59,951.80,,1713.23,90,,,percent of total billed charges,90% of total Billed charges,1802.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1391.76,155,,,Fee Schedule,155% of CMS OPPS Rate,897.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,897.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1351.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1351.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1382.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1382.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,862.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1795.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1631.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1091.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1391.76,155,,,Fee Schedule,155% of CMS OPPS Rate,897.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2794.11,155,,,Fee Schedule,155% of CMS OPPS Rate,2794.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,897.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,926.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,897.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1846.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1846.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2794.11,
MA REMOVE VAGINAL TISSUE,3527857,CDM,960,RC,57111,HCPCS,Outpatient,,,4568.92,2284.46,,4112.03,90,,,percent of total billed charges,90% of total Billed charges,3423.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2643.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2268.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2551.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2551.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2603.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2603.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1550.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3411.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3071.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2056.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2643.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,5306.8,155,,,Fee Schedule,155% of CMS OPPS Rate,5306.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1518.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3315,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3315,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5306.8,
57130- Excision/vaginal septum,3431366,CDM,510,RC,57130,HCPCS,Outpatient,,,595.82,297.91,,536.24,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,476.66,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,536.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,577.95,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,548.15,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,536.24,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,417.07,70,,,percent of total billed charges,70% of total billed charges,536.24,90,,,percent of total billed charges,90% of total billed charges,566.03,95,,,percent of total billed charges,95% of total billed charges,566.03,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,512.41,86,,,percent of total billed charges,86% of total billed charges,476.66,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,577.95,97,,,percent of total billed charges,97% of total billed charges,536.24,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,577.95,97,,,percent of total billed charges,97% of total billed charges,554.11,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,577.95,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,417.07,13784.12,
57135-MA REMOVE VAGINA LESION,3430152,CDM,510,RC,57135,HCPCS,Outpatient,,,637.46,318.73,,573.71,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,509.97,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.71,90,,,Percent of total Billed charges,90% of total billed charges,157.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,618.34,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,586.46,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,573.71,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,446.22,70,,,percent of total billed charges,70% of total billed charges,573.71,90,,,percent of total billed charges,90% of total billed charges,605.59,95,,,percent of total billed charges,95% of total billed charges,605.59,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,548.22,86,,,percent of total billed charges,86% of total billed charges,509.97,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,618.34,97,,,percent of total billed charges,97% of total billed charges,573.71,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.34,97,,,percent of total billed charges,97% of total billed charges,592.84,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,143,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,618.34,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,143,13784.12,
57155 - Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy,3800930,CDM,983,RC,57155,HCPCS,Outpatient,,,997.96,498.98,,898.16,90,,,percent of total billed charges,90% of total Billed charges,651.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,179.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,428.5,155,,,Fee Schedule,155% of CMS OPPS Rate,276.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,467.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,467.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,425.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,425.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,502.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,312.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,428.5,155,,,Fee Schedule,155% of CMS OPPS Rate,276.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1010.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,656.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,656.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,179.75,1010.17,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,510,RC,57156,HCPCS,Outpatient,,,572.82,286.41,,515.54,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,458.26,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,555.64,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,526.99,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,515.54,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,400.97,70,,,percent of total billed charges,70% of total billed charges,515.54,90,,,percent of total billed charges,90% of total billed charges,544.18,95,,,percent of total billed charges,95% of total billed charges,544.18,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,492.63,86,,,percent of total billed charges,86% of total billed charges,458.26,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,555.64,97,,,percent of total billed charges,97% of total billed charges,515.54,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,555.64,97,,,percent of total billed charges,97% of total billed charges,532.72,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,555.64,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.39,1423.33,
57156- Vaginal insert/clin brachytherapy,3431367,CDM,510,RC,57156,HCPCS,Outpatient,,,572.82,286.41,,515.54,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,458.26,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,555.64,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,526.99,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,515.54,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,400.97,70,,,percent of total billed charges,70% of total billed charges,515.54,90,,,percent of total billed charges,90% of total billed charges,544.18,95,,,percent of total billed charges,95% of total billed charges,544.18,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,492.63,86,,,percent of total billed charges,86% of total billed charges,458.26,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,555.64,97,,,percent of total billed charges,97% of total billed charges,515.54,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,555.64,97,,,percent of total billed charges,97% of total billed charges,532.72,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,555.64,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.39,1423.33,
57156-Ins Vag Brachytx Device,4169512,CDM,360,RC,57156,HCPCS,Outpatient,,,571.64,285.82,,514.48,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,457.31,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,554.49,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,525.91,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.48,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,400.15,70,,,percent of total billed charges,70% of total billed charges,514.48,90,,,percent of total billed charges,90% of total billed charges,543.06,95,,,percent of total billed charges,95% of total billed charges,543.06,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.61,86,,,percent of total billed charges,86% of total billed charges,457.31,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.49,97,,,percent of total billed charges,97% of total billed charges,514.48,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.49,97,,,percent of total billed charges,97% of total billed charges,531.63,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,554.49,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.39,1423.33,
57156-Ins Vag Brachytx Device - Pro Fee,4169513,CDM,983,RC,57156,HCPCS,Outpatient,,,347.18,173.59,,312.46,90,,,percent of total billed charges,90% of total Billed charges,362.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.19,155,,,Fee Schedule,155% of CMS OPPS Rate,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,224.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,224.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.19,155,,,Fee Schedule,155% of CMS OPPS Rate,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,562.06,155,,,Fee Schedule,155% of CMS OPPS Rate,562.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,158.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.4,562.06,
57160- Insert/pessary/other support devic,3431368,CDM,510,RC,57160,HCPCS,Outpatient,,,190.67,95.34,,171.6,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.54,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.6,90,,,Percent of total Billed charges,90% of total billed charges,16.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.95,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.42,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.6,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.47,70,,,percent of total billed charges,70% of total billed charges,171.6,90,,,percent of total billed charges,90% of total billed charges,181.14,95,,,percent of total billed charges,95% of total billed charges,181.14,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.98,86,,,percent of total billed charges,86% of total billed charges,152.54,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.95,97,,,percent of total billed charges,97% of total billed charges,171.6,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.95,97,,,percent of total billed charges,97% of total billed charges,177.32,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.95,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.15,868.4,
57170- Fitting of diaphragm/cap,3431369,CDM,510,RC,57170,HCPCS,Outpatient,,,201.04,100.52,,180.94,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,160.83,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.94,90,,,Percent of total Billed charges,90% of total billed charges,46.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,195.01,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,184.96,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,180.94,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,140.73,70,,,percent of total billed charges,70% of total billed charges,180.94,90,,,percent of total billed charges,90% of total billed charges,190.99,95,,,percent of total billed charges,95% of total billed charges,190.99,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,172.89,86,,,percent of total billed charges,86% of total billed charges,160.83,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,195.01,97,,,percent of total billed charges,97% of total billed charges,180.94,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.01,97,,,percent of total billed charges,97% of total billed charges,186.97,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.01,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.31,868.4,
57180- Vag hem/non OB/hemostat agent/pac,3431370,CDM,510,RC,57180,HCPCS,Outpatient,,,506.84,253.42,,456.16,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,405.47,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.16,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,491.63,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,466.29,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,456.16,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,354.79,70,,,percent of total billed charges,70% of total billed charges,456.16,90,,,percent of total billed charges,90% of total billed charges,481.5,95,,,percent of total billed charges,95% of total billed charges,481.5,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,435.88,86,,,percent of total billed charges,86% of total billed charges,405.47,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,491.63,97,,,percent of total billed charges,97% of total billed charges,456.16,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.63,97,,,percent of total billed charges,97% of total billed charges,471.36,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.63,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,868.4,
57200- Colporrhapy/vag injury sut/non OB,3431371,CDM,510,RC,57200,HCPCS,Outpatient,,,866.27,433.14,,779.64,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,693.02,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,779.64,90,,,Percent of total Billed charges,90% of total billed charges,144.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,840.28,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,796.97,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,779.64,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,606.39,70,,,percent of total billed charges,70% of total billed charges,779.64,90,,,percent of total billed charges,90% of total billed charges,822.96,95,,,percent of total billed charges,95% of total billed charges,822.96,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,744.99,86,,,percent of total billed charges,86% of total billed charges,693.02,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,840.28,97,,,percent of total billed charges,97% of total billed charges,779.64,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,840.28,97,,,percent of total billed charges,97% of total billed charges,805.63,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,840.28,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131.5,13784.12,
"57210 - PF Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical)",3699547,CDM,510,RC,57210,HCPCS,Outpatient,,,1034.67,517.34,,931.2,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,827.74,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,931.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1003.63,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,951.9,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,931.2,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,724.27,70,,,percent of total billed charges,70% of total billed charges,931.2,90,,,percent of total billed charges,90% of total billed charges,982.94,95,,,percent of total billed charges,95% of total billed charges,982.94,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,889.82,86,,,percent of total billed charges,86% of total billed charges,827.74,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1003.63,97,,,percent of total billed charges,97% of total billed charges,931.2,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1003.63,97,,,percent of total billed charges,97% of total billed charges,962.24,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1003.63,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,724.27,13784.12,
57220- Urethral sphincter op/vag approach,3431373,CDM,510,RC,57220,HCPCS,Outpatient,,,907.1,453.55,,816.39,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,725.68,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,879.89,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,834.53,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,816.39,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,634.97,70,,,percent of total billed charges,70% of total billed charges,816.39,90,,,percent of total billed charges,90% of total billed charges,861.75,95,,,percent of total billed charges,95% of total billed charges,861.75,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,780.11,86,,,percent of total billed charges,86% of total billed charges,725.68,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,879.89,97,,,percent of total billed charges,97% of total billed charges,816.39,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,879.89,97,,,percent of total billed charges,97% of total billed charges,843.6,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,879.89,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,634.97,22596.74,
"57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cy",3622085,CDM,510,RC,57240,HCPCS,Outpatient,,,1620.01,810.01,,1458.01,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.01,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1458.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1571.41,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1490.41,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1458.01,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.01,70,,,percent of total billed charges,70% of total billed charges,1458.01,90,,,percent of total billed charges,90% of total billed charges,1539.01,95,,,percent of total billed charges,95% of total billed charges,1539.01,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1393.21,86,,,percent of total billed charges,86% of total billed charges,1296.01,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1571.41,97,,,percent of total billed charges,97% of total billed charges,1458.01,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1571.41,97,,,percent of total billed charges,97% of total billed charges,1506.61,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1571.41,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1134.01,22596.74,
"57240PF Anterior colporrhaphy, repair of cystocele with or w",4272096,CDM,975,RC,57240,HCPCS,Outpatient,,,1437.77,718.89,,1293.99,90,,,percent of total billed charges,90% of total Billed charges,1214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,263.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,938.57,155,,,Fee Schedule,155% of CMS OPPS Rate,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,605.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1037,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,920.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,920.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,600.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1211.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1085.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,717.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,938.57,155,,,Fee Schedule,155% of CMS OPPS Rate,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1882.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1360.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,263.5,1882.8,
57250PF Posterior Colporrhaphy Repair Rectocele w/wo Perineo,4165148,CDM,960,RC,57250,HCPCS,Outpatient,,,1445.97,722.99,,1301.37,90,,,percent of total billed charges,90% of total Billed charges,1222.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,608.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,943.92,155,,,Fee Schedule,155% of CMS OPPS Rate,608.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,927.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,608.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1043.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1043.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,926.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,926.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,588.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,608.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1217.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1093.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,726.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,943.92,155,,,Fee Schedule,155% of CMS OPPS Rate,608.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1895.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1895.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,608.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,707.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,608.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1387.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1387.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,1895.12,
57260PF Combined Anteroposterior Colporrhaphy w/wo Cystouret,4265149,CDM,960,RC,57260,HCPCS,Outpatient,,,1833.99,917.00,,1650.59,90,,,percent of total billed charges,90% of total Billed charges,1550.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,772.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,495,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1197.2,155,,,Fee Schedule,155% of CMS OPPS Rate,772.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1182.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,772.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1329.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1329.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1185.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1185.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,742.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1398.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,933.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1197.2,155,,,Fee Schedule,155% of CMS OPPS Rate,772.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,2403.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2403.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,772.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,495,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,787.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,772.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1711.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1711.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,495,2403.32,
57265- Ant/post colporrhap/enterocele rpr,3431684,CDM,761,RC,57265,HCPCS,Outpatient,,,2320.64,1160.32,,2088.58,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1856.51,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2088.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2251.02,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2134.99,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2088.58,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1624.45,70,,,percent of total billed charges,70% of total billed charges,2088.58,90,,,percent of total billed charges,90% of total billed charges,2204.61,95,,,percent of total billed charges,95% of total billed charges,2204.61,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1995.75,86,,,percent of total billed charges,86% of total billed charges,1856.51,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2251.02,97,,,percent of total billed charges,97% of total billed charges,2088.58,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2251.02,97,,,percent of total billed charges,97% of total billed charges,2158.2,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2251.02,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1624.45,22596.74,
57267PF Addon Insertion Mesh/Other Prosthesis Repair Pelvic,4265150,CDM,960,RC,57267,HCPCS,Outpatient,,,593.98,296.99,,534.58,90,,,percent of total billed charges,90% of total Billed charges,502.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,250.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,218.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,387.73,155,,,Fee Schedule,155% of CMS OPPS Rate,250.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,435.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,392.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,392.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,261.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,500.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,463.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,387.73,155,,,Fee Schedule,155% of CMS OPPS Rate,250.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,778.32,155,,,Fee Schedule,155% of CMS OPPS Rate,778.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,250.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,302.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,250.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,528.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,218.3,778.32,
57268- PF REPAIR OF BOWEL BULGE,4133416,CDM,960,RC,57268,HCPCS,Outpatient,,,1330.54,665.27,,1197.49,90,,,percent of total billed charges,90% of total Billed charges,996.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,496.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,262.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,769.23,155,,,Fee Schedule,155% of CMS OPPS Rate,496.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,851.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,749.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,749.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,457.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,992.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,883.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,581.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,769.23,155,,,Fee Schedule,155% of CMS OPPS Rate,496.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1544.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,496.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,496.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,981.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,981.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,262.5,1544.73,
57280 - Colpopexy abdominal approach,4241833,CDM,960,RC,57280,HCPCS,Outpatient,,,2028.37,1014.19,,1825.53,90,,,percent of total billed charges,90% of total Billed charges,1922.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,956.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1482.99,155,,,Fee Schedule,155% of CMS OPPS Rate,956.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1281.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,956.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1441.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1441.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1473.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1473.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,920.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,956.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1913.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1739.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1157.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1482.99,155,,,Fee Schedule,155% of CMS OPPS Rate,956.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2979.26,155,,,Fee Schedule,155% of CMS OPPS Rate,2979.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,956.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,956.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1953.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.5,2979.26,
57282PF Colpopexy Vaginal Extra-peritoneal Approach,4265151,CDM,960,RC,57282,HCPCS,Outpatient,,,1630.16,815.08,,1467.14,90,,,percent of total billed charges,90% of total Billed charges,1378.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,686.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,445.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1064.15,155,,,Fee Schedule,155% of CMS OPPS Rate,686.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,698.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,686.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,785.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,785.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,790.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,790.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,488.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1373.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,933.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,611.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1064.15,155,,,Fee Schedule,155% of CMS OPPS Rate,686.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2136.02,155,,,Fee Schedule,155% of CMS OPPS Rate,2136.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,686.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,754.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,686.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1018.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1018.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,445.3,2136.02,
57283PF Colpopexy/vaginal/intra-peritioneal,4265152,CDM,960,RC,57283,HCPCS,Outpatient,,,1645.92,822.96,,1481.33,90,,,percent of total billed charges,90% of total Billed charges,1390.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,693.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,517.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1074.43,155,,,Fee Schedule,155% of CMS OPPS Rate,693.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,931.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,693.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1047.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1047.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1067.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1067.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,657.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,693.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1386.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1259.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,839.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1074.43,155,,,Fee Schedule,155% of CMS OPPS Rate,693.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2154.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2154.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,693.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,716.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,693.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1415.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,517.7,2154.53,
57284- Paravaginal defect repair/open abd,3431685,CDM,761,RC,57284,HCPCS,Outpatient,,,2211.82,1105.91,,1990.64,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1769.46,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1990.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2145.47,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2034.87,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1990.64,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.27,70,,,percent of total billed charges,70% of total billed charges,1990.64,90,,,percent of total billed charges,90% of total billed charges,2101.23,95,,,percent of total billed charges,95% of total billed charges,2101.23,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1902.17,86,,,percent of total billed charges,86% of total billed charges,1769.46,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2145.47,97,,,percent of total billed charges,97% of total billed charges,1990.64,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2145.47,97,,,percent of total billed charges,97% of total billed charges,2056.99,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2145.47,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1548.27,22596.74,
57287PF Removal/Revision Sling for Stress Incontinence,4265153,CDM,960,RC,57287,HCPCS,Outpatient,,,1719.18,859.59,,1547.26,90,,,percent of total billed charges,90% of total Billed charges,1455.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,724.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,595.19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1122.26,155,,,Fee Schedule,155% of CMS OPPS Rate,724.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1090.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,724.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1226.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1226.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1077.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1077.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,665.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,724.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1448.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1271.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,825.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1122.26,155,,,Fee Schedule,155% of CMS OPPS Rate,724.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,2255.67,155,,,Fee Schedule,155% of CMS OPPS Rate,2255.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,724.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,785.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,724.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1368.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,595.19,2255.67,
57288PF Sling Operation for Stress Incontinence,4265154,CDM,960,RC,57288,HCPCS,Outpatient,,,1734.76,867.38,,1561.28,90,,,percent of total billed charges,90% of total Billed charges,1466.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,730.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,592,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1132.43,155,,,Fee Schedule,155% of CMS OPPS Rate,730.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1117.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,730.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1256.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1256.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1112.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1112.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,726.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1461.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1312.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,862.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1132.43,155,,,Fee Schedule,155% of CMS OPPS Rate,730.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2273.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2273.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,730.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,592,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,903.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,730.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1419.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1419.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,592,2273.46,
57292 - Construction artificial vagina w/ graft,4241834,CDM,960,RC,57292,HCPCS,Outpatient,,,1746.35,873.18,,1571.72,90,,,percent of total billed charges,90% of total Billed charges,1652.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,823.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,720,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1276.81,155,,,Fee Schedule,155% of CMS OPPS Rate,823.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,823.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1237.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1237.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1265.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1265.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,794.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,823.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1647.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1492.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1001.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1276.81,155,,,Fee Schedule,155% of CMS OPPS Rate,823.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2562.04,155,,,Fee Schedule,155% of CMS OPPS Rate,2562.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,823.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,720,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,865.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,823.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1680.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1680.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,720,2562.04,
57295 - REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP,3997204,CDM,960,RC,57295,HCPCS,Outpatient,,,1320.38,660.19,,1188.34,90,,,percent of total billed charges,90% of total Billed charges,989.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,492.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,339.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,763.39,155,,,Fee Schedule,155% of CMS OPPS Rate,492.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,492.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,735.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,735.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,744.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,744.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,471.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,878.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,577.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,763.39,155,,,Fee Schedule,155% of CMS OPPS Rate,492.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1532.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1532.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,492.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,475.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,492.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,973.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,973.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,339.66,1532.97,
57296 - Revision (including removal) of prosthetic vaginal graft; open abdominal approach,3783272,CDM,510,RC,57296,HCPCS,Outpatient,,,2555.53,1277.77,,2299.98,90,,,percent of total billed charges,90% of total Billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2044.42,80,,,Percent of total Billed charges,80% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2478.86,97,,,Percent of total billed charges,97% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2351.09,92,,,Percent of total billed charges,92% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2299.98,90,,,percent of total billed charges,90% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1788.87,70,,,percent of total billed charges,70% of total billed charges,2299.98,90,,,percent of total billed charges,90% of total billed charges,2427.75,95,,,percent of total billed charges,95% of total billed charges,2427.75,95,,,percent of total billed charges,95% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2197.76,86,,,percent of total billed charges,86% of total billed charges,2044.42,80,,,percent of total billed charges,80% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2478.86,97,,,percent of total billed charges,97% of total billed charges,2299.98,90,,,percent of total billed charges,90% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2478.86,97,,,percent of total billed charges,97% of total billed charges,2376.64,93,,,percent of total billed charges,93% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2478.86,97,,,percent of total billed charges,97% of total billed charges,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1788.87,2555.53,
57300-PF REPAIR RECTUM-VAG FISTULA,3430183,CDM,510,RC,57300,HCPCS,Outpatient,,,1610.33,805.17,,1449.3,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1288.26,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1562.02,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1481.5,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1449.3,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1127.23,70,,,percent of total billed charges,70% of total billed charges,1449.3,90,,,percent of total billed charges,90% of total billed charges,1529.81,95,,,percent of total billed charges,95% of total billed charges,1529.81,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1384.88,86,,,percent of total billed charges,86% of total billed charges,1288.26,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1562.02,97,,,percent of total billed charges,97% of total billed charges,1449.3,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1562.02,97,,,percent of total billed charges,97% of total billed charges,1497.61,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1562.02,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1127.23,13784.12,
MA REPAIR RECTUM-VAG FISTULA,3527855,CDM,960,RC,57300,HCPCS,Outpatient,,,1610.33,805.17,,1449.3,90,,,percent of total billed charges,90% of total Billed charges,1203.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,597.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,405.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,926.31,155,,,Fee Schedule,155% of CMS OPPS Rate,597.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,597.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,881.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,881.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,889.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,889.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,502.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,597.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1195.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1049.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,698.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,926.31,155,,,Fee Schedule,155% of CMS OPPS Rate,597.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1864.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1864.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,597.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,597.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,1136.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1136.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,405.5,1864.88,
57305- PF REPAIR RECTUM-VAGINA FISTULA,4133421,CDM,960,RC,57305,HCPCS,Outpatient,,,2623.99,1312.00,,2361.59,90,,,percent of total billed charges,90% of total Billed charges,1960.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,973.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1509.33,155,,,Fee Schedule,155% of CMS OPPS Rate,973.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1429.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,973.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1607.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1607.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1476.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1476.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,837.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,973.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1947.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1742.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1192.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1509.33,155,,,Fee Schedule,155% of CMS OPPS Rate,973.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,3038.71,155,,,Fee Schedule,155% of CMS OPPS Rate,3038.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,973.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,921.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,973.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1898.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1898.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,3038.71,
57320PF Closure Vesicovaginal Fistula Vaginal Approach,4265155,CDM,960,RC,57320,HCPCS,Outpatient,,,1326.1,663.05,,1193.49,90,,,percent of total billed charges,90% of total Billed charges,1119.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,558.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,865.68,155,,,Fee Schedule,155% of CMS OPPS Rate,558.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,558.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,819.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,819.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,828.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,828.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,520.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1117,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,634.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,865.68,155,,,Fee Schedule,155% of CMS OPPS Rate,558.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1735.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1735.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,558.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,646.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,558.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1066.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,473.64,1735.97,
57330 - Repair Bladder-Vagina Lesion,4189311,CDM,960,RC,57330,HCPCS,Outpatient,,,1793.44,896.72,,1614.1,90,,,percent of total billed charges,90% of total Billed charges,1502.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,747.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1158.5,155,,,Fee Schedule,155% of CMS OPPS Rate,747.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1005.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,747.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1131.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1131.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1148.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1148.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,748.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1494.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1355.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,870.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1158.5,155,,,Fee Schedule,155% of CMS OPPS Rate,747.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2329.25,155,,,Fee Schedule,155% of CMS OPPS Rate,2329.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,747.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,832.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,747.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1471.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,544,2329.25,
MA DILATION OF VAGINA,3527858,CDM,960,RC,57400,HCPCS,Outpatient,,,345.41,172.71,,310.87,90,,,percent of total billed charges,90% of total Billed charges,258.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.94,155,,,Fee Schedule,155% of CMS OPPS Rate,128.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,201.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,201.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,159.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198.94,155,,,Fee Schedule,155% of CMS OPPS Rate,128.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.26,155,,,Fee Schedule,155% of CMS OPPS Rate,400.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,128.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,272.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37,400.26,
57410PF Pelvic Examination Under Anesthesia,4265156,CDM,960,RC,57410,HCPCS,Outpatient,,,245.82,122.91,,221.24,90,,,percent of total billed charges,90% of total Billed charges,207.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.46,155,,,Fee Schedule,155% of CMS OPPS Rate,103.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,158.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,161.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,161.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,160.46,155,,,Fee Schedule,155% of CMS OPPS Rate,103.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.83,155,,,Fee Schedule,155% of CMS OPPS Rate,321.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,232.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,218.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.5,321.83,
57415PF Remove Vaginal Foreign Body,4267372,CDM,960,RC,57415,HCPCS,Outpatient,,,405.12,202.56,,364.61,90,,,percent of total billed charges,90% of total Billed charges,343.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,264.46,155,,,Fee Schedule,155% of CMS OPPS Rate,170.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,299.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,195.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,264.46,155,,,Fee Schedule,155% of CMS OPPS Rate,170.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,531.7,155,,,Fee Schedule,155% of CMS OPPS Rate,531.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,170.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,214.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,323,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,323,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,95,531.7,
57420- Colposcopy/vagina/cervix,3431385,CDM,360,RC,57420,HCPCS,Outpatient,,,339.84,169.92,,305.86,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,271.87,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.86,90,,,Percent of total Billed charges,90% of total billed charges,89.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,329.64,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,312.65,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,305.86,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,237.89,70,,,percent of total billed charges,70% of total billed charges,305.86,90,,,percent of total billed charges,90% of total billed charges,322.85,95,,,percent of total billed charges,95% of total billed charges,322.85,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,292.26,86,,,percent of total billed charges,86% of total billed charges,271.87,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,329.64,97,,,percent of total billed charges,97% of total billed charges,305.86,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.64,97,,,percent of total billed charges,97% of total billed charges,316.05,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,329.64,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81.73,1423.33,
57421- Colposcopy/cervix/bx vagina/cervix,3431386,CDM,360,RC,57421,HCPCS,Outpatient,,,458.2,229.10,,412.38,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,366.56,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,412.38,90,,,Percent of total Billed charges,90% of total billed charges,124.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,444.45,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,421.54,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,412.38,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,320.74,70,,,percent of total billed charges,70% of total billed charges,412.38,90,,,percent of total billed charges,90% of total billed charges,435.29,95,,,percent of total billed charges,95% of total billed charges,435.29,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,394.05,86,,,percent of total billed charges,86% of total billed charges,366.56,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,444.45,97,,,percent of total billed charges,97% of total billed charges,412.38,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,444.45,97,,,percent of total billed charges,97% of total billed charges,426.13,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,444.45,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.78,3429.49,
"57423 - PF Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic app",3715240,CDM,510,RC,57423,HCPCS,Outpatient,,,2469.27,1234.64,,2222.34,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1975.42,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2222.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2395.19,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.73,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2222.34,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1728.49,70,,,percent of total billed charges,70% of total billed charges,2222.34,90,,,percent of total billed charges,90% of total billed charges,2345.81,95,,,percent of total billed charges,95% of total billed charges,2345.81,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2123.57,86,,,percent of total billed charges,86% of total billed charges,1975.42,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2395.19,97,,,percent of total billed charges,97% of total billed charges,2222.34,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2395.19,97,,,percent of total billed charges,97% of total billed charges,2296.42,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2395.19,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1728.49,44301.74,
57423PF Paravaginal defect repair (including repair of cysto,4272097,CDM,975,RC,57423,HCPCS,Outpatient,,,2187.82,1093.91,,1969.04,90,,,percent of total billed charges,90% of total Billed charges,1849.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,921.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,658.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1428.2,155,,,Fee Schedule,155% of CMS OPPS Rate,921.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1233.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,921.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1387.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1387.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1420.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1420.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,872.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,921.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1842.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1675.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1120.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1428.2,155,,,Fee Schedule,155% of CMS OPPS Rate,921.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2867.42,155,,,Fee Schedule,155% of CMS OPPS Rate,2867.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,921.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,764.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,921.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1884.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1884.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,658.05,2867.42,
"57425-PF LAPAROSCOPY, SURG COLPOPEXY",3430189,CDM,510,RC,57425,HCPCS,Outpatient,,,2587.48,1293.74,,2328.73,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2069.98,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2328.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2509.86,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2380.48,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2328.73,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1811.24,70,,,percent of total billed charges,70% of total billed charges,2328.73,90,,,percent of total billed charges,90% of total billed charges,2458.11,95,,,percent of total billed charges,95% of total billed charges,2458.11,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2225.23,86,,,percent of total billed charges,86% of total billed charges,2069.98,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2509.86,97,,,percent of total billed charges,97% of total billed charges,2328.73,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2509.86,97,,,percent of total billed charges,97% of total billed charges,2406.36,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2509.86,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1811.24,44301.74,
57426 - REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC,4037690,CDM,983,RC,57426,HCPCS,Outpatient,,,2303.51,1151.76,,2073.16,90,,,percent of total billed charges,90% of total Billed charges,1724.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,858.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,680.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1329.98,155,,,Fee Schedule,155% of CMS OPPS Rate,858.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1143.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,858.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1286.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1286.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1308.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1308.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,879.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1716.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1544.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1022.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1329.98,155,,,Fee Schedule,155% of CMS OPPS Rate,858.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2672.57,155,,,Fee Schedule,155% of CMS OPPS Rate,2672.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,858.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1025.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,858.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1702.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1702.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,680.33,2672.57,
57452- Colposcopy/cervix/up/adjacent vag,3431387,CDM,360,RC,57452,HCPCS,Outpatient,,,326.38,163.19,,293.74,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,261.1,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.74,90,,,Percent of total Billed charges,90% of total billed charges,43.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,316.59,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,300.27,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,293.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,228.47,70,,,percent of total billed charges,70% of total billed charges,293.74,90,,,percent of total billed charges,90% of total billed charges,310.06,95,,,percent of total billed charges,95% of total billed charges,310.06,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,280.69,86,,,percent of total billed charges,86% of total billed charges,261.1,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,316.59,97,,,percent of total billed charges,97% of total billed charges,293.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.59,97,,,percent of total billed charges,97% of total billed charges,303.53,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,316.59,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.5,868.4,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,312.35,156.18,,281.12,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,249.88,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.12,90,,,Percent of total Billed charges,90% of total billed charges,116.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,302.98,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,287.36,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,281.12,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,218.65,70,,,percent of total billed charges,70% of total billed charges,281.12,90,,,percent of total billed charges,90% of total billed charges,296.73,95,,,percent of total billed charges,95% of total billed charges,296.73,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,268.62,86,,,percent of total billed charges,86% of total billed charges,249.88,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,302.98,97,,,percent of total billed charges,97% of total billed charges,281.12,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.98,97,,,percent of total billed charges,97% of total billed charges,290.49,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,302.98,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.94,1423.33,
57455- Colposcopy/cervix/biopsy,3431389,CDM,360,RC,57455,HCPCS,Outpatient,,,418.18,209.09,,376.36,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,334.54,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.36,90,,,Percent of total Billed charges,90% of total billed charges,111.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,405.63,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,384.73,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,376.36,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,292.73,70,,,percent of total billed charges,70% of total billed charges,376.36,90,,,percent of total billed charges,90% of total billed charges,397.27,95,,,percent of total billed charges,95% of total billed charges,397.27,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,359.63,86,,,percent of total billed charges,86% of total billed charges,334.54,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,405.63,97,,,percent of total billed charges,97% of total billed charges,376.36,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.63,97,,,percent of total billed charges,97% of total billed charges,388.91,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,405.63,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,101.68,1423.33,
57456- Colposcopy/cervix/endocerv curettage,3431390,CDM,360,RC,57456,HCPCS,Outpatient,,,391.74,195.87,,352.57,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,313.39,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.57,90,,,Percent of total Billed charges,90% of total billed charges,104.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,379.99,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,360.4,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,352.57,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,274.22,70,,,percent of total billed charges,70% of total billed charges,352.57,90,,,percent of total billed charges,90% of total billed charges,372.15,95,,,percent of total billed charges,95% of total billed charges,372.15,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,336.9,86,,,percent of total billed charges,86% of total billed charges,313.39,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,379.99,97,,,percent of total billed charges,97% of total billed charges,352.57,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,379.99,97,,,percent of total billed charges,97% of total billed charges,364.32,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,379.99,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.01,1423.33,
57460- Colposcopy/cervix/LEEP,3431391,CDM,510,RC,57460,HCPCS,Outpatient,,,806.42,403.21,,725.78,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,645.14,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,725.78,90,,,Percent of total Billed charges,90% of total billed charges,164.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,782.23,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,741.91,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,725.78,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,564.49,70,,,percent of total billed charges,70% of total billed charges,725.78,90,,,percent of total billed charges,90% of total billed charges,766.1,95,,,percent of total billed charges,95% of total billed charges,766.1,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,693.52,86,,,percent of total billed charges,86% of total billed charges,645.14,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,782.23,97,,,percent of total billed charges,97% of total billed charges,725.78,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,782.23,97,,,percent of total billed charges,97% of total billed charges,749.97,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,782.23,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,149.8,13784.12,
57461- Colposcopy/cervix/ conization,3431392,CDM,510,RC,57461,HCPCS,Outpatient,,,905.65,452.83,,815.09,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,724.52,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,815.09,90,,,Percent of total Billed charges,90% of total billed charges,190.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,878.48,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,833.2,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,815.09,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,633.96,70,,,percent of total billed charges,70% of total billed charges,815.09,90,,,percent of total billed charges,90% of total billed charges,860.37,95,,,percent of total billed charges,95% of total billed charges,860.37,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,778.86,86,,,percent of total billed charges,86% of total billed charges,724.52,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,878.48,97,,,percent of total billed charges,97% of total billed charges,815.09,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.48,97,,,percent of total billed charges,97% of total billed charges,842.25,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,878.48,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.53,13784.12,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,393.05,196.53,,353.75,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,314.44,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.75,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,381.26,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,361.61,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,353.75,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,275.14,70,,,percent of total billed charges,70% of total billed charges,353.75,90,,,percent of total billed charges,90% of total billed charges,373.4,95,,,percent of total billed charges,95% of total billed charges,373.4,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,338.02,86,,,percent of total billed charges,86% of total billed charges,314.44,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,381.26,97,,,percent of total billed charges,97% of total billed charges,353.75,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.26,97,,,percent of total billed charges,97% of total billed charges,365.54,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.26,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.12,3429.49,
57500PF Bx Cervix Single/Multiple/Local Excision Lesion w/wo,4265157,CDM,960,RC,57500,HCPCS,Outpatient,,,174.04,87.02,,156.64,90,,,percent of total billed charges,90% of total Billed charges,221.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.6,155,,,Fee Schedule,155% of CMS OPPS Rate,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,89.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.6,155,,,Fee Schedule,155% of CMS OPPS Rate,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.69,155,,,Fee Schedule,155% of CMS OPPS Rate,342.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.12,342.69,
57505- Endocervical curettage,3431394,CDM,360,RC,57505,HCPCS,Outpatient,,,393.72,196.86,,354.35,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,314.98,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.35,90,,,Percent of total Billed charges,90% of total billed charges,24.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,381.91,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,362.22,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,354.35,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,275.6,70,,,percent of total billed charges,70% of total billed charges,354.35,90,,,percent of total billed charges,90% of total billed charges,374.03,95,,,percent of total billed charges,95% of total billed charges,374.03,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,338.6,86,,,percent of total billed charges,86% of total billed charges,314.98,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,381.91,97,,,percent of total billed charges,97% of total billed charges,354.35,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.91,97,,,percent of total billed charges,97% of total billed charges,366.16,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.91,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22,3429.49,
57511- Cautery/cervix/cryocautery,3431395,CDM,510,RC,57511,HCPCS,Outpatient,,,513.99,257.00,,462.59,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,411.19,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.59,90,,,Percent of total Billed charges,90% of total billed charges,56.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,498.57,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,472.87,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,462.59,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,359.79,70,,,percent of total billed charges,70% of total billed charges,462.59,90,,,percent of total billed charges,90% of total billed charges,488.29,95,,,percent of total billed charges,95% of total billed charges,488.29,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,442.03,86,,,percent of total billed charges,86% of total billed charges,411.19,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,498.57,97,,,percent of total billed charges,97% of total billed charges,462.59,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.57,97,,,percent of total billed charges,97% of total billed charges,478.01,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,498.57,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.5,1423.33,
57520 - Conization/Cervix/Cold Knife/Laser,4133230,CDM,960,RC,57520,HCPCS,Outpatient,,,912.15,456.08,,820.94,90,,,percent of total billed charges,90% of total Billed charges,631.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,288.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.01,90,,,Percent of total Billed charges,90% of total billed charges,211.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,447.44,155,,,Fee Schedule,155% of CMS OPPS Rate,288.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,288.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,426.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,426.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,503.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,447.44,155,,,Fee Schedule,155% of CMS OPPS Rate,288.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,979.07,155,,,Fee Schedule,155% of CMS OPPS Rate,979.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,288.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,288.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,612,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,612,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,211.5,979.07,
57520- Conization/cervix/cold knife/laser,3431686,CDM,761,RC,57520,HCPCS,Outpatient,,,912.15,456.08,,820.94,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,729.72,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,820.94,90,,,Percent of total Billed charges,90% of total billed charges,232.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,884.79,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,839.18,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,820.94,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,638.51,70,,,percent of total billed charges,70% of total billed charges,820.94,90,,,percent of total billed charges,90% of total billed charges,866.54,95,,,percent of total billed charges,95% of total billed charges,866.54,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,784.45,86,,,percent of total billed charges,86% of total billed charges,729.72,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,884.79,97,,,percent of total billed charges,97% of total billed charges,820.94,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,884.79,97,,,percent of total billed charges,97% of total billed charges,848.3,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,884.79,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,211.5,13784.12,
57522- Conization/cerv/loop electrode exc,3431396,CDM,510,RC,57522,HCPCS,Outpatient,,,786.86,393.43,,708.17,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,629.49,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.17,90,,,Percent of total Billed charges,90% of total billed charges,239.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,763.25,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,723.91,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,708.17,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,550.8,70,,,percent of total billed charges,70% of total billed charges,708.17,90,,,percent of total billed charges,90% of total billed charges,747.52,95,,,percent of total billed charges,95% of total billed charges,747.52,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,676.7,86,,,percent of total billed charges,86% of total billed charges,629.49,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,763.25,97,,,percent of total billed charges,97% of total billed charges,708.17,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,763.25,97,,,percent of total billed charges,97% of total billed charges,731.78,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,763.25,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,217.95,13784.12,
57530-PF REMOVAL OF CERVIX,3430191,CDM,510,RC,57530,HCPCS,Outpatient,,,977.78,488.89,,880,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,782.22,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,880,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,948.45,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,899.56,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,880,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,684.45,70,,,percent of total billed charges,70% of total billed charges,880,90,,,percent of total billed charges,90% of total billed charges,928.89,95,,,percent of total billed charges,95% of total billed charges,928.89,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,840.89,86,,,percent of total billed charges,86% of total billed charges,782.22,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,948.45,97,,,percent of total billed charges,97% of total billed charges,880,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,948.45,97,,,percent of total billed charges,97% of total billed charges,909.34,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,948.45,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,684.45,22596.74,
57800- Dilation/cervical canal/instrument,3431397,CDM,510,RC,57800,HCPCS,Outpatient,,,197.8,98.90,,178.02,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,158.24,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.02,90,,,Percent of total Billed charges,90% of total billed charges,45.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,191.87,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,181.98,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,178.02,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,138.46,70,,,percent of total billed charges,70% of total billed charges,178.02,90,,,percent of total billed charges,90% of total billed charges,187.91,95,,,percent of total billed charges,95% of total billed charges,187.91,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,170.11,86,,,percent of total billed charges,86% of total billed charges,158.24,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,191.87,97,,,percent of total billed charges,97% of total billed charges,178.02,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.87,97,,,percent of total billed charges,97% of total billed charges,183.95,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.87,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.5,13784.12,
58100- EMB w/o cervical dilation,3431398,CDM,360,RC,58100,HCPCS,Outpatient,,,264.47,132.24,,238.02,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,211.58,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.02,90,,,Percent of total Billed charges,90% of total billed charges,56.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,256.54,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,243.31,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,238.02,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,185.13,70,,,percent of total billed charges,70% of total billed charges,238.02,90,,,percent of total billed charges,90% of total billed charges,251.25,95,,,percent of total billed charges,95% of total billed charges,251.25,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,227.44,86,,,percent of total billed charges,86% of total billed charges,211.58,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,256.54,97,,,percent of total billed charges,97% of total billed charges,238.02,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.54,97,,,percent of total billed charges,97% of total billed charges,245.96,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.54,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51,868.4,
58100-PF ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX,4321483,CDM,981,RC,58100,HCPCS,Outpatient,,,126.28,63.14,,113.65,90,,,percent of total billed charges,90% of total Billed charges,162.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.87,90,,,Percent of total Billed charges,90% of total billed charges,51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.87,155,,,Fee Schedule,155% of CMS OPPS Rate,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.87,155,,,Fee Schedule,155% of CMS OPPS Rate,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.01,155,,,Fee Schedule,155% of CMS OPPS Rate,252.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,220.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51,252.01,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,94.93,47.47,,85.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,75.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,85.44,90,,,Percent of total Billed charges,90% of total billed charges,35.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,87.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,60.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,74.66,78.65,,,percent of total billed charges,78.65% of total billed charges,84.8,89.33,,,percent of total billed charges,89.33% of total billed charges,85.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.45,70,,,percent of total billed charges,70% of total billed charges,85.44,90,,,percent of total billed charges,90% of total billed charges,90.18,95,,,percent of total billed charges,95% of total billed charges,90.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.64,86,,,percent of total billed charges,86% of total billed charges,75.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,92.08,97,,,percent of total billed charges,97% of total billed charges,85.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,92.08,97,,,percent of total billed charges,97% of total billed charges,88.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,92.08,
58120- D&C/diagnostic/therapeutic/non OB,3431400,CDM,510,RC,58120,HCPCS,Outpatient,,,773.17,386.59,,695.85,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,618.54,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,749.97,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,711.32,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,695.85,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,541.22,70,,,percent of total billed charges,70% of total billed charges,695.85,90,,,percent of total billed charges,90% of total billed charges,734.51,95,,,percent of total billed charges,95% of total billed charges,734.51,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,664.93,86,,,percent of total billed charges,86% of total billed charges,618.54,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,749.97,97,,,percent of total billed charges,97% of total billed charges,695.85,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.97,97,,,percent of total billed charges,97% of total billed charges,719.05,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,749.97,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,541.22,13784.12,
58140-PF MYOMECTOMY ABDOM METHOD,3430195,CDM,510,RC,58140,HCPCS,Outpatient,,,2488.94,1244.47,,2240.05,90,,,percent of total billed charges,90% of total Billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1991.15,80,,,Percent of total Billed charges,80% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2240.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2414.27,97,,,Percent of total billed charges,97% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2289.82,92,,,Percent of total billed charges,92% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2240.05,90,,,percent of total billed charges,90% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1742.26,70,,,percent of total billed charges,70% of total billed charges,2240.05,90,,,percent of total billed charges,90% of total billed charges,2364.49,95,,,percent of total billed charges,95% of total billed charges,2364.49,95,,,percent of total billed charges,95% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2140.49,86,,,percent of total billed charges,86% of total billed charges,1991.15,80,,,percent of total billed charges,80% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2414.27,97,,,percent of total billed charges,97% of total billed charges,2240.05,90,,,percent of total billed charges,90% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2414.27,97,,,percent of total billed charges,97% of total billed charges,2314.71,93,,,percent of total billed charges,93% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2414.27,97,,,percent of total billed charges,97% of total billed charges,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2488.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1742.26,2488.94,
58145- Myomectomy/1-4 myomas/vag approach,3431401,CDM,510,RC,58145,HCPCS,Outpatient,,,1502.26,751.13,,1352.03,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1201.81,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1352.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1457.19,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.08,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1352.03,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.58,70,,,percent of total billed charges,70% of total billed charges,1352.03,90,,,percent of total billed charges,90% of total billed charges,1427.15,95,,,percent of total billed charges,95% of total billed charges,1427.15,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1291.94,86,,,percent of total billed charges,86% of total billed charges,1201.81,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1457.19,97,,,percent of total billed charges,97% of total billed charges,1352.03,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1457.19,97,,,percent of total billed charges,97% of total billed charges,1397.1,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1457.19,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1051.58,13784.12,
58146- Myomectomy/5 or>/abd approach,3431402,CDM,510,RC,58146,HCPCS,Outpatient,,,3086.58,1543.29,,2777.92,90,,,percent of total billed charges,90% of total Billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2469.26,80,,,Percent of total Billed charges,80% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2777.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2993.98,97,,,Percent of total billed charges,97% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2839.65,92,,,Percent of total billed charges,92% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2777.92,90,,,percent of total billed charges,90% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2160.61,70,,,percent of total billed charges,70% of total billed charges,2777.92,90,,,percent of total billed charges,90% of total billed charges,2932.25,95,,,percent of total billed charges,95% of total billed charges,2932.25,95,,,percent of total billed charges,95% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2654.46,86,,,percent of total billed charges,86% of total billed charges,2469.26,80,,,percent of total billed charges,80% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2993.98,97,,,percent of total billed charges,97% of total billed charges,2777.92,90,,,percent of total billed charges,90% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2993.98,97,,,percent of total billed charges,97% of total billed charges,2870.52,93,,,percent of total billed charges,93% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2993.98,97,,,percent of total billed charges,97% of total billed charges,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3086.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2160.61,3086.58,
58150- Tot abd hysterect w/w/o tubes/ovar,3431403,CDM,510,RC,58150,HCPCS,Outpatient,,,2688.94,1344.47,,2420.05,90,,,percent of total billed charges,90% of total Billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2151.15,80,,,Percent of total Billed charges,80% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2420.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2608.27,97,,,Percent of total billed charges,97% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.82,92,,,Percent of total billed charges,92% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2420.05,90,,,percent of total billed charges,90% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1882.26,70,,,percent of total billed charges,70% of total billed charges,2420.05,90,,,percent of total billed charges,90% of total billed charges,2554.49,95,,,percent of total billed charges,95% of total billed charges,2554.49,95,,,percent of total billed charges,95% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2312.49,86,,,percent of total billed charges,86% of total billed charges,2151.15,80,,,percent of total billed charges,80% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.27,97,,,percent of total billed charges,97% of total billed charges,2420.05,90,,,percent of total billed charges,90% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2608.27,97,,,percent of total billed charges,97% of total billed charges,2500.71,93,,,percent of total billed charges,93% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2608.27,97,,,percent of total billed charges,97% of total billed charges,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2688.94,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1882.26,2688.94,
58152- TAH w/MMK,3431687,CDM,510,RC,58152,HCPCS,Outpatient,,,3305.84,1652.92,,2975.26,90,,,percent of total billed charges,90% of total Billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2644.67,80,,,Percent of total Billed charges,80% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2975.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3206.66,97,,,Percent of total billed charges,97% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3041.37,92,,,Percent of total billed charges,92% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2975.26,90,,,percent of total billed charges,90% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2314.09,70,,,percent of total billed charges,70% of total billed charges,2975.26,90,,,percent of total billed charges,90% of total billed charges,3140.55,95,,,percent of total billed charges,95% of total billed charges,3140.55,95,,,percent of total billed charges,95% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2843.02,86,,,percent of total billed charges,86% of total billed charges,2644.67,80,,,percent of total billed charges,80% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3206.66,97,,,percent of total billed charges,97% of total billed charges,2975.26,90,,,percent of total billed charges,90% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3206.66,97,,,percent of total billed charges,97% of total billed charges,3074.43,93,,,percent of total billed charges,93% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3206.66,97,,,percent of total billed charges,97% of total billed charges,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3305.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2314.09,3305.84,
"58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(",3622575,CDM,960,RC,58180,HCPCS,Outpatient,,,2553.21,1276.61,,2297.89,90,,,percent of total billed charges,90% of total Billed charges,1913.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,953.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1478.48,155,,,Fee Schedule,155% of CMS OPPS Rate,953.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,953.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1439.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1439.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1475.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1475.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,903.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1907.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1740.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1171.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1478.48,155,,,Fee Schedule,155% of CMS OPPS Rate,953.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,2966.62,155,,,Fee Schedule,155% of CMS OPPS Rate,2966.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,953.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1035.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,953.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1969.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1969.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2966.62,
58200- Abdominal hysterectomy/total,3431688,CDM,510,RC,58200,HCPCS,Outpatient,,,3572.27,1786.14,,3215.04,90,,,percent of total billed charges,90% of total Billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2857.82,80,,,Percent of total Billed charges,80% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3215.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3465.1,97,,,Percent of total billed charges,97% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3286.49,92,,,Percent of total billed charges,92% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3215.04,90,,,percent of total billed charges,90% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2500.59,70,,,percent of total billed charges,70% of total billed charges,3215.04,90,,,percent of total billed charges,90% of total billed charges,3393.66,95,,,percent of total billed charges,95% of total billed charges,3393.66,95,,,percent of total billed charges,95% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3072.15,86,,,percent of total billed charges,86% of total billed charges,2857.82,80,,,percent of total billed charges,80% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.1,97,,,percent of total billed charges,97% of total billed charges,3215.04,90,,,percent of total billed charges,90% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3465.1,97,,,percent of total billed charges,97% of total billed charges,3322.21,93,,,percent of total billed charges,93% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3465.1,97,,,percent of total billed charges,97% of total billed charges,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3572.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2500.59,3572.27,
58210-PF EXTENSIVE HYSTERECTOMY,3430207,CDM,510,RC,58210,HCPCS,Outpatient,,,4828.2,2414.10,,4345.38,90,,,percent of total billed charges,90% of total Billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3862.56,80,,,Percent of total Billed charges,80% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4345.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4683.35,97,,,Percent of total billed charges,97% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4441.94,92,,,Percent of total billed charges,92% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4345.38,90,,,percent of total billed charges,90% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3379.74,70,,,percent of total billed charges,70% of total billed charges,4345.38,90,,,percent of total billed charges,90% of total billed charges,4586.79,95,,,percent of total billed charges,95% of total billed charges,4586.79,95,,,percent of total billed charges,95% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4152.25,86,,,percent of total billed charges,86% of total billed charges,3862.56,80,,,percent of total billed charges,80% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4683.35,97,,,percent of total billed charges,97% of total billed charges,4345.38,90,,,percent of total billed charges,90% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4683.35,97,,,percent of total billed charges,97% of total billed charges,4490.23,93,,,percent of total billed charges,93% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4683.35,97,,,percent of total billed charges,97% of total billed charges,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4828.2,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3379.74,4828.2,
58240-PF REMOVAL OF PELVIS CONTENTS,3430209,CDM,510,RC,58240,HCPCS,Outpatient,,,7786.17,3893.09,,7007.55,90,,,percent of total billed charges,90% of total Billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6228.94,80,,,Percent of total Billed charges,80% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7007.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7552.58,97,,,Percent of total billed charges,97% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7163.28,92,,,Percent of total billed charges,92% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7007.55,90,,,percent of total billed charges,90% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5450.32,70,,,percent of total billed charges,70% of total billed charges,7007.55,90,,,percent of total billed charges,90% of total billed charges,7396.86,95,,,percent of total billed charges,95% of total billed charges,7396.86,95,,,percent of total billed charges,95% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6696.11,86,,,percent of total billed charges,86% of total billed charges,6228.94,80,,,percent of total billed charges,80% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7552.58,97,,,percent of total billed charges,97% of total billed charges,7007.55,90,,,percent of total billed charges,90% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7552.58,97,,,percent of total billed charges,97% of total billed charges,7241.14,93,,,percent of total billed charges,93% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,7552.58,97,,,percent of total billed charges,97% of total billed charges,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,7786.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5450.32,7786.17,
58260- Vaginal hysterectomy/250 g or<,3431405,CDM,510,RC,58260,HCPCS,Outpatient,,,2230.59,1115.30,,2007.53,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1784.47,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2007.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2163.67,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2052.14,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2007.53,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1561.41,70,,,percent of total billed charges,70% of total billed charges,2007.53,90,,,percent of total billed charges,90% of total billed charges,2119.06,95,,,percent of total billed charges,95% of total billed charges,2119.06,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1918.31,86,,,percent of total billed charges,86% of total billed charges,1784.47,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2163.67,97,,,percent of total billed charges,97% of total billed charges,2007.53,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2163.67,97,,,percent of total billed charges,97% of total billed charges,2074.45,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2163.67,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1561.41,22596.74,
58262- Vag hys/<250g/rmv tube/& or ovarie,3431407,CDM,510,RC,58262,HCPCS,Outpatient,,,2468.85,1234.43,,2221.97,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1975.08,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2221.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2394.78,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.34,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2221.97,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1728.2,70,,,percent of total billed charges,70% of total billed charges,2221.97,90,,,percent of total billed charges,90% of total billed charges,2345.41,95,,,percent of total billed charges,95% of total billed charges,2345.41,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2123.21,86,,,percent of total billed charges,86% of total billed charges,1975.08,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2394.78,97,,,percent of total billed charges,97% of total billed charges,2221.97,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2394.78,97,,,percent of total billed charges,97% of total billed charges,2296.03,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2394.78,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1728.2,22596.74,
58263- Vag hys/<250g/rmv tube/rpr entero,3431408,CDM,510,RC,58263,HCPCS,Outpatient,,,2648.61,1324.31,,2383.75,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2118.89,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2383.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2569.15,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2436.72,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2383.75,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.03,70,,,percent of total billed charges,70% of total billed charges,2383.75,90,,,percent of total billed charges,90% of total billed charges,2516.18,95,,,percent of total billed charges,95% of total billed charges,2516.18,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2277.8,86,,,percent of total billed charges,86% of total billed charges,2118.89,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2569.15,97,,,percent of total billed charges,97% of total billed charges,2383.75,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2569.15,97,,,percent of total billed charges,97% of total billed charges,2463.21,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2569.15,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1854.03,22596.74,
58267- TVH/uterus < 250g w/MMK,3431689,CDM,510,RC,58267,HCPCS,Outpatient,,,2851.87,1425.94,,2566.68,90,,,percent of total billed charges,90% of total Billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2281.5,80,,,Percent of total Billed charges,80% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2566.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2766.31,97,,,Percent of total billed charges,97% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2623.72,92,,,Percent of total billed charges,92% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2566.68,90,,,percent of total billed charges,90% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1996.31,70,,,percent of total billed charges,70% of total billed charges,2566.68,90,,,percent of total billed charges,90% of total billed charges,2709.28,95,,,percent of total billed charges,95% of total billed charges,2709.28,95,,,percent of total billed charges,95% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2452.61,86,,,percent of total billed charges,86% of total billed charges,2281.5,80,,,percent of total billed charges,80% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2766.31,97,,,percent of total billed charges,97% of total billed charges,2566.68,90,,,percent of total billed charges,90% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2766.31,97,,,percent of total billed charges,97% of total billed charges,2652.24,93,,,percent of total billed charges,93% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2766.31,97,,,percent of total billed charges,97% of total billed charges,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2851.87,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1996.31,2851.87,
58270PF Vaginal Hysterectomy Uterus 250g or Less w/Repair En,4265158,CDM,960,RC,58270,HCPCS,Outpatient,,,2114.04,1057.02,,1902.64,90,,,percent of total billed charges,90% of total Billed charges,1787.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,890.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,605,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1380.03,155,,,Fee Schedule,155% of CMS OPPS Rate,890.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1187.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,890.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1335.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1335.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1367.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1367.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,847.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1780.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1613.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1084.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1380.03,155,,,Fee Schedule,155% of CMS OPPS Rate,890.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,2770.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2770.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,890.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,605,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1006.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,890.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1814.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1814.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,605,2770.32,
58290- TVH/uterus > 250g,3431690,CDM,360,RC,58290,HCPCS,Outpatient,,,3075.56,1537.78,,2768,90,,,percent of total billed charges,90% of total Billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2460.45,80,,,Percent of total Billed charges,80% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2768,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2983.29,97,,,Percent of total billed charges,97% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2829.52,92,,,Percent of total billed charges,92% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate,16720.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6290.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26655.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33762.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2768,90,,,percent of total billed charges,90% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate,2152.89,70,,,percent of total billed charges,70% of total billed charges,2768,90,,,percent of total billed charges,90% of total billed charges,2921.78,95,,,percent of total billed charges,95% of total billed charges,2921.78,95,,,percent of total billed charges,95% of total billed charges,6290.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12580.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2644.98,86,,,percent of total billed charges,86% of total billed charges,2460.45,80,,,percent of total billed charges,80% of total billed charges,6930.68,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2983.29,97,,,percent of total billed charges,97% of total billed charges,2768,90,,,percent of total billed charges,90% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2983.29,97,,,percent of total billed charges,97% of total billed charges,2860.27,93,,,percent of total billed charges,93% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2983.29,97,,,percent of total billed charges,97% of total billed charges,6290.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,6290.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5346.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2152.89,33762.98,
58291- TVH/uterus > 250g/salping/ooph,3431691,CDM,360,RC,58291,HCPCS,Outpatient,,,3325.96,1662.98,,2993.36,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2660.77,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,2993.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3226.18,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3059.88,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2993.36,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2328.17,70,,,percent of total billed charges,70% of total billed charges,2993.36,90,,,percent of total billed charges,90% of total billed charges,3159.66,95,,,percent of total billed charges,95% of total billed charges,3159.66,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2860.33,86,,,percent of total billed charges,86% of total billed charges,2660.77,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3226.18,97,,,percent of total billed charges,97% of total billed charges,2993.36,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,3226.18,97,,,percent of total billed charges,97% of total billed charges,3093.14,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3226.18,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2328.17,22596.74,
58300- Insertion/intrauterine device,3431410,CDM,360,RC,58300,HCPCS,Outpatient,,,275.39,137.70,,247.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,247.85,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,267.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,253.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,175.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,216.6,78.65,,,percent of total billed charges,78.65% of total billed charges,246.01,89.33,,,percent of total billed charges,89.33% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,192.77,70,,,percent of total billed charges,70% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,261.62,95,,,percent of total billed charges,95% of total billed charges,261.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.84,86,,,percent of total billed charges,86% of total billed charges,220.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.13,97,,,percent of total billed charges,97% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.13,97,,,percent of total billed charges,97% of total billed charges,256.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,267.13,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,510,RC,58300,HCPCS,Outpatient,,,275.39,137.70,,247.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,247.85,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,267.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,253.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,175.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,216.6,78.65,,,percent of total billed charges,78.65% of total billed charges,246.01,89.33,,,percent of total billed charges,89.33% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,192.77,70,,,percent of total billed charges,70% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,261.62,95,,,percent of total billed charges,95% of total billed charges,261.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.84,86,,,percent of total billed charges,86% of total billed charges,220.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.13,97,,,percent of total billed charges,97% of total billed charges,247.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.13,97,,,percent of total billed charges,97% of total billed charges,256.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,267.13,
58301- Remove intrauterine device,3431411,CDM,360,RC,58301,HCPCS,Outpatient,,,285,142.50,,256.5,90,,,percent of total billed charges,90% of total Billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,228,80,,,Percent of total Billed charges,80% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.5,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,276.45,97,,,Percent of total billed charges,97% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,262.2,92,,,Percent of total billed charges,92% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,256.5,90,,,percent of total billed charges,90% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,199.5,70,,,percent of total billed charges,70% of total billed charges,256.5,90,,,percent of total billed charges,90% of total billed charges,270.75,95,,,percent of total billed charges,95% of total billed charges,270.75,95,,,percent of total billed charges,95% of total billed charges,265.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,245.1,86,,,percent of total billed charges,86% of total billed charges,228,80,,,percent of total billed charges,80% of total billed charges,279.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,276.45,97,,,percent of total billed charges,97% of total billed charges,256.5,90,,,percent of total billed charges,90% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.45,97,,,percent of total billed charges,97% of total billed charges,265.05,93,,,percent of total billed charges,93% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,276.45,97,,,percent of total billed charges,97% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.25,1423.34,
58301-PF REMOVAL INTRAUTERINE DEVICE IUD,4321604,CDM,981,RC,58301,HCPCS,Outpatient,,,132.38,66.19,,119.14,90,,,percent of total billed charges,90% of total Billed charges,173.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,102.58,155,,,Fee Schedule,155% of CMS OPPS Rate,66.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,102.58,155,,,Fee Schedule,155% of CMS OPPS Rate,66.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.69,155,,,Fee Schedule,155% of CMS OPPS Rate,268.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,66.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.25,268.69,
58322- Artificial insemination/intrauterine,3431412,CDM,510,RC,58322,HCPCS,Outpatient,,,235.09,117.55,,211.58,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,188.07,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.04,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,216.28,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,211.58,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,164.56,70,,,percent of total billed charges,70% of total billed charges,211.58,90,,,percent of total billed charges,90% of total billed charges,223.34,95,,,percent of total billed charges,95% of total billed charges,223.34,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.18,86,,,percent of total billed charges,86% of total billed charges,188.07,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.04,97,,,percent of total billed charges,97% of total billed charges,211.58,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.04,97,,,percent of total billed charges,97% of total billed charges,218.63,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,228.04,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.52,868.4,
58340- Cath/saline/contrast/SIS/hysteosal,3431413,CDM,510,RC,58340,HCPCS,Outpatient,,,118.59,59.30,,106.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,94.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,106.73,90,,,Percent of total Billed charges,90% of total billed charges,57.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,115.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,109.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,75.73,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,93.27,78.65,,,percent of total billed charges,78.65% of total billed charges,105.94,89.33,,,percent of total billed charges,89.33% of total billed charges,106.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.01,70,,,percent of total billed charges,70% of total billed charges,106.73,90,,,percent of total billed charges,90% of total billed charges,112.66,95,,,percent of total billed charges,95% of total billed charges,112.66,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.99,86,,,percent of total billed charges,86% of total billed charges,94.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,115.03,97,,,percent of total billed charges,97% of total billed charges,106.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.03,97,,,percent of total billed charges,97% of total billed charges,110.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,115.03,
58350- Oviduct chromotubation,3431414,CDM,510,RC,58350,HCPCS,Outpatient,,,389.8,194.90,,350.82,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,311.84,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.11,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,358.62,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,350.82,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,272.86,70,,,percent of total billed charges,70% of total billed charges,350.82,90,,,percent of total billed charges,90% of total billed charges,370.31,95,,,percent of total billed charges,95% of total billed charges,370.31,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,335.23,86,,,percent of total billed charges,86% of total billed charges,311.84,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,378.11,97,,,percent of total billed charges,97% of total billed charges,350.82,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.11,97,,,percent of total billed charges,97% of total billed charges,362.51,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,378.11,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,272.86,22596.74,
58520 - HYSTERORRHAPHY REPAIR RUPT UTERUS NONOBSTETRICAL,4249120,CDM,983,RC,58520,HCPCS,Outpatient,,,2107.74,1053.87,,1896.97,90,,,percent of total billed charges,90% of total Billed charges,1595.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,795.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1232.81,155,,,Fee Schedule,155% of CMS OPPS Rate,795.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1061.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,795.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1194.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1194.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1220.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1220.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,745.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,795.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1590.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1440.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,966.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1232.81,155,,,Fee Schedule,155% of CMS OPPS Rate,795.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2472.78,155,,,Fee Schedule,155% of CMS OPPS Rate,2472.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,795.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,853.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,795.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1662.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1662.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2472.78,
58542 - Laps supracrv hysterect 250 gm/rmvl tube/ovar,4241835,CDM,960,RC,58542,HCPCS,Outpatient,,,1749.17,874.59,,1574.25,90,,,percent of total billed charges,90% of total Billed charges,1656.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,671.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1278.87,155,,,Fee Schedule,155% of CMS OPPS Rate,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,825.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1267.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1267.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,886.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1495.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1000.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1278.87,155,,,Fee Schedule,155% of CMS OPPS Rate,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2566.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2566.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,671.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1031.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1985.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1985.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,671.26,2566.82,
58542 - PF Laps Supracrv Hysterect 250 gm/< Rmvl Tube/Ovar,4311909,CDM,960,RC,58542,HCPCS,Outpatient,,,1959.07,979.54,,1763.16,90,,,percent of total billed charges,90% of total Billed charges,1656.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,671.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1278.87,155,,,Fee Schedule,155% of CMS OPPS Rate,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1102.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,825.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1239.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1239.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1267.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1267.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,886.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1650.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1495.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1000.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1278.87,155,,,Fee Schedule,155% of CMS OPPS Rate,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2566.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2566.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,671.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1031.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,825.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1985.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1985.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,671.26,2566.82,
"58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;",3622389,CDM,510,RC,58543,HCPCS,Outpatient,,,2244.77,1122.39,,2020.29,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1795.82,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2020.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2177.43,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2065.19,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2020.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1571.34,70,,,percent of total billed charges,70% of total billed charges,2020.29,90,,,percent of total billed charges,90% of total billed charges,2132.53,95,,,percent of total billed charges,95% of total billed charges,2132.53,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1930.5,86,,,percent of total billed charges,86% of total billed charges,1795.82,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2177.43,97,,,percent of total billed charges,97% of total billed charges,2020.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2177.43,97,,,percent of total billed charges,97% of total billed charges,2087.64,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2177.43,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1571.34,44301.74,
"58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250",3622563,CDM,510,RC,58545,HCPCS,Outpatient,,,2401.35,1200.68,,2161.22,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.08,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2161.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2329.31,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2209.24,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2161.22,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1680.95,70,,,percent of total billed charges,70% of total billed charges,2161.22,90,,,percent of total billed charges,90% of total billed charges,2281.28,95,,,percent of total billed charges,95% of total billed charges,2281.28,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2065.16,86,,,percent of total billed charges,86% of total billed charges,1921.08,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2329.31,97,,,percent of total billed charges,97% of total billed charges,2161.22,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2329.31,97,,,percent of total billed charges,97% of total billed charges,2233.26,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2329.31,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1680.95,25409.89,
"58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myo",3622758,CDM,510,RC,58546,HCPCS,Outpatient,,,2978.1,1489.05,,2680.29,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2382.48,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2680.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2888.76,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2739.85,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2680.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2084.67,70,,,percent of total billed charges,70% of total billed charges,2680.29,90,,,percent of total billed charges,90% of total billed charges,2829.2,95,,,percent of total billed charges,95% of total billed charges,2829.2,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2561.17,86,,,percent of total billed charges,86% of total billed charges,2382.48,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2888.76,97,,,percent of total billed charges,97% of total billed charges,2680.29,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2888.76,97,,,percent of total billed charges,97% of total billed charges,2769.63,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2888.76,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2084.67,44301.74,
58548-PF LAP RADICAL HYSTERECTOMY,3430231,CDM,510,RC,58548,HCPCS,Outpatient,,,4980.37,2490.19,,4482.33,90,,,percent of total billed charges,90% of total Billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3984.3,80,,,Percent of total Billed charges,80% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4482.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4830.96,97,,,Percent of total billed charges,97% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4581.94,92,,,Percent of total billed charges,92% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4482.33,90,,,percent of total billed charges,90% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3486.26,70,,,percent of total billed charges,70% of total billed charges,4482.33,90,,,percent of total billed charges,90% of total billed charges,4731.35,95,,,percent of total billed charges,95% of total billed charges,4731.35,95,,,percent of total billed charges,95% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4283.12,86,,,percent of total billed charges,86% of total billed charges,3984.3,80,,,percent of total billed charges,80% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.96,97,,,percent of total billed charges,97% of total billed charges,4482.33,90,,,percent of total billed charges,90% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4830.96,97,,,percent of total billed charges,97% of total billed charges,4631.74,93,,,percent of total billed charges,93% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4830.96,97,,,percent of total billed charges,97% of total billed charges,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4980.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3486.26,4980.37,
58550 - PF Laps Vaginal Hysterectomy Uterus 250 gm/<,4311910,CDM,960,RC,58550,HCPCS,Outpatient,,,2081.37,1040.69,,1873.23,90,,,percent of total billed charges,90% of total Billed charges,1758.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,876.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,729.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1358.71,155,,,Fee Schedule,155% of CMS OPPS Rate,876.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1323.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1323.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1354.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1354.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,847.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1753.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1597.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1073.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1358.71,155,,,Fee Schedule,155% of CMS OPPS Rate,876.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,2725.49,155,,,Fee Schedule,155% of CMS OPPS Rate,2725.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,876.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,729.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,962.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,876.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1816.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1816.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,729.29,2725.49,
58550- Lap/surg/vag hysterectomy< 250g,3431417,CDM,510,RC,58550,HCPCS,Outpatient,,,2344.97,1172.49,,2110.47,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1875.98,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2110.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2274.62,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2157.37,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2110.47,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1641.48,70,,,percent of total billed charges,70% of total billed charges,2110.47,90,,,percent of total billed charges,90% of total billed charges,2227.72,95,,,percent of total billed charges,95% of total billed charges,2227.72,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2016.67,86,,,percent of total billed charges,86% of total billed charges,1875.98,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2274.62,97,,,percent of total billed charges,97% of total billed charges,2110.47,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2274.62,97,,,percent of total billed charges,97% of total billed charges,2180.82,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2274.62,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1641.48,25409.89,
58552- Laparo-Vag Hyst Incl T/O,3431418,CDM,510,RC,58552,HCPCS,Outpatient,,,2607.47,1303.74,,2346.72,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2085.98,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2529.25,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2398.87,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2346.72,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1825.23,70,,,percent of total billed charges,70% of total billed charges,2346.72,90,,,percent of total billed charges,90% of total billed charges,2477.1,95,,,percent of total billed charges,95% of total billed charges,2477.1,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2242.42,86,,,percent of total billed charges,86% of total billed charges,2085.98,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2529.25,97,,,percent of total billed charges,97% of total billed charges,2346.72,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2529.25,97,,,percent of total billed charges,97% of total billed charges,2424.95,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2529.25,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1825.23,44301.74,
58553- LAVH/uterus > 250g,3431692,CDM,761,RC,58553,HCPCS,Outpatient,,,2994.51,1497.26,,2695.06,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2395.61,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2695.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2904.67,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2754.95,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2695.06,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2096.16,70,,,percent of total billed charges,70% of total billed charges,2695.06,90,,,percent of total billed charges,90% of total billed charges,2844.78,95,,,percent of total billed charges,95% of total billed charges,2844.78,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2575.28,86,,,percent of total billed charges,86% of total billed charges,2395.61,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2904.67,97,,,percent of total billed charges,97% of total billed charges,2695.06,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2904.67,97,,,percent of total billed charges,97% of total billed charges,2784.89,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2904.67,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2096.16,44301.74,
58554- LAVH/uterus > 250g/salping/ooph,3431693,CDM,761,RC,58554,HCPCS,Outpatient,,,3480.02,1740.01,,3132.02,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2784.02,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,3132.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3375.62,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,3201.62,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3132.02,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2436.01,70,,,percent of total billed charges,70% of total billed charges,3132.02,90,,,percent of total billed charges,90% of total billed charges,3306.02,95,,,percent of total billed charges,95% of total billed charges,3306.02,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2992.82,86,,,percent of total billed charges,86% of total billed charges,2784.02,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3375.62,97,,,percent of total billed charges,97% of total billed charges,3132.02,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,3375.62,97,,,percent of total billed charges,97% of total billed charges,3236.42,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3375.62,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2436.01,44301.74,
58555- Hysterscopy/diagnostic,3431419,CDM,510,RC,58555,HCPCS,Outpatient,,,924.25,462.13,,831.83,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,739.4,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,831.83,90,,,Percent of total Billed charges,90% of total billed charges,191.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,896.52,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,850.31,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,831.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,646.98,70,,,percent of total billed charges,70% of total billed charges,831.83,90,,,percent of total billed charges,90% of total billed charges,878.04,95,,,percent of total billed charges,95% of total billed charges,878.04,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,794.86,86,,,percent of total billed charges,86% of total billed charges,739.4,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,896.52,97,,,percent of total billed charges,97% of total billed charges,831.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,896.52,97,,,percent of total billed charges,97% of total billed charges,859.55,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,896.52,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,174.27,13784.12,
"58555 IN OFFICE Hysteroscopy, diagnostic",4213197,CDM,983,RC,58555,HCPCS,Outpatient,,,6166.53,3083.27,,5549.88,90,,,percent of total billed charges,90% of total Billed charges,497.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.6,90,,,Percent of total Billed charges,90% of total billed charges,174.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,232.59,155,,,Fee Schedule,155% of CMS OPPS Rate,150.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,234.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,234.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,186.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,232.59,155,,,Fee Schedule,155% of CMS OPPS Rate,150.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.28,155,,,Fee Schedule,155% of CMS OPPS Rate,771.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,302.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,601.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,150.06,5549.88,
58558- Hysteroscopy/endometrium bx,3431420,CDM,510,RC,58558,HCPCS,Outpatient,,,3357.88,1678.94,,3022.09,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2686.3,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3022.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3257.14,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3089.25,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3022.09,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2350.52,70,,,percent of total billed charges,70% of total billed charges,3022.09,90,,,percent of total billed charges,90% of total billed charges,3189.99,95,,,percent of total billed charges,95% of total billed charges,3189.99,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2887.78,86,,,percent of total billed charges,86% of total billed charges,2686.3,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3257.14,97,,,percent of total billed charges,97% of total billed charges,3022.09,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3257.14,97,,,percent of total billed charges,97% of total billed charges,3122.83,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3257.14,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2182.83,13784.12,
58558 IN OFFICE Hysteroscopy with sampling (biopsy) of endom,4213198,CDM,983,RC,58558,HCPCS,Outpatient,,,8013.58,4006.79,,7212.22,90,,,percent of total billed charges,90% of total Billed charges,1492.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.77,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.61,155,,,Fee Schedule,155% of CMS OPPS Rate,230.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,358.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,358.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,256.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,423,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,285.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,356.61,155,,,Fee Schedule,155% of CMS OPPS Rate,230.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2313.75,155,,,Fee Schedule,155% of CMS OPPS Rate,2313.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1440.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,788.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,230.07,7212.22,
58559 - HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS,4037694,CDM,983,RC,58559,HCPCS,Outpatient,,,758.14,379.07,,682.33,90,,,percent of total billed charges,90% of total Billed charges,567.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.35,90,,,Percent of total Billed charges,90% of total billed charges,305.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,437.84,155,,,Fee Schedule,155% of CMS OPPS Rate,282.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,430.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,430.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,443.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,443.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,315.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,523.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,354.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,437.84,155,,,Fee Schedule,155% of CMS OPPS Rate,282.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,879.72,155,,,Fee Schedule,155% of CMS OPPS Rate,879.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,282.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,378.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,282.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,708.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,282.48,879.72,
"58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)",3621643,CDM,510,RC,58560,HCPCS,Outpatient,,,833.68,416.84,,750.31,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,666.94,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.31,90,,,Percent of total Billed charges,90% of total billed charges,371.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.67,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,766.99,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.31,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,583.58,70,,,percent of total billed charges,70% of total billed charges,750.31,90,,,percent of total billed charges,90% of total billed charges,792,95,,,percent of total billed charges,95% of total billed charges,792,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.96,86,,,percent of total billed charges,86% of total billed charges,666.94,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.67,97,,,percent of total billed charges,97% of total billed charges,750.31,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.67,97,,,percent of total billed charges,97% of total billed charges,775.32,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.67,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,337.82,22596.74,
58561- Hysteroscopy/leiomyomata removal,3431421,CDM,510,RC,58561,HCPCS,Outpatient,,,952.79,476.40,,857.51,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,762.23,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,924.21,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,876.57,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,857.51,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,666.95,70,,,percent of total billed charges,70% of total billed charges,857.51,90,,,percent of total billed charges,90% of total billed charges,905.15,95,,,percent of total billed charges,95% of total billed charges,905.15,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,819.4,86,,,percent of total billed charges,86% of total billed charges,762.23,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,924.21,97,,,percent of total billed charges,97% of total billed charges,857.51,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.21,97,,,percent of total billed charges,97% of total billed charges,886.09,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,924.21,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,666.95,22596.74,
58562- Hysteroscopy/impacted FB removal,3431422,CDM,510,RC,58562,HCPCS,Outpatient,,,1114.1,557.05,,1002.69,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,891.28,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1080.68,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.97,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1002.69,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,779.87,70,,,percent of total billed charges,70% of total billed charges,1002.69,90,,,percent of total billed charges,90% of total billed charges,1058.4,95,,,percent of total billed charges,95% of total billed charges,1058.4,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,958.13,86,,,percent of total billed charges,86% of total billed charges,891.28,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1080.68,97,,,percent of total billed charges,97% of total billed charges,1002.69,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.68,97,,,percent of total billed charges,97% of total billed charges,1036.11,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1080.68,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,779.87,13784.12,
58562 IN OFFICE Hysteroscopy with removal of impacted foreig,4213199,CDM,983,RC,58562,HCPCS,Outpatient,,,6316.9,3158.45,,5685.21,90,,,percent of total billed charges,90% of total Billed charges,639.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,341.62,155,,,Fee Schedule,155% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,344.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,344.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,201.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,406.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,273.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,341.62,155,,,Fee Schedule,155% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,990.98,155,,,Fee Schedule,155% of CMS OPPS Rate,990.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,220.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,820.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,820.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,201.29,5685.21,
58563- Hysteroscopy/endometrial ablation,3431423,CDM,510,RC,58563,HCPCS,Outpatient,,,5319.54,2659.77,,4787.59,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4255.63,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4787.59,90,,,Percent of total Billed charges,90% of total billed charges,347.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5159.95,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4893.98,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4787.59,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3723.68,70,,,percent of total billed charges,70% of total billed charges,4787.59,90,,,percent of total billed charges,90% of total billed charges,5053.56,95,,,percent of total billed charges,95% of total billed charges,5053.56,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4574.8,86,,,percent of total billed charges,86% of total billed charges,4255.63,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5159.95,97,,,percent of total billed charges,97% of total billed charges,4787.59,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,5159.95,97,,,percent of total billed charges,97% of total billed charges,4947.17,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5159.95,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,315.9,22596.74,
58565- Hysteroscopy/diagnostic,3431424,CDM,510,RC,58565,HCPCS,Outpatient,,,4225.37,2112.69,,3802.83,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3380.3,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,3802.83,90,,,Percent of total Billed charges,90% of total billed charges,446.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4098.61,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,3887.34,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3802.83,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,2957.76,70,,,percent of total billed charges,70% of total billed charges,3802.83,90,,,percent of total billed charges,90% of total billed charges,4014.1,95,,,percent of total billed charges,95% of total billed charges,4014.1,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3633.82,86,,,percent of total billed charges,86% of total billed charges,3380.3,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4098.61,97,,,percent of total billed charges,97% of total billed charges,3802.83,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4098.61,97,,,percent of total billed charges,97% of total billed charges,3929.59,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4098.61,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,405.57,22596.74,
58570PF Lap Surgical w/Total Hysterectomy Uterus 250g or Less,4263177,CDM,975,RC,58570,HCPCS,Outpatient,,,1900,950.00,,1710,90,,,percent of total billed charges,90% of total Billed charges,1602.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,654.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1240.29,155,,,Fee Schedule,155% of CMS OPPS Rate,800.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1188.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1188.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1213.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1213.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,846.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,800.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1600.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1432.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,958.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1240.29,155,,,Fee Schedule,155% of CMS OPPS Rate,800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2484.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1090.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,800.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1912.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1912.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,654.54,2484.32,
58571PF Laparoscopic Total Hysterectomy Uterus 250g/< w/Removal Tubes Ovaries,4263178,CDM,975,RC,58571,HCPCS,Outpatient,,,2131.83,1065.92,,1918.65,90,,,percent of total billed charges,90% of total Billed charges,1801.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,716.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1391.64,155,,,Fee Schedule,155% of CMS OPPS Rate,897.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,897.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1341.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1341.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1368.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1368.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,948.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1795.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1615.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1081.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1391.64,155,,,Fee Schedule,155% of CMS OPPS Rate,897.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2792.9,155,,,Fee Schedule,155% of CMS OPPS Rate,2792.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,897.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1186.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,897.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2125.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2125.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,716.34,2792.9,
58572  Laparoscopy Total Hysterecotmy Uterus >250 GM,3899059,CDM,983,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,2477.36,90,,,percent of total billed charges,90% of total Billed charges,2065.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,813.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1597.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1373.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1030.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1544.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1581.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1581.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1075.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2061.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1866.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1254.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1597.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,3202.11,155,,,Fee Schedule,155% of CMS OPPS Rate,3202.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1357.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,2382.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2382.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,813.33,3202.11,
"58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;",3622748,CDM,510,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,2477.36,90,,,percent of total billed charges,90% of total Billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2202.1,80,,,Percent of total Billed charges,80% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2477.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2670.04,97,,,Percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,2532.41,92,,,Percent of total billed charges,92% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,21939.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34975.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44301.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2477.36,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.83,70,,,percent of total billed charges,70% of total billed charges,2477.36,90,,,percent of total billed charges,90% of total billed charges,2614.99,95,,,percent of total billed charges,95% of total billed charges,2614.99,95,,,percent of total billed charges,95% of total billed charges,8253.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16507.25,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2367.25,86,,,percent of total billed charges,86% of total billed charges,2202.1,80,,,percent of total billed charges,80% of total billed charges,8698.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2670.04,97,,,percent of total billed charges,97% of total billed charges,2477.36,90,,,percent of total billed charges,90% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,2670.04,97,,,percent of total billed charges,97% of total billed charges,2559.94,93,,,percent of total billed charges,93% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2670.04,97,,,percent of total billed charges,97% of total billed charges,8253.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8253.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7015.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1926.83,44301.74,
58573PF Lap Surgical w/Total Hysterectomy Uterus Greater Than 250g w/Removal Tubes/Ovaries,4263179,CDM,975,RC,58573,HCPCS,Outpatient,,,2865.04,1432.52,,2578.54,90,,,percent of total billed charges,90% of total Billed charges,2422.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1206.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,916.36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1870.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1206.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1610.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1206.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1811.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1811.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1854.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1854.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1210.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2413.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2188.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1471.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1870.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1206.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,3754.19,155,,,Fee Schedule,155% of CMS OPPS Rate,3754.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1206.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1527.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1206.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2726.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2726.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,916.36,3754.19,
58575 - PF LAPS TOT HYST RESJ MAL,3527836,CDM,960,RC,58575,HCPCS,Outpatient,,,5122.79,2561.40,,4610.51,90,,,percent of total billed charges,90% of total Billed charges,3836.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1910.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1519.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2960.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1910.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2524.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1910.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2839.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2839.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2907.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2907.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2065.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1910.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3820.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3430.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2305.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2960.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1910.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,5946.48,155,,,Fee Schedule,155% of CMS OPPS Rate,5946.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1910.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1519.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2076.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1910.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1519.52,5946.48,
"58578 - Unlisted laparoscopy procedure, uterus",3899064,CDM,983,RC,58578,HCPCS,Outpatient,,,963.92,481.96,,867.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.18,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.18,867.53,
58600- Tubal ligation,3431694,CDM,761,RC,58600,HCPCS,Outpatient,,,979.81,489.91,,881.83,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,783.85,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,881.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,950.42,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,901.43,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,881.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,685.87,70,,,percent of total billed charges,70% of total billed charges,881.83,90,,,percent of total billed charges,90% of total billed charges,930.82,95,,,percent of total billed charges,95% of total billed charges,930.82,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,842.64,86,,,percent of total billed charges,86% of total billed charges,783.85,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,950.42,97,,,percent of total billed charges,97% of total billed charges,881.83,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.42,97,,,percent of total billed charges,97% of total billed charges,911.22,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,950.42,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,685.87,13784.12,
58605- Ligation/transect/fallop tubes/PP,3431425,CDM,510,RC,58605,HCPCS,Outpatient,,,892.79,446.40,,803.51,90,,,percent of total billed charges,90% of total Billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.23,80,,,Percent of total Billed charges,80% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,866.01,97,,,Percent of total billed charges,97% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,821.37,92,,,Percent of total billed charges,92% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,803.51,90,,,percent of total billed charges,90% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,624.95,70,,,percent of total billed charges,70% of total billed charges,803.51,90,,,percent of total billed charges,90% of total billed charges,848.15,95,,,percent of total billed charges,95% of total billed charges,848.15,95,,,percent of total billed charges,95% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,767.8,86,,,percent of total billed charges,86% of total billed charges,714.23,80,,,percent of total billed charges,80% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,866.01,97,,,percent of total billed charges,97% of total billed charges,803.51,90,,,percent of total billed charges,90% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,866.01,97,,,percent of total billed charges,97% of total billed charges,830.29,93,,,percent of total billed charges,93% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,866.01,97,,,percent of total billed charges,97% of total billed charges,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,892.79,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,624.95,892.79,
58611- Ligate/fallopian tubes/add-on,3431427,CDM,510,RC,58611,HCPCS,Outpatient,,,203.33,101.67,,183,90,,,percent of total billed charges,90% of total Billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,162.66,80,,,Percent of total Billed charges,80% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,183,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,197.23,97,,,Percent of total billed charges,97% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.06,92,,,Percent of total billed charges,92% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,183,90,,,percent of total billed charges,90% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,142.33,70,,,percent of total billed charges,70% of total billed charges,183,90,,,percent of total billed charges,90% of total billed charges,193.16,95,,,percent of total billed charges,95% of total billed charges,193.16,95,,,percent of total billed charges,95% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.86,86,,,percent of total billed charges,86% of total billed charges,162.66,80,,,percent of total billed charges,80% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,197.23,97,,,percent of total billed charges,97% of total billed charges,183,90,,,percent of total billed charges,90% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,197.23,97,,,percent of total billed charges,97% of total billed charges,189.1,93,,,percent of total billed charges,93% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,197.23,97,,,percent of total billed charges,97% of total billed charges,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,203.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,142.33,203.33,
58660- Laparoscopy/adhesion lysis,3431428,CDM,510,RC,58660,HCPCS,Outpatient,,,1821.32,910.66,,1639.19,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1457.06,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1639.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1766.68,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.61,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1639.19,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1274.92,70,,,percent of total billed charges,70% of total billed charges,1639.19,90,,,percent of total billed charges,90% of total billed charges,1730.25,95,,,percent of total billed charges,95% of total billed charges,1730.25,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1566.34,86,,,percent of total billed charges,86% of total billed charges,1457.06,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1766.68,97,,,percent of total billed charges,97% of total billed charges,1639.19,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1766.68,97,,,percent of total billed charges,97% of total billed charges,1693.83,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1766.68,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1274.92,25409.89,
58661PF Lap Surgical w/Removal Adnexal Structures,4265159,CDM,960,RC,58661,HCPCS,Outpatient,,,1543.4,771.70,,1389.06,90,,,percent of total billed charges,90% of total Billed charges,1303.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,650.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,565.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1007.53,155,,,Fee Schedule,155% of CMS OPPS Rate,650.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,650.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,975.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1000.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1000.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,620.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,650.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1300.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1180.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,796.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1007.53,155,,,Fee Schedule,155% of CMS OPPS Rate,650.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2019.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2019.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,650.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,723.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,650.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1325.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1325.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,565.06,2019.82,
58662PF Lap Surgical w/Fulguration/Excision Lesions Ovary/Pe,4265160,CDM,960,RC,58662,HCPCS,Outpatient,,,1680.52,840.26,,1512.47,90,,,percent of total billed charges,90% of total Billed charges,1419.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,707.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1386.78,90,,,Percent of total Billed charges,90% of total billed charges,565.49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1097.04,155,,,Fee Schedule,155% of CMS OPPS Rate,707.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,707.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1066.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1066.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1092.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1092.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,679.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1415.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1289.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,869.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1097.04,155,,,Fee Schedule,155% of CMS OPPS Rate,707.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2199.62,155,,,Fee Schedule,155% of CMS OPPS Rate,2199.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,707.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,720.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,707.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1449.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1449.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,565.49,2199.62,
58670- Laparoscopy/oviduct fulguration,3431431,CDM,510,RC,58670,HCPCS,Outpatient,,,982.94,491.47,,884.65,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,786.35,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,884.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,953.45,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,904.3,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,884.65,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,688.06,70,,,percent of total billed charges,70% of total billed charges,884.65,90,,,percent of total billed charges,90% of total billed charges,933.79,95,,,percent of total billed charges,95% of total billed charges,933.79,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,845.33,86,,,percent of total billed charges,86% of total billed charges,786.35,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,953.45,97,,,percent of total billed charges,97% of total billed charges,884.65,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,953.45,97,,,percent of total billed charges,97% of total billed charges,914.13,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,953.45,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,688.06,25409.89,
58671- Laparoscopy/surg/occlude/oviducts,3431695,CDM,761,RC,58671,HCPCS,Outpatient,,,981.38,490.69,,883.24,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,785.1,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,883.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,951.94,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,902.87,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,883.24,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,686.97,70,,,percent of total billed charges,70% of total billed charges,883.24,90,,,percent of total billed charges,90% of total billed charges,932.31,95,,,percent of total billed charges,95% of total billed charges,932.31,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,843.99,86,,,percent of total billed charges,86% of total billed charges,785.1,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,951.94,97,,,percent of total billed charges,97% of total billed charges,883.24,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,951.94,97,,,percent of total billed charges,97% of total billed charges,912.68,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,951.94,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,686.97,25409.89,
"58672 - Laparoscopy, surgical; with fimbrioplasty",4037695,CDM,983,RC,58672,HCPCS,Outpatient,,,1955.14,977.57,,1759.63,90,,,percent of total billed charges,90% of total Billed charges,1464.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,729.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130.51,155,,,Fee Schedule,155% of CMS OPPS Rate,729.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,729.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1102.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1102.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1131.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1131.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,721.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1458.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1334.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,899.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1130.51,155,,,Fee Schedule,155% of CMS OPPS Rate,729.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2270.05,155,,,Fee Schedule,155% of CMS OPPS Rate,2270.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,729.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,830.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,729.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1517.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,721.76,2270.05,
58673- Laparoscopy/salpingostomy,3431432,CDM,510,RC,58673,HCPCS,Outpatient,,,2118.6,1059.30,,1906.74,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1694.88,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1906.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2055.04,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1949.11,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1906.74,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.02,70,,,percent of total billed charges,70% of total billed charges,1906.74,90,,,percent of total billed charges,90% of total billed charges,2012.67,95,,,percent of total billed charges,95% of total billed charges,2012.67,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1822,86,,,percent of total billed charges,86% of total billed charges,1694.88,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2055.04,97,,,percent of total billed charges,97% of total billed charges,1906.74,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2055.04,97,,,percent of total billed charges,97% of total billed charges,1970.3,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2055.04,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1483.02,25409.89,
58700- Salpingectomy,3431433,CDM,510,RC,58700,HCPCS,Outpatient,,,2126.93,1063.47,,1914.24,90,,,percent of total billed charges,90% of total Billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1701.54,80,,,Percent of total Billed charges,80% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1914.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2063.12,97,,,Percent of total billed charges,97% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1956.78,92,,,Percent of total billed charges,92% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1914.24,90,,,percent of total billed charges,90% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1488.85,70,,,percent of total billed charges,70% of total billed charges,1914.24,90,,,percent of total billed charges,90% of total billed charges,2020.58,95,,,percent of total billed charges,95% of total billed charges,2020.58,95,,,percent of total billed charges,95% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1829.16,86,,,percent of total billed charges,86% of total billed charges,1701.54,80,,,percent of total billed charges,80% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2063.12,97,,,percent of total billed charges,97% of total billed charges,1914.24,90,,,percent of total billed charges,90% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2063.12,97,,,percent of total billed charges,97% of total billed charges,1978.04,93,,,percent of total billed charges,93% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2063.12,97,,,percent of total billed charges,97% of total billed charges,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1488.85,2126.93,
58720 - PF Salpingo-Oophorectomy Compl/ Prtl Uni/ Bi Spx,4311911,CDM,960,RC,58720,HCPCS,Outpatient,,,1779.16,889.58,,1601.24,90,,,percent of total billed charges,90% of total Billed charges,1503.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,749.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1443.3,90,,,Percent of total Billed charges,90% of total billed charges,371.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1161.42,155,,,Fee Schedule,155% of CMS OPPS Rate,749.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,749.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1115.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1115.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1137.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1137.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,684.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1498.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1341.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,902.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1161.42,155,,,Fee Schedule,155% of CMS OPPS Rate,749.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2330.87,155,,,Fee Schedule,155% of CMS OPPS Rate,2330.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,749.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,784.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,749.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1483.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1483.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,371.5,2330.87,
58720- Salpingo-oophorectomy,3431434,CDM,510,RC,58720,HCPCS,Outpatient,,,2006.46,1003.23,,1805.81,90,,,percent of total billed charges,90% of total Billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1605.17,80,,,Percent of total Billed charges,80% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1805.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1946.27,97,,,Percent of total billed charges,97% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1845.94,92,,,Percent of total billed charges,92% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1805.81,90,,,percent of total billed charges,90% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1404.52,70,,,percent of total billed charges,70% of total billed charges,1805.81,90,,,percent of total billed charges,90% of total billed charges,1906.14,95,,,percent of total billed charges,95% of total billed charges,1906.14,95,,,percent of total billed charges,95% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1725.56,86,,,percent of total billed charges,86% of total billed charges,1605.17,80,,,percent of total billed charges,80% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.27,97,,,percent of total billed charges,97% of total billed charges,1805.81,90,,,percent of total billed charges,90% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1946.27,97,,,percent of total billed charges,97% of total billed charges,1866.01,93,,,percent of total billed charges,93% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1946.27,97,,,percent of total billed charges,97% of total billed charges,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2006.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1404.52,2006.46,
58800 - PF Drainage Ovarian Cyst Uni/Bi Spx Vaginal Appr,4305361,CDM,960,RC,58800,HCPCS,Outpatient,,,655.91,327.96,,590.32,90,,,percent of total billed charges,90% of total Billed charges,665.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,166.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,479.54,155,,,Fee Schedule,155% of CMS OPPS Rate,309.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,309.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,465,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,465,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,284.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,618.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,548.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,362.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,479.54,155,,,Fee Schedule,155% of CMS OPPS Rate,309.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1031.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1031.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,309.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,334.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,309.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,643.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,643.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,166.5,1031.62,
58805- Ovarian cyst drainage/abd approach,3431435,CDM,510,RC,58805,HCPCS,Outpatient,,,1127.13,563.57,,1014.42,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,901.7,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1093.32,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.96,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1014.42,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,788.99,70,,,percent of total billed charges,70% of total billed charges,1014.42,90,,,percent of total billed charges,90% of total billed charges,1070.77,95,,,percent of total billed charges,95% of total billed charges,1070.77,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,969.33,86,,,percent of total billed charges,86% of total billed charges,901.7,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1093.32,97,,,percent of total billed charges,97% of total billed charges,1014.42,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1093.32,97,,,percent of total billed charges,97% of total billed charges,1048.23,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1093.32,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,788.99,13784.12,
58825-PF TRANSPOSITION OVARY,3430277,CDM,510,RC,58825,HCPCS,Outpatient,,,1887.83,943.92,,1699.05,90,,,percent of total billed charges,90% of total Billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1510.26,80,,,Percent of total Billed charges,80% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1699.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1831.2,97,,,Percent of total billed charges,97% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1736.8,92,,,Percent of total billed charges,92% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1699.05,90,,,percent of total billed charges,90% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1321.48,70,,,percent of total billed charges,70% of total billed charges,1699.05,90,,,percent of total billed charges,90% of total billed charges,1793.44,95,,,percent of total billed charges,95% of total billed charges,1793.44,95,,,percent of total billed charges,95% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1623.53,86,,,percent of total billed charges,86% of total billed charges,1510.26,80,,,percent of total billed charges,80% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1831.2,97,,,percent of total billed charges,97% of total billed charges,1699.05,90,,,percent of total billed charges,90% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1831.2,97,,,percent of total billed charges,97% of total billed charges,1755.68,93,,,percent of total billed charges,93% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1831.2,97,,,percent of total billed charges,97% of total billed charges,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1887.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1321.48,1887.83,
58925 - PF Ovarian Cystectomy Uni/ Bi,4311912,CDM,960,RC,58925,HCPCS,Outpatient,,,1809.87,904.94,,1628.88,90,,,percent of total billed charges,90% of total Billed charges,1528.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,762.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1474.66,90,,,Percent of total Billed charges,90% of total billed charges,331,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1181.46,155,,,Fee Schedule,155% of CMS OPPS Rate,762.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1010.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,762.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1136.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1136.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1161.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1161.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,695.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1524.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1370.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,931.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1181.46,155,,,Fee Schedule,155% of CMS OPPS Rate,762.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,2369.72,155,,,Fee Schedule,155% of CMS OPPS Rate,2369.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,762.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,331,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,739.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,762.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,331,2369.72,
58925- Ovarian cyctectomy/uni/bilateral,3431696,CDM,510,RC,58925,HCPCS,Outpatient,,,2038.7,1019.35,,1834.83,90,,,percent of total billed charges,90% of total Billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1630.96,80,,,Percent of total Billed charges,80% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1834.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1977.54,97,,,Percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1875.6,92,,,Percent of total billed charges,92% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,11190.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17839.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22596.74,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1834.83,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,1427.09,70,,,percent of total billed charges,70% of total billed charges,1834.83,90,,,percent of total billed charges,90% of total billed charges,1936.77,95,,,percent of total billed charges,95% of total billed charges,1936.77,95,,,percent of total billed charges,95% of total billed charges,4209.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8419.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1753.28,86,,,percent of total billed charges,86% of total billed charges,1630.96,80,,,percent of total billed charges,80% of total billed charges,4416.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1977.54,97,,,percent of total billed charges,97% of total billed charges,1834.83,90,,,percent of total billed charges,90% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.54,97,,,percent of total billed charges,97% of total billed charges,1895.99,93,,,percent of total billed charges,93% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1977.54,97,,,percent of total billed charges,97% of total billed charges,4209.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,4209.87,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3578.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1427.09,22596.74,
58940- Oophorectomy,3431436,CDM,510,RC,58940,HCPCS,Outpatient,,,1466.83,733.42,,1320.15,90,,,percent of total billed charges,90% of total Billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1173.46,80,,,Percent of total Billed charges,80% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1320.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1422.83,97,,,Percent of total billed charges,97% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1349.48,92,,,Percent of total billed charges,92% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1320.15,90,,,percent of total billed charges,90% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1026.78,70,,,percent of total billed charges,70% of total billed charges,1320.15,90,,,percent of total billed charges,90% of total billed charges,1393.49,95,,,percent of total billed charges,95% of total billed charges,1393.49,95,,,percent of total billed charges,95% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1261.47,86,,,percent of total billed charges,86% of total billed charges,1173.46,80,,,percent of total billed charges,80% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1422.83,97,,,percent of total billed charges,97% of total billed charges,1320.15,90,,,percent of total billed charges,90% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1422.83,97,,,percent of total billed charges,97% of total billed charges,1364.15,93,,,percent of total billed charges,93% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1422.83,97,,,percent of total billed charges,97% of total billed charges,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1466.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1026.78,1466.83,
58943-PF REMOVAL OF OVARY(S),3430283,CDM,510,RC,58943,HCPCS,Outpatient,,,3097.37,1548.69,,2787.63,90,,,percent of total billed charges,90% of total Billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2477.9,80,,,Percent of total Billed charges,80% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2787.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3004.45,97,,,Percent of total billed charges,97% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2849.58,92,,,Percent of total billed charges,92% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2787.63,90,,,percent of total billed charges,90% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2168.16,70,,,percent of total billed charges,70% of total billed charges,2787.63,90,,,percent of total billed charges,90% of total billed charges,2942.5,95,,,percent of total billed charges,95% of total billed charges,2942.5,95,,,percent of total billed charges,95% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2663.74,86,,,percent of total billed charges,86% of total billed charges,2477.9,80,,,percent of total billed charges,80% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3004.45,97,,,percent of total billed charges,97% of total billed charges,2787.63,90,,,percent of total billed charges,90% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3004.45,97,,,percent of total billed charges,97% of total billed charges,2880.55,93,,,percent of total billed charges,93% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3004.45,97,,,percent of total billed charges,97% of total billed charges,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2168.16,3097.37,
58951-PF RESECT OVARIAN MALIGNANCY,3430285,CDM,510,RC,58951,HCPCS,Outpatient,,,3819.03,1909.52,,3437.13,90,,,percent of total billed charges,90% of total Billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3055.22,80,,,Percent of total Billed charges,80% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3437.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3704.46,97,,,Percent of total billed charges,97% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3513.51,92,,,Percent of total billed charges,92% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3437.13,90,,,percent of total billed charges,90% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2673.32,70,,,percent of total billed charges,70% of total billed charges,3437.13,90,,,percent of total billed charges,90% of total billed charges,3628.08,95,,,percent of total billed charges,95% of total billed charges,3628.08,95,,,percent of total billed charges,95% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3284.37,86,,,percent of total billed charges,86% of total billed charges,3055.22,80,,,percent of total billed charges,80% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3704.46,97,,,percent of total billed charges,97% of total billed charges,3437.13,90,,,percent of total billed charges,90% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3704.46,97,,,percent of total billed charges,97% of total billed charges,3551.7,93,,,percent of total billed charges,93% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3704.46,97,,,percent of total billed charges,97% of total billed charges,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3819.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2673.32,3819.03,
"58952 - (PF) Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral",3635229,CDM,510,RC,58952,HCPCS,Outpatient,,,4354.52,2177.26,,3919.07,90,,,percent of total billed charges,90% of total Billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3483.62,80,,,Percent of total Billed charges,80% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4223.88,97,,,Percent of total billed charges,97% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4006.16,92,,,Percent of total billed charges,92% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3919.07,90,,,percent of total billed charges,90% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3048.16,70,,,percent of total billed charges,70% of total billed charges,3919.07,90,,,percent of total billed charges,90% of total billed charges,4136.79,95,,,percent of total billed charges,95% of total billed charges,4136.79,95,,,percent of total billed charges,95% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3744.89,86,,,percent of total billed charges,86% of total billed charges,3483.62,80,,,percent of total billed charges,80% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4223.88,97,,,percent of total billed charges,97% of total billed charges,3919.07,90,,,percent of total billed charges,90% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4223.88,97,,,percent of total billed charges,97% of total billed charges,4049.7,93,,,percent of total billed charges,93% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4223.88,97,,,percent of total billed charges,97% of total billed charges,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4354.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3048.16,4354.52,
"58953-PF TAH, RAD DISSECT",3430288,CDM,510,RC,58953,HCPCS,Outpatient,,,5301.58,2650.79,,4771.42,90,,,percent of total billed charges,90% of total Billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4241.26,80,,,Percent of total Billed charges,80% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4771.42,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5142.53,97,,,Percent of total billed charges,97% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4877.45,92,,,Percent of total billed charges,92% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4771.42,90,,,percent of total billed charges,90% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3711.11,70,,,percent of total billed charges,70% of total billed charges,4771.42,90,,,percent of total billed charges,90% of total billed charges,5036.5,95,,,percent of total billed charges,95% of total billed charges,5036.5,95,,,percent of total billed charges,95% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4559.36,86,,,percent of total billed charges,86% of total billed charges,4241.26,80,,,percent of total billed charges,80% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5142.53,97,,,percent of total billed charges,97% of total billed charges,4771.42,90,,,percent of total billed charges,90% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5142.53,97,,,percent of total billed charges,97% of total billed charges,4930.47,93,,,percent of total billed charges,93% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5142.53,97,,,percent of total billed charges,97% of total billed charges,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5301.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,5301.58,
58954-PF TAH RAD DEBULK/LYMPH,3430290,CDM,510,RC,58954,HCPCS,Outpatient,,,5740.48,2870.24,,5166.43,90,,,percent of total billed charges,90% of total Billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4592.38,80,,,Percent of total Billed charges,80% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5166.43,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5568.27,97,,,Percent of total billed charges,97% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5281.24,92,,,Percent of total billed charges,92% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5166.43,90,,,percent of total billed charges,90% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4018.34,70,,,percent of total billed charges,70% of total billed charges,5166.43,90,,,percent of total billed charges,90% of total billed charges,5453.46,95,,,percent of total billed charges,95% of total billed charges,5453.46,95,,,percent of total billed charges,95% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4936.81,86,,,percent of total billed charges,86% of total billed charges,4592.38,80,,,percent of total billed charges,80% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5568.27,97,,,percent of total billed charges,97% of total billed charges,5166.43,90,,,percent of total billed charges,90% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5568.27,97,,,percent of total billed charges,97% of total billed charges,5338.65,93,,,percent of total billed charges,93% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5568.27,97,,,percent of total billed charges,97% of total billed charges,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5740.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1000,5740.48,
58956 - BSO W/TOT OMENTECTOMY & HYSTERECTOMY MALIGNANC,4037698,CDM,983,RC,58956,HCPCS,Outpatient,,,3596,1798.00,,3236.4,90,,,percent of total billed charges,90% of total Billed charges,2697.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1344.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1013.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2084.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1344.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2001.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1344.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2250.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2250.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2069.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2069.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1307.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1344.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2689.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2441.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1641.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2084.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1344.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,4180.41,155,,,Fee Schedule,155% of CMS OPPS Rate,4180.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1344.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1013.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1402.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1344.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2725.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2725.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1013.58,4180.41,
58957-PF RESECT RECURRENT GYN MAL,3430292,CDM,510,RC,58957,HCPCS,Outpatient,,,4213.45,2106.73,,3792.11,90,,,percent of total billed charges,90% of total Billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3370.76,80,,,Percent of total Billed charges,80% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3792.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4087.05,97,,,Percent of total billed charges,97% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3876.37,92,,,Percent of total billed charges,92% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3792.11,90,,,percent of total billed charges,90% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.42,70,,,percent of total billed charges,70% of total billed charges,3792.11,90,,,percent of total billed charges,90% of total billed charges,4002.78,95,,,percent of total billed charges,95% of total billed charges,4002.78,95,,,percent of total billed charges,95% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3623.57,86,,,percent of total billed charges,86% of total billed charges,3370.76,80,,,percent of total billed charges,80% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4087.05,97,,,percent of total billed charges,97% of total billed charges,3792.11,90,,,percent of total billed charges,90% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4087.05,97,,,percent of total billed charges,97% of total billed charges,3918.51,93,,,percent of total billed charges,93% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4087.05,97,,,percent of total billed charges,97% of total billed charges,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4213.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2949.42,4213.45,
58958-PF RESECT RECUR GYN MAL W/LYM,3430294,CDM,510,RC,58958,HCPCS,Outpatient,,,4425.47,2212.74,,3982.92,90,,,percent of total billed charges,90% of total Billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3540.38,80,,,Percent of total Billed charges,80% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3982.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4292.71,97,,,Percent of total billed charges,97% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4071.43,92,,,Percent of total billed charges,92% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3982.92,90,,,percent of total billed charges,90% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.83,70,,,percent of total billed charges,70% of total billed charges,3982.92,90,,,percent of total billed charges,90% of total billed charges,4204.2,95,,,percent of total billed charges,95% of total billed charges,4204.2,95,,,percent of total billed charges,95% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3805.9,86,,,percent of total billed charges,86% of total billed charges,3540.38,80,,,percent of total billed charges,80% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4292.71,97,,,percent of total billed charges,97% of total billed charges,3982.92,90,,,percent of total billed charges,90% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4292.71,97,,,percent of total billed charges,97% of total billed charges,4115.69,93,,,percent of total billed charges,93% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4292.71,97,,,percent of total billed charges,97% of total billed charges,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4425.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3097.83,4425.47,
58999PF Unlisted Procedure Female Genital System Nonobstetri,4265161,CDM,960,RC,58999,HCPCS,Outpatient,,,295.61,147.81,,266.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.68,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.68,266.05,
59000- Amniocentesis/diagnostic,3431697,CDM,761,RC,59000,HCPCS,Outpatient,,,301.78,150.89,,271.6,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,241.42,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.6,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,292.73,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,277.64,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,271.6,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,211.25,70,,,percent of total billed charges,70% of total billed charges,271.6,90,,,percent of total billed charges,90% of total billed charges,286.69,95,,,percent of total billed charges,95% of total billed charges,286.69,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,259.53,86,,,percent of total billed charges,86% of total billed charges,241.42,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,292.73,97,,,percent of total billed charges,97% of total billed charges,271.6,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.73,97,,,percent of total billed charges,97% of total billed charges,280.66,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,292.73,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,3429.49,
59001- Amniocentesis/fluid reduction/US,3431698,CDM,761,RC,59001,HCPCS,Outpatient,,,480.98,240.49,,432.88,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,384.78,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.88,90,,,Percent of total Billed charges,90% of total billed charges,142.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,466.55,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,442.5,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,432.88,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,336.69,70,,,percent of total billed charges,70% of total billed charges,432.88,90,,,percent of total billed charges,90% of total billed charges,456.93,95,,,percent of total billed charges,95% of total billed charges,456.93,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,413.64,86,,,percent of total billed charges,86% of total billed charges,384.78,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,466.55,97,,,percent of total billed charges,97% of total billed charges,432.88,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,466.55,97,,,percent of total billed charges,97% of total billed charges,447.31,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,466.55,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129.46,1423.33,
59012- Cordocentesis/intrauterine,3431699,CDM,761,RC,59012,HCPCS,Outpatient,,,543.38,271.69,,489.04,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,434.7,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,489.04,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,527.08,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,499.91,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,489.04,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,380.37,70,,,percent of total billed charges,70% of total billed charges,489.04,90,,,percent of total billed charges,90% of total billed charges,516.21,95,,,percent of total billed charges,95% of total billed charges,516.21,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,467.31,86,,,percent of total billed charges,86% of total billed charges,434.7,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,527.08,97,,,percent of total billed charges,97% of total billed charges,489.04,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.08,97,,,percent of total billed charges,97% of total billed charges,505.34,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,527.08,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1423.33,
59025 - PF Fetal Nonstress Test,3431701,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,111.74,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,99.33,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.74,90,,,Percent of total Billed charges,90% of total billed charges,5.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.44,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,114.23,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,86.91,70,,,percent of total billed charges,70% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.78,86,,,percent of total billed charges,86% of total billed charges,99.33,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.44,97,,,percent of total billed charges,97% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.44,97,,,percent of total billed charges,97% of total billed charges,115.47,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.44,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.72,868.4,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,111.74,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,99.33,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.74,90,,,Percent of total Billed charges,90% of total billed charges,5.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.44,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,114.23,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,86.91,70,,,percent of total billed charges,70% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.78,86,,,percent of total billed charges,86% of total billed charges,99.33,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.44,97,,,percent of total billed charges,97% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.44,97,,,percent of total billed charges,97% of total billed charges,115.47,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.44,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.72,868.4,
Fetal Non Stress Test,624591,CDM,920,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,111.74,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,99.33,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.74,90,,,Percent of total Billed charges,90% of total billed charges,5.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.44,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,114.23,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,86.91,70,,,percent of total billed charges,70% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,117.95,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.78,86,,,percent of total billed charges,86% of total billed charges,99.33,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.44,97,,,percent of total billed charges,97% of total billed charges,111.74,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.44,97,,,percent of total billed charges,97% of total billed charges,115.47,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.44,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.72,868.4,
59051- Fetal monitoring/labor/interp only,3431703,CDM,510,RC,59051,HCPCS,Outpatient,,,113.37,56.69,,102.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,90.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,102.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,104.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,72.4,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,89.17,78.65,,,percent of total billed charges,78.65% of total billed charges,101.28,89.33,,,percent of total billed charges,89.33% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.36,70,,,percent of total billed charges,70% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,107.7,95,,,percent of total billed charges,95% of total billed charges,107.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.5,86,,,percent of total billed charges,86% of total billed charges,90.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,105.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.4,109.97,
59070- Transabdominal amnioinfusion/US,3431704,CDM,761,RC,59070,HCPCS,Outpatient,,,1050.3,525.15,,945.27,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,840.24,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1018.79,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,966.28,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,945.27,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,735.21,70,,,percent of total billed charges,70% of total billed charges,945.27,90,,,percent of total billed charges,90% of total billed charges,997.79,95,,,percent of total billed charges,95% of total billed charges,997.79,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,903.26,86,,,percent of total billed charges,86% of total billed charges,840.24,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1018.79,97,,,percent of total billed charges,97% of total billed charges,945.27,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1018.79,97,,,percent of total billed charges,97% of total billed charges,976.78,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1018.79,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,225.39,1423.33,
59120- Surg tx/ectopic preg/salp/ooph,3431706,CDM,510,RC,59120,HCPCS,Outpatient,,,2200.91,1100.46,,1980.82,90,,,percent of total billed charges,90% of total Billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1760.73,80,,,Percent of total Billed charges,80% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1980.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2134.88,97,,,Percent of total billed charges,97% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2024.84,92,,,Percent of total billed charges,92% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1980.82,90,,,percent of total billed charges,90% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1540.64,70,,,percent of total billed charges,70% of total billed charges,1980.82,90,,,percent of total billed charges,90% of total billed charges,2090.86,95,,,percent of total billed charges,95% of total billed charges,2090.86,95,,,percent of total billed charges,95% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1892.78,86,,,percent of total billed charges,86% of total billed charges,1760.73,80,,,percent of total billed charges,80% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2134.88,97,,,percent of total billed charges,97% of total billed charges,1980.82,90,,,percent of total billed charges,90% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2134.88,97,,,percent of total billed charges,97% of total billed charges,2046.85,93,,,percent of total billed charges,93% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2134.88,97,,,percent of total billed charges,97% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1540.64,2200.91,
59121- Surg tx/ectopic preg w/o salp/ooph,3431707,CDM,510,RC,59121,HCPCS,Outpatient,,,2204.03,1102.02,,1983.63,90,,,percent of total billed charges,90% of total Billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1763.22,80,,,Percent of total Billed charges,80% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1983.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2137.91,97,,,Percent of total billed charges,97% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2027.71,92,,,Percent of total billed charges,92% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1983.63,90,,,percent of total billed charges,90% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1542.82,70,,,percent of total billed charges,70% of total billed charges,1983.63,90,,,percent of total billed charges,90% of total billed charges,2093.83,95,,,percent of total billed charges,95% of total billed charges,2093.83,95,,,percent of total billed charges,95% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1895.47,86,,,percent of total billed charges,86% of total billed charges,1763.22,80,,,percent of total billed charges,80% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2137.91,97,,,percent of total billed charges,97% of total billed charges,1983.63,90,,,percent of total billed charges,90% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2137.91,97,,,percent of total billed charges,97% of total billed charges,2049.75,93,,,percent of total billed charges,93% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2137.91,97,,,percent of total billed charges,97% of total billed charges,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2204.03,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1542.82,2204.03,
59150 - PF Laps Tx Ectopic Preg w/o Salping &/ Oophorectomy,4311913,CDM,960,RC,59150,HCPCS,Outpatient,,,1911.13,955.57,,1720.02,90,,,percent of total billed charges,90% of total Billed charges,1608.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256.65,90,,,Percent of total Billed charges,90% of total billed charges,409.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1247.56,155,,,Fee Schedule,155% of CMS OPPS Rate,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,804.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1178.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1224.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1224.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,749.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1609.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1354.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1066.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1247.56,155,,,Fee Schedule,155% of CMS OPPS Rate,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,2492.79,155,,,Fee Schedule,155% of CMS OPPS Rate,2492.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,811.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,804.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1592.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1592.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,409.5,2492.79,
59151 - PF Laps T Ectopic Preg w/ Salping &/ Oophorectomy,4311914,CDM,960,RC,59151,HCPCS,Outpatient,,,1870.51,935.26,,1683.46,90,,,percent of total billed charges,90% of total Billed charges,1573.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,787.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1228.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1221.04,155,,,Fee Schedule,155% of CMS OPPS Rate,787.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,787.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1150.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1150.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1196.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1196.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,735.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1575.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1324.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1044.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1221.04,155,,,Fee Schedule,155% of CMS OPPS Rate,787.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,2439.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2439.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,787.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,753.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,787.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,1551.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1551.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,735.5,2439.5,
59151- Lap/ectopic pregnancy/salping/ooph,3431708,CDM,761,RC,59151,HCPCS,Outpatient,,,2090.53,1045.27,,1881.48,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1672.42,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1881.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2027.81,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1923.29,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1881.48,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1463.37,70,,,percent of total billed charges,70% of total billed charges,1881.48,90,,,percent of total billed charges,90% of total billed charges,1986,95,,,percent of total billed charges,95% of total billed charges,1986,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1797.86,86,,,percent of total billed charges,86% of total billed charges,1672.42,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2027.81,97,,,percent of total billed charges,97% of total billed charges,1881.48,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2027.81,97,,,percent of total billed charges,97% of total billed charges,1944.19,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2027.81,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1463.37,25409.89,
59160- D&C/postpartum,3431710,CDM,761,RC,59160,HCPCS,Outpatient,,,715.87,357.94,,644.28,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,572.7,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,644.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,694.39,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,658.6,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,644.28,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,501.11,70,,,percent of total billed charges,70% of total billed charges,644.28,90,,,percent of total billed charges,90% of total billed charges,680.08,95,,,percent of total billed charges,95% of total billed charges,680.08,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,615.65,86,,,percent of total billed charges,86% of total billed charges,572.7,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,694.39,97,,,percent of total billed charges,97% of total billed charges,644.28,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.39,97,,,percent of total billed charges,97% of total billed charges,665.76,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,694.39,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.11,13784.12,
59200- Insertion/cervical dilator,3431711,CDM,510,RC,59200,HCPCS,Outpatient,,,269.9,134.95,,242.91,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,215.92,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,261.8,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,248.31,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.91,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,188.93,70,,,percent of total billed charges,70% of total billed charges,242.91,90,,,percent of total billed charges,90% of total billed charges,256.41,95,,,percent of total billed charges,95% of total billed charges,256.41,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,232.11,86,,,percent of total billed charges,86% of total billed charges,215.92,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.8,97,,,percent of total billed charges,97% of total billed charges,242.91,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.8,97,,,percent of total billed charges,97% of total billed charges,251.01,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,261.8,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,188.93,1423.33,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,602.33,301.17,,542.1,90,,,percent of total billed charges,90% of total Billed charges,376.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,132.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,200.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.36,155,,,Fee Schedule,155% of CMS OPPS Rate,583.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,132.94,583.36,
59320- Cerclage,3431712,CDM,761,RC,59320,HCPCS,Outpatient,,,407.89,203.95,,367.1,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,326.31,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,395.65,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,375.26,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.1,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,285.52,70,,,percent of total billed charges,70% of total billed charges,367.1,90,,,percent of total billed charges,90% of total billed charges,387.5,95,,,percent of total billed charges,95% of total billed charges,387.5,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,350.79,86,,,percent of total billed charges,86% of total billed charges,326.31,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,395.65,97,,,percent of total billed charges,97% of total billed charges,367.1,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.65,97,,,percent of total billed charges,97% of total billed charges,379.34,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,395.65,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.52,13784.12,
59325 Removal Cerclage Cervix,3604862,CDM,960,RC,59325,HCPCS,Outpatient,,,649.52,324.76,,584.57,90,,,percent of total billed charges,90% of total Billed charges,489.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,245.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,193,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,380.43,155,,,Fee Schedule,155% of CMS OPPS Rate,245.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,381.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,381.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,337.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,380.43,155,,,Fee Schedule,155% of CMS OPPS Rate,245.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,758.99,155,,,Fee Schedule,155% of CMS OPPS Rate,758.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,245.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,193,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,245.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,445.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193,758.99,
59400- Obstetric care/routine,3431713,CDM,510,RC,59400,HCPCS,Outpatient,,,6389.57,3194.79,,5750.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5111.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5750.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6197.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5878.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4080.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,5025.54,78.65,,,percent of total billed charges,78.65% of total billed charges,5707.91,89.33,,,percent of total billed charges,89.33% of total billed charges,5750.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4472.7,70,,,percent of total billed charges,70% of total billed charges,5750.61,90,,,percent of total billed charges,90% of total billed charges,6070.09,95,,,percent of total billed charges,95% of total billed charges,6070.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5495.03,86,,,percent of total billed charges,86% of total billed charges,5111.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6197.88,97,,,percent of total billed charges,97% of total billed charges,5750.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6197.88,97,,,percent of total billed charges,97% of total billed charges,5942.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6197.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4080.52,6197.88,
59409- Vaginal delivery only,3431714,CDM,761,RC,59409,HCPCS,Outpatient,,,2178.25,1089.13,,1960.43,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.6,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2112.9,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.99,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1960.43,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.78,70,,,percent of total billed charges,70% of total billed charges,1960.43,90,,,percent of total billed charges,90% of total billed charges,2069.34,95,,,percent of total billed charges,95% of total billed charges,2069.34,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1873.3,86,,,percent of total billed charges,86% of total billed charges,1742.6,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2112.9,97,,,percent of total billed charges,97% of total billed charges,1960.43,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.9,97,,,percent of total billed charges,97% of total billed charges,2025.77,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2112.9,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1524.78,13784.12,
59409-PF VAGINAL DELIVERY ONLY,4321484,CDM,981,RC,59409,HCPCS,Outpatient,,,1638.26,819.13,,1474.43,90,,,percent of total billed charges,90% of total Billed charges,1638.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1200,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1269.65,155,,,Fee Schedule,155% of CMS OPPS Rate,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,819.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1141.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1278.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1278.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,860,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1638.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1415.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1116.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1269.65,155,,,Fee Schedule,155% of CMS OPPS Rate,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2539.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2539.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1367.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,819.13,2539.24,
OBSTETRICAL DELIVERY,3428491,CDM,981,RC,59409,HCPCS,Outpatient,,,2178.25,1089.13,,1960.43,90,,,percent of total billed charges,90% of total Billed charges,1638.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1200,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1269.65,155,,,Fee Schedule,155% of CMS OPPS Rate,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1014.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,819.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1141.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1141.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1278.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1278.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,860,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1638.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1415.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1116.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1269.65,155,,,Fee Schedule,155% of CMS OPPS Rate,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2539.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2539.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1367.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,819.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,819.13,2539.24,
59410- Vaginal delivery/postpartum care,3431715,CDM,761,RC,59410,HCPCS,Outpatient,,,2866.09,1433.05,,2579.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2292.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2579.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2780.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2636.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1830.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2254.24,78.65,,,percent of total billed charges,78.65% of total billed charges,2560.32,89.33,,,percent of total billed charges,89.33% of total billed charges,2579.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2006.26,70,,,percent of total billed charges,70% of total billed charges,2579.48,90,,,percent of total billed charges,90% of total billed charges,2722.79,95,,,percent of total billed charges,95% of total billed charges,2722.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2464.84,86,,,percent of total billed charges,86% of total billed charges,2292.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2780.11,97,,,percent of total billed charges,97% of total billed charges,2579.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2780.11,97,,,percent of total billed charges,97% of total billed charges,2665.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2780.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830.35,2780.11,
59412 - Antepartum Manipulation,4189312,CDM,960,RC,59412,HCPCS,Outpatient,,,247.53,123.77,,222.78,90,,,percent of total billed charges,90% of total Billed charges,208.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.11,155,,,Fee Schedule,155% of CMS OPPS Rate,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.11,155,,,Fee Schedule,155% of CMS OPPS Rate,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.7,155,,,Fee Schedule,155% of CMS OPPS Rate,323.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.16,323.7,
59414- Delivery of placenta,3431717,CDM,761,RC,59414,HCPCS,Outpatient,,,244.85,122.43,,220.37,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,195.88,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.37,90,,,Percent of total Billed charges,90% of total billed charges,93.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,237.5,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,225.26,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.37,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,171.4,70,,,percent of total billed charges,70% of total billed charges,220.37,90,,,percent of total billed charges,90% of total billed charges,232.61,95,,,percent of total billed charges,95% of total billed charges,232.61,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,210.57,86,,,percent of total billed charges,86% of total billed charges,195.88,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,237.5,97,,,percent of total billed charges,97% of total billed charges,220.37,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.5,97,,,percent of total billed charges,97% of total billed charges,227.71,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.5,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.42,13784.12,
59425- Antepartum care only/4-6 visits,3431718,CDM,761,RC,59425,HCPCS,Outpatient,,,1477.15,738.58,,1329.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1181.72,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1329.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1432.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1358.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,943.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1161.81,78.65,,,percent of total billed charges,78.65% of total billed charges,1319.56,89.33,,,percent of total billed charges,89.33% of total billed charges,1329.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1034.01,70,,,percent of total billed charges,70% of total billed charges,1329.44,90,,,percent of total billed charges,90% of total billed charges,1403.29,95,,,percent of total billed charges,95% of total billed charges,1403.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1270.35,86,,,percent of total billed charges,86% of total billed charges,1181.72,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1432.84,97,,,percent of total billed charges,97% of total billed charges,1329.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1432.84,97,,,percent of total billed charges,97% of total billed charges,1373.75,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1432.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.34,1432.84,
59426- Antepartum care only/7 or > visits,3431719,CDM,761,RC,59426,HCPCS,Outpatient,,,2697.73,1348.87,,2427.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2158.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2427.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2616.8,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2481.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1722.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2121.82,78.65,,,percent of total billed charges,78.65% of total billed charges,2409.93,89.33,,,percent of total billed charges,89.33% of total billed charges,2427.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1888.41,70,,,percent of total billed charges,70% of total billed charges,2427.96,90,,,percent of total billed charges,90% of total billed charges,2562.84,95,,,percent of total billed charges,95% of total billed charges,2562.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2320.05,86,,,percent of total billed charges,86% of total billed charges,2158.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2616.8,97,,,percent of total billed charges,97% of total billed charges,2427.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2616.8,97,,,percent of total billed charges,97% of total billed charges,2508.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2616.8,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1722.83,2616.8,
59430- Postpartum care only,3431720,CDM,510,RC,59430,HCPCS,Outpatient,,,693.26,346.63,,623.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,554.61,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,623.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,672.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,637.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,442.73,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,545.26,78.65,,,percent of total billed charges,78.65% of total billed charges,619.3,89.33,,,percent of total billed charges,89.33% of total billed charges,623.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,485.28,70,,,percent of total billed charges,70% of total billed charges,623.93,90,,,percent of total billed charges,90% of total billed charges,658.6,95,,,percent of total billed charges,95% of total billed charges,658.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.2,86,,,percent of total billed charges,86% of total billed charges,554.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,672.46,97,,,percent of total billed charges,97% of total billed charges,623.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,672.46,97,,,percent of total billed charges,97% of total billed charges,644.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.73,672.46,
59510- Total OB care/cesarean delivery,3431721,CDM,761,RC,59510,HCPCS,Outpatient,,,7085.78,3542.89,,6377.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5668.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6377.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6873.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6518.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4525.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,5573.12,78.65,,,percent of total billed charges,78.65% of total billed charges,6329.84,89.33,,,percent of total billed charges,89.33% of total billed charges,6377.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4960.05,70,,,percent of total billed charges,70% of total billed charges,6377.2,90,,,percent of total billed charges,90% of total billed charges,6731.49,95,,,percent of total billed charges,95% of total billed charges,6731.49,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6093.77,86,,,percent of total billed charges,86% of total billed charges,5668.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6873.21,97,,,percent of total billed charges,97% of total billed charges,6377.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6873.21,97,,,percent of total billed charges,97% of total billed charges,6589.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6873.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4525.13,6873.21,
59514- Cesarean delivery only,3431722,CDM,360,RC,59514,HCPCS,Outpatient,,,2470.44,1235.22,,2223.4,90,,,percent of total billed charges,90% of total Billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1976.35,80,,,Percent of total Billed charges,80% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2223.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2396.33,97,,,Percent of total billed charges,97% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2272.8,92,,,Percent of total billed charges,92% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2223.4,90,,,percent of total billed charges,90% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.31,70,,,percent of total billed charges,70% of total billed charges,2223.4,90,,,percent of total billed charges,90% of total billed charges,2346.92,95,,,percent of total billed charges,95% of total billed charges,2346.92,95,,,percent of total billed charges,95% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2124.58,86,,,percent of total billed charges,86% of total billed charges,1976.35,80,,,percent of total billed charges,80% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2396.33,97,,,percent of total billed charges,97% of total billed charges,2223.4,90,,,percent of total billed charges,90% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2396.33,97,,,percent of total billed charges,97% of total billed charges,2297.51,93,,,percent of total billed charges,93% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2396.33,97,,,percent of total billed charges,97% of total billed charges,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2470.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.31,2470.44,
59515- Cesarean deliv w/ postpartum care,3431723,CDM,761,RC,59515,HCPCS,Outpatient,,,3539.59,1769.80,,3185.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2831.67,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3185.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3433.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3256.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2260.46,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2783.97,78.65,,,percent of total billed charges,78.65% of total billed charges,3161.97,89.33,,,percent of total billed charges,89.33% of total billed charges,3185.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2477.71,70,,,percent of total billed charges,70% of total billed charges,3185.63,90,,,percent of total billed charges,90% of total billed charges,3362.61,95,,,percent of total billed charges,95% of total billed charges,3362.61,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3044.05,86,,,percent of total billed charges,86% of total billed charges,2831.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3433.4,97,,,percent of total billed charges,97% of total billed charges,3185.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3433.4,97,,,percent of total billed charges,97% of total billed charges,3291.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3433.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2260.46,3433.4,
59610- Total OB care/VBAC,3431725,CDM,761,RC,59610,HCPCS,Outpatient,,,6714.54,3357.27,,6043.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5371.63,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6043.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6513.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6177.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4288.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,5281.13,78.65,,,percent of total billed charges,78.65% of total billed charges,5998.21,89.33,,,percent of total billed charges,89.33% of total billed charges,6043.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4700.18,70,,,percent of total billed charges,70% of total billed charges,6043.09,90,,,percent of total billed charges,90% of total billed charges,6378.81,95,,,percent of total billed charges,95% of total billed charges,6378.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5774.5,86,,,percent of total billed charges,86% of total billed charges,5371.63,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6513.1,97,,,percent of total billed charges,97% of total billed charges,6043.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6513.1,97,,,percent of total billed charges,97% of total billed charges,6244.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6513.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.05,6513.1,
59612- VBAC delivery only(w/orw/o epis & or forcps);,3569392,CDM,510,RC,59612,HCPCS,Outpatient,,,2470.19,1235.10,,2223.17,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1976.15,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2223.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2396.08,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2272.57,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2223.17,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1729.13,70,,,percent of total billed charges,70% of total billed charges,2223.17,90,,,percent of total billed charges,90% of total billed charges,2346.68,95,,,percent of total billed charges,95% of total billed charges,2346.68,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2124.36,86,,,percent of total billed charges,86% of total billed charges,1976.15,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2396.08,97,,,percent of total billed charges,97% of total billed charges,2223.17,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2396.08,97,,,percent of total billed charges,97% of total billed charges,2297.28,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2396.08,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1729.13,13784.12,
59614- VBAC/include postpartum care,3431726,CDM,761,RC,59614,HCPCS,Outpatient,,,3119.3,1559.65,,2807.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2495.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2807.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3025.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2869.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1992.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2453.4,78.65,,,percent of total billed charges,78.65% of total billed charges,2786.52,89.33,,,percent of total billed charges,89.33% of total billed charges,2807.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2183.51,70,,,percent of total billed charges,70% of total billed charges,2807.37,90,,,percent of total billed charges,90% of total billed charges,2963.34,95,,,percent of total billed charges,95% of total billed charges,2963.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2682.6,86,,,percent of total billed charges,86% of total billed charges,2495.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3025.72,97,,,percent of total billed charges,97% of total billed charges,2807.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3025.72,97,,,percent of total billed charges,97% of total billed charges,2900.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3025.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1992.05,3025.72,
59618- Total OB care/C-sec after VBAC,3431727,CDM,761,RC,59618,HCPCS,Outpatient,,,7166.25,3583.13,,6449.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5733,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6449.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6951.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6592.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4576.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,5636.41,78.65,,,percent of total billed charges,78.65% of total billed charges,6401.73,89.33,,,percent of total billed charges,89.33% of total billed charges,6449.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5016.38,70,,,percent of total billed charges,70% of total billed charges,6449.63,90,,,percent of total billed charges,90% of total billed charges,6807.94,95,,,percent of total billed charges,95% of total billed charges,6807.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6162.98,86,,,percent of total billed charges,86% of total billed charges,5733,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6951.26,97,,,percent of total billed charges,97% of total billed charges,6449.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6951.26,97,,,percent of total billed charges,97% of total billed charges,6664.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6951.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4576.52,6951.26,
59620- Cesarean delivery after failed VBAC,3431728,CDM,510,RC,59620,HCPCS,Outpatient,,,2557.65,1278.83,,2301.89,90,,,percent of total billed charges,90% of total Billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2046.12,80,,,Percent of total Billed charges,80% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2301.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2480.92,97,,,Percent of total billed charges,97% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2353.04,92,,,Percent of total billed charges,92% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2301.89,90,,,percent of total billed charges,90% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1790.36,70,,,percent of total billed charges,70% of total billed charges,2301.89,90,,,percent of total billed charges,90% of total billed charges,2429.77,95,,,percent of total billed charges,95% of total billed charges,2429.77,95,,,percent of total billed charges,95% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2199.58,86,,,percent of total billed charges,86% of total billed charges,2046.12,80,,,percent of total billed charges,80% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2480.92,97,,,percent of total billed charges,97% of total billed charges,2301.89,90,,,percent of total billed charges,90% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2480.92,97,,,percent of total billed charges,97% of total billed charges,2378.61,93,,,percent of total billed charges,93% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2480.92,97,,,percent of total billed charges,97% of total billed charges,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2557.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1790.36,2557.65,
59622- Delivery only/pp care/failed VBAC,3431729,CDM,761,RC,59622,HCPCS,Outpatient,,,3665.86,1832.93,,3299.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2932.69,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3299.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3555.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3372.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2341.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2883.28,78.65,,,percent of total billed charges,78.65% of total billed charges,3274.77,89.33,,,percent of total billed charges,89.33% of total billed charges,3299.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2566.1,70,,,percent of total billed charges,70% of total billed charges,3299.27,90,,,percent of total billed charges,90% of total billed charges,3482.57,95,,,percent of total billed charges,95% of total billed charges,3482.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3152.64,86,,,percent of total billed charges,86% of total billed charges,2932.69,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3555.88,97,,,percent of total billed charges,97% of total billed charges,3299.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3555.88,97,,,percent of total billed charges,97% of total billed charges,3409.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3555.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2341.1,3555.88,
59812- Surgical tx/miscarriage,3431730,CDM,761,RC,59812,HCPCS,Outpatient,,,959.23,479.62,,863.31,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,767.38,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.31,90,,,Percent of total Billed charges,90% of total billed charges,199.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,930.45,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,882.49,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,863.31,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,671.46,70,,,percent of total billed charges,70% of total billed charges,863.31,90,,,percent of total billed charges,90% of total billed charges,911.27,95,,,percent of total billed charges,95% of total billed charges,911.27,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,824.94,86,,,percent of total billed charges,86% of total billed charges,767.38,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,930.45,97,,,percent of total billed charges,97% of total billed charges,863.31,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.45,97,,,percent of total billed charges,97% of total billed charges,892.08,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,930.45,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,181.5,13784.12,
59820- Tx of miscarriage/surgical/1st tri,3431731,CDM,761,RC,59820,HCPCS,Outpatient,,,1147.93,573.97,,1033.14,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,918.34,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1033.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1113.49,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1056.1,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1033.14,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,803.55,70,,,percent of total billed charges,70% of total billed charges,1033.14,90,,,percent of total billed charges,90% of total billed charges,1090.53,95,,,percent of total billed charges,95% of total billed charges,1090.53,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,987.22,86,,,percent of total billed charges,86% of total billed charges,918.34,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1113.49,97,,,percent of total billed charges,97% of total billed charges,1033.14,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.49,97,,,percent of total billed charges,97% of total billed charges,1067.57,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1113.49,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,803.55,13784.12,
59821- Surg tx/missed abortion/2nd tri,3431732,CDM,761,RC,59821,HCPCS,Outpatient,,,1139.01,569.51,,1025.11,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,911.21,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1025.11,90,,,Percent of total Billed charges,90% of total billed charges,254.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1104.84,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.89,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1025.11,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,797.31,70,,,percent of total billed charges,70% of total billed charges,1025.11,90,,,percent of total billed charges,90% of total billed charges,1082.06,95,,,percent of total billed charges,95% of total billed charges,1082.06,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,979.55,86,,,percent of total billed charges,86% of total billed charges,911.21,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1104.84,97,,,percent of total billed charges,97% of total billed charges,1025.11,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1104.84,97,,,percent of total billed charges,97% of total billed charges,1059.28,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,231,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1104.84,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,231,13784.12,
59840 - PF Induced Abortion By Dilation and Curettage,4315550,CDM,960,RC,59840,HCPCS,Outpatient,,,471.09,235.55,,423.98,90,,,percent of total billed charges,90% of total Billed charges,470.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.92,90,,,Percent of total Billed charges,90% of total billed charges,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,344.43,155,,,Fee Schedule,155% of CMS OPPS Rate,222.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,288.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,324.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,331.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,331.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,208.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,367.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,283.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,344.43,155,,,Fee Schedule,155% of CMS OPPS Rate,222.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,729.66,155,,,Fee Schedule,155% of CMS OPPS Rate,729.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,274.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,439.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.5,729.66,
59855- Induced abortion/vag supp/delivery,3431733,CDM,360,RC,59855,HCPCS,Outpatient,,,1140.44,570.22,,1026.4,90,,,percent of total billed charges,90% of total Billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,912.35,80,,,Percent of total Billed charges,80% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1026.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1106.23,97,,,Percent of total billed charges,97% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1049.2,92,,,Percent of total billed charges,92% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1026.4,90,,,percent of total billed charges,90% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,798.31,70,,,percent of total billed charges,70% of total billed charges,1026.4,90,,,percent of total billed charges,90% of total billed charges,1083.42,95,,,percent of total billed charges,95% of total billed charges,1083.42,95,,,percent of total billed charges,95% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,980.78,86,,,percent of total billed charges,86% of total billed charges,912.35,80,,,percent of total billed charges,80% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1106.23,97,,,percent of total billed charges,97% of total billed charges,1026.4,90,,,percent of total billed charges,90% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1106.23,97,,,percent of total billed charges,97% of total billed charges,1060.61,93,,,percent of total billed charges,93% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1106.23,97,,,percent of total billed charges,97% of total billed charges,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1140.44,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,798.31,1140.44,
59870- Uterine evac/curet/hydatiform mole,3431735,CDM,761,RC,59870,HCPCS,Outpatient,,,1411.7,705.85,,1270.53,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.36,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1270.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1369.35,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.76,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1270.53,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,988.19,70,,,percent of total billed charges,70% of total billed charges,1270.53,90,,,percent of total billed charges,90% of total billed charges,1341.12,95,,,percent of total billed charges,95% of total billed charges,1341.12,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1214.06,86,,,percent of total billed charges,86% of total billed charges,1129.36,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1369.35,97,,,percent of total billed charges,97% of total billed charges,1270.53,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1369.35,97,,,percent of total billed charges,97% of total billed charges,1312.88,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1369.35,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,988.19,13784.12,
59899 Unlisted procedure maternity care and delivery Bakri,3623306,CDM,510,RC,59899,HCPCS,Outpatient,,,6648.32,3324.16,,5983.49,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5318.66,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,5983.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6448.87,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,6116.45,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5983.49,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,4653.82,70,,,percent of total billed charges,70% of total billed charges,5983.49,90,,,percent of total billed charges,90% of total billed charges,6315.9,95,,,percent of total billed charges,95% of total billed charges,6315.9,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5717.56,86,,,percent of total billed charges,86% of total billed charges,5318.66,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6448.87,97,,,percent of total billed charges,97% of total billed charges,5983.49,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,6448.87,97,,,percent of total billed charges,97% of total billed charges,6182.94,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6448.87,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.52,6448.87,
60100- Bx thyroid/percutan core needle,3431283,CDM,320,RC,60100,HCPCS,Outpatient,,,280.6,140.30,,252.54,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,224.48,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.54,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,272.18,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,258.15,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,252.54,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,196.42,70,,,percent of total billed charges,70% of total billed charges,252.54,90,,,percent of total billed charges,90% of total billed charges,266.57,95,,,percent of total billed charges,95% of total billed charges,266.57,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,241.32,86,,,percent of total billed charges,86% of total billed charges,224.48,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,272.18,97,,,percent of total billed charges,97% of total billed charges,252.54,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.18,97,,,percent of total billed charges,97% of total billed charges,260.96,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.18,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3163.8,
CT add Needle Bx Thyroid,645120,CDM,320,RC,60100,HCPCS,Outpatient,,,281.04,140.52,,252.94,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,224.83,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.94,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,272.61,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,258.56,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,252.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,196.73,70,,,percent of total billed charges,70% of total billed charges,252.94,90,,,percent of total billed charges,90% of total billed charges,266.99,95,,,percent of total billed charges,95% of total billed charges,266.99,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,241.69,86,,,percent of total billed charges,86% of total billed charges,224.83,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,272.61,97,,,percent of total billed charges,97% of total billed charges,252.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.61,97,,,percent of total billed charges,97% of total billed charges,261.37,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.61,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3163.8,
Read,4181210,CDM,972,RC,60100,HCPCS,Outpatient,,,112.41,56.21,,101.17,90,,,percent of total billed charges,90% of total Billed charges,181.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.3,155,,,Fee Schedule,155% of CMS OPPS Rate,76.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,119.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,119.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.3,155,,,Fee Schedule,155% of CMS OPPS Rate,76.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.84,155,,,Fee Schedule,155% of CMS OPPS Rate,281.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,161.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,217.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.58,281.84,
US add Needle Bx Thyroid,645156,CDM,320,RC,60100,HCPCS,Outpatient,,,281.04,140.52,,252.94,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,224.83,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.94,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,272.61,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,258.56,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,252.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,196.73,70,,,percent of total billed charges,70% of total billed charges,252.94,90,,,percent of total billed charges,90% of total billed charges,266.99,95,,,percent of total billed charges,95% of total billed charges,266.99,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,241.69,86,,,percent of total billed charges,86% of total billed charges,224.83,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,272.61,97,,,percent of total billed charges,97% of total billed charges,252.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.61,97,,,percent of total billed charges,97% of total billed charges,261.37,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.61,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3163.8,
60200 - PF Exc Cyst/Adenoma Thyroid/Transection Isthmus,4305362,CDM,960,RC,60200,HCPCS,Outpatient,,,1400.62,700.31,,1260.56,90,,,percent of total billed charges,90% of total Billed charges,1322.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,660.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,399,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1024.04,155,,,Fee Schedule,155% of CMS OPPS Rate,660.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,886.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,660.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,997.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,997.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1005.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1005.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,529.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1186.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,808.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1024.04,155,,,Fee Schedule,155% of CMS OPPS Rate,660.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2049.92,155,,,Fee Schedule,155% of CMS OPPS Rate,2049.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,660.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,399,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,638.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,660.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1355.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1355.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,399,2049.92,
60210 - PF Prtl Thyroid Lobectomy Uni w/wo Isthmusectomy,4301618,CDM,960,RC,60210,HCPCS,Outpatient,,,1488.71,744.36,,1339.84,90,,,percent of total billed charges,90% of total Billed charges,1408.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,702.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,605.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1088.43,155,,,Fee Schedule,155% of CMS OPPS Rate,702.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,945.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,702.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1062.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1079.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1079.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,567.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1273.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,877.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1088.43,155,,,Fee Schedule,155% of CMS OPPS Rate,702.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,2182.48,155,,,Fee Schedule,155% of CMS OPPS Rate,2182.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,702.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,788.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,702.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,1455.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1455.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,567.34,2182.48,
60220- Total thyroid lobectomy/unilateral,3431284,CDM,361,RC,60220,HCPCS,Outpatient,,,1870.43,935.22,,1683.39,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1496.34,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1683.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1814.32,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1720.8,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1683.39,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.3,70,,,percent of total billed charges,70% of total billed charges,1683.39,90,,,percent of total billed charges,90% of total billed charges,1776.91,95,,,percent of total billed charges,95% of total billed charges,1776.91,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1608.57,86,,,percent of total billed charges,86% of total billed charges,1496.34,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1814.32,97,,,percent of total billed charges,97% of total billed charges,1683.39,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1814.32,97,,,percent of total billed charges,97% of total billed charges,1739.5,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1814.32,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1309.3,25409.89,
"60240- Thyroidectomy, total or complete",3569393,CDM,510,RC,60240,HCPCS,Outpatient,,,2443.68,1221.84,,2199.31,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1954.94,80,,,Percent of total Billed charges,80% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2199.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2370.37,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2248.19,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2199.31,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1710.58,70,,,percent of total billed charges,70% of total billed charges,2199.31,90,,,percent of total billed charges,90% of total billed charges,2321.5,95,,,percent of total billed charges,95% of total billed charges,2321.5,95,,,percent of total billed charges,95% of total billed charges,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2101.56,86,,,percent of total billed charges,86% of total billed charges,1954.94,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2370.37,97,,,percent of total billed charges,97% of total billed charges,2199.31,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2370.37,97,,,percent of total billed charges,97% of total billed charges,2272.62,93,,,percent of total billed charges,93% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2370.37,97,,,percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1710.58,25409.89,
"60260 - Thyroidectomy, total or complete",3899067,CDM,983,RC,60260,HCPCS,Outpatient,,,2897.49,1448.75,,2607.74,90,,,percent of total billed charges,90% of total Billed charges,2171.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1082.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,374.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1677.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1082.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1456.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1082.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1638.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1638.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1669.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1669.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,875.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1082.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2164.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1970.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1351.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1677.57,155,,,Fee Schedule,155% of CMS OPPS Rate,1082.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,3366.37,155,,,Fee Schedule,155% of CMS OPPS Rate,3366.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1082.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1078.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1082.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2261.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2261.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,374.5,3366.37,
"60271-PF Rmvl Thyroid, Transcervical",4322117,CDM,960,RC,60271,HCPCS,Outpatient,,,2054.58,1027.29,,1849.12,90,,,percent of total billed charges,90% of total Billed charges,2105.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1049.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,924.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1627.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1049.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1412.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1049.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1588.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1588.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1619.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1619.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,847.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1049.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2099.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1910.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1316.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1627.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1049.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3263.51,155,,,Fee Schedule,155% of CMS OPPS Rate,3263.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1049.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1146.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1049.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2176.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2176.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,847.38,3263.51,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,361,RC,60300,HCPCS,Outpatient,,,270.06,135.03,,243.05,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,216.05,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.05,90,,,Percent of total Billed charges,90% of total billed charges,40.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.96,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,248.46,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,243.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,189.04,70,,,percent of total billed charges,70% of total billed charges,243.05,90,,,percent of total billed charges,90% of total billed charges,256.56,95,,,percent of total billed charges,95% of total billed charges,256.56,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,232.25,86,,,percent of total billed charges,86% of total billed charges,216.05,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.96,97,,,percent of total billed charges,97% of total billed charges,243.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.96,97,,,percent of total billed charges,97% of total billed charges,251.16,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.96,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.81,3163.8,
60500- Parathyroidectomy or expl parathy,3431286,CDM,510,RC,60500,HCPCS,Outpatient,,,2585.62,1292.81,,2327.06,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2068.5,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2327.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2508.05,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2378.77,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2327.06,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1809.93,70,,,percent of total billed charges,70% of total billed charges,2327.06,90,,,percent of total billed charges,90% of total billed charges,2456.34,95,,,percent of total billed charges,95% of total billed charges,2456.34,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2223.63,86,,,percent of total billed charges,86% of total billed charges,2068.5,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2508.05,97,,,percent of total billed charges,97% of total billed charges,2327.06,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2508.05,97,,,percent of total billed charges,97% of total billed charges,2404.63,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2508.05,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1809.93,26031.56,
60502- Re-exploration of parathyroids,3431287,CDM,510,RC,60502,HCPCS,Outpatient,,,3474.67,1737.34,,3127.2,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2779.74,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3127.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3370.43,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3196.7,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3127.2,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2432.27,70,,,percent of total billed charges,70% of total billed charges,3127.2,90,,,percent of total billed charges,90% of total billed charges,3300.94,95,,,percent of total billed charges,95% of total billed charges,3300.94,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2988.22,86,,,percent of total billed charges,86% of total billed charges,2779.74,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3370.43,97,,,percent of total billed charges,97% of total billed charges,3127.2,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3370.43,97,,,percent of total billed charges,97% of total billed charges,3231.44,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3370.43,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2432.27,26031.56,
60512- Parathyroid autotransplantation,3431288,CDM,510,RC,60512,HCPCS,Outpatient,,,649.18,324.59,,584.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,519.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,584.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,597.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,414.58,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,510.59,78.65,,,percent of total billed charges,78.65% of total billed charges,579.92,89.33,,,percent of total billed charges,89.33% of total billed charges,584.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,454.43,70,,,percent of total billed charges,70% of total billed charges,584.26,90,,,percent of total billed charges,90% of total billed charges,616.72,95,,,percent of total billed charges,95% of total billed charges,616.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.29,86,,,percent of total billed charges,86% of total billed charges,519.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,629.7,97,,,percent of total billed charges,97% of total billed charges,584.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.7,97,,,percent of total billed charges,97% of total billed charges,603.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.58,629.7,
60521-PF Thymectomy Prtl/Tot w/o Rad Mdstnl Dsn,4322118,CDM,960,RC,60521,HCPCS,Outpatient,,,2202.7,1101.35,,1982.43,90,,,percent of total billed charges,90% of total Billed charges,2252.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1122.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1740.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1122.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1657.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1122.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1864.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1864.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1744.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1744.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,904.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1122.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2245.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2058.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1480.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1740.26,155,,,Fee Schedule,155% of CMS OPPS Rate,1122.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,3491.76,155,,,Fee Schedule,155% of CMS OPPS Rate,3491.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1122.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1358,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1122.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2317.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2317.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,904.49,3491.76,
60540 - Adrenalectomy w/Expl w/wo Bx Abdl/Lmbr/Drsal Spx,4169599,CDM,983,RC,60540,HCPCS,Outpatient,,,2556.27,1278.14,,2300.64,90,,,percent of total billed charges,90% of total Billed charges,2148.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1071.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,675,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1661.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1071.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1585.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1071.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1783.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1783.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1652.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1652.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,855.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1071.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2143.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1950.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1357.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1661.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1071.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,3330.05,155,,,Fee Schedule,155% of CMS OPPS Rate,3330.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1071.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,675,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1196.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1071.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2124.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2124.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,675,3330.05,
60600- Exc carotid body tumor w/o exc art,3431289,CDM,510,RC,60600,HCPCS,Outpatient,,,3671.01,1835.51,,3303.91,90,,,percent of total billed charges,90% of total Billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2936.81,80,,,Percent of total Billed charges,80% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3303.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3560.88,97,,,Percent of total billed charges,97% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3377.33,92,,,Percent of total billed charges,92% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3303.91,90,,,percent of total billed charges,90% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2569.71,70,,,percent of total billed charges,70% of total billed charges,3303.91,90,,,percent of total billed charges,90% of total billed charges,3487.46,95,,,percent of total billed charges,95% of total billed charges,3487.46,95,,,percent of total billed charges,95% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3157.07,86,,,percent of total billed charges,86% of total billed charges,2936.81,80,,,percent of total billed charges,80% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3560.88,97,,,percent of total billed charges,97% of total billed charges,3303.91,90,,,percent of total billed charges,90% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3560.88,97,,,percent of total billed charges,97% of total billed charges,3414.04,93,,,percent of total billed charges,93% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3560.88,97,,,percent of total billed charges,97% of total billed charges,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3671.01,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2569.71,3671.01,
"60650 - Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gl",3800931,CDM,983,RC,60650,HCPCS,Outpatient,,,3186.46,1593.23,,2867.81,90,,,percent of total billed charges,90% of total Billed charges,2387.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1189.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1842.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1189.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1825.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1189.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2052.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2052.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1854.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1854.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,959.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1189.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2378.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2187.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1538.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1842.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1189.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,3700.19,155,,,Fee Schedule,155% of CMS OPPS Rate,3700.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1189.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1200.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1189.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2418.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2418.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,959.65,3700.19,
61070- Puncture shunt tube/aspirate/inj,3435318,CDM,510,RC,61070,HCPCS,Outpatient,,,148.81,74.41,,133.93,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,119.05,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.93,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,144.35,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,136.91,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.93,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,104.17,70,,,percent of total billed charges,70% of total billed charges,133.93,90,,,percent of total billed charges,90% of total billed charges,141.37,95,,,percent of total billed charges,95% of total billed charges,141.37,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.98,86,,,percent of total billed charges,86% of total billed charges,119.05,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,144.35,97,,,percent of total billed charges,97% of total billed charges,133.93,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.35,97,,,percent of total billed charges,97% of total billed charges,138.39,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.35,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,3141.23,
61107-PF TWIST DRILL HOLE IMPLT VENTRICULAR CATH/DEVICE,4321485,CDM,981,RC,61107,HCPCS,Outpatient,,,646.52,323.26,,581.87,90,,,percent of total billed charges,90% of total Billed charges,643.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,323.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,289.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,501.05,155,,,Fee Schedule,155% of CMS OPPS Rate,323.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,440.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,497.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,497.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,307.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,646.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,587.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,465.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,501.05,155,,,Fee Schedule,155% of CMS OPPS Rate,323.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,997.3,155,,,Fee Schedule,155% of CMS OPPS Rate,997.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,323.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,530.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,323.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,648.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,289.18,997.3,
"61210- Pierce Skull, Implant Devise",3435319,CDM,510,RC,61210,HCPCS,Outpatient,,,998.6,499.30,,898.74,90,,,percent of total billed charges,90% of total Billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,798.88,80,,,Percent of total Billed charges,80% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,898.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,968.64,97,,,Percent of total billed charges,97% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,918.71,92,,,Percent of total billed charges,92% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,898.74,90,,,percent of total billed charges,90% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,699.02,70,,,percent of total billed charges,70% of total billed charges,898.74,90,,,percent of total billed charges,90% of total billed charges,948.67,95,,,percent of total billed charges,95% of total billed charges,948.67,95,,,percent of total billed charges,95% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,858.8,86,,,percent of total billed charges,86% of total billed charges,798.88,80,,,percent of total billed charges,80% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,968.64,97,,,percent of total billed charges,97% of total billed charges,898.74,90,,,percent of total billed charges,90% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,968.64,97,,,percent of total billed charges,97% of total billed charges,928.7,93,,,percent of total billed charges,93% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,968.64,97,,,percent of total billed charges,97% of total billed charges,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,998.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,699.02,998.6,
61312- Open Skull For Drainage,3435320,CDM,510,RC,61312,HCPCS,Outpatient,,,5609.11,2804.56,,5048.2,90,,,percent of total billed charges,90% of total Billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4487.29,80,,,Percent of total Billed charges,80% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5048.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5440.84,97,,,Percent of total billed charges,97% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5160.38,92,,,Percent of total billed charges,92% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5048.2,90,,,percent of total billed charges,90% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3926.38,70,,,percent of total billed charges,70% of total billed charges,5048.2,90,,,percent of total billed charges,90% of total billed charges,5328.65,95,,,percent of total billed charges,95% of total billed charges,5328.65,95,,,percent of total billed charges,95% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4823.83,86,,,percent of total billed charges,86% of total billed charges,4487.29,80,,,percent of total billed charges,80% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5440.84,97,,,percent of total billed charges,97% of total billed charges,5048.2,90,,,percent of total billed charges,90% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5440.84,97,,,percent of total billed charges,97% of total billed charges,5216.47,93,,,percent of total billed charges,93% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5440.84,97,,,percent of total billed charges,97% of total billed charges,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5609.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3926.38,5609.11,
61500- Removal Of Skull Lesion,3435321,CDM,510,RC,61500,HCPCS,Outpatient,,,3479.62,1739.81,,3131.66,90,,,percent of total billed charges,90% of total Billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2783.7,80,,,Percent of total Billed charges,80% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3131.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3375.23,97,,,Percent of total billed charges,97% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3201.25,92,,,Percent of total billed charges,92% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3131.66,90,,,percent of total billed charges,90% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2435.73,70,,,percent of total billed charges,70% of total billed charges,3131.66,90,,,percent of total billed charges,90% of total billed charges,3305.64,95,,,percent of total billed charges,95% of total billed charges,3305.64,95,,,percent of total billed charges,95% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2992.47,86,,,percent of total billed charges,86% of total billed charges,2783.7,80,,,percent of total billed charges,80% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3375.23,97,,,percent of total billed charges,97% of total billed charges,3131.66,90,,,percent of total billed charges,90% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3375.23,97,,,percent of total billed charges,97% of total billed charges,3236.05,93,,,percent of total billed charges,93% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3375.23,97,,,percent of total billed charges,97% of total billed charges,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.62,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2435.73,3479.62,
61510- Removal Of Brain Lesion,3435322,CDM,510,RC,61510,HCPCS,Outpatient,,,5934.93,2967.47,,5341.44,90,,,percent of total billed charges,90% of total Billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4747.94,80,,,Percent of total Billed charges,80% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5341.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5756.88,97,,,Percent of total billed charges,97% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5460.14,92,,,Percent of total billed charges,92% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5341.44,90,,,percent of total billed charges,90% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4154.45,70,,,percent of total billed charges,70% of total billed charges,5341.44,90,,,percent of total billed charges,90% of total billed charges,5638.18,95,,,percent of total billed charges,95% of total billed charges,5638.18,95,,,percent of total billed charges,95% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5104.04,86,,,percent of total billed charges,86% of total billed charges,4747.94,80,,,percent of total billed charges,80% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5756.88,97,,,percent of total billed charges,97% of total billed charges,5341.44,90,,,percent of total billed charges,90% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5756.88,97,,,percent of total billed charges,97% of total billed charges,5519.48,93,,,percent of total billed charges,93% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5756.88,97,,,percent of total billed charges,97% of total billed charges,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5934.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4154.45,5934.93,
61512- Remove Brain Lining Lesion,3435323,CDM,510,RC,61512,HCPCS,Outpatient,,,6915.56,3457.78,,6224,90,,,percent of total billed charges,90% of total Billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5532.45,80,,,Percent of total Billed charges,80% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6224,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6708.09,97,,,Percent of total billed charges,97% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6362.32,92,,,Percent of total billed charges,92% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6224,90,,,percent of total billed charges,90% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4840.89,70,,,percent of total billed charges,70% of total billed charges,6224,90,,,percent of total billed charges,90% of total billed charges,6569.78,95,,,percent of total billed charges,95% of total billed charges,6569.78,95,,,percent of total billed charges,95% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5947.38,86,,,percent of total billed charges,86% of total billed charges,5532.45,80,,,percent of total billed charges,80% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6708.09,97,,,percent of total billed charges,97% of total billed charges,6224,90,,,percent of total billed charges,90% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6708.09,97,,,percent of total billed charges,97% of total billed charges,6431.47,93,,,percent of total billed charges,93% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6708.09,97,,,percent of total billed charges,97% of total billed charges,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6915.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4840.89,6915.56,
61781- Stereotac comput assist/cran/intra,3435324,CDM,510,RC,61781,HCPCS,Outpatient,,,641.11,320.56,,577,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,512.89,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,577,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,621.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,589.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,409.43,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,504.25,78.65,,,percent of total billed charges,78.65% of total billed charges,572.71,89.33,,,percent of total billed charges,89.33% of total billed charges,577,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,448.78,70,,,percent of total billed charges,70% of total billed charges,577,90,,,percent of total billed charges,90% of total billed charges,609.05,95,,,percent of total billed charges,95% of total billed charges,609.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.35,86,,,percent of total billed charges,86% of total billed charges,512.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.88,97,,,percent of total billed charges,97% of total billed charges,577,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,621.88,97,,,percent of total billed charges,97% of total billed charges,596.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.43,621.88,
61782- Stereotac localiz/cranial/extradur,3435325,CDM,510,RC,61782,HCPCS,Outpatient,,,456.76,228.38,,411.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,365.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,411.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,443.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,420.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,291.7,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,359.25,78.65,,,percent of total billed charges,78.65% of total billed charges,408.03,89.33,,,percent of total billed charges,89.33% of total billed charges,411.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,319.73,70,,,percent of total billed charges,70% of total billed charges,411.08,90,,,percent of total billed charges,90% of total billed charges,433.92,95,,,percent of total billed charges,95% of total billed charges,433.92,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.81,86,,,percent of total billed charges,86% of total billed charges,365.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,443.06,97,,,percent of total billed charges,97% of total billed charges,411.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,443.06,97,,,percent of total billed charges,97% of total billed charges,424.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.7,443.06,
61783- Sterotactic localization/spinal,3435326,CDM,510,RC,61783,HCPCS,Outpatient,,,629.94,314.97,,566.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,503.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,566.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,611.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,579.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,402.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,495.46,78.65,,,percent of total billed charges,78.65% of total billed charges,562.74,89.33,,,percent of total billed charges,89.33% of total billed charges,566.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,440.96,70,,,percent of total billed charges,70% of total billed charges,566.95,90,,,percent of total billed charges,90% of total billed charges,598.44,95,,,percent of total billed charges,95% of total billed charges,598.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,541.75,86,,,percent of total billed charges,86% of total billed charges,503.95,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,611.04,97,,,percent of total billed charges,97% of total billed charges,566.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,611.04,97,,,percent of total billed charges,97% of total billed charges,585.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,611.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.29,611.04,
61799- Stereotac radiosur/ad cran les/com,3435327,CDM,510,RC,61799,HCPCS,Outpatient,,,825.24,412.62,,742.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,660.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,742.72,90,,,Percent of total Billed charges,90% of total billed charges,170.87,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,800.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,759.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,527.02,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,649.07,78.65,,,percent of total billed charges,78.65% of total billed charges,737.2,89.33,,,percent of total billed charges,89.33% of total billed charges,742.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,577.67,70,,,percent of total billed charges,70% of total billed charges,742.72,90,,,percent of total billed charges,90% of total billed charges,783.98,95,,,percent of total billed charges,95% of total billed charges,783.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.71,86,,,percent of total billed charges,86% of total billed charges,660.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,800.48,97,,,percent of total billed charges,97% of total billed charges,742.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,800.48,97,,,percent of total billed charges,97% of total billed charges,767.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,800.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.34,800.48,
61880 - Revision or removal of intracranial neurostimulator electrodes,3783275,CDM,510,RC,61880,HCPCS,Outpatient,,,1555.86,777.93,,1400.27,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.69,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1400.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1509.18,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1431.39,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1400.27,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1089.1,70,,,percent of total billed charges,70% of total billed charges,1400.27,90,,,percent of total billed charges,90% of total billed charges,1478.07,95,,,percent of total billed charges,95% of total billed charges,1478.07,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1338.04,86,,,percent of total billed charges,86% of total billed charges,1244.69,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1509.18,97,,,percent of total billed charges,97% of total billed charges,1400.27,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1509.18,97,,,percent of total billed charges,97% of total billed charges,1446.95,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1509.18,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1089.1,15832.85,
"61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or ind",3622067,CDM,510,RC,61885,HCPCS,Outpatient,,,1386.02,693.01,,1247.42,90,,,percent of total billed charges,90% of total Billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1108.82,80,,,Percent of total Billed charges,80% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1344.44,97,,,Percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.14,92,,,Percent of total billed charges,92% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,51943.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82809.03,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,104890.11,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.42,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,970.21,70,,,percent of total billed charges,70% of total billed charges,1247.42,90,,,percent of total billed charges,90% of total billed charges,1316.72,95,,,percent of total billed charges,95% of total billed charges,1316.72,95,,,percent of total billed charges,95% of total billed charges,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39083.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1191.98,86,,,percent of total billed charges,86% of total billed charges,1108.82,80,,,percent of total billed charges,80% of total billed charges,19932.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.44,97,,,percent of total billed charges,97% of total billed charges,1247.42,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.44,97,,,percent of total billed charges,97% of total billed charges,1289,93,,,percent of total billed charges,93% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1344.44,97,,,percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,19541.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16610.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,970.21,104890.11,
61888 - REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR,3997209,CDM,960,RC,61888,HCPCS,Outpatient,,,1068.68,534.34,,961.81,90,,,percent of total billed charges,90% of total Billed charges,806.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,404.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,342.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,627.18,155,,,Fee Schedule,155% of CMS OPPS Rate,404.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,552.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,607.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,607.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,373.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,404.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,716.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,540.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,627.18,155,,,Fee Schedule,155% of CMS OPPS Rate,404.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1250.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1250.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,404.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,376.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,404.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,788.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,342.72,1250.06,
62220- Create shunt/ventric/atri/jug/auri,3435328,CDM,510,RC,62220,HCPCS,Outpatient,,,2635.02,1317.51,,2371.52,90,,,percent of total billed charges,90% of total Billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2108.02,80,,,Percent of total Billed charges,80% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2371.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2555.97,97,,,Percent of total billed charges,97% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2424.22,92,,,Percent of total billed charges,92% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2371.52,90,,,percent of total billed charges,90% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1844.51,70,,,percent of total billed charges,70% of total billed charges,2371.52,90,,,percent of total billed charges,90% of total billed charges,2503.27,95,,,percent of total billed charges,95% of total billed charges,2503.27,95,,,percent of total billed charges,95% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2266.12,86,,,percent of total billed charges,86% of total billed charges,2108.02,80,,,percent of total billed charges,80% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.97,97,,,percent of total billed charges,97% of total billed charges,2371.52,90,,,percent of total billed charges,90% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2555.97,97,,,percent of total billed charges,97% of total billed charges,2450.57,93,,,percent of total billed charges,93% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2555.97,97,,,percent of total billed charges,97% of total billed charges,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2635.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1844.51,2635.02,
62223- Create shunt/ventric/perito/pleura,3435329,CDM,510,RC,62223,HCPCS,Outpatient,,,2785.67,1392.84,,2507.1,90,,,percent of total billed charges,90% of total Billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2228.54,80,,,Percent of total Billed charges,80% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2507.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2702.1,97,,,Percent of total billed charges,97% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2562.82,92,,,Percent of total billed charges,92% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2507.1,90,,,percent of total billed charges,90% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1949.97,70,,,percent of total billed charges,70% of total billed charges,2507.1,90,,,percent of total billed charges,90% of total billed charges,2646.39,95,,,percent of total billed charges,95% of total billed charges,2646.39,95,,,percent of total billed charges,95% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.68,86,,,percent of total billed charges,86% of total billed charges,2228.54,80,,,percent of total billed charges,80% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2702.1,97,,,percent of total billed charges,97% of total billed charges,2507.1,90,,,percent of total billed charges,90% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2702.1,97,,,percent of total billed charges,97% of total billed charges,2590.67,93,,,percent of total billed charges,93% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2702.1,97,,,percent of total billed charges,97% of total billed charges,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2785.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1949.97,2785.67,
62252- Reprogram CSF shunt,3435330,CDM,510,RC,62252,HCPCS,Outpatient,,,86.38,43.19,,77.74,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,69.1,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.79,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,79.47,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,77.74,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,60.47,70,,,percent of total billed charges,70% of total billed charges,77.74,90,,,percent of total billed charges,90% of total billed charges,82.06,95,,,percent of total billed charges,95% of total billed charges,82.06,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,74.29,86,,,percent of total billed charges,86% of total billed charges,69.1,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,83.79,97,,,percent of total billed charges,97% of total billed charges,77.74,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.79,97,,,percent of total billed charges,97% of total billed charges,80.33,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83.79,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60.47,1348.7,
62270- Spinal puncture/lumbar/diagnostic,3435331,CDM,320,RC,62270,HCPCS,Outpatient,,,319.89,159.95,,287.9,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,255.91,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.9,90,,,Percent of total Billed charges,90% of total billed charges,46.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,310.29,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,294.3,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,287.9,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,223.92,70,,,percent of total billed charges,70% of total billed charges,287.9,90,,,percent of total billed charges,90% of total billed charges,303.9,95,,,percent of total billed charges,95% of total billed charges,303.9,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,275.11,86,,,percent of total billed charges,86% of total billed charges,255.91,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,310.29,97,,,percent of total billed charges,97% of total billed charges,287.9,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.29,97,,,percent of total billed charges,97% of total billed charges,297.5,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.29,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42,3141.23,
62270-PF DIAGNOSTIC LUMBAR SPINAL PUNCTURE,4321603,CDM,981,RC,62270,HCPCS,Outpatient,,,126.32,63.16,,113.69,90,,,percent of total billed charges,90% of total Billed charges,183.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.58,90,,,Percent of total Billed charges,90% of total billed charges,42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.32,155,,,Fee Schedule,155% of CMS OPPS Rate,284.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,302.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42,312.58,
Clinic Lumbar Puncture,3435540,CDM,510,RC,62270,HCPCS,Outpatient,,,319.89,159.95,,287.9,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,255.91,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.9,90,,,Percent of total Billed charges,90% of total billed charges,46.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,310.29,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,294.3,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,287.9,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,223.92,70,,,percent of total billed charges,70% of total billed charges,287.9,90,,,percent of total billed charges,90% of total billed charges,303.9,95,,,percent of total billed charges,95% of total billed charges,303.9,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,275.11,86,,,percent of total billed charges,86% of total billed charges,255.91,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,310.29,97,,,percent of total billed charges,97% of total billed charges,287.9,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.29,97,,,percent of total billed charges,97% of total billed charges,297.5,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.29,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42,3141.23,
DR add Spinal Puncture Diagnostic,645859,CDM,320,RC,62270,HCPCS,Outpatient,,,331.09,165.55,,297.98,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,264.87,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.98,90,,,Percent of total Billed charges,90% of total billed charges,46.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,321.16,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,304.6,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,297.98,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,231.76,70,,,percent of total billed charges,70% of total billed charges,297.98,90,,,percent of total billed charges,90% of total billed charges,314.54,95,,,percent of total billed charges,95% of total billed charges,314.54,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.74,86,,,percent of total billed charges,86% of total billed charges,264.87,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,321.16,97,,,percent of total billed charges,97% of total billed charges,297.98,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.16,97,,,percent of total billed charges,97% of total billed charges,307.91,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.16,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42,3141.23,
62272- Spinal puncture/CSF drainage,3435332,CDM,510,RC,62272,HCPCS,Outpatient,,,184.2,92.10,,165.78,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,147.36,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.78,90,,,Percent of total Billed charges,90% of total billed charges,40.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,178.67,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,169.46,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,165.78,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,128.94,70,,,percent of total billed charges,70% of total billed charges,165.78,90,,,percent of total billed charges,90% of total billed charges,174.99,95,,,percent of total billed charges,95% of total billed charges,174.99,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,158.41,86,,,percent of total billed charges,86% of total billed charges,147.36,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,178.67,97,,,percent of total billed charges,97% of total billed charges,165.78,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.67,97,,,percent of total billed charges,97% of total billed charges,171.31,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.67,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37,3141.23,
62272-PF THERAPEUTIC SPINAL PUNCTURE DRAINAGE CSF,4321602,CDM,981,RC,62272,HCPCS,Outpatient,,,184.2,92.10,,165.78,90,,,percent of total billed charges,90% of total Billed charges,257.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.74,155,,,Fee Schedule,155% of CMS OPPS Rate,92.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.74,155,,,Fee Schedule,155% of CMS OPPS Rate,92.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.44,155,,,Fee Schedule,155% of CMS OPPS Rate,398.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,316.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,390.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37,398.44,
62273-PF INJECTION EPIDURAL BLOOD/CLOT PATCH,4321601,CDM,981,RC,62273,HCPCS,Outpatient,,,221.12,110.56,,199.01,90,,,percent of total billed charges,90% of total Billed charges,272.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,171.37,155,,,Fee Schedule,155% of CMS OPPS Rate,110.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,181.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,171.37,155,,,Fee Schedule,155% of CMS OPPS Rate,110.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.14,155,,,Fee Schedule,155% of CMS OPPS Rate,422.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,155.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48,422.14,
64400-PF INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH,4321600,CDM,981,RC,64400,HCPCS,Outpatient,,,99.78,49.89,,89.8,90,,,percent of total billed charges,90% of total Billed charges,149.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,64.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.97,155,,,Fee Schedule,155% of CMS OPPS Rate,231.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13,235.28,
64405- Inj/anest/greater occipital nerve,3435384,CDM,510,RC,64405,HCPCS,Outpatient,,,195.72,97.86,,176.15,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,156.58,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.15,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,189.85,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,180.06,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,176.15,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,137,70,,,percent of total billed charges,70% of total billed charges,176.15,90,,,percent of total billed charges,90% of total billed charges,185.93,95,,,percent of total billed charges,95% of total billed charges,185.93,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,168.32,86,,,percent of total billed charges,86% of total billed charges,156.58,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,189.85,97,,,percent of total billed charges,97% of total billed charges,176.15,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.85,97,,,percent of total billed charges,97% of total billed charges,182.02,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.85,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,1325.49,
64405-PF INJECTION AA&/STRD GREATER OCCIPITAL NERVE,4321599,CDM,981,RC,64405,HCPCS,Outpatient,,,106.48,53.24,,95.83,90,,,percent of total billed charges,90% of total Billed charges,126.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.52,155,,,Fee Schedule,155% of CMS OPPS Rate,53.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,60.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.52,155,,,Fee Schedule,155% of CMS OPPS Rate,53.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.6,155,,,Fee Schedule,155% of CMS OPPS Rate,196.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,239.36,
64417-PF INJECTION AA&/STRD AXILLARY NERVE,4321598,CDM,981,RC,64417,HCPCS,Outpatient,,,124.72,62.36,,112.25,90,,,percent of total billed charges,90% of total Billed charges,187.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.97,155,,,Fee Schedule,155% of CMS OPPS Rate,289.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,258.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,289.97,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,510,RC,64425,HCPCS,Outpatient,,,279.15,139.58,,251.24,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,223.32,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.24,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,270.78,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,256.82,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,251.24,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,195.41,70,,,percent of total billed charges,70% of total billed charges,251.24,90,,,percent of total billed charges,90% of total billed charges,265.19,95,,,percent of total billed charges,95% of total billed charges,265.19,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,240.07,86,,,percent of total billed charges,86% of total billed charges,223.32,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,270.78,97,,,percent of total billed charges,97% of total billed charges,251.24,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.78,97,,,percent of total billed charges,97% of total billed charges,259.61,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.78,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,3141.23,
64447-PF INJECTION AA&/STRD FEMORAL NERVE,4321597,CDM,981,RC,64447,HCPCS,Outpatient,,,124.16,62.08,,111.74,90,,,percent of total billed charges,90% of total Billed charges,146.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.21,155,,,Fee Schedule,155% of CMS OPPS Rate,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.21,155,,,Fee Schedule,155% of CMS OPPS Rate,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.26,155,,,Fee Schedule,155% of CMS OPPS Rate,227.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,238,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.4,238,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,360,RC,64450,HCPCS,Outpatient,,,191.07,95.54,,171.96,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,152.86,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.96,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.34,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,175.78,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.96,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,133.75,70,,,percent of total billed charges,70% of total billed charges,171.96,90,,,percent of total billed charges,90% of total billed charges,181.52,95,,,percent of total billed charges,95% of total billed charges,181.52,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.32,86,,,percent of total billed charges,86% of total billed charges,152.86,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.34,97,,,percent of total billed charges,97% of total billed charges,171.96,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.34,97,,,percent of total billed charges,97% of total billed charges,177.7,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.34,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,3141.23,
64450-PF INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH,4321596,CDM,981,RC,64450,HCPCS,Outpatient,,,81.6,40.80,,73.44,90,,,percent of total billed charges,90% of total Billed charges,112.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.7,90,,,Percent of total Billed charges,90% of total billed charges,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,63.22,155,,,Fee Schedule,155% of CMS OPPS Rate,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,49.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,63.22,155,,,Fee Schedule,155% of CMS OPPS Rate,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.58,155,,,Fee Schedule,155% of CMS OPPS Rate,174.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,210.8,
64455-PF NJX AA&/STRD PLANTAR COMMON DIGITAL NERVES,4321595,CDM,981,RC,64455,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,81.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.51,155,,,Fee Schedule,155% of CMS OPPS Rate,33.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,51.51,155,,,Fee Schedule,155% of CMS OPPS Rate,33.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.14,155,,,Fee Schedule,155% of CMS OPPS Rate,126.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,33.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,95.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33.23,126.14,
64520-PF INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC,4321594,CDM,981,RC,64520,HCPCS,Outpatient,,,161.24,80.62,,145.12,90,,,percent of total billed charges,90% of total Billed charges,241.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,124.96,155,,,Fee Schedule,155% of CMS OPPS Rate,80.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,124.96,155,,,Fee Schedule,155% of CMS OPPS Rate,80.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.88,155,,,Fee Schedule,155% of CMS OPPS Rate,374.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,80.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,393.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,393.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54,393.04,
64561 Percutaneous neurostimulator,3428327,CDM,960,RC,64561,HCPCS,Outpatient,,,706.19,353.10,,635.57,90,,,percent of total billed charges,90% of total Billed charges,1002.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,546.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,355.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1554.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1288.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1545.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1545.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,297.41,1554.28,
64581- Implant neurostim electrode/sacral,3435405,CDM,510,RC,64581,HCPCS,Outpatient,,,1735.96,867.98,,1562.36,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1388.77,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1562.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1683.88,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1597.08,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1562.36,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.17,70,,,percent of total billed charges,70% of total billed charges,1562.36,90,,,percent of total billed charges,90% of total billed charges,1649.16,95,,,percent of total billed charges,95% of total billed charges,1649.16,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1492.93,86,,,percent of total billed charges,86% of total billed charges,1388.77,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1683.88,97,,,percent of total billed charges,97% of total billed charges,1562.36,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1683.88,97,,,percent of total billed charges,97% of total billed charges,1614.44,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1683.88,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1215.17,32194.6,
64585- Revise/rmv/perph neurostim electro,3435406,CDM,510,RC,64585,HCPCS,Outpatient,,,615.13,307.57,,553.62,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,492.1,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,596.68,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,565.92,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,553.62,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,430.59,70,,,percent of total billed charges,70% of total billed charges,553.62,90,,,percent of total billed charges,90% of total billed charges,584.37,95,,,percent of total billed charges,95% of total billed charges,584.37,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,529.01,86,,,percent of total billed charges,86% of total billed charges,492.1,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,596.68,97,,,percent of total billed charges,97% of total billed charges,553.62,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,596.68,97,,,percent of total billed charges,97% of total billed charges,572.07,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,596.68,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,430.59,15832.85,
64590- Ins/rpl prph sac/gstr npgr,3435407,CDM,510,RC,64590,HCPCS,Outpatient,,,666.45,333.23,,599.81,90,,,percent of total billed charges,90% of total Billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,533.16,80,,,Percent of total Billed charges,80% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,646.46,97,,,Percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,613.13,92,,,Percent of total billed charges,92% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,51943.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82809.03,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,104890.11,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,599.81,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,466.52,70,,,percent of total billed charges,70% of total billed charges,599.81,90,,,percent of total billed charges,90% of total billed charges,633.13,95,,,percent of total billed charges,95% of total billed charges,633.13,95,,,percent of total billed charges,95% of total billed charges,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39083.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,573.15,86,,,percent of total billed charges,86% of total billed charges,533.16,80,,,percent of total billed charges,80% of total billed charges,19932.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,646.46,97,,,percent of total billed charges,97% of total billed charges,599.81,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,646.46,97,,,percent of total billed charges,97% of total billed charges,619.8,93,,,percent of total billed charges,93% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,646.46,97,,,percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,19541.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16610.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,466.52,104890.11,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,510,RC,64595,HCPCS,Outpatient,,,580.66,290.33,,522.59,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,464.53,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,563.24,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,534.21,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,522.59,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,406.46,70,,,percent of total billed charges,70% of total billed charges,522.59,90,,,percent of total billed charges,90% of total billed charges,551.63,95,,,percent of total billed charges,95% of total billed charges,551.63,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,499.37,86,,,percent of total billed charges,86% of total billed charges,464.53,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,563.24,97,,,percent of total billed charges,97% of total billed charges,522.59,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.24,97,,,percent of total billed charges,97% of total billed charges,540.01,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,563.24,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,406.46,15832.85,
64831-PF SUTURE DIGITAL NERVE HAND/FOOT 1 NERVE,4321592,CDM,981,RC,64831,HCPCS,Outpatient,,,1349.3,674.65,,1214.37,90,,,percent of total billed charges,90% of total Billed charges,1350,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,674.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,412,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1045.69,155,,,Fee Schedule,155% of CMS OPPS Rate,674.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,856.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,674.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,963.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1026.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1026.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,645.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1211.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,802.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1045.69,155,,,Fee Schedule,155% of CMS OPPS Rate,674.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,2092.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2092.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,674.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,412,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,638.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,674.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1397.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1397.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,412,2092.5,
64999-PF UNLISTED PROCEDURE NERVOUS SYSTEM,4321486,CDM,981,RC,64999,HCPCS,Outpatient,,,208,104.00,,187.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.4,187.2,
65093 - Revise Eye w/ Implant,4189313,CDM,960,RC,65093,HCPCS,Outpatient,,,1405.18,702.59,,1264.66,90,,,percent of total billed charges,90% of total Billed charges,1377.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,683.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1059.52,155,,,Fee Schedule,155% of CMS OPPS Rate,683.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1047.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,683.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1178.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,962.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,962.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,495.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1367.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1135.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,678.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1059.52,155,,,Fee Schedule,155% of CMS OPPS Rate,683.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2134.92,155,,,Fee Schedule,155% of CMS OPPS Rate,2134.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,683.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,671.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,683.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1279.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1279.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2134.92,
65101 - Enucleation of eye; without implant,3899071,CDM,983,RC,65101,HCPCS,Outpatient,,,1623.96,811.98,,1461.56,90,,,percent of total billed charges,90% of total Billed charges,1587.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,788.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,478.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1222.7,155,,,Fee Schedule,155% of CMS OPPS Rate,788.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1218.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1370.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1370.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1120.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1120.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,582.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,788.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1577.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1321.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,788.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1222.7,155,,,Fee Schedule,155% of CMS OPPS Rate,788.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2460.58,155,,,Fee Schedule,155% of CMS OPPS Rate,2460.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,788.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,478.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,684.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,788.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1505.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1505.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,478.5,2460.58,
"65103 - PF Enucleation of eye; with implant, muscles not attached to implant",3715277,CDM,960,RC,65103,HCPCS,Outpatient,,,1679.85,839.93,,1511.87,90,,,percent of total billed charges,90% of total Billed charges,1638.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,813.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1260.97,155,,,Fee Schedule,155% of CMS OPPS Rate,813.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1263.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,813.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1421.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1421.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1163.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1163.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,606.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,813.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1627.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1372.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,818.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1260.97,155,,,Fee Schedule,155% of CMS OPPS Rate,813.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2538.95,155,,,Fee Schedule,155% of CMS OPPS Rate,2538.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,813.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,813.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1575.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1575.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,2538.95,
"65135 - Insertion of ocular implant secondary; after enucleation, muscles not attached to implant",3800918,CDM,983,RC,65135,HCPCS,Outpatient,,,1651.44,825.72,,1486.3,90,,,percent of total billed charges,90% of total Billed charges,1612.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,801.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,525,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1242.28,155,,,Fee Schedule,155% of CMS OPPS Rate,801.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,801.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1381.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1381.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1130.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1130.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,584.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1602.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1334.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,795.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1242.28,155,,,Fee Schedule,155% of CMS OPPS Rate,801.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2499.65,155,,,Fee Schedule,155% of CMS OPPS Rate,2499.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,801.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,707.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,801.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1519.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1519.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,525,2499.65,
65205- Remove FB/extern eye/Conjunc/sup,3431303,CDM,960,RC,65205,HCPCS,Outpatient,,,57.13,28.57,,51.42,90,,,percent of total billed charges,90% of total Billed charges,56.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.29,155,,,Fee Schedule,155% of CMS OPPS Rate,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,43.29,155,,,Fee Schedule,155% of CMS OPPS Rate,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.86,155,,,Fee Schedule,155% of CMS OPPS Rate,86.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,110.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.93,110.84,
65205-PF REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL,4321591,CDM,981,RC,65205,HCPCS,Outpatient,,,57.13,28.57,,51.42,90,,,percent of total billed charges,90% of total Billed charges,56.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.29,155,,,Fee Schedule,155% of CMS OPPS Rate,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,43.29,155,,,Fee Schedule,155% of CMS OPPS Rate,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.86,155,,,Fee Schedule,155% of CMS OPPS Rate,86.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,110.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.93,110.84,
65210- Rmv FB/conjunc/sub/sclera/nonperf,3431304,CDM,960,RC,65210,HCPCS,Outpatient,,,70.26,35.13,,63.23,90,,,percent of total billed charges,90% of total Billed charges,71.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.21,155,,,Fee Schedule,155% of CMS OPPS Rate,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,37.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.21,155,,,Fee Schedule,155% of CMS OPPS Rate,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.04,155,,,Fee Schedule,155% of CMS OPPS Rate,111.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,138.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.33,138.72,
65210-PF RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR,4321590,CDM,981,RC,65210,HCPCS,Outpatient,,,70.26,35.13,,63.23,90,,,percent of total billed charges,90% of total Billed charges,71.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.21,155,,,Fee Schedule,155% of CMS OPPS Rate,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,37.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.21,155,,,Fee Schedule,155% of CMS OPPS Rate,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.04,155,,,Fee Schedule,155% of CMS OPPS Rate,111.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,138.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.33,138.72,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,75.01,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,66.67,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.01,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.84,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,76.67,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,75.01,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,58.34,70,,,percent of total billed charges,70% of total billed charges,75.01,90,,,percent of total billed charges,90% of total billed charges,79.17,95,,,percent of total billed charges,95% of total billed charges,79.17,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.67,86,,,percent of total billed charges,86% of total billed charges,66.67,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.84,97,,,percent of total billed charges,97% of total billed charges,75.01,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.84,97,,,percent of total billed charges,97% of total billed charges,77.51,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.84,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,1840.7,
65220-PF RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP,4321589,CDM,981,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,75.01,90,,,percent of total billed charges,90% of total Billed charges,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.44,90,,,Percent of total Billed charges,90% of total billed charges,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.42,155,,,Fee Schedule,155% of CMS OPPS Rate,151.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,897.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.5,897.45,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,88.95,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,79.06,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.95,90,,,Percent of total Billed charges,90% of total billed charges,28.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,95.87,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,90.92,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,88.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,69.18,70,,,percent of total billed charges,70% of total billed charges,88.95,90,,,percent of total billed charges,90% of total billed charges,93.89,95,,,percent of total billed charges,95% of total billed charges,93.89,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,84.99,86,,,percent of total billed charges,86% of total billed charges,79.06,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,95.87,97,,,percent of total billed charges,97% of total billed charges,88.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.87,97,,,percent of total billed charges,97% of total billed charges,91.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.87,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26,566.05,
65222-PF RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP,4321588,CDM,981,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,88.95,90,,,percent of total billed charges,90% of total Billed charges,110.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.8,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.42,155,,,Fee Schedule,155% of CMS OPPS Rate,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.42,155,,,Fee Schedule,155% of CMS OPPS Rate,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.85,155,,,Fee Schedule,155% of CMS OPPS Rate,171.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,153,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,171.85,
65435- Rmv corneal epith/w w/o chem caut,3431307,CDM,510,RC,65435,HCPCS,Outpatient,,,204.02,102.01,,183.62,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,163.22,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.62,90,,,Percent of total Billed charges,90% of total billed charges,61.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,197.9,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,187.7,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,183.62,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,142.81,70,,,percent of total billed charges,70% of total billed charges,183.62,90,,,percent of total billed charges,90% of total billed charges,193.82,95,,,percent of total billed charges,95% of total billed charges,193.82,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,175.46,86,,,percent of total billed charges,86% of total billed charges,163.22,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,197.9,97,,,percent of total billed charges,97% of total billed charges,183.62,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,197.9,97,,,percent of total billed charges,97% of total billed charges,189.74,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.9,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55.95,4254.22,
65435-PF RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION,4321487,CDM,981,RC,65435,HCPCS,Outpatient,,,128.98,64.49,,116.08,90,,,percent of total billed charges,90% of total Billed charges,141.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,99.94,155,,,Fee Schedule,155% of CMS OPPS Rate,64.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,100.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,100.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,72.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,99.94,155,,,Fee Schedule,155% of CMS OPPS Rate,64.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.86,155,,,Fee Schedule,155% of CMS OPPS Rate,218.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,64.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.91,218.86,
66821- Cataract/secondar/discission/laser,3431308,CDM,510,RC,66821,HCPCS,Outpatient,,,822.4,411.20,,740.16,90,,,percent of total billed charges,90% of total Billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,657.92,80,,,Percent of total Billed charges,80% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,740.16,90,,,Percent of total Billed charges,90% of total billed charges,238.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,797.73,97,,,Percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,756.61,92,,,Percent of total billed charges,92% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2042.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2587.57,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,740.16,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,575.68,70,,,percent of total billed charges,70% of total billed charges,740.16,90,,,percent of total billed charges,90% of total billed charges,781.28,95,,,percent of total billed charges,95% of total billed charges,781.28,95,,,percent of total billed charges,95% of total billed charges,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,707.26,86,,,percent of total billed charges,86% of total billed charges,657.92,80,,,percent of total billed charges,80% of total billed charges,524.1,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,797.73,97,,,percent of total billed charges,97% of total billed charges,740.16,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.73,97,,,percent of total billed charges,97% of total billed charges,764.83,93,,,percent of total billed charges,93% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,797.73,97,,,percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,409.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.51,2587.57,
66984- Extracaps catarac rmv/w lens prost,3431309,CDM,510,RC,66984,HCPCS,Outpatient,,,1356.41,678.21,,1220.77,90,,,percent of total billed charges,90% of total Billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.13,80,,,Percent of total Billed charges,80% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.77,90,,,Percent of total Billed charges,90% of total billed charges,662.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1315.72,97,,,Percent of total billed charges,97% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.9,92,,,Percent of total billed charges,92% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5213.45,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1961.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8311.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10527.54,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1220.77,90,,,percent of total billed charges,90% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate,949.49,70,,,percent of total billed charges,70% of total billed charges,1220.77,90,,,percent of total billed charges,90% of total billed charges,1288.59,95,,,percent of total billed charges,95% of total billed charges,1288.59,95,,,percent of total billed charges,95% of total billed charges,1961.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3922.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1166.51,86,,,percent of total billed charges,86% of total billed charges,1085.13,80,,,percent of total billed charges,80% of total billed charges,2090.34,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1315.72,97,,,percent of total billed charges,97% of total billed charges,1220.77,90,,,percent of total billed charges,90% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.72,97,,,percent of total billed charges,97% of total billed charges,1261.46,93,,,percent of total billed charges,93% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,602.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1315.72,97,,,percent of total billed charges,97% of total billed charges,1961.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1961.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1667.12,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,602.53,10527.54,
67229- Tx retionpathy/preterm/birth-1yr,3431311,CDM,510,RC,67229,HCPCS,Outpatient,,,2896.83,1448.42,,2607.15,90,,,percent of total billed charges,90% of total Billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2317.46,80,,,Percent of total Billed charges,80% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2607.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2809.93,97,,,Percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2665.08,92,,,Percent of total billed charges,92% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2042.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2587.57,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2607.15,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2027.78,70,,,percent of total billed charges,70% of total billed charges,2607.15,90,,,percent of total billed charges,90% of total billed charges,2751.99,95,,,percent of total billed charges,95% of total billed charges,2751.99,95,,,percent of total billed charges,95% of total billed charges,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2491.27,86,,,percent of total billed charges,86% of total billed charges,2317.46,80,,,percent of total billed charges,80% of total billed charges,524.1,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2809.93,97,,,percent of total billed charges,97% of total billed charges,2607.15,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2809.93,97,,,percent of total billed charges,97% of total billed charges,2694.05,93,,,percent of total billed charges,93% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2809.93,97,,,percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,409.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,409.76,2809.93,
67299- Unlisted procedure/post seg/eye,3431312,CDM,510,RC,67229,HCPCS,Outpatient,,,2896.83,1448.42,,2607.15,90,,,percent of total billed charges,90% of total Billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2317.46,80,,,Percent of total Billed charges,80% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2607.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2809.93,97,,,Percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2665.08,92,,,Percent of total billed charges,92% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2042.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2587.57,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2607.15,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,2027.78,70,,,percent of total billed charges,70% of total billed charges,2607.15,90,,,percent of total billed charges,90% of total billed charges,2751.99,95,,,percent of total billed charges,95% of total billed charges,2751.99,95,,,percent of total billed charges,95% of total billed charges,482.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,964.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2491.27,86,,,percent of total billed charges,86% of total billed charges,2317.46,80,,,percent of total billed charges,80% of total billed charges,524.1,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2809.93,97,,,percent of total billed charges,97% of total billed charges,2607.15,90,,,percent of total billed charges,90% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2809.93,97,,,percent of total billed charges,97% of total billed charges,2694.05,93,,,percent of total billed charges,93% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2809.93,97,,,percent of total billed charges,97% of total billed charges,482.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,409.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,409.76,2809.93,
"67400 Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or",3622572,CDM,960,RC,67400,HCPCS,Outpatient,,,1988.43,994.22,,1789.59,90,,,percent of total billed charges,90% of total Billed charges,1941.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,965.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,663,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1496.23,155,,,Fee Schedule,155% of CMS OPPS Rate,965.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1510.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,965.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1699.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1699.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1397.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1397.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,732.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,965.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1930.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1649.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,988.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1496.23,155,,,Fee Schedule,155% of CMS OPPS Rate,965.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,3009.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3009.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,965.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,663,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,852.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,965.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1906.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1906.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,663,3009.28,
67412 - Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion,3572815,CDM,960,RC,67412,HCPCS,Outpatient,,,1893.2,946.60,,1703.88,90,,,percent of total billed charges,90% of total Billed charges,1859.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,921.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,586,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1428.71,155,,,Fee Schedule,155% of CMS OPPS Rate,921.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1415.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1592.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1592.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1308.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1308.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,669.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,921.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1843.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1543.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,926.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1428.71,155,,,Fee Schedule,155% of CMS OPPS Rate,921.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2881.62,155,,,Fee Schedule,155% of CMS OPPS Rate,2881.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,921.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,586,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,917.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,921.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1740.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1740.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,586,2881.62,
67413 - PF Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of for,3715383,CDM,960,RC,67413,HCPCS,Outpatient,,,1846.18,923.09,,1661.56,90,,,percent of total billed charges,90% of total Billed charges,1811.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,900.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1396.3,155,,,Fee Schedule,155% of CMS OPPS Rate,900.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1398.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,900.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1573.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1573.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1294.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1294.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,672.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1801.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1527.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,920.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1396.3,155,,,Fee Schedule,155% of CMS OPPS Rate,900.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2807.7,155,,,Fee Schedule,155% of CMS OPPS Rate,2807.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,900.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,859.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,900.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1756.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1756.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,672.89,2807.7,
67700-PF BLEPHAROTOMY DRAINAGE ABSCESS EYELID,4321488,CDM,981,RC,67700,HCPCS,Outpatient,,,224.66,112.33,,202.19,90,,,percent of total billed charges,90% of total Billed charges,332.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.79,155,,,Fee Schedule,155% of CMS OPPS Rate,515.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,507.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,507.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.81,515.79,
67800 - PF Excision of chalazion; single,4371199,CDM,960,RC,67800,HCPCS,Outpatient,,,199,99.50,,179.1,90,,,percent of total billed charges,90% of total Billed charges,215.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.46,155,,,Fee Schedule,155% of CMS OPPS Rate,334.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.49,334.46,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,230.9,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,205.25,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.86,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,236.04,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.9,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,179.59,70,,,percent of total billed charges,70% of total billed charges,230.9,90,,,percent of total billed charges,90% of total billed charges,243.73,95,,,percent of total billed charges,95% of total billed charges,243.73,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,220.64,86,,,percent of total billed charges,86% of total billed charges,205.25,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.86,97,,,percent of total billed charges,97% of total billed charges,230.9,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.86,97,,,percent of total billed charges,97% of total billed charges,238.6,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248.86,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,179.59,4254.22,
"67801- PF Excision Chalazion Mltpl,Les, same eyelid",4347142,CDM,960,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,230.9,90,,,percent of total billed charges,90% of total Billed charges,276.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.38,155,,,Fee Schedule,155% of CMS OPPS Rate,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,191.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,191.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,193.38,155,,,Fee Schedule,155% of CMS OPPS Rate,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.09,155,,,Fee Schedule,155% of CMS OPPS Rate,429.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,359,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,104.62,429.09,
"67808- PF Excision Chalazion Mltpl,Les, same eyelid",4347143,CDM,960,RC,67808,HCPCS,Outpatient,,,712.32,356.16,,641.09,90,,,percent of total billed charges,90% of total Billed charges,685.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.7,155,,,Fee Schedule,155% of CMS OPPS Rate,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,527.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,527.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,290.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,621.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.7,155,,,Fee Schedule,155% of CMS OPPS Rate,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1062.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1062.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,762.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,290.19,1062.17,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,457.08,228.54,,411.37,90,,,percent of total billed charges,90% of total Billed charges,237.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.22,155,,,Fee Schedule,155% of CMS OPPS Rate,368.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.01,422.28,
67810- Incisional biopsy/eyelid,3431318,CDM,510,RC,67810,HCPCS,Outpatient,,,135.17,67.59,,121.65,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,108.14,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,131.11,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,124.36,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,121.65,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,94.62,70,,,percent of total billed charges,70% of total billed charges,121.65,90,,,percent of total billed charges,90% of total billed charges,128.41,95,,,percent of total billed charges,95% of total billed charges,128.41,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,116.25,86,,,percent of total billed charges,86% of total billed charges,108.14,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,131.11,97,,,percent of total billed charges,97% of total billed charges,121.65,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.11,97,,,percent of total billed charges,97% of total billed charges,125.71,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131.11,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94.62,1290.49,
67820- PF Correction Trichiasis Epilation Forceps Only,4347144,CDM,960,RC,67820,HCPCS,Outpatient,,,43.21,21.61,,38.89,90,,,percent of total billed charges,90% of total Billed charges,39.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.7,155,,,Fee Schedule,155% of CMS OPPS Rate,60.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.73,104.16,
"67825 - PF Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryothe",3700901,CDM,960,RC,67825,HCPCS,Outpatient,,,235.11,117.56,,211.6,90,,,percent of total billed charges,90% of total Billed charges,239.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.03,155,,,Fee Schedule,155% of CMS OPPS Rate,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,203.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,122.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.03,155,,,Fee Schedule,155% of CMS OPPS Rate,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.62,155,,,Fee Schedule,155% of CMS OPPS Rate,370.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,252.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,261.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,95.7,370.62,
67825 - PF Correction Trichiasis Epilation Other Than Forceps,4347145,CDM,960,RC,67825,HCPCS,Outpatient,,,235.11,117.56,,211.6,90,,,percent of total billed charges,90% of total Billed charges,239.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.03,155,,,Fee Schedule,155% of CMS OPPS Rate,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,203.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,122.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.03,155,,,Fee Schedule,155% of CMS OPPS Rate,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.62,155,,,Fee Schedule,155% of CMS OPPS Rate,370.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,252.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,261.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,95.7,370.62,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,305.03,152.52,,274.53,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,244.02,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,295.88,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,280.63,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,274.53,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,213.52,70,,,percent of total billed charges,70% of total billed charges,274.53,90,,,percent of total billed charges,90% of total billed charges,289.78,95,,,percent of total billed charges,95% of total billed charges,289.78,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,262.33,86,,,percent of total billed charges,86% of total billed charges,244.02,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,295.88,97,,,percent of total billed charges,97% of total billed charges,274.53,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.88,97,,,percent of total billed charges,97% of total billed charges,283.68,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,295.88,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,213.52,4254.22,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,695.43,347.72,,625.89,90,,,percent of total billed charges,90% of total Billed charges,409.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,267.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.12,155,,,Fee Schedule,155% of CMS OPPS Rate,634.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.6,634.12,
67850- PF Destruction Lesion Lid Margn <1cm,4347146,CDM,960,RC,67850,HCPCS,Outpatient,,,255.86,127.93,,230.27,90,,,percent of total billed charges,90% of total Billed charges,324.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,224.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,135.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,502.57,155,,,Fee Schedule,155% of CMS OPPS Rate,502.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.71,502.57,
67875 - PF Temp Closure Eyelids Suture,4347147,CDM,960,RC,67875,HCPCS,Outpatient,,,186.79,93.40,,168.11,90,,,percent of total billed charges,90% of total Billed charges,258.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.14,155,,,Fee Schedule,155% of CMS OPPS Rate,401.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.79,454,
67880- PF Construction Intermargin Adhes/Tarsorrh/Canthorrh,4347148,CDM,960,RC,67880,HCPCS,Outpatient,,,712.32,356.16,,641.09,90,,,percent of total billed charges,90% of total Billed charges,778.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,290.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,373.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,587.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,918.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,918.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,290.41,1205.98,
67900- PF Rpr Brown Ptosis,4347149,CDM,960,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,885.94,90,,,percent of total billed charges,90% of total Billed charges,1082.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,401.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,529.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1677.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1677.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,631.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1292,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1292,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,401.67,1677.66,
67900- Repair brow ptosis,3431324,CDM,960,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,885.94,90,,,percent of total billed charges,90% of total Billed charges,1082.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,401.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,529.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1677.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1677.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,631.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1292,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1292,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,401.67,1677.66,
67901- PF Rpr Blepharoptosis Frontalis Musc Sutr/Oth Matrl,4347150,CDM,960,RC,67901,HCPCS,Outpatient,,,1141.66,570.83,,1027.49,90,,,percent of total billed charges,90% of total Billed charges,1294.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855,155,,,Fee Schedule,155% of CMS OPPS Rate,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,551.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1008.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1008.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,839.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,839.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,454.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,990.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,855,155,,,Fee Schedule,155% of CMS OPPS Rate,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,2006.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2006.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.39,2006.1,
67903- Blepharoptosis/levator resct/int,3431325,CDM,510,RC,67903,HCPCS,Outpatient,,,1505.09,752.55,,1354.58,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1204.07,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1354.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1459.94,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1384.68,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1354.58,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1053.56,70,,,percent of total billed charges,70% of total billed charges,1354.58,90,,,percent of total billed charges,90% of total billed charges,1429.84,95,,,percent of total billed charges,95% of total billed charges,1429.84,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1294.38,86,,,percent of total billed charges,86% of total billed charges,1204.07,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1459.94,97,,,percent of total billed charges,97% of total billed charges,1354.58,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1459.94,97,,,percent of total billed charges,97% of total billed charges,1399.73,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.94,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1053.56,10307.08,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,510,RC,67903,HCPCS,Outpatient,,,1505.09,752.55,,1354.58,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1204.07,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1354.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1459.94,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1384.68,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1354.58,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1053.56,70,,,percent of total billed charges,70% of total billed charges,1354.58,90,,,percent of total billed charges,90% of total billed charges,1429.84,95,,,percent of total billed charges,95% of total billed charges,1429.84,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1294.38,86,,,percent of total billed charges,86% of total billed charges,1204.07,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1459.94,97,,,percent of total billed charges,97% of total billed charges,1354.58,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1459.94,97,,,percent of total billed charges,97% of total billed charges,1399.73,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.94,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1053.56,10307.08,
67904 - PF Repair of blepharoptosis; (tarso) levator resecti,3641193,CDM,510,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,1041.41,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,925.7,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1041.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1122.41,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1064.55,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1041.41,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,809.98,70,,,percent of total billed charges,70% of total billed charges,1041.41,90,,,percent of total billed charges,90% of total billed charges,1099.26,95,,,percent of total billed charges,95% of total billed charges,1099.26,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,995.12,86,,,percent of total billed charges,86% of total billed charges,925.7,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1122.41,97,,,percent of total billed charges,97% of total billed charges,1041.41,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1122.41,97,,,percent of total billed charges,97% of total billed charges,1076.12,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1122.41,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,809.98,10307.08,
67904- Blepharoptosis/levator resct/ext,3431326,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,1041.41,90,,,percent of total billed charges,90% of total Billed charges,1250.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1029.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,470.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,614.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1938.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,756.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1485.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,470.57,1938.29,
67904- PF Rpr Blepharoptosis Levator Resc/Advmnt Xtrnl,4347151,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,1041.41,90,,,percent of total billed charges,90% of total Billed charges,1250.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1029.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,470.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,614.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1938.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,756.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1485.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,470.57,1938.29,
67909- PF Reduction Overcorrection Ptosis,4347152,CDM,960,RC,67909,HCPCS,Outpatient,,,846.9,423.45,,762.21,90,,,percent of total billed charges,90% of total Billed charges,923.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,452.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1431.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1431.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,559.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1082.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1082.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,345.97,1431.67,
67911- Correction of lid retraction,3566797,CDM,960,RC,67911,HCPCS,Outpatient,,,1086.63,543.32,,977.97,90,,,percent of total billed charges,90% of total Billed charges,1046.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,522.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.89,155,,,Fee Schedule,155% of CMS OPPS Rate,522.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,859.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,522.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,967.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,967.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,806.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,806.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,442.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1045.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,951.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,576.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,809.89,155,,,Fee Schedule,155% of CMS OPPS Rate,522.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1622.14,155,,,Fee Schedule,155% of CMS OPPS Rate,1622.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,522.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,476.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,522.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,1168.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1168.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,442.79,1622.14,
67912- Lagophthalmos/implt up eyelid load,3431328,CDM,960,RC,67912,HCPCS,Outpatient,,,948.74,474.37,,853.87,90,,,percent of total billed charges,90% of total Billed charges,1302.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.05,155,,,Fee Schedule,155% of CMS OPPS Rate,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,457.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,840.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,701.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,701.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,386.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,914.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,827.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,510.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,709.05,155,,,Fee Schedule,155% of CMS OPPS Rate,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2019.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2019.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,969.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1717.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1717.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,386.72,2019.5,
67914 - Repair of ectropion; suture,3572816,CDM,960,RC,67914,HCPCS,Outpatient,,,635.26,317.63,,571.73,90,,,percent of total billed charges,90% of total Billed charges,757.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.98,155,,,Fee Schedule,155% of CMS OPPS Rate,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,563.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,464.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,464.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,258.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,547.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,329.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,470.98,155,,,Fee Schedule,155% of CMS OPPS Rate,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1173.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,601.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,303.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,774.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,774.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,258.78,1173.63,
67917- Repair ectropion/extensive,3431329,CDM,960,RC,67917,HCPCS,Outpatient,,,884.23,442.12,,795.81,90,,,percent of total billed charges,90% of total Billed charges,1010,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.25,155,,,Fee Schedule,155% of CMS OPPS Rate,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,469.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,660.25,155,,,Fee Schedule,155% of CMS OPPS Rate,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1565.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,597.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1183.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.96,1565.5,
67923- Rpr entropion/excise tarsal wedge,3431330,CDM,960,RC,67923,HCPCS,Outpatient,,,832.21,416.11,,748.99,90,,,percent of total billed charges,90% of total Billed charges,969.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.64,155,,,Fee Schedule,155% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,400.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,742.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,616.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,616.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,339.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,439.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,620.64,155,,,Fee Schedule,155% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1502.59,155,,,Fee Schedule,155% of CMS OPPS Rate,1502.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,791.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1147.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1147.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,339.38,1502.59,
"67924 - PF Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs opera",3641194,CDM,960,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,795.52,90,,,percent of total billed charges,90% of total Billed charges,1031.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,468.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1599.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1599.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,579.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1179.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.9,1599.04,
67924- Repair entropion/extensive,3431331,CDM,960,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,795.52,90,,,percent of total billed charges,90% of total Billed charges,1031.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,468.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1599.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1599.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,579.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1179.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.9,1599.04,
67950- Canthoplasty/reconstruct canthus,3431334,CDM,960,RC,67950,HCPCS,Outpatient,,,896.57,448.29,,806.91,90,,,percent of total billed charges,90% of total Billed charges,980.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.13,155,,,Fee Schedule,155% of CMS OPPS Rate,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,432.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,798.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,664.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,664.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,365.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,784.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,477.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,670.13,155,,,Fee Schedule,155% of CMS OPPS Rate,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1519.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1519.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,552.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1155.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365.55,1519.48,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,791.69,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,703.72,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,853.26,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,809.28,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,791.69,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,615.76,70,,,percent of total billed charges,70% of total billed charges,791.69,90,,,percent of total billed charges,90% of total billed charges,835.67,95,,,percent of total billed charges,95% of total billed charges,835.67,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,756.5,86,,,percent of total billed charges,86% of total billed charges,703.72,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,853.26,97,,,percent of total billed charges,97% of total billed charges,791.69,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,853.26,97,,,percent of total billed charges,97% of total billed charges,818.07,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,853.26,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,615.76,10307.08,
67961- PF Excision & Rpr Eyelid < 1/4 Lid Margin,4347153,CDM,960,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,791.69,90,,,percent of total billed charges,90% of total Billed charges,970.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,784.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,358.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,466.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1504.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,542.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1158.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,358.5,1504.88,
67966- PF Excision & Rpr Eyelid 1/4 Lid Margin,4347154,CDM,960,RC,67966,HCPCS,Outpatient,,,1271.3,635.65,,1144.17,90,,,percent of total billed charges,90% of total Billed charges,1342.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.27,155,,,Fee Schedule,155% of CMS OPPS Rate,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,612.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1132.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1132.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,946.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,946.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,517.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1224.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1116.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,679.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,949.27,155,,,Fee Schedule,155% of CMS OPPS Rate,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2081.14,155,,,Fee Schedule,155% of CMS OPPS Rate,2081.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,611.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1572.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1572.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,517.37,2081.14,
"67971 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing e",3622247,CDM,960,RC,67971,HCPCS,Outpatient,,,1397.84,698.92,,1258.06,90,,,percent of total billed charges,90% of total Billed charges,1351.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,674.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.57,155,,,Fee Schedule,155% of CMS OPPS Rate,674.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1108.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,674.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1246.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1246.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1042.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1042.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,568.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,674.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1230.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,748.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1045.57,155,,,Fee Schedule,155% of CMS OPPS Rate,674.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2095.32,155,,,Fee Schedule,155% of CMS OPPS Rate,2095.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,674.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,835.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,674.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1517.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,568.94,2095.32,
67973 - Reconstruction of Eyelid,3899074,CDM,983,RC,67973,HCPCS,Outpatient,,,1802.23,901.12,,1622.01,90,,,percent of total billed charges,90% of total Billed charges,1738.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,867.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1345.11,155,,,Fee Schedule,155% of CMS OPPS Rate,867.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1426.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,867.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1604.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1604.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1344,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1344,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,731.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1735.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1585.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,965.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1345.11,155,,,Fee Schedule,155% of CMS OPPS Rate,867.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,2694.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2694.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,867.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1144.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,867.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1960.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,731.77,2694.44,
67975- EYE RECONSTRUCTION OF EYELID,3514655,CDM,960,RC,67975,HCPCS,Outpatient,,,1323.2,661.60,,1190.88,90,,,percent of total billed charges,90% of total Billed charges,1278.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,638.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,989.5,155,,,Fee Schedule,155% of CMS OPPS Rate,638.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1050.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,638.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1181.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1181.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,987.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,987.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,538.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,638.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1276.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1165.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,710.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,989.5,155,,,Fee Schedule,155% of CMS OPPS Rate,638.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1982.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1982.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,638.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,607.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,638.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1434.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1434.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,538.41,1982.05,
"67999 - PF Unlisted Procedure, Eyelids",4309237,CDM,960,RC,67999,HCPCS,Outpatient,,,696,348.00,,626.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,626.4,
"68020 - Incision of conjunctiva, drainage of cyst",3899075,CDM,983,RC,68020,HCPCS,Outpatient,,,213.14,106.57,,191.83,90,,,percent of total billed charges,90% of total Billed charges,216.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.37,155,,,Fee Schedule,155% of CMS OPPS Rate,102.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.37,155,,,Fee Schedule,155% of CMS OPPS Rate,102.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.92,155,,,Fee Schedule,155% of CMS OPPS Rate,334.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,102.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,102.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.88,334.92,
68320 - Conjunctivoplasty; with conjunctival graft or extensive rearrangement,3572817,CDM,960,RC,68320,HCPCS,Outpatient,,,1042.53,521.27,,938.28,90,,,percent of total billed charges,90% of total Billed charges,1191.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,501.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777,155,,,Fee Schedule,155% of CMS OPPS Rate,501.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,501.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,929.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,769.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,769.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,425.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,501.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1002.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,907.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,547.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,777,155,,,Fee Schedule,155% of CMS OPPS Rate,501.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1847.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1847.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,501.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,481.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,501.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1447.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,425.05,1847.15,
68330 - Revise Eyelid Lining,4189314,CDM,960,RC,68330,HCPCS,Outpatient,,,889.28,444.64,,800.35,90,,,percent of total billed charges,90% of total Billed charges,1006.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,427.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.59,155,,,Fee Schedule,155% of CMS OPPS Rate,427.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,427.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,793.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,793.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,657.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,657.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,363.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,775.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,467.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,662.59,155,,,Fee Schedule,155% of CMS OPPS Rate,427.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1559.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1559.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,427.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,427.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1211.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,363.43,1559.89,
68420- Incise/drain tear sac,3431338,CDM,510,RC,68420,HCPCS,Outpatient,,,821.84,410.92,,739.66,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,657.47,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,739.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,797.18,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,756.09,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,739.66,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,575.29,70,,,percent of total billed charges,70% of total billed charges,739.66,90,,,percent of total billed charges,90% of total billed charges,780.75,95,,,percent of total billed charges,95% of total billed charges,780.75,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,706.78,86,,,percent of total billed charges,86% of total billed charges,657.47,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,797.18,97,,,percent of total billed charges,97% of total billed charges,739.66,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.18,97,,,percent of total billed charges,97% of total billed charges,764.31,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,797.18,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,575.29,10307.08,
68440- PF Snip Incision Lacrimal Punctum,4347155,CDM,960,RC,68440,HCPCS,Outpatient,,,191.61,95.81,,172.45,90,,,percent of total billed charges,90% of total Billed charges,187.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.23,155,,,Fee Schedule,155% of CMS OPPS Rate,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,139.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,139.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.23,155,,,Fee Schedule,155% of CMS OPPS Rate,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.31,155,,,Fee Schedule,155% of CMS OPPS Rate,291.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,310.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.18,310.19,
68510 Biopsy of lacrimal gland,3621571,CDM,960,RC,68510,HCPCS,Outpatient,,,563.26,281.63,,506.93,90,,,percent of total billed charges,90% of total Billed charges,696.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.18,155,,,Fee Schedule,155% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,503.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,427.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,427.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,543.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,504.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,312.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,421.18,155,,,Fee Schedule,155% of CMS OPPS Rate,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1079.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1079.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,628.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,271.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,899.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,228.83,1079.2,
68700 Plastic repair of canaliculi,3622075,CDM,960,RC,68700,HCPCS,Outpatient,,,1166.76,583.38,,1050.08,90,,,percent of total billed charges,90% of total Billed charges,1124.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,561.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,869.75,155,,,Fee Schedule,155% of CMS OPPS Rate,561.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,925.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,561.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1040.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1040.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,865.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,865.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,475.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,561.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1122.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1021.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,617.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,869.75,155,,,Fee Schedule,155% of CMS OPPS Rate,561.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1742.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1742.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,561.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,489.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,561.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1257.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1257.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,475.47,1742.53,
68705- PF Correction Everted Punctum Cautery,4347156,CDM,960,RC,68705,HCPCS,Outpatient,,,320.78,160.39,,288.7,90,,,percent of total billed charges,90% of total Billed charges,399.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.79,155,,,Fee Schedule,155% of CMS OPPS Rate,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,236.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,236.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,239.79,155,,,Fee Schedule,155% of CMS OPPS Rate,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.02,155,,,Fee Schedule,155% of CMS OPPS Rate,619.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,469.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131.11,619.02,
68720- Dacryocystorhinostomy,3431339,CDM,510,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,1825.76,90,,,percent of total billed charges,90% of total Billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1622.9,80,,,Percent of total Billed charges,80% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1825.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1967.76,97,,,Percent of total billed charges,97% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1866.33,92,,,Percent of total billed charges,92% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8439.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3174.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13453.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17041,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1825.76,90,,,percent of total billed charges,90% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.03,70,,,percent of total billed charges,70% of total billed charges,1825.76,90,,,percent of total billed charges,90% of total billed charges,1927.19,95,,,percent of total billed charges,95% of total billed charges,1927.19,95,,,percent of total billed charges,95% of total billed charges,3174.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6349.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1744.61,86,,,percent of total billed charges,86% of total billed charges,1622.9,80,,,percent of total billed charges,80% of total billed charges,3232.98,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1967.76,97,,,percent of total billed charges,97% of total billed charges,1825.76,90,,,percent of total billed charges,90% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1967.76,97,,,percent of total billed charges,97% of total billed charges,1886.62,93,,,percent of total billed charges,93% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1967.76,97,,,percent of total billed charges,97% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3174.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2698.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1420.03,17041,
68720 -OCC Dacryocystorhinostomy,3548682,CDM,510,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,1825.76,90,,,percent of total billed charges,90% of total Billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1622.9,80,,,Percent of total Billed charges,80% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1825.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1967.76,97,,,Percent of total billed charges,97% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1866.33,92,,,Percent of total billed charges,92% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8439.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3174.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13453.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,17041,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1825.76,90,,,percent of total billed charges,90% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1420.03,70,,,percent of total billed charges,70% of total billed charges,1825.76,90,,,percent of total billed charges,90% of total billed charges,1927.19,95,,,percent of total billed charges,95% of total billed charges,1927.19,95,,,percent of total billed charges,95% of total billed charges,3174.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6349.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1744.61,86,,,percent of total billed charges,86% of total billed charges,1622.9,80,,,percent of total billed charges,80% of total billed charges,3232.98,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1967.76,97,,,percent of total billed charges,97% of total billed charges,1825.76,90,,,percent of total billed charges,90% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1967.76,97,,,percent of total billed charges,97% of total billed charges,1886.62,93,,,percent of total billed charges,93% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1967.76,97,,,percent of total billed charges,97% of total billed charges,3174.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3174.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2698.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1420.03,17041,
"68760 - PF Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery",4347157,CDM,960,RC,68760,HCPCS,Outpatient,,,281.92,140.96,,253.73,90,,,percent of total billed charges,90% of total Billed charges,339.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.85,155,,,Fee Schedule,155% of CMS OPPS Rate,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,207.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,207.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,209.85,155,,,Fee Schedule,155% of CMS OPPS Rate,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.58,155,,,Fee Schedule,155% of CMS OPPS Rate,526.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,398.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.09,526.58,
68761- PF Clsr Lacrimal Punctum Plug Ea,4347158,CDM,960,RC,68761,HCPCS,Outpatient,,,224.95,112.48,,202.46,90,,,percent of total billed charges,90% of total Billed charges,245.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.48,155,,,Fee Schedule,155% of CMS OPPS Rate,380.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,204.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.71,380.48,
68801- PF Dilation Lacrimal Punctum w/wo Irrigation,4347159,CDM,960,RC,68801,HCPCS,Outpatient,,,151.9,75.95,,136.71,90,,,percent of total billed charges,90% of total Billed charges,160.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.52,155,,,Fee Schedule,155% of CMS OPPS Rate,249.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,136.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,244.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.54,249.52,
"68811 - (PF) Probing of nasolacrimal duct, with or without irrigation; requiring general anesth",3635230,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,235.91,90,,,percent of total billed charges,90% of total Billed charges,251.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,137.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.1,155,,,Fee Schedule,155% of CMS OPPS Rate,389.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.87,425,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,235.91,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,209.7,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,254.26,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,241.15,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,235.91,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,183.48,70,,,percent of total billed charges,70% of total billed charges,235.91,90,,,percent of total billed charges,90% of total billed charges,249.01,95,,,percent of total billed charges,95% of total billed charges,249.01,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.42,86,,,percent of total billed charges,86% of total billed charges,209.7,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.26,97,,,percent of total billed charges,97% of total billed charges,235.91,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.26,97,,,percent of total billed charges,97% of total billed charges,243.77,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,254.26,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.48,10307.08,
"68811-PF Probe Nasolacrimal Duct w/wo Irrig, Req Gen Anes",4347160,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,235.91,90,,,percent of total billed charges,90% of total Billed charges,251.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,137.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.1,155,,,Fee Schedule,155% of CMS OPPS Rate,389.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.87,425,
68815- PF Probe Nasolacrimal Duct w/wo Irrig Ins Tube/Stnt,4347161,CDM,960,RC,68815,HCPCS,Outpatient,,,429.19,214.60,,386.27,90,,,percent of total billed charges,90% of total Billed charges,555.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,373.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.92,155,,,Fee Schedule,155% of CMS OPPS Rate,860.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,723.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,874.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,874.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,174.94,874.48,
68840- PF Probe Lacrimal Canaliculi w/wo Irrig,4347162,CDM,960,RC,68840,HCPCS,Outpatient,,,225.17,112.59,,202.65,90,,,percent of total billed charges,90% of total Billed charges,231.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.18,155,,,Fee Schedule,155% of CMS OPPS Rate,359.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.92,359.18,
69000- Drainage external ear/simple,3430621,CDM,510,RC,69000,HCPCS,Outpatient,,,468.97,234.49,,422.07,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,375.18,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.07,90,,,Percent of total Billed charges,90% of total billed charges,47.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,454.9,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,431.45,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,422.07,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,328.28,70,,,percent of total billed charges,70% of total billed charges,422.07,90,,,percent of total billed charges,90% of total billed charges,445.52,95,,,percent of total billed charges,95% of total billed charges,445.52,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,403.31,86,,,percent of total billed charges,86% of total billed charges,375.18,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,454.9,97,,,percent of total billed charges,97% of total billed charges,422.07,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.9,97,,,percent of total billed charges,97% of total billed charges,436.14,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,454.9,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43,3163.8,
69000-PF DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE,4321586,CDM,981,RC,69000,HCPCS,Outpatient,,,238.86,119.43,,214.97,90,,,percent of total billed charges,90% of total Billed charges,295.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,185.1,155,,,Fee Schedule,155% of CMS OPPS Rate,119.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.1,155,,,Fee Schedule,155% of CMS OPPS Rate,119.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.44,155,,,Fee Schedule,155% of CMS OPPS Rate,458.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,119.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,119.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,374,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,374,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43,458.44,
69005-PF DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX,4321489,CDM,981,RC,69005,HCPCS,Outpatient,,,309.1,154.55,,278.19,90,,,percent of total billed charges,90% of total Billed charges,364,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,239.55,155,,,Fee Schedule,155% of CMS OPPS Rate,154.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,232.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,232.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,273.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,239.55,155,,,Fee Schedule,155% of CMS OPPS Rate,154.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.2,155,,,Fee Schedule,155% of CMS OPPS Rate,564.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,154.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,210.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,154.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,437.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,137.48,564.2,
69020 Drain outer ear canal lesion,3584872,CDM,960,RC,69020,HCPCS,Outpatient,,,585.93,292.97,,527.34,90,,,percent of total billed charges,90% of total Billed charges,357.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,212.43,155,,,Fee Schedule,155% of CMS OPPS Rate,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,150.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,212.43,155,,,Fee Schedule,155% of CMS OPPS Rate,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.92,155,,,Fee Schedule,155% of CMS OPPS Rate,553.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,472.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,553.92,
69020-PF DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS,4321585,CDM,981,RC,69020,HCPCS,Outpatient,,,274.12,137.06,,246.71,90,,,percent of total billed charges,90% of total Billed charges,357.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,212.43,155,,,Fee Schedule,155% of CMS OPPS Rate,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,274.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,150.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,212.43,155,,,Fee Schedule,155% of CMS OPPS Rate,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.92,155,,,Fee Schedule,155% of CMS OPPS Rate,553.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,472.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,472.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,553.92,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,93.28,46.64,,83.95,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,74.62,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.95,90,,,Percent of total Billed charges,90% of total billed charges,45.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.48,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,85.82,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,83.95,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,65.3,70,,,percent of total billed charges,70% of total billed charges,83.95,90,,,percent of total billed charges,90% of total billed charges,88.62,95,,,percent of total billed charges,95% of total billed charges,88.62,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.22,86,,,percent of total billed charges,86% of total billed charges,74.62,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.48,97,,,percent of total billed charges,97% of total billed charges,83.95,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.48,97,,,percent of total billed charges,97% of total billed charges,86.75,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.48,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.69,1013.19,
69105- Biopsy external auditory canal,3435906,CDM,976,RC,69105,HCPCS,Outpatient,,,126.95,63.48,,114.26,90,,,percent of total billed charges,90% of total Billed charges,188,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,56.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.63,155,,,Fee Schedule,155% of CMS OPPS Rate,61.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,94.63,155,,,Fee Schedule,155% of CMS OPPS Rate,61.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.4,155,,,Fee Schedule,155% of CMS OPPS Rate,291.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,284.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.26,291.4,
69200 Remove foreign body from external auditory canal; without general anesthesia,3584873,CDM,960,RC,69200,HCPCS,Outpatient,,,201.44,100.72,,181.3,90,,,percent of total billed charges,90% of total Billed charges,121.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.69,155,,,Fee Schedule,155% of CMS OPPS Rate,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,71.69,155,,,Fee Schedule,155% of CMS OPPS Rate,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.08,155,,,Fee Schedule,155% of CMS OPPS Rate,189.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30,248.2,
69200-PF RMVL FB XTRNL AUDITORY CANAL W/O ANES,4321584,CDM,981,RC,69200,HCPCS,Outpatient,,,92.52,46.26,,83.27,90,,,percent of total billed charges,90% of total Billed charges,121.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.69,155,,,Fee Schedule,155% of CMS OPPS Rate,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,71.69,155,,,Fee Schedule,155% of CMS OPPS Rate,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.08,155,,,Fee Schedule,155% of CMS OPPS Rate,189.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30,248.2,
69205 Remove foreign body from external auditory canal; with general anesthesia,3584874,CDM,960,RC,69205,HCPCS,Outpatient,,,242.21,121.11,,217.99,90,,,percent of total billed charges,90% of total Billed charges,183.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.82,155,,,Fee Schedule,155% of CMS OPPS Rate,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,166.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.82,155,,,Fee Schedule,155% of CMS OPPS Rate,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.99,155,,,Fee Schedule,155% of CMS OPPS Rate,283.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.81,283.99,
69205-PF RMVL FB XTRNL AUDITORY CANAL ANES,4321490,CDM,981,RC,69205,HCPCS,Outpatient,,,184.3,92.15,,165.87,90,,,percent of total billed charges,90% of total Billed charges,183.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.82,155,,,Fee Schedule,155% of CMS OPPS Rate,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,166.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.82,155,,,Fee Schedule,155% of CMS OPPS Rate,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.99,155,,,Fee Schedule,155% of CMS OPPS Rate,283.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,117.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.81,283.99,
69209- Ear Irrigation,3435631,CDM,450,RC,69209,HCPCS,Outpatient,,,35.85,17.93,,32.27,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,28.68,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.77,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,32.27,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,25.1,70,,,percent of total billed charges,70% of total billed charges,32.27,90,,,percent of total billed charges,90% of total billed charges,34.06,95,,,percent of total billed charges,95% of total billed charges,34.06,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30.83,86,,,percent of total billed charges,86% of total billed charges,28.68,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,34.77,97,,,percent of total billed charges,97% of total billed charges,32.27,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.77,97,,,percent of total billed charges,97% of total billed charges,33.34,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.77,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.1,280.22,
69209-PF Remove Impacted Ear Wax Uni,4321583,CDM,981,RC,69209,HCPCS,Outpatient,,,27.08,13.54,,24.37,90,,,percent of total billed charges,90% of total Billed charges,27.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.99,155,,,Fee Schedule,155% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.99,155,,,Fee Schedule,155% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.87,155,,,Fee Schedule,155% of CMS OPPS Rate,41.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.27,41.87,
69210- Remove impacted ear wax-,3430623,CDM,761,RC,69210,HCPCS,Outpatient,,,121.35,60.68,,109.22,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,97.08,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.71,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,111.64,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,109.22,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,84.95,70,,,percent of total billed charges,70% of total billed charges,109.22,90,,,percent of total billed charges,90% of total billed charges,115.28,95,,,percent of total billed charges,95% of total billed charges,115.28,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,104.36,86,,,percent of total billed charges,86% of total billed charges,97.08,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,117.71,97,,,percent of total billed charges,97% of total billed charges,109.22,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.71,97,,,percent of total billed charges,97% of total billed charges,112.86,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.71,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
69210-PF REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,4321582,CDM,981,RC,69210,HCPCS,Outpatient,,,64.52,32.26,,58.07,90,,,percent of total billed charges,90% of total Billed charges,77.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50,155,,,Fee Schedule,155% of CMS OPPS Rate,32.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50,155,,,Fee Schedule,155% of CMS OPPS Rate,32.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.71,155,,,Fee Schedule,155% of CMS OPPS Rate,120.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,32.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.75,120.71,
"69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning)",3584876,CDM,960,RC,69222,HCPCS,Outpatient,,,538.78,269.39,,484.9,90,,,percent of total billed charges,90% of total Billed charges,331.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.57,155,,,Fee Schedule,155% of CMS OPPS Rate,129.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,227.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,143.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.57,155,,,Fee Schedule,155% of CMS OPPS Rate,129.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.58,155,,,Fee Schedule,155% of CMS OPPS Rate,514.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,448.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92.5,514.58,
69420 Maringotomy including aspiration and/or eustacian tube inflation,3584877,CDM,960,RC,69420,HCPCS,Outpatient,,,475.94,237.97,,428.35,90,,,percent of total billed charges,90% of total Billed charges,293.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,177.71,155,,,Fee Schedule,155% of CMS OPPS Rate,114.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,177.71,155,,,Fee Schedule,155% of CMS OPPS Rate,114.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,455.11,155,,,Fee Schedule,155% of CMS OPPS Rate,455.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,114.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.5,455.11,
69421 Maringotomy including aspiration and/or eustacian tube inflation requiring general anesthesia,3584878,CDM,960,RC,69421,HCPCS,Outpatient,,,386.4,193.20,,347.76,90,,,percent of total billed charges,90% of total Billed charges,290.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.12,90,,,Percent of total Billed charges,90% of total billed charges,74.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,225.29,155,,,Fee Schedule,155% of CMS OPPS Rate,145.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,290.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,252.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,160.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,225.29,155,,,Fee Schedule,155% of CMS OPPS Rate,145.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.51,155,,,Fee Schedule,155% of CMS OPPS Rate,450.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,145.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,145.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,310.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.5,450.51,
"69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia",3584879,CDM,960,RC,69433,HCPCS,Outpatient,,,504.31,252.16,,453.88,90,,,percent of total billed charges,90% of total Billed charges,316.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.01,155,,,Fee Schedule,155% of CMS OPPS Rate,126.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,193.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,223.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,141.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.01,155,,,Fee Schedule,155% of CMS OPPS Rate,126.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,489.96,155,,,Fee Schedule,155% of CMS OPPS Rate,489.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,126.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,126.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,409.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.5,489.96,
"69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia",3584880,CDM,960,RC,69436,HCPCS,Outpatient,,,407.73,203.87,,366.96,90,,,percent of total billed charges,90% of total Billed charges,306.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.44,90,,,Percent of total Billed charges,90% of total billed charges,98.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,237.35,155,,,Fee Schedule,155% of CMS OPPS Rate,153.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,237.35,155,,,Fee Schedule,155% of CMS OPPS Rate,153.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,474.98,155,,,Fee Schedule,155% of CMS OPPS Rate,474.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,334.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,98.5,474.98,
69610 Repair of eardrum,3584881,CDM,960,RC,69610,HCPCS,Outpatient,,,980.97,490.49,,882.87,90,,,percent of total billed charges,90% of total Billed charges,650.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,281.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,436.56,155,,,Fee Schedule,155% of CMS OPPS Rate,281.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,381.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,281.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,429.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,429.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,429.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,264.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,563.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,507.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,330.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,436.56,155,,,Fee Schedule,155% of CMS OPPS Rate,281.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1008.31,155,,,Fee Schedule,155% of CMS OPPS Rate,1008.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,281.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,281.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,798.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83,1008.31,
69631 Repair eardrum structures,3584882,CDM,960,RC,69631,HCPCS,Outpatient,,,2284.81,1142.41,,2056.33,90,,,percent of total billed charges,90% of total Billed charges,1712.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,853.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,694,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1322.2,155,,,Fee Schedule,155% of CMS OPPS Rate,853.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,853.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1307.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1307.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1270.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1270.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,773.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,853.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1706.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1499.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,944.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1322.2,155,,,Fee Schedule,155% of CMS OPPS Rate,853.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,2653.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2653.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,853.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,694,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,941.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,853.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1834.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1834.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,694,2653.91,
"69705 - (50) Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); u",3715282,CDM,510,RC,69705,HCPCS,Outpatient,,,6764.82,3382.41,,6088.34,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,5411.86,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6088.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6561.88,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6223.63,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6088.34,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4735.37,70,,,percent of total billed charges,70% of total billed charges,6088.34,90,,,percent of total billed charges,90% of total billed charges,6426.58,95,,,percent of total billed charges,95% of total billed charges,6426.58,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5817.75,86,,,percent of total billed charges,86% of total billed charges,5411.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6561.88,97,,,percent of total billed charges,97% of total billed charges,6088.34,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6561.88,97,,,percent of total billed charges,97% of total billed charges,6291.28,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6561.88,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4122.32,26031.56,
"69705 - PF Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); uni",3715278,CDM,510,RC,69705,HCPCS,Outpatient,,,455.84,227.92,,410.26,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,364.67,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,442.16,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,419.37,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,410.26,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,319.09,70,,,percent of total billed charges,70% of total billed charges,410.26,90,,,percent of total billed charges,90% of total billed charges,433.05,95,,,percent of total billed charges,95% of total billed charges,433.05,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,392.02,86,,,percent of total billed charges,86% of total billed charges,364.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,442.16,97,,,percent of total billed charges,97% of total billed charges,410.26,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.16,97,,,percent of total billed charges,97% of total billed charges,423.93,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,442.16,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,319.09,26031.56,
69705 - Surg Naspharyngoscopy Dilat Eustachian Tube Uni,3899078,CDM,983,RC,69705,HCPCS,Outpatient,,,6764.82,3382.41,,6088.34,90,,,percent of total billed charges,90% of total Billed charges,2715.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.67,155,,,Fee Schedule,155% of CMS OPPS Rate,171.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2029.45,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.67,155,,,Fee Schedule,155% of CMS OPPS Rate,171.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,4208.58,155,,,Fee Schedule,155% of CMS OPPS Rate,4208.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.4,6088.34,
72170-PELVIS AP,3431942,CDM,320,RC,72170,HCPCS,Outpatient,,,20.78,10.39,,18.7,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.33,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.7,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,20.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,19.12,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.7,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,14.55,70,,,percent of total billed charges,70% of total billed charges,18.7,90,,,percent of total billed charges,90% of total billed charges,19.74,95,,,percent of total billed charges,95% of total billed charges,19.74,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.87,86,,,percent of total billed charges,86% of total billed charges,16.62,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.16,97,,,percent of total billed charges,97% of total billed charges,18.7,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.16,97,,,percent of total billed charges,97% of total billed charges,19.33,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,20.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,521.05,
72170-PF PELVIS AP,3580896,CDM,960,RC,72170,HCPCS,Outpatient,,,68.39,34.20,,61.55,90,,,percent of total billed charges,90% of total Billed charges,34.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,24.26,155,,,Fee Schedule,155% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,48.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.33,61.55,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,510,RC,73206,HCPCS,Outpatient,,,225.46,112.73,,202.91,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,420.2,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.91,90,,,Percent of total Billed charges,90% of total billed charges,207.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.7,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,207.42,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,202.91,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,157.82,70,,,percent of total billed charges,70% of total billed charges,202.91,90,,,percent of total billed charges,90% of total billed charges,214.19,95,,,percent of total billed charges,95% of total billed charges,214.19,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,193.9,86,,,percent of total billed charges,86% of total billed charges,180.37,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.7,97,,,percent of total billed charges,97% of total billed charges,202.91,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.7,97,,,percent of total billed charges,97% of total billed charges,209.68,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.7,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
"74330 - (26) XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899079,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,135.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,330.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,330.29,
"74330 - (TC) XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899080,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,135.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,330.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,330.29,
"74330 - XR Cmbnd NDSC Cath Bilatry & Pancreatic Ductal Sys, RS&I",3899081,CDM,960,RC,74330,HCPCS,Outpatient,,,150.15,75.08,,135.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,330.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,234.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,330.29,
74340 - XR Guide for GI Tube,3896935,CDM,960,RC,74340,HCPCS,Outpatient,,,138.23,69.12,,124.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,211.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.84,211.49,
74360 - XR Guide GI Dilation,3896941,CDM,960,RC,74360,HCPCS,Outpatient,,,142.96,71.48,,128.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,228.66,
74360-PF XR Guide GI Dilation,4322119,CDM,960,RC,74360,HCPCS,Outpatient,,,51.58,25.79,,46.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.42,228.66,
DR Retrograde Cysto in OR,603432,CDM,320,RC,74430,HCPCS,Outpatient,,,100.89,50.45,,90.8,90,,,percent of total billed charges,90% of total Billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,49.08,250,,,Fee Schedule,250% of Fee Schedule Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.8,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,97.86,97,,,Percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,92.82,92,,,Percent of total billed charges,92% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,889.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1796.14,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,90.8,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,70.62,70,,,percent of total billed charges,70% of total billed charges,90.8,90,,,percent of total billed charges,90% of total billed charges,95.85,95,,,percent of total billed charges,95% of total billed charges,95.85,95,,,percent of total billed charges,95% of total billed charges,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,86.77,86,,,percent of total billed charges,86% of total billed charges,80.71,80,,,percent of total billed charges,80% of total billed charges,394.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,97.86,97,,,percent of total billed charges,97% of total billed charges,90.8,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.86,97,,,percent of total billed charges,97% of total billed charges,93.83,93,,,percent of total billed charges,93% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.86,97,,,percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,284.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1796.14,
Read,602093,CDM,972,RC,74430,HCPCS,Outpatient,,,40.35,20.18,,36.32,90,,,percent of total billed charges,90% of total Billed charges,46.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,64.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,76.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,77.59,
Read,602310,CDM,972,RC,74430,HCPCS,Outpatient,,,40.35,20.18,,36.32,90,,,percent of total billed charges,90% of total Billed charges,46.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,64.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,76.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,77.59,
Read,601958,CDM,972,RC,74455,HCPCS,Outpatient,,,99.26,49.63,,89.33,90,,,percent of total billed charges,90% of total Billed charges,159.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.94,155,,,Fee Schedule,155% of CMS OPPS Rate,78.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,140,,,Fee Schedule,140% of CMS OPPS Rate,78.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.94,140,,,Fee Schedule,140% of CMS OPPS Rate,223.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,89.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,160.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,223.58,
"74740 - Hysterosalpingography, radiological supervision and interpretation",3640901,CDM,510,RC,74740,HCPCS,Outpatient,,,238.05,119.03,,214.25,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,133.7,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.25,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,230.91,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,219.01,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.25,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.64,70,,,percent of total billed charges,70% of total billed charges,214.25,90,,,percent of total billed charges,90% of total billed charges,226.15,95,,,percent of total billed charges,95% of total billed charges,226.15,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.72,86,,,percent of total billed charges,86% of total billed charges,190.44,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,230.91,97,,,percent of total billed charges,97% of total billed charges,214.25,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.91,97,,,percent of total billed charges,97% of total billed charges,221.39,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.91,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,1138.43,
Read,602099,CDM,972,RC,74740,HCPCS,Outpatient,,,91.32,45.66,,82.19,90,,,percent of total billed charges,90% of total Billed charges,139.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.66,155,,,Fee Schedule,155% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,174.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,121.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,121.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.66,140,,,Fee Schedule,140% of CMS OPPS Rate,68.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.66,140,,,Fee Schedule,140% of CMS OPPS Rate,195.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.53,195.58,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,510,RC,75557,HCPCS,Outpatient,,,291.73,145.87,,262.56,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,440.03,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.56,90,,,Percent of total Billed charges,90% of total billed charges,276.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.98,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,268.39,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,262.56,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,204.21,70,,,percent of total billed charges,70% of total billed charges,262.56,90,,,percent of total billed charges,90% of total billed charges,277.14,95,,,percent of total billed charges,95% of total billed charges,277.14,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.89,86,,,percent of total billed charges,86% of total billed charges,233.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.98,97,,,percent of total billed charges,97% of total billed charges,262.56,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.98,97,,,percent of total billed charges,97% of total billed charges,271.31,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.98,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.28,1138.43,
75557- (26) - Cardiac magnetic resonance imaging for morphology and function without contrast materi,3715134,CDM,510,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,657.97,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,440.03,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.97,90,,,Percent of total Billed charges,90% of total billed charges,276.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,709.15,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,672.59,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,657.97,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,511.76,70,,,percent of total billed charges,70% of total billed charges,657.97,90,,,percent of total billed charges,90% of total billed charges,694.53,95,,,percent of total billed charges,95% of total billed charges,694.53,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,628.73,86,,,percent of total billed charges,86% of total billed charges,584.86,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,709.15,97,,,percent of total billed charges,97% of total billed charges,657.97,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.15,97,,,percent of total billed charges,97% of total billed charges,679.9,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.15,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.28,1138.43,
Read,3347959,CDM,972,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,657.97,90,,,percent of total billed charges,90% of total Billed charges,323.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,221.1,155,,,Fee Schedule,155% of CMS OPPS Rate,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,315.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,294.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.1,140,,,Fee Schedule,140% of CMS OPPS Rate,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.1,140,,,Fee Schedule,140% of CMS OPPS Rate,452.38,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,692.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157.93,692.76,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,510,RC,75559,HCPCS,Outpatient,,,363.05,181.53,,326.75,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,653.88,250,,,Fee Schedule,250% of Fee Schedule Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.75,90,,,Percent of total Billed charges,90% of total billed charges,276.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,352.16,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,334.01,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,326.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,254.14,70,,,percent of total billed charges,70% of total billed charges,326.75,90,,,percent of total billed charges,90% of total billed charges,344.9,95,,,percent of total billed charges,95% of total billed charges,344.9,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,312.22,86,,,percent of total billed charges,86% of total billed charges,290.44,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,352.16,97,,,percent of total billed charges,97% of total billed charges,326.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.16,97,,,percent of total billed charges,97% of total billed charges,337.64,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,352.16,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.54,2452.82,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,510,RC,75561,HCPCS,Outpatient,,,322.95,161.48,,290.66,90,,,percent of total billed charges,90% of total Billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,629.9,250,,,Fee Schedule,250% of Fee Schedule Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.66,90,,,Percent of total Billed charges,90% of total billed charges,423.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.26,97,,,Percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,297.11,92,,,Percent of total billed charges,92% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,889.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1796.13,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,290.66,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,226.07,70,,,percent of total billed charges,70% of total billed charges,290.66,90,,,percent of total billed charges,90% of total billed charges,306.8,95,,,percent of total billed charges,95% of total billed charges,306.8,95,,,percent of total billed charges,95% of total billed charges,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,277.74,86,,,percent of total billed charges,86% of total billed charges,258.36,80,,,percent of total billed charges,80% of total billed charges,394.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,313.26,97,,,percent of total billed charges,97% of total billed charges,290.66,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.26,97,,,percent of total billed charges,97% of total billed charges,300.34,93,,,percent of total billed charges,93% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.26,97,,,percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,284.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,226.07,1796.13,
Read,3347961,CDM,972,RC,75561,HCPCS,Outpatient,,,952.9,476.45,,857.61,90,,,percent of total billed charges,90% of total Billed charges,463.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,486.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,316.58,155,,,Fee Schedule,155% of CMS OPPS Rate,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,226.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,849.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,570.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,570.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,419.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,421.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.58,140,,,Fee Schedule,140% of CMS OPPS Rate,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.58,140,,,Fee Schedule,140% of CMS OPPS Rate,648.21,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,657.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,922.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,922.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,226.13,922.8,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,510,RC,75565,HCPCS,Outpatient,,,31.23,15.62,,28.11,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,86.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,19.94,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.56,78.65,,,percent of total billed charges,78.65% of total billed charges,27.9,89.33,,,percent of total billed charges,89.33% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.86,70,,,percent of total billed charges,70% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.86,86,,,percent of total billed charges,86% of total billed charges,24.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.29,97,,,percent of total billed charges,97% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.29,97,,,percent of total billed charges,97% of total billed charges,29.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.94,86.88,
75571PF CT Heart No Contrast Quant Eval Coronary Calcium,4281207,CDM,960,RC,75571,HCPCS,Outpatient,,,198.2,99.10,,178.38,90,,,percent of total billed charges,90% of total Billed charges,132.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,56.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.4,155,,,Fee Schedule,155% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.4,140,,,Fee Schedule,140% of CMS OPPS Rate,66,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.4,140,,,Fee Schedule,140% of CMS OPPS Rate,185.67,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.84,212.03,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,510,RC,75572,HCPCS,Outpatient,,,218.84,109.42,,196.96,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,379,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.96,90,,,Percent of total Billed charges,90% of total billed charges,185.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,212.27,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,201.33,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,196.96,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,153.19,70,,,percent of total billed charges,70% of total billed charges,196.96,90,,,percent of total billed charges,90% of total billed charges,207.9,95,,,percent of total billed charges,95% of total billed charges,207.9,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,188.2,86,,,percent of total billed charges,86% of total billed charges,175.07,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,212.27,97,,,percent of total billed charges,97% of total billed charges,196.96,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.27,97,,,percent of total billed charges,97% of total billed charges,203.52,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.27,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,510,RC,75574,HCPCS,Outpatient,,,298.21,149.11,,268.39,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,420.2,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.39,90,,,Percent of total Billed charges,90% of total billed charges,227.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,289.26,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,274.35,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,268.39,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,208.75,70,,,percent of total billed charges,70% of total billed charges,268.39,90,,,percent of total billed charges,90% of total billed charges,283.3,95,,,percent of total billed charges,95% of total billed charges,283.3,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,256.46,86,,,percent of total billed charges,86% of total billed charges,238.57,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,289.26,97,,,percent of total billed charges,97% of total billed charges,268.39,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.26,97,,,percent of total billed charges,97% of total billed charges,277.34,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,289.26,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
FFR professional fee,3616894,CDM,960,RC,75580,HCPCS,Outpatient,,,265.93,132.97,,239.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.78,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.78,239.34,
"75605- Aortography/thor, serialogrph,radio sup& intp",3569425,CDM,510,RC,75605,HCPCS,Outpatient,,,304.81,152.41,,274.33,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,165.15,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.33,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,295.67,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,280.43,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,274.33,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,213.37,70,,,percent of total billed charges,70% of total billed charges,274.33,90,,,percent of total billed charges,90% of total billed charges,289.57,95,,,percent of total billed charges,95% of total billed charges,289.57,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,262.14,86,,,percent of total billed charges,86% of total billed charges,243.85,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,295.67,97,,,percent of total billed charges,97% of total billed charges,274.33,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.67,97,,,percent of total billed charges,97% of total billed charges,283.47,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,295.67,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,25056.98,
"75605-Aortography, thoracic, by serialography",4271185,CDM,481,RC,75605,HCPCS,Outpatient,,,238.29,119.15,,214.46,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,165.15,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.46,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.14,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,219.23,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.46,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,166.8,70,,,percent of total billed charges,70% of total billed charges,214.46,90,,,percent of total billed charges,90% of total billed charges,226.38,95,,,percent of total billed charges,95% of total billed charges,226.38,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.93,86,,,percent of total billed charges,86% of total billed charges,190.63,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.14,97,,,percent of total billed charges,97% of total billed charges,214.46,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.14,97,,,percent of total billed charges,97% of total billed charges,221.61,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.14,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,25056.98,
"75605-PF Aortography, thoracic, by serialography",4271186,CDM,960,RC,75605,HCPCS,Outpatient,,,238.29,119.15,,214.46,90,,,percent of total billed charges,90% of total Billed charges,120.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,83.61,155,,,Fee Schedule,155% of CMS OPPS Rate,59.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,263.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,181.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,181.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.61,140,,,Fee Schedule,140% of CMS OPPS Rate,59.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.61,140,,,Fee Schedule,140% of CMS OPPS Rate,168.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,59.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.38,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,288.38,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39,525.85,
"75625(26)- Aortography, abdominal, by serialography, radiological supervision and interpretation",3621145,CDM,510,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,161.43,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.81,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.85,70,,,percent of total billed charges,70% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,146.02,86,,,percent of total billed charges,86% of total billed charges,135.83,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.7,97,,,percent of total billed charges,97% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.7,97,,,percent of total billed charges,97% of total billed charges,157.9,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,14522.85,
"75625-IR AORTOGRAPHY, ABDOMINAL",3431943,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,161.43,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.81,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.85,70,,,percent of total billed charges,70% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,146.02,86,,,percent of total billed charges,86% of total billed charges,135.83,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.7,97,,,percent of total billed charges,97% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.7,97,,,percent of total billed charges,97% of total billed charges,157.9,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,14522.85,
75625-Peripheral Angio Aortagram,3431944,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,161.43,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.81,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.85,70,,,percent of total billed charges,70% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,146.02,86,,,percent of total billed charges,86% of total billed charges,135.83,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.7,97,,,percent of total billed charges,97% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.7,97,,,percent of total billed charges,97% of total billed charges,157.9,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,14522.85,
Aortography (Cardiology),,,320,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,161.43,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.81,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.85,70,,,percent of total billed charges,70% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,146.02,86,,,percent of total billed charges,86% of total billed charges,135.83,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.7,97,,,percent of total billed charges,97% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.7,97,,,percent of total billed charges,97% of total billed charges,157.9,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,14522.85,
IR Abdominal Aortagram,603549,CDM,320,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,161.43,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.81,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.7,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.21,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.85,70,,,percent of total billed charges,70% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,161.3,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,146.02,86,,,percent of total billed charges,86% of total billed charges,135.83,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.7,97,,,percent of total billed charges,97% of total billed charges,152.81,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.7,97,,,percent of total billed charges,97% of total billed charges,157.9,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.7,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,14522.85,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,172.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.06,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.44,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,175.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,133.83,70,,,percent of total billed charges,70% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.41,86,,,percent of total billed charges,86% of total billed charges,152.94,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.44,97,,,percent of total billed charges,97% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.44,97,,,percent of total billed charges,97% of total billed charges,177.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.44,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133.83,14522.85,
75630-ABD ANGIOGRAM W BILATERAL RUNOFF,3431945,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,172.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.06,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.44,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,175.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,133.83,70,,,percent of total billed charges,70% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.41,86,,,percent of total billed charges,86% of total billed charges,152.94,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.44,97,,,percent of total billed charges,97% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.44,97,,,percent of total billed charges,97% of total billed charges,177.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.44,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133.83,14522.85,
75630-Peripheral Angio Aortagram w Runoff,3431946,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,172.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.06,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.44,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,175.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,133.83,70,,,percent of total billed charges,70% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.41,86,,,percent of total billed charges,86% of total billed charges,152.94,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.44,97,,,percent of total billed charges,97% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.44,97,,,percent of total billed charges,97% of total billed charges,177.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.44,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133.83,14522.85,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,172.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.06,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.44,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,175.89,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,133.83,70,,,percent of total billed charges,70% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,181.62,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.41,86,,,percent of total billed charges,86% of total billed charges,152.94,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.44,97,,,percent of total billed charges,97% of total billed charges,172.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.44,97,,,percent of total billed charges,97% of total billed charges,177.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.44,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133.83,14522.85,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-IR FEMORAL OR POPLITEAL ANGIO LT,3431947,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-IR PERIPHERAL ANGIOGRAPHY RT,3431948,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-Peripheral Angio Lower Extremity LT,3431949,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-Peripheral Angio Lower Extremity RT,3431950,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-Peripheral Angio Tibal Peroneal,3431951,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75710-Peripherial Angio Left,3431952,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.71,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,156.11,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,118.78,70,,,percent of total billed charges,70% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,161.2,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,145.92,86,,,percent of total billed charges,86% of total billed charges,135.74,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,164.59,97,,,percent of total billed charges,97% of total billed charges,152.71,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.59,97,,,percent of total billed charges,97% of total billed charges,157.8,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Read,630452,CDM,972,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
Read,630454,CDM,972,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,510,RC,75716,HCPCS,Outpatient,,,247.87,123.94,,223.08,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.08,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,240.43,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,228.04,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,223.08,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.51,70,,,percent of total billed charges,70% of total billed charges,223.08,90,,,percent of total billed charges,90% of total billed charges,235.48,95,,,percent of total billed charges,95% of total billed charges,235.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,213.17,86,,,percent of total billed charges,86% of total billed charges,198.3,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,240.43,97,,,percent of total billed charges,97% of total billed charges,223.08,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.43,97,,,percent of total billed charges,97% of total billed charges,230.52,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,240.43,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75716-BILATERIAL RUN OFF,3431953,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,206.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.56,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.62,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,211.15,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,160.66,70,,,percent of total billed charges,70% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.38,86,,,percent of total billed charges,86% of total billed charges,183.61,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.62,97,,,percent of total billed charges,97% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.62,97,,,percent of total billed charges,97% of total billed charges,213.44,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.62,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75716-Peripheral Angio Bilateral,3431954,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,206.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.56,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.62,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,211.15,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,160.66,70,,,percent of total billed charges,70% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.38,86,,,percent of total billed charges,86% of total billed charges,183.61,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.62,97,,,percent of total billed charges,97% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.62,97,,,percent of total billed charges,97% of total billed charges,213.44,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.62,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75716-Peripheral Angio Lower Extremity BILAT,3431955,CDM,320,RC,75716,HCPCS,Outpatient,,,229.51,114.76,,206.56,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.56,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.62,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,211.15,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,160.66,70,,,percent of total billed charges,70% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,218.03,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.38,86,,,percent of total billed charges,86% of total billed charges,183.61,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.62,97,,,percent of total billed charges,97% of total billed charges,206.56,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.62,97,,,percent of total billed charges,97% of total billed charges,213.44,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.62,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
IR Ext Run Off Bilat,603550,CDM,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,367.32,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.32,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,395.89,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,375.48,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,285.69,70,,,percent of total billed charges,70% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,350.99,86,,,percent of total billed charges,86% of total billed charges,326.5,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,395.89,97,,,percent of total billed charges,97% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.89,97,,,percent of total billed charges,97% of total billed charges,379.56,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,395.89,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Peripheral Angio Lower Extremity BILAT,,,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,367.32,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.32,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,395.89,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,375.48,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,285.69,70,,,percent of total billed charges,70% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,350.99,86,,,percent of total billed charges,86% of total billed charges,326.5,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,395.89,97,,,percent of total billed charges,97% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.89,97,,,percent of total billed charges,97% of total billed charges,379.56,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,395.89,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Peripheral Angiography Bilat (Cardiology),,,320,RC,75716,HCPCS,Outpatient,,,408.13,204.07,,367.32,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.32,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,395.89,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,375.48,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,285.69,70,,,percent of total billed charges,70% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,387.72,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,350.99,86,,,percent of total billed charges,86% of total billed charges,326.5,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,395.89,97,,,percent of total billed charges,97% of total billed charges,367.32,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.89,97,,,percent of total billed charges,97% of total billed charges,379.56,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,395.89,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Read,630450,CDM,972,RC,75716,HCPCS,Outpatient,,,163.25,81.63,,146.93,90,,,percent of total billed charges,90% of total Billed charges,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.1,155,,,Fee Schedule,155% of CMS OPPS Rate,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,184.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.1,140,,,Fee Schedule,140% of CMS OPPS Rate,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.1,140,,,Fee Schedule,140% of CMS OPPS Rate,177.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,402.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,402.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,537.85,
75726 - (26) ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3999217,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,388.35,90,,,percent of total billed charges,90% of total Billed charges,137.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,95.44,155,,,Fee Schedule,155% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,373.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,192.21,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.29,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.29,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,523.85,
75726 - (TC) ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3997609,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,388.35,90,,,percent of total billed charges,90% of total Billed charges,137.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,95.44,155,,,Fee Schedule,155% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,373.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,192.21,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.29,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.29,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,523.85,
75726 - ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I,3997210,CDM,960,RC,75726,HCPCS,Outpatient,,,431.5,215.75,,388.35,90,,,percent of total billed charges,90% of total Billed charges,137.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,95.44,155,,,Fee Schedule,155% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,373.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,259.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.44,140,,,Fee Schedule,140% of CMS OPPS Rate,192.21,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.29,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.29,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,523.85,
75726-Peripheral Angio Celiac,3431956,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,209.95,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.95,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,226.28,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,214.62,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,163.3,70,,,percent of total billed charges,70% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,200.62,86,,,percent of total billed charges,86% of total billed charges,186.62,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,226.28,97,,,percent of total billed charges,97% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.28,97,,,percent of total billed charges,97% of total billed charges,216.95,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.28,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
75726-Peripheral Angio Mesenteric,3431957,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,209.95,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.95,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,226.28,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,214.62,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,163.3,70,,,percent of total billed charges,70% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,200.62,86,,,percent of total billed charges,86% of total billed charges,186.62,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,226.28,97,,,percent of total billed charges,97% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.28,97,,,percent of total billed charges,97% of total billed charges,216.95,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.28,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
75726-Peripheral Angio Splenic,3431958,CDM,320,RC,75726,HCPCS,Outpatient,,,233.28,116.64,,209.95,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.95,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,226.28,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,214.62,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,163.3,70,,,percent of total billed charges,70% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,221.62,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,200.62,86,,,percent of total billed charges,86% of total billed charges,186.62,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,226.28,97,,,percent of total billed charges,97% of total billed charges,209.95,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.28,97,,,percent of total billed charges,97% of total billed charges,216.95,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.28,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
Peripheral Angio Celiac,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,385.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,416.01,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,394.57,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,300.22,70,,,percent of total billed charges,70% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,368.84,86,,,percent of total billed charges,86% of total billed charges,343.1,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,416.01,97,,,percent of total billed charges,97% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.01,97,,,percent of total billed charges,97% of total billed charges,398.86,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.01,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
Peripheral Angio Mesenteric,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,385.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,416.01,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,394.57,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,300.22,70,,,percent of total billed charges,70% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,368.84,86,,,percent of total billed charges,86% of total billed charges,343.1,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,416.01,97,,,percent of total billed charges,97% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.01,97,,,percent of total billed charges,97% of total billed charges,398.86,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.01,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
Peripheral Angio Splenic,,,320,RC,75726,HCPCS,Outpatient,,,428.88,214.44,,385.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,189.13,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,416.01,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,394.57,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,300.22,70,,,percent of total billed charges,70% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,407.44,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,368.84,86,,,percent of total billed charges,86% of total billed charges,343.1,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,416.01,97,,,percent of total billed charges,97% of total billed charges,385.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.01,97,,,percent of total billed charges,97% of total billed charges,398.86,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,416.01,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
75736-Peripheral Angio Iliac,3431959,CDM,320,RC,75736,HCPCS,Outpatient,,,130.07,65.04,,117.06,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,211.98,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.06,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.17,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,119.66,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.06,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,91.05,70,,,percent of total billed charges,70% of total billed charges,117.06,90,,,percent of total billed charges,90% of total billed charges,123.57,95,,,percent of total billed charges,95% of total billed charges,123.57,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,111.86,86,,,percent of total billed charges,86% of total billed charges,104.06,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.17,97,,,percent of total billed charges,97% of total billed charges,117.06,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.17,97,,,percent of total billed charges,97% of total billed charges,120.97,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.17,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
75736-Peripheral Angio Pelvic Selective Supra,3431960,CDM,320,RC,75736,HCPCS,Outpatient,,,101.1,50.55,,90.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,211.98,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,98.07,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,93.01,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,90.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,70.77,70,,,percent of total billed charges,70% of total billed charges,90.99,90,,,percent of total billed charges,90% of total billed charges,96.05,95,,,percent of total billed charges,95% of total billed charges,96.05,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,86.95,86,,,percent of total billed charges,86% of total billed charges,80.88,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,98.07,97,,,percent of total billed charges,97% of total billed charges,90.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.07,97,,,percent of total billed charges,97% of total billed charges,94.02,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,98.07,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
Peripheral Angio Iliac,,,320,RC,75736,HCPCS,Outpatient,,,349.99,175.00,,314.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,211.98,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,339.49,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,321.99,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,244.99,70,,,percent of total billed charges,70% of total billed charges,314.99,90,,,percent of total billed charges,90% of total billed charges,332.49,95,,,percent of total billed charges,95% of total billed charges,332.49,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.99,86,,,percent of total billed charges,86% of total billed charges,279.99,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.49,97,,,percent of total billed charges,97% of total billed charges,314.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.49,97,,,percent of total billed charges,97% of total billed charges,325.49,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.49,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
Peripheral Angio Pelvic Selective Supra,,,320,RC,75736,HCPCS,Outpatient,,,349.99,175.00,,314.99,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,211.98,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.99,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,339.49,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,321.99,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,244.99,70,,,percent of total billed charges,70% of total billed charges,314.99,90,,,percent of total billed charges,90% of total billed charges,332.49,95,,,percent of total billed charges,95% of total billed charges,332.49,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.99,86,,,percent of total billed charges,86% of total billed charges,279.99,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.49,97,,,percent of total billed charges,97% of total billed charges,314.99,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.49,97,,,percent of total billed charges,97% of total billed charges,325.49,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.49,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,25056.98,
75741 - Angiography Pulm Unil Slctv RS&I,4189315,CDM,960,RC,75741,HCPCS,Outpatient,,,292.34,146.17,,263.11,90,,,percent of total billed charges,90% of total Billed charges,125.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.28,155,,,Fee Schedule,155% of CMS OPPS Rate,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,289.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,148.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.28,140,,,Fee Schedule,140% of CMS OPPS Rate,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.28,140,,,Fee Schedule,140% of CMS OPPS Rate,175.56,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,495.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,495.82,
75741-Pulmonary Angiography,3431961,CDM,320,RC,75741,HCPCS,Outpatient,,,150.51,75.26,,135.46,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,174.9,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.46,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.99,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,138.47,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,105.36,70,,,percent of total billed charges,70% of total billed charges,135.46,90,,,percent of total billed charges,90% of total billed charges,142.98,95,,,percent of total billed charges,95% of total billed charges,142.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.44,86,,,percent of total billed charges,86% of total billed charges,120.41,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.99,97,,,percent of total billed charges,97% of total billed charges,135.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.99,97,,,percent of total billed charges,97% of total billed charges,139.97,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.99,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75741-Pulmonary Angiography RT,3431962,CDM,320,RC,75741,HCPCS,Outpatient,,,150.51,75.26,,135.46,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,174.9,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.46,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.99,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,138.47,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,105.36,70,,,percent of total billed charges,70% of total billed charges,135.46,90,,,percent of total billed charges,90% of total billed charges,142.98,95,,,percent of total billed charges,95% of total billed charges,142.98,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.44,86,,,percent of total billed charges,86% of total billed charges,120.41,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.99,97,,,percent of total billed charges,97% of total billed charges,135.46,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.99,97,,,percent of total billed charges,97% of total billed charges,139.97,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.99,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Pulmonary Angiography LT,,,320,RC,75741,HCPCS,Outpatient,,,323.6,161.80,,291.24,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,174.9,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.24,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.89,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,297.71,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,291.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,226.52,70,,,percent of total billed charges,70% of total billed charges,291.24,90,,,percent of total billed charges,90% of total billed charges,307.42,95,,,percent of total billed charges,95% of total billed charges,307.42,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,278.3,86,,,percent of total billed charges,86% of total billed charges,258.88,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,313.89,97,,,percent of total billed charges,97% of total billed charges,291.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.89,97,,,percent of total billed charges,97% of total billed charges,300.95,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.89,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Pulmonary Angiography RT,,,320,RC,75741,HCPCS,Outpatient,,,323.6,161.80,,291.24,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,174.9,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.24,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.89,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,297.71,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,291.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,226.52,70,,,percent of total billed charges,70% of total billed charges,291.24,90,,,percent of total billed charges,90% of total billed charges,307.42,95,,,percent of total billed charges,95% of total billed charges,307.42,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,278.3,86,,,percent of total billed charges,86% of total billed charges,258.88,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,313.89,97,,,percent of total billed charges,97% of total billed charges,291.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.89,97,,,percent of total billed charges,97% of total billed charges,300.95,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.89,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75743-Pulmonary Angiography BILAT,3431963,CDM,320,RC,75743,HCPCS,Outpatient,,,191.45,95.73,,172.31,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,177.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.31,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.71,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,176.13,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.31,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,134.02,70,,,percent of total billed charges,70% of total billed charges,172.31,90,,,percent of total billed charges,90% of total billed charges,181.88,95,,,percent of total billed charges,95% of total billed charges,181.88,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.65,86,,,percent of total billed charges,86% of total billed charges,153.16,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.71,97,,,percent of total billed charges,97% of total billed charges,172.31,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.71,97,,,percent of total billed charges,97% of total billed charges,178.05,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.71,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Pulmonary Angiography BILAT,3427256,CDM,960,RC,75743,HCPCS,Outpatient,,,368.88,184.44,,331.99,90,,,percent of total billed charges,90% of total Billed charges,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.91,155,,,Fee Schedule,155% of CMS OPPS Rate,63.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,165.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.91,140,,,Fee Schedule,140% of CMS OPPS Rate,63.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.91,140,,,Fee Schedule,140% of CMS OPPS Rate,179.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,63.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,566.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,566.85,
75746 - Angrph Pulm Nonslctv Cath/Ven NJX RS&I,4189316,CDM,960,RC,75746,HCPCS,Outpatient,,,297.39,148.70,,267.65,90,,,percent of total billed charges,90% of total Billed charges,144.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.15,155,,,Fee Schedule,155% of CMS OPPS Rate,72.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.15,140,,,Fee Schedule,140% of CMS OPPS Rate,72.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.15,140,,,Fee Schedule,140% of CMS OPPS Rate,202.08,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,487.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,317.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25,487.19,
75746-Pulmonary Angiography Non Selective,3431964,CDM,481,RC,75746,HCPCS,Outpatient,,,131.28,65.64,,118.15,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,193.63,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.15,90,,,Percent of total Billed charges,90% of total billed charges,16.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,127.34,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,120.78,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,118.15,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,91.9,70,,,percent of total billed charges,70% of total billed charges,118.15,90,,,percent of total billed charges,90% of total billed charges,124.72,95,,,percent of total billed charges,95% of total billed charges,124.72,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.9,86,,,percent of total billed charges,86% of total billed charges,105.02,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,127.34,97,,,percent of total billed charges,97% of total billed charges,118.15,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.34,97,,,percent of total billed charges,97% of total billed charges,122.09,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.34,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15,14522.85,
Pulmonary Angiography Non Selective,,,320,RC,75746,HCPCS,Outpatient,,,329.98,164.99,,296.98,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,193.63,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,296.98,90,,,Percent of total Billed charges,90% of total billed charges,16.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,320.08,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,303.58,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,296.98,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,230.99,70,,,percent of total billed charges,70% of total billed charges,296.98,90,,,percent of total billed charges,90% of total billed charges,313.48,95,,,percent of total billed charges,95% of total billed charges,313.48,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,283.78,86,,,percent of total billed charges,86% of total billed charges,263.98,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,320.08,97,,,percent of total billed charges,97% of total billed charges,296.98,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.08,97,,,percent of total billed charges,97% of total billed charges,306.88,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,320.08,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15,14522.85,
75756 - (26) Artery XR Chest,3899082,CDM,960,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,351.79,90,,,percent of total billed charges,90% of total Billed charges,186.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.73,155,,,Fee Schedule,155% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,168.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,260.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,489.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,338.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,489.67,
75756 - (TC) Artery XR Chest,3899085,CDM,960,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,351.79,90,,,percent of total billed charges,90% of total Billed charges,186.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.73,155,,,Fee Schedule,155% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,168.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,260.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,489.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,338.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,489.67,
"75756 - Angiography, internal mammary, radiological supervision and interpretation",3760901,CDM,983,RC,75756,HCPCS,Outpatient,,,390.88,195.44,,351.79,90,,,percent of total billed charges,90% of total Billed charges,186.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.73,155,,,Fee Schedule,155% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,168.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.73,140,,,Fee Schedule,140% of CMS OPPS Rate,260.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,489.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,338.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,489.67,
75774 - Angrph Slctv Ea Vsl Studied After Basic XM RS&I,4201242,CDM,983,RC,75774,HCPCS,Outpatient,,,99,49.50,,89.1,90,,,percent of total billed charges,90% of total Billed charges,90.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,63.01,155,,,Fee Schedule,155% of CMS OPPS Rate,45.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.01,140,,,Fee Schedule,140% of CMS OPPS Rate,45.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.01,140,,,Fee Schedule,140% of CMS OPPS Rate,127.19,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,45.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,488.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,190.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,488.35,
75774-Periph Angio Selec add Visceral,3431965,CDM,320,RC,75774,HCPCS,Outpatient,,,246.09,123.05,,221.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,138.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,221.48,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,238.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,226.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,157.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,193.56,78.65,,,percent of total billed charges,78.65% of total billed charges,219.84,89.33,,,percent of total billed charges,89.33% of total billed charges,221.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.26,70,,,percent of total billed charges,70% of total billed charges,221.48,90,,,percent of total billed charges,90% of total billed charges,233.79,95,,,percent of total billed charges,95% of total billed charges,233.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.64,86,,,percent of total billed charges,86% of total billed charges,196.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,238.71,97,,,percent of total billed charges,97% of total billed charges,221.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,238.71,97,,,percent of total billed charges,97% of total billed charges,228.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,238.71,
Periph Angio Selec add Visceral,,,320,RC,75774,HCPCS,Outpatient,,,240.73,120.37,,216.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,138.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,216.66,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,221.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,153.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,189.34,78.65,,,percent of total billed charges,78.65% of total billed charges,215.05,89.33,,,percent of total billed charges,89.33% of total billed charges,216.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,168.51,70,,,percent of total billed charges,70% of total billed charges,216.66,90,,,percent of total billed charges,90% of total billed charges,228.69,95,,,percent of total billed charges,95% of total billed charges,228.69,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,86,,,percent of total billed charges,86% of total billed charges,192.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,233.51,97,,,percent of total billed charges,97% of total billed charges,216.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,233.51,97,,,percent of total billed charges,97% of total billed charges,223.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,233.51,
75820 - Venography Extremity Unilateral RS&I,4201239,CDM,983,RC,75820,HCPCS,Outpatient,,,105.72,52.86,,95.15,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
75820-Venography Extremity,3431966,CDM,320,RC,75820,HCPCS,Outpatient,,,82.55,41.28,,74.3,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.15,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.3,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.07,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,75.95,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.3,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,57.79,70,,,percent of total billed charges,70% of total billed charges,74.3,90,,,percent of total billed charges,90% of total billed charges,78.42,95,,,percent of total billed charges,95% of total billed charges,78.42,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.99,86,,,percent of total billed charges,86% of total billed charges,66.04,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.07,97,,,percent of total billed charges,97% of total billed charges,74.3,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.07,97,,,percent of total billed charges,97% of total billed charges,76.77,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.07,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
75820-Venography Extremity RT,3431967,CDM,320,RC,75820,HCPCS,Outpatient,,,82.55,41.28,,74.3,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.15,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.3,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.07,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,75.95,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.3,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,57.79,70,,,percent of total billed charges,70% of total billed charges,74.3,90,,,percent of total billed charges,90% of total billed charges,78.42,95,,,percent of total billed charges,95% of total billed charges,78.42,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.99,86,,,percent of total billed charges,86% of total billed charges,66.04,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.07,97,,,percent of total billed charges,97% of total billed charges,74.3,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.07,97,,,percent of total billed charges,97% of total billed charges,76.77,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.07,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Read,601960,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,96.85,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
Read,601962,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,96.85,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
Read,601965,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,96.85,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
Read,601969,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,96.85,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
Read,601971,CDM,972,RC,75820,HCPCS,Outpatient,,,107.61,53.81,,96.85,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,237.91,
Venogram Arm Lt (Cardiology),,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,242.13,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.15,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.13,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,260.96,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,247.51,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,188.32,70,,,percent of total billed charges,70% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.37,86,,,percent of total billed charges,86% of total billed charges,215.22,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,260.96,97,,,percent of total billed charges,97% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.96,97,,,percent of total billed charges,97% of total billed charges,250.2,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.96,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Venogram Rt. (Cardiology),,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,242.13,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.15,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.13,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,260.96,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,247.51,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,188.32,70,,,percent of total billed charges,70% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.37,86,,,percent of total billed charges,86% of total billed charges,215.22,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,260.96,97,,,percent of total billed charges,97% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.96,97,,,percent of total billed charges,97% of total billed charges,250.2,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.96,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Venography Extremity LT,,,320,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,242.13,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.15,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.13,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,260.96,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,247.51,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,188.32,70,,,percent of total billed charges,70% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,255.58,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.37,86,,,percent of total billed charges,86% of total billed charges,215.22,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,260.96,97,,,percent of total billed charges,97% of total billed charges,242.13,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.96,97,,,percent of total billed charges,97% of total billed charges,250.2,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.96,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Venography Extremity RT,3427267,CDM,960,RC,75820,HCPCS,Outpatient,,,269.03,134.52,,242.13,90,,,percent of total billed charges,90% of total Billed charges,107.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,150.26,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,242.13,
"75822 - PF Venography, extremity, bilateral, radiological supervision and interpretation",3761000,CDM,983,RC,75822,HCPCS,Outpatient,,,338.16,169.08,,304.34,90,,,percent of total billed charges,90% of total Billed charges,115.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,80.15,155,,,Fee Schedule,155% of CMS OPPS Rate,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,140,,,Fee Schedule,140% of CMS OPPS Rate,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.15,140,,,Fee Schedule,140% of CMS OPPS Rate,162.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,294.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,304.34,
"75822 - Venography, extremity, bilateral, radiological supervision and interpretation",3761052,CDM,320,RC,75822,HCPCS,Outpatient,,,338.16,169.08,,304.34,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.34,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,328.02,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,311.11,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,304.34,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,236.71,70,,,percent of total billed charges,70% of total billed charges,304.34,90,,,percent of total billed charges,90% of total billed charges,321.25,95,,,percent of total billed charges,95% of total billed charges,321.25,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,290.82,86,,,percent of total billed charges,86% of total billed charges,270.53,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,328.02,97,,,percent of total billed charges,97% of total billed charges,304.34,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.02,97,,,percent of total billed charges,97% of total billed charges,314.49,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.02,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
75822-Venography Extremity BILAT,3431968,CDM,320,RC,75822,HCPCS,Outpatient,,,123.95,61.98,,111.56,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.56,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.23,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,114.03,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.56,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,86.77,70,,,percent of total billed charges,70% of total billed charges,111.56,90,,,percent of total billed charges,90% of total billed charges,117.75,95,,,percent of total billed charges,95% of total billed charges,117.75,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.6,86,,,percent of total billed charges,86% of total billed charges,99.16,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.23,97,,,percent of total billed charges,97% of total billed charges,111.56,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.23,97,,,percent of total billed charges,97% of total billed charges,115.27,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.23,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Read,601967,CDM,972,RC,75822,HCPCS,Outpatient,,,132.29,66.15,,119.06,90,,,percent of total billed charges,90% of total Billed charges,115.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,80.15,155,,,Fee Schedule,155% of CMS OPPS Rate,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.15,140,,,Fee Schedule,140% of CMS OPPS Rate,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.15,140,,,Fee Schedule,140% of CMS OPPS Rate,162.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,294.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,294.93,
Venogram Arms Bilat (Cardiology),,,320,RC,75822,HCPCS,Outpatient,,,330.72,165.36,,297.65,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.65,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,320.8,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,304.26,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,297.65,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,231.5,70,,,percent of total billed charges,70% of total billed charges,297.65,90,,,percent of total billed charges,90% of total billed charges,314.18,95,,,percent of total billed charges,95% of total billed charges,314.18,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.42,86,,,percent of total billed charges,86% of total billed charges,264.58,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,320.8,97,,,percent of total billed charges,97% of total billed charges,297.65,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.8,97,,,percent of total billed charges,97% of total billed charges,307.57,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,320.8,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Venography Extremity BILAT,,,320,RC,75822,HCPCS,Outpatient,,,330.72,165.36,,297.65,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.65,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,320.8,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,304.26,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,297.65,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,231.5,70,,,percent of total billed charges,70% of total billed charges,297.65,90,,,percent of total billed charges,90% of total billed charges,314.18,95,,,percent of total billed charges,95% of total billed charges,314.18,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.42,86,,,percent of total billed charges,86% of total billed charges,264.58,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,320.8,97,,,percent of total billed charges,97% of total billed charges,297.65,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.8,97,,,percent of total billed charges,97% of total billed charges,307.57,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,320.8,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
75825 - Venography caval inferior w/ serial,4241822,CDM,510,RC,75825,HCPCS,Outpatient,,,227.14,113.57,,204.43,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,157.68,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.43,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,220.33,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,208.97,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,204.43,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,159,70,,,percent of total billed charges,70% of total billed charges,204.43,90,,,percent of total billed charges,90% of total billed charges,215.78,95,,,percent of total billed charges,95% of total billed charges,215.78,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,195.34,86,,,percent of total billed charges,86% of total billed charges,181.71,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,220.33,97,,,percent of total billed charges,97% of total billed charges,204.43,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.33,97,,,percent of total billed charges,97% of total billed charges,211.24,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,220.33,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75825-Venography Caval Inferior w serial,3431969,CDM,320,RC,75825,HCPCS,Outpatient,,,133.27,66.64,,119.94,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,157.68,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.94,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,129.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,122.61,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,119.94,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,93.29,70,,,percent of total billed charges,70% of total billed charges,119.94,90,,,percent of total billed charges,90% of total billed charges,126.61,95,,,percent of total billed charges,95% of total billed charges,126.61,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,114.61,86,,,percent of total billed charges,86% of total billed charges,106.62,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,129.27,97,,,percent of total billed charges,97% of total billed charges,119.94,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.27,97,,,percent of total billed charges,97% of total billed charges,123.94,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
Inferior VenaCava Gram (Cardiology),3316227,CDM,960,RC,75825,HCPCS,Outpatient,,,283.92,141.96,,255.53,90,,,percent of total billed charges,90% of total Billed charges,109.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.67,155,,,Fee Schedule,155% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,152.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,532.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,283.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,532.85,
Read,631581,CDM,972,RC,75825,HCPCS,Outpatient,,,113.57,56.79,,102.21,90,,,percent of total billed charges,90% of total Billed charges,109.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.67,155,,,Fee Schedule,155% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,152.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,532.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,283.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,532.85,
Venography Caval Inferior w serial,3427269,CDM,960,RC,75825,HCPCS,Outpatient,,,283.92,141.96,,255.53,90,,,percent of total billed charges,90% of total Billed charges,109.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.67,155,,,Fee Schedule,155% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,152.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,532.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,283.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,532.85,
75827-Venography Caval Sup w Serialography,3431970,CDM,320,RC,75827,HCPCS,Outpatient,,,134.34,67.17,,120.91,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,166.65,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.91,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,130.31,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,123.59,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,120.91,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,94.04,70,,,percent of total billed charges,70% of total billed charges,120.91,90,,,percent of total billed charges,90% of total billed charges,127.62,95,,,percent of total billed charges,95% of total billed charges,127.62,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,115.53,86,,,percent of total billed charges,86% of total billed charges,107.47,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,130.31,97,,,percent of total billed charges,97% of total billed charges,120.91,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.31,97,,,percent of total billed charges,97% of total billed charges,124.94,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.31,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
Venography Caval Sup w Serialography,,,320,RC,75827,HCPCS,Outpatient,,,296.27,148.14,,266.64,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,166.65,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.64,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,287.38,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,272.57,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,266.64,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,207.39,70,,,percent of total billed charges,70% of total billed charges,266.64,90,,,percent of total billed charges,90% of total billed charges,281.46,95,,,percent of total billed charges,95% of total billed charges,281.46,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,254.79,86,,,percent of total billed charges,86% of total billed charges,237.02,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,287.38,97,,,percent of total billed charges,97% of total billed charges,266.64,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.38,97,,,percent of total billed charges,97% of total billed charges,275.53,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,287.38,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
"75893-PF Venous sampling through catheter, w/wo angiography",4271259,CDM,960,RC,75893,HCPCS,Outpatient,,,199.32,99.66,,179.39,90,,,percent of total billed charges,90% of total Billed charges,138.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.08,155,,,Fee Schedule,155% of CMS OPPS Rate,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.08,140,,,Fee Schedule,140% of CMS OPPS Rate,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.08,140,,,Fee Schedule,140% of CMS OPPS Rate,194.5,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,460.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.39,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,229.39,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.34,460.85,
"75893-Venous sampling through catheter, w/wo angiography",4271258,CDM,481,RC,75893,HCPCS,Outpatient,,,199.32,99.66,,179.39,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,191.38,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.34,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,183.37,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,179.39,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,139.52,70,,,percent of total billed charges,70% of total billed charges,179.39,90,,,percent of total billed charges,90% of total billed charges,189.35,95,,,percent of total billed charges,95% of total billed charges,189.35,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,171.42,86,,,percent of total billed charges,86% of total billed charges,159.46,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,193.34,97,,,percent of total billed charges,97% of total billed charges,179.39,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.34,97,,,percent of total billed charges,97% of total billed charges,185.37,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,193.34,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.52,25056.98,
75957-ENDOVASCULAR TAA REPAIR INTERP,3430924,CDM,510,RC,75957,HCPCS,Outpatient,,,1555.02,777.51,,1399.52,90,,,percent of total billed charges,90% of total Billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1244.02,80,,,Percent of total Billed charges,80% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1399.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1508.37,97,,,Percent of total billed charges,97% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1430.62,92,,,Percent of total billed charges,92% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1399.52,90,,,percent of total billed charges,90% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1088.51,70,,,percent of total billed charges,70% of total billed charges,1399.52,90,,,percent of total billed charges,90% of total billed charges,1477.27,95,,,percent of total billed charges,95% of total billed charges,1477.27,95,,,percent of total billed charges,95% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1337.32,86,,,percent of total billed charges,86% of total billed charges,1244.02,80,,,percent of total billed charges,80% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1508.37,97,,,percent of total billed charges,97% of total billed charges,1399.52,90,,,percent of total billed charges,90% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1508.37,97,,,percent of total billed charges,97% of total billed charges,1446.17,93,,,percent of total billed charges,93% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1508.37,97,,,percent of total billed charges,97% of total billed charges,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1555.02,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1088.51,1555.02,
75984-NEPHROSTOMY TUBE CHANGE SUP/INTREP,3431972,CDM,320,RC,75984,HCPCS,Outpatient,,,83.2,41.60,,74.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,142.7,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.88,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,76.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,53.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,65.44,78.65,,,percent of total billed charges,78.65% of total billed charges,74.32,89.33,,,percent of total billed charges,89.33% of total billed charges,74.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.24,70,,,percent of total billed charges,70% of total billed charges,74.88,90,,,percent of total billed charges,90% of total billed charges,79.04,95,,,percent of total billed charges,95% of total billed charges,79.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.55,86,,,percent of total billed charges,86% of total billed charges,66.56,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,80.7,97,,,percent of total billed charges,97% of total billed charges,74.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.7,97,,,percent of total billed charges,97% of total billed charges,77.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,142.7,
75984-PF NEPHROSTOMY TUBE CHANGE SUP/INTREP,3580897,CDM,960,RC,75984,HCPCS,Outpatient,,,242.19,121.10,,217.97,90,,,percent of total billed charges,90% of total Billed charges,105.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,72.41,155,,,Fee Schedule,155% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,147.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,211.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.5,217.97,
DR Cath Exchange,3334388,CDM,320,RC,75984,HCPCS,Outpatient,,,234.68,117.34,,211.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,142.7,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.21,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,227.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,215.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,149.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,184.58,78.65,,,percent of total billed charges,78.65% of total billed charges,209.64,89.33,,,percent of total billed charges,89.33% of total billed charges,211.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.28,70,,,percent of total billed charges,70% of total billed charges,211.21,90,,,percent of total billed charges,90% of total billed charges,222.95,95,,,percent of total billed charges,95% of total billed charges,222.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.82,86,,,percent of total billed charges,86% of total billed charges,187.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.64,97,,,percent of total billed charges,97% of total billed charges,211.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.64,97,,,percent of total billed charges,97% of total billed charges,218.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,227.64,
Read,596772,CDM,972,RC,75984,HCPCS,Outpatient,,,93.87,46.94,,84.48,90,,,percent of total billed charges,90% of total Billed charges,105.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,72.41,155,,,Fee Schedule,155% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,147.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,211.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.5,211.04,
Read,1449207,CDM,972,RC,75984,HCPCS,Outpatient,,,93.87,46.94,,84.48,90,,,percent of total billed charges,90% of total Billed charges,105.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,72.41,155,,,Fee Schedule,155% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.41,140,,,Fee Schedule,140% of CMS OPPS Rate,147.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,211.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.5,211.04,
Fluid Drainage w Tube Placement,3323636,CDM,350,RC,75989,HCPCS,Outpatient,,,279.29,139.65,,251.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,132.95,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,251.36,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,270.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,256.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,178.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,219.67,78.65,,,percent of total billed charges,78.65% of total billed charges,249.49,89.33,,,percent of total billed charges,89.33% of total billed charges,251.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.5,70,,,percent of total billed charges,70% of total billed charges,251.36,90,,,percent of total billed charges,90% of total billed charges,265.33,95,,,percent of total billed charges,95% of total billed charges,265.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.19,86,,,percent of total billed charges,86% of total billed charges,223.43,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,270.91,97,,,percent of total billed charges,97% of total billed charges,251.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.91,97,,,percent of total billed charges,97% of total billed charges,259.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,270.91,
76000-CARDIAC FLURO,3431973,CDM,320,RC,76000,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,1138.43,
Cardiac Fluoro,3348623,CDM,960,RC,76000,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,49.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,69.12,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,97.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,97.65,
Read,602005,CDM,972,RC,76000,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,49.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,69.12,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,97.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,97.65,
Read,602029,CDM,972,RC,76000,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,49.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,69.12,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,97.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,97.65,
Read,602035,CDM,972,RC,76010,HCPCS,Outpatient,,,29,14.50,,26.1,90,,,percent of total billed charges,90% of total Billed charges,37.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,52.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,49.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.5,55.62,
Read,602057,CDM,972,RC,76080,HCPCS,Outpatient,,,59.05,29.53,,53.15,90,,,percent of total billed charges,90% of total Billed charges,62.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,43.43,155,,,Fee Schedule,155% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.43,140,,,Fee Schedule,140% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.43,140,,,Fee Schedule,140% of CMS OPPS Rate,88.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.38,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,113.38,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,114.67,
3D TEE Imaging,3569848,CDM,350,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,22.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,15.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,19.69,78.65,,,percent of total billed charges,78.65% of total billed charges,22.36,89.33,,,percent of total billed charges,89.33% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.52,70,,,percent of total billed charges,70% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,23.78,95,,,percent of total billed charges,95% of total billed charges,23.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,86,,,percent of total billed charges,86% of total billed charges,20.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,23.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,28.1,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,510,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,22.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,15.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,19.69,78.65,,,percent of total billed charges,78.65% of total billed charges,22.36,89.33,,,percent of total billed charges,89.33% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.52,70,,,percent of total billed charges,70% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,23.78,95,,,percent of total billed charges,95% of total billed charges,23.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.53,86,,,percent of total billed charges,86% of total billed charges,20.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,22.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,23.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.98,28.1,
76512-PF OPHTHALMIC US DX B-SCAN W/WO NON-QUAN A-SCAN,4321493,CDM,981,RC,76512,HCPCS,Outpatient,,,89.22,44.61,,80.3,90,,,percent of total billed charges,90% of total Billed charges,31.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.81,155,,,Fee Schedule,155% of CMS OPPS Rate,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.81,140,,,Fee Schedule,140% of CMS OPPS Rate,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.81,140,,,Fee Schedule,140% of CMS OPPS Rate,43.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,174.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15.58,174.99,
76536-PF US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM,4321494,CDM,981,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,181.75,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,235.02,
76604-PF US CHEST REAL TIME W/IMAGE DOCUMENTATION,4321495,CDM,981,RC,76604,HCPCS,Outpatient,,,106.06,53.03,,95.45,90,,,percent of total billed charges,90% of total Billed charges,53.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.09,155,,,Fee Schedule,155% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,74.49,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,163.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.78,163.19,
76641 - (26) US Breast Complete,3896985,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,82.9,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
76642-PF US BREAST UNI REAL TIME WITH IMAGE LIMITED,4321496,CDM,981,RC,76642,HCPCS,Outpatient,,,157.04,78.52,,141.34,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
Read,596621,CDM,972,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
Read,3370923,CDM,972,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
US HKBT Abdomen  Complete:Read,3317830,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,510,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,67.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.75,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,73.02,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,69.26,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,67.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,52.7,70,,,percent of total billed charges,70% of total billed charges,67.75,90,,,percent of total billed charges,90% of total billed charges,71.52,95,,,percent of total billed charges,95% of total billed charges,71.52,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,64.74,86,,,percent of total billed charges,86% of total billed charges,60.22,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,73.02,97,,,percent of total billed charges,97% of total billed charges,67.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.02,97,,,percent of total billed charges,97% of total billed charges,70.01,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.02,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
76705-PF US ABDOMINAL REAL TIME W/IMAGE LIMITED,4321499,CDM,981,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3351898,CDM,402,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.3,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.6,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.52,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,113.01,70,,,percent of total billed charges,70% of total billed charges,145.3,90,,,percent of total billed charges,90% of total billed charges,153.37,95,,,percent of total billed charges,95% of total billed charges,153.37,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.84,86,,,percent of total billed charges,86% of total billed charges,129.15,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.6,97,,,percent of total billed charges,97% of total billed charges,145.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.6,97,,,percent of total billed charges,97% of total billed charges,150.14,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.6,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
Read,3358604,CDM,402,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.3,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.6,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.52,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,113.01,70,,,percent of total billed charges,70% of total billed charges,145.3,90,,,percent of total billed charges,90% of total billed charges,153.37,95,,,percent of total billed charges,95% of total billed charges,153.37,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.84,86,,,percent of total billed charges,86% of total billed charges,129.15,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.6,97,,,percent of total billed charges,97% of total billed charges,145.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.6,97,,,percent of total billed charges,97% of total billed charges,150.14,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.6,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
Read,596618,CDM,972,RC,76705,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3351918,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3351922,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
US Abdomen Limited,3345544,CDM,402,RC,76705,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.57,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.71,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,91.44,70,,,percent of total billed charges,70% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.34,86,,,percent of total billed charges,86% of total billed charges,104.5,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.71,97,,,percent of total billed charges,97% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.71,97,,,percent of total billed charges,97% of total billed charges,121.49,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.71,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
76775-CL Renal Artery Ultrasound BILAT,3431974,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
76775-CL Renal Artery Ultrasound LT,3431975,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
76775-CL Renal Artery Ultrasound RT,3431976,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
76775PF Us exam abdo back wall lim,4267406,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
76775-PF US RETROPERITONEAL REAL TIME W/IMAGE LIMITED,4321500,CDM,981,RC,76775,HCPCS,Outpatient,,,110.04,55.02,,99.04,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
US Retroperitoneal Organs Limited,1225055,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.57,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.71,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,91.44,70,,,percent of total billed charges,70% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.34,86,,,percent of total billed charges,86% of total billed charges,104.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.71,97,,,percent of total billed charges,97% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.71,97,,,percent of total billed charges,97% of total billed charges,121.49,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.71,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.05,
76815-PF US PREGNANT UTERUS LIMITED 1/> FETUSES,4321501,CDM,981,RC,76815,HCPCS,Outpatient,,,150.34,75.17,,135.31,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,169.75,
76817-PF US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG,4321502,CDM,981,RC,76817,HCPCS,Outpatient,,,171.12,85.56,,154.01,90,,,percent of total billed charges,90% of total Billed charges,101.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.36,155,,,Fee Schedule,155% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,142.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.26,192.69,
76830-PF US TRANSVAGINAL,4321505,CDM,981,RC,76830,HCPCS,Outpatient,,,218.34,109.17,,196.51,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,249.4,
76870PF Us exam scrotum,4267407,CDM,972,RC,76870,HCPCS,Outpatient,,,219.21,109.61,,197.29,90,,,percent of total billed charges,90% of total Billed charges,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,143.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,143.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.09,140,,,Fee Schedule,140% of CMS OPPS Rate,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.09,140,,,Fee Schedule,140% of CMS OPPS Rate,175.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.21,232.01,
76882-PF US LMTD JT/FCL EVAL NONVASC XTR STRUX R-T W/IMG,4321506,CDM,981,RC,76882,HCPCS,Outpatient,,,81.36,40.68,,73.22,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,115.72,
76937-PF Ultrasound Guided Access,3580899,CDM,960,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,87.25,90,,,percent of total billed charges,90% of total Billed charges,45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,155,,,Fee Schedule,155% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,140,,,Fee Schedule,140% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,140,,,Fee Schedule,140% of CMS OPPS Rate,63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.14,87.25,
76937-PF US Guided Access,3580898,CDM,960,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,87.25,90,,,percent of total billed charges,90% of total Billed charges,45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,155,,,Fee Schedule,155% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,140,,,Fee Schedule,140% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,140,,,Fee Schedule,140% of CMS OPPS Rate,63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.14,87.25,
76937-PF US VASC ACCESS SITS VSL PATENCY NDL ENTRY,4321507,CDM,981,RC,76937,HCPCS,Outpatient,,,72.72,36.36,,65.45,90,,,percent of total billed charges,90% of total Billed charges,45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,155,,,Fee Schedule,155% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,140,,,Fee Schedule,140% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,140,,,Fee Schedule,140% of CMS OPPS Rate,63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.14,70.73,
76937-Ultrasound Guided Access,3560636,CDM,402,RC,76937,HCPCS,Outpatient,,,34.45,17.23,,31.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.01,90,,,Percent of total Billed charges,90% of total billed charges,13.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,31.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,22,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,27.1,78.65,,,percent of total billed charges,78.65% of total billed charges,30.77,89.33,,,percent of total billed charges,89.33% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.12,70,,,percent of total billed charges,70% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,32.73,95,,,percent of total billed charges,95% of total billed charges,32.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,86,,,percent of total billed charges,86% of total billed charges,27.56,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,33.42,97,,,percent of total billed charges,97% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.42,97,,,percent of total billed charges,97% of total billed charges,32.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,41.2,
76937-US Guided Access,3552626,CDM,402,RC,76937,HCPCS,Outpatient,,,34.45,17.23,,31.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.01,90,,,Percent of total Billed charges,90% of total billed charges,13.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,31.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,22,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,27.1,78.65,,,percent of total billed charges,78.65% of total billed charges,30.77,89.33,,,percent of total billed charges,89.33% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.12,70,,,percent of total billed charges,70% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,32.73,95,,,percent of total billed charges,95% of total billed charges,32.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,86,,,percent of total billed charges,86% of total billed charges,27.56,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,33.42,97,,,percent of total billed charges,97% of total billed charges,31.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.42,97,,,percent of total billed charges,97% of total billed charges,32.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,41.2,
"76942 (TC) - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676898,CDM,402,RC,76942,HCPCS,Outpatient,,,144.64,72.32,,130.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.18,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,140.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,133.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,92.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,113.76,78.65,,,percent of total billed charges,78.65% of total billed charges,129.21,89.33,,,percent of total billed charges,89.33% of total billed charges,130.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,101.25,70,,,percent of total billed charges,70% of total billed charges,130.18,90,,,percent of total billed charges,90% of total billed charges,137.41,95,,,percent of total billed charges,95% of total billed charges,137.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.39,86,,,percent of total billed charges,86% of total billed charges,115.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,140.3,97,,,percent of total billed charges,97% of total billed charges,130.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,140.3,97,,,percent of total billed charges,97% of total billed charges,134.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,140.3,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,81.09,40.55,,72.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.98,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,74.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,63.78,78.65,,,percent of total billed charges,78.65% of total billed charges,72.44,89.33,,,percent of total billed charges,89.33% of total billed charges,72.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.76,70,,,percent of total billed charges,70% of total billed charges,72.98,90,,,percent of total billed charges,90% of total billed charges,77.04,95,,,percent of total billed charges,95% of total billed charges,77.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.74,86,,,percent of total billed charges,86% of total billed charges,64.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,78.66,97,,,percent of total billed charges,97% of total billed charges,72.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.66,97,,,percent of total billed charges,97% of total billed charges,75.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,78.66,
Read,3370937,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,52.07,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3370947,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,52.07,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575235,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575237,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575241,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575273,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575291,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575293,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575313,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3575339,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3749005,CDM,972,RC,76942,HCPCS,Outpatient,,,57.85,28.93,,52.07,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3997155,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3997157,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,3749007,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,116.64,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,125.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,119.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,82.77,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,101.93,78.65,,,percent of total billed charges,78.65% of total billed charges,115.77,89.33,,,percent of total billed charges,89.33% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.72,70,,,percent of total billed charges,70% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.46,86,,,percent of total billed charges,86% of total billed charges,103.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,120.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,125.71,
Ultrasound Guided Access,3427174,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
US Guidance Aspiration Bx or Injection:Read,596563,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
"US Guide for BX, Cyst asp, inject,loc",630214,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,116.64,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,125.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,119.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,82.77,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,101.93,78.65,,,percent of total billed charges,78.65% of total billed charges,115.77,89.33,,,percent of total billed charges,89.33% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.72,70,,,percent of total billed charges,70% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.46,86,,,percent of total billed charges,86% of total billed charges,103.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,120.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,125.71,
76946- Echo guide for amniocentesis,3430620,CDM,510,RC,76946,HCPCS,Outpatient,,,80.6,40.30,,72.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.54,90,,,Percent of total Billed charges,90% of total billed charges,20.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.18,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,74.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,63.39,78.65,,,percent of total billed charges,78.65% of total billed charges,72,89.33,,,percent of total billed charges,89.33% of total billed charges,72.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.42,70,,,percent of total billed charges,70% of total billed charges,72.54,90,,,percent of total billed charges,90% of total billed charges,76.57,95,,,percent of total billed charges,95% of total billed charges,76.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.32,86,,,percent of total billed charges,86% of total billed charges,64.48,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,78.18,97,,,percent of total billed charges,97% of total billed charges,72.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.18,97,,,percent of total billed charges,97% of total billed charges,74.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.18,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,78.18,
Read,1980101,CDM,972,RC,76946,HCPCS,Outpatient,,,32.48,16.24,,29.23,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,18.14,155,,,Fee Schedule,155% of CMS OPPS Rate,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,140,,,Fee Schedule,140% of CMS OPPS Rate,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.14,140,,,Fee Schedule,140% of CMS OPPS Rate,35.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,60.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.96,79.5,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,510,RC,76965,HCPCS,Outpatient,,,172.75,86.38,,155.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.57,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,158.93,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,110.32,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,135.87,78.65,,,percent of total billed charges,78.65% of total billed charges,154.32,89.33,,,percent of total billed charges,89.33% of total billed charges,155.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.93,70,,,percent of total billed charges,70% of total billed charges,155.48,90,,,percent of total billed charges,90% of total billed charges,164.11,95,,,percent of total billed charges,95% of total billed charges,164.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.57,86,,,percent of total billed charges,86% of total billed charges,138.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,167.57,97,,,percent of total billed charges,97% of total billed charges,155.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.57,97,,,percent of total billed charges,97% of total billed charges,160.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.57,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,167.57,
"76998 -PF Ultrasonic Guidance, Intraoperative",4349188,CDM,983,RC,76998,HCPCS,Outpatient,,,91.06,45.53,,81.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,123.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,246.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,246.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.95,246.96,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,510,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.97,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,44.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,38.43,78.65,,,percent of total billed charges,78.65% of total billed charges,43.65,89.33,,,percent of total billed charges,89.33% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.2,70,,,percent of total billed charges,70% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,86,,,percent of total billed charges,86% of total billed charges,39.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,45.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,151.68,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,510,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,224.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,224.77,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,242.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,229.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,159.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,78.65,,,percent of total billed charges,78.65% of total billed charges,223.1,89.33,,,percent of total billed charges,89.33% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,174.82,70,,,percent of total billed charges,70% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,237.25,95,,,percent of total billed charges,95% of total billed charges,237.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.78,86,,,percent of total billed charges,86% of total billed charges,199.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,242.25,97,,,percent of total billed charges,97% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,242.25,97,,,percent of total billed charges,97% of total billed charges,232.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,242.25,
"77001-Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",4331251,CDM,481,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.97,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,44.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,38.43,78.65,,,percent of total billed charges,78.65% of total billed charges,43.65,89.33,,,percent of total billed charges,89.33% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.2,70,,,percent of total billed charges,70% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,86,,,percent of total billed charges,86% of total billed charges,39.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,45.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,151.68,
"77001-PF Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",4331252,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,97.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.4,155,,,Fee Schedule,155% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,136.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.97,223.49,
77001-PF Fluoro Central Venous Access Dev Plcmnt,4322120,CDM,960,RC,77001,HCPCS,Outpatient,,,34.58,17.29,,31.12,90,,,percent of total billed charges,90% of total Billed charges,69.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,48.41,155,,,Fee Schedule,155% of CMS OPPS Rate,34.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.41,140,,,Fee Schedule,140% of CMS OPPS Rate,34.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.41,140,,,Fee Schedule,140% of CMS OPPS Rate,96.82,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.12,223.49,
"Add On Code: Fluoro guidance with a central venous catheter insert, replacement, removal",,,320,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.97,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,44.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,38.43,78.65,,,percent of total billed charges,78.65% of total billed charges,43.65,89.33,,,percent of total billed charges,89.33% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.2,70,,,percent of total billed charges,70% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,46.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,86,,,percent of total billed charges,86% of total billed charges,39.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,43.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.39,97,,,percent of total billed charges,97% of total billed charges,45.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,151.68,
DR Central Venous Placement,655838,CDM,320,RC,77001,HCPCS,Outpatient,,,239.83,119.92,,215.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,215.85,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,232.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,220.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,153.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,188.63,78.65,,,percent of total billed charges,78.65% of total billed charges,214.24,89.33,,,percent of total billed charges,89.33% of total billed charges,215.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.88,70,,,percent of total billed charges,70% of total billed charges,215.85,90,,,percent of total billed charges,90% of total billed charges,227.84,95,,,percent of total billed charges,95% of total billed charges,227.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.25,86,,,percent of total billed charges,86% of total billed charges,191.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,97,,,percent of total billed charges,97% of total billed charges,215.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,97,,,percent of total billed charges,97% of total billed charges,223.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,232.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,232.64,
Read,2960105,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,86.34,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.78,155,,,Fee Schedule,155% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,207.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.37,223.49,
Read,3370935,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,86.34,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.78,155,,,Fee Schedule,155% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,207.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.37,223.49,
Read,3575271,CDM,972,RC,77001,HCPCS,Outpatient,,,95.93,47.97,,86.34,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.78,155,,,Fee Schedule,155% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,207.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.37,223.49,
DR Fluoro Guidance Non-Spine,3318488,CDM,320,RC,77002,HCPCS,Outpatient,,,278.92,139.46,,251.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,155.43,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,251.03,90,,,Percent of total Billed charges,90% of total billed charges,39.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,270.55,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,256.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,178.12,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,219.38,78.65,,,percent of total billed charges,78.65% of total billed charges,249.16,89.33,,,percent of total billed charges,89.33% of total billed charges,251.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.24,70,,,percent of total billed charges,70% of total billed charges,251.03,90,,,percent of total billed charges,90% of total billed charges,264.97,95,,,percent of total billed charges,95% of total billed charges,264.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.87,86,,,percent of total billed charges,86% of total billed charges,223.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,270.55,97,,,percent of total billed charges,97% of total billed charges,251.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.55,97,,,percent of total billed charges,97% of total billed charges,259.4,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.55,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,270.55,
Read,3351618,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,100.41,90,,,percent of total billed charges,90% of total Billed charges,158.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.35,155,,,Fee Schedule,155% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,222.32,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.39,222.32,
Read,3351620,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,100.41,90,,,percent of total billed charges,90% of total Billed charges,158.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.35,155,,,Fee Schedule,155% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,222.32,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.39,222.32,
Read,3351886,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,100.41,90,,,percent of total billed charges,90% of total Billed charges,158.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.35,155,,,Fee Schedule,155% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,222.32,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.39,222.32,
Read,3351888,CDM,972,RC,77002,HCPCS,Outpatient,,,111.57,55.79,,100.41,90,,,percent of total billed charges,90% of total Billed charges,158.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.35,155,,,Fee Schedule,155% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.35,140,,,Fee Schedule,140% of CMS OPPS Rate,222.32,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.39,222.32,
77013-PF CT Guide/Mon  for Tiss Abl,4322121,CDM,960,RC,77013,HCPCS,Outpatient,,,346.92,173.46,,312.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,919.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1034.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1034.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,693.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,693.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.34,1034.13,
77014-COMPUTED TOMOGRAPHY GUID PLACEMENT,3424707,CDM,983,RC,77014,HCPCS,Outpatient,,,105.66,52.83,,95.09,90,,,percent of total billed charges,90% of total Billed charges,134.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.21,155,,,Fee Schedule,155% of CMS OPPS Rate,66.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,116.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.21,140,,,Fee Schedule,140% of CMS OPPS Rate,66.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.21,140,,,Fee Schedule,140% of CMS OPPS Rate,187.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.58,354.57,
Read,1551103,CDM,972,RC,77021,HCPCS,Outpatient,,,406.12,203.06,,365.51,90,,,percent of total billed charges,90% of total Billed charges,634.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,257.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,439.8,155,,,Fee Schedule,155% of CMS OPPS Rate,314.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,899.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,621.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,621.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,374.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,406.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.8,140,,,Fee Schedule,140% of CMS OPPS Rate,314.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.8,140,,,Fee Schedule,140% of CMS OPPS Rate,887.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,314.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,515,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,314.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,747.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,257.58,899.54,
GYN VFA with DEXA:Read,3576812,CDM,972,RC,77085,HCPCS,Outpatient,,,123.79,61.90,,111.41,90,,,percent of total billed charges,90% of total Billed charges,64.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.88,155,,,Fee Schedule,155% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,90.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,111.41,
Read,3575425,CDM,972,RC,77086,HCPCS,Outpatient,,,79.44,39.72,,71.5,90,,,percent of total billed charges,90% of total Billed charges,43.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,155,,,Fee Schedule,155% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,61.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,71.5,
77263-RADIATION THERAPY PLANNING,3400483,CDM,983,RC,77263,HCPCS,Outpatient,,,357.69,178.85,,321.92,90,,,percent of total billed charges,90% of total Billed charges,328.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.48,155,,,Fee Schedule,155% of CMS OPPS Rate,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,184.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.48,140,,,Fee Schedule,140% of CMS OPPS Rate,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.48,140,,,Fee Schedule,140% of CMS OPPS Rate,460.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,313.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.13,460.39,
77280-SET RADIATION THERAPY FIELD SIMPLE Profee,3565220,CDM,983,RC,77280,HCPCS,Outpatient,,,86.67,43.34,,78,90,,,percent of total billed charges,90% of total Billed charges,173.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.34,155,,,Fee Schedule,155% of CMS OPPS Rate,86.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,370.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,370.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,220.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.34,140,,,Fee Schedule,140% of CMS OPPS Rate,86.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.34,140,,,Fee Schedule,140% of CMS OPPS Rate,242.68,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,86.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,188.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,86.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,345.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60,451.33,
77285-SET RADIATION THERAPY FIELD INTERMEDIATE Profee,3571478,CDM,983,RC,77285,HCPCS,Outpatient,,,1054.74,527.37,,949.27,90,,,percent of total billed charges,90% of total Billed charges,677.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,336,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,470.4,155,,,Fee Schedule,155% of CMS OPPS Rate,336,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,619.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,619.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,351.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,336,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,672,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,590.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.4,140,,,Fee Schedule,140% of CMS OPPS Rate,336,100,,,Fee Schedule,100% of CMS OPPS Rate ,470.4,140,,,Fee Schedule,140% of CMS OPPS Rate,948.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,336,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,336,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,612.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85,949.27,
77290-SET RADIATION THERAPY FIELD COMPLEX Profee,3565221,CDM,983,RC,77290,HCPCS,Outpatient,,,194.7,97.35,,175.23,90,,,percent of total billed charges,90% of total Billed charges,389.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,272.58,155,,,Fee Schedule,155% of CMS OPPS Rate,194.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,809.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,809.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,666.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,666.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,414.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.58,140,,,Fee Schedule,140% of CMS OPPS Rate,194.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.58,140,,,Fee Schedule,140% of CMS OPPS Rate,545.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,194.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,471.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1004.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,121.5,1004.07,
77293-RESPIRATOR MOTION MGMT SIMUL Profee,3565222,CDM,983,RC,77293,HCPCS,Outpatient,,,249.31,124.66,,224.38,90,,,percent of total billed charges,90% of total Billed charges,498.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,349.03,155,,,Fee Schedule,155% of CMS OPPS Rate,249.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,652.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,734.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,734.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,610.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,610.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,373.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,498.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.03,140,,,Fee Schedule,140% of CMS OPPS Rate,249.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.03,140,,,Fee Schedule,140% of CMS OPPS Rate,698.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,249.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,444.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,249.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.38,734.2,
77295-3D TREATMENT COMP DOSIMETRY Profee,3565223,CDM,983,RC,77295,HCPCS,Outpatient,,,531.87,265.94,,478.68,90,,,percent of total billed charges,90% of total Billed charges,441.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,548.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,311.01,155,,,Fee Schedule,155% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,705.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,793.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,793.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,677.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,677.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,483.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,444.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.01,140,,,Fee Schedule,140% of CMS OPPS Rate,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,311.01,140,,,Fee Schedule,140% of CMS OPPS Rate,618.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1185.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,836.29,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,836.29,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,222.15,1185.3,
77300-RADIATION THERAPY DOSE PLAN Profee,3565225,CDM,983,RC,77300,HCPCS,Outpatient,,,78.36,39.18,,70.52,90,,,percent of total billed charges,90% of total Billed charges,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.57,155,,,Fee Schedule,155% of CMS OPPS Rate,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.57,140,,,Fee Schedule,140% of CMS OPPS Rate,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.57,140,,,Fee Schedule,140% of CMS OPPS Rate,80.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.18,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,125.18,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.98,125.18,
77301-RADIOTHERAPY DOSE PLAN IMRT Profee,3565226,CDM,983,RC,77301,HCPCS,Outpatient,,,991.31,495.66,,892.18,90,,,percent of total billed charges,90% of total Billed charges,1982.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,991.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1080.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1387.83,155,,,Fee Schedule,155% of CMS OPPS Rate,991.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2760.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,991.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3105.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3105.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2579.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2579.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1567.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,991.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1982.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,991.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1387.83,140,,,Fee Schedule,140% of CMS OPPS Rate,991.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1387.83,140,,,Fee Schedule,140% of CMS OPPS Rate,2775.67,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,991.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1365.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,991.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,3504.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3504.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,892.18,3504.42,
77307-(26) TELETHX ISODOSE PLAN CPLX Profee,3565228,CDM,983,RC,77307,HCPCS,Outpatient,,,359.72,179.86,,323.75,90,,,percent of total billed charges,90% of total Billed charges,233.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,217.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.37,155,,,Fee Schedule,155% of CMS OPPS Rate,117.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,419.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,471.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,406.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,406.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,239.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.37,140,,,Fee Schedule,140% of CMS OPPS Rate,117.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.37,140,,,Fee Schedule,140% of CMS OPPS Rate,326.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,117.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,117.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.41,471.45,
77316 - (26) Brachytx Isodose Plan Simple,3898893,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,169.96,90,,,percent of total billed charges,90% of total Billed charges,297.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.26,155,,,Fee Schedule,155% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,416.51,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.7,416.51,
77316 - Brachytx Isodose Plan Simple,3898907,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,169.96,90,,,percent of total billed charges,90% of total Billed charges,297.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.26,155,,,Fee Schedule,155% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,416.51,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.7,416.51,
77316-(26)-BRACHYTX ISODOSE PLAN SIMPLE,3537568,CDM,333,RC,77316,HCPCS,Outpatient,,,168.58,84.29,,151.72,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,279.63,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.72,90,,,Percent of total Billed charges,90% of total billed charges,93.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,163.52,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,155.09,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,151.72,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,118.01,70,,,percent of total billed charges,70% of total billed charges,151.72,90,,,percent of total billed charges,90% of total billed charges,160.15,95,,,percent of total billed charges,95% of total billed charges,160.15,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,144.98,86,,,percent of total billed charges,86% of total billed charges,134.86,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,163.52,97,,,percent of total billed charges,97% of total billed charges,151.72,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.52,97,,,percent of total billed charges,97% of total billed charges,156.78,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,163.52,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.08,1748.8,
77317 - (26) Brachytx Isodose Intermed,3898913,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,224.19,90,,,percent of total billed charges,90% of total Billed charges,393.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.14,155,,,Fee Schedule,155% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,550.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.42,550.8,
77317 - Brachytx Isodose Intermed,3898927,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,224.19,90,,,percent of total billed charges,90% of total Billed charges,393.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.14,155,,,Fee Schedule,155% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,550.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.42,550.8,
77318 - (26) Bractx Isodose Complex,3898933,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,352.75,90,,,percent of total billed charges,90% of total Billed charges,531.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.23,155,,,Fee Schedule,155% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,744.25,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,744.25,
77318 - Bractx Isodose Complex,3898947,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,352.75,90,,,percent of total billed charges,90% of total Billed charges,531.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.23,155,,,Fee Schedule,155% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,744.25,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,744.25,
77321-SPECIAL TELETX PORT PLAN Profee,3565229,CDM,983,RC,77321,HCPCS,Outpatient,,,118.72,59.36,,106.85,90,,,percent of total billed charges,90% of total Billed charges,76.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.63,155,,,Fee Schedule,155% of CMS OPPS Rate,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.63,140,,,Fee Schedule,140% of CMS OPPS Rate,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.63,140,,,Fee Schedule,140% of CMS OPPS Rate,107,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,221,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.71,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,171.71,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.31,221,
77331-SPECIAL RADIATION DOSIMETRY,3400452,CDM,333,RC,77331,HCPCS,Outpatient,,,161.81,80.91,,145.63,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,41.25,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.63,90,,,Percent of total Billed charges,90% of total billed charges,19.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.96,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,148.87,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.63,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,113.27,70,,,percent of total billed charges,70% of total billed charges,145.63,90,,,percent of total billed charges,90% of total billed charges,153.72,95,,,percent of total billed charges,95% of total billed charges,153.72,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,139.16,86,,,percent of total billed charges,86% of total billed charges,129.45,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.96,97,,,percent of total billed charges,97% of total billed charges,145.63,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.96,97,,,percent of total billed charges,97% of total billed charges,150.48,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.96,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.46,650.24,
77331-SPECIAL RADIATION DOSIMETRY Profee,3565230,CDM,983,RC,77331,HCPCS,Outpatient,,,109.22,54.61,,98.3,90,,,percent of total billed charges,90% of total Billed charges,33.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,23.44,155,,,Fee Schedule,155% of CMS OPPS Rate,16.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.44,140,,,Fee Schedule,140% of CMS OPPS Rate,16.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.44,140,,,Fee Schedule,140% of CMS OPPS Rate,46.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,119.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.74,119.28,
77332-RADIATION TREATMENT AID(S) SIMPLE,3400453,CDM,333,RC,77332,HCPCS,Outpatient,,,94.8,47.40,,85.32,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,61.68,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.32,90,,,Percent of total Billed charges,90% of total billed charges,35.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,91.96,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,87.22,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,85.32,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,66.36,70,,,percent of total billed charges,70% of total billed charges,85.32,90,,,percent of total billed charges,90% of total billed charges,90.06,95,,,percent of total billed charges,95% of total billed charges,90.06,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81.53,86,,,percent of total billed charges,86% of total billed charges,75.84,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,91.96,97,,,percent of total billed charges,97% of total billed charges,85.32,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.96,97,,,percent of total billed charges,97% of total billed charges,88.16,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.96,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.5,650.24,
77332-RADIATION TREATMENT AID(S) SIMPLE Profee,3565231,CDM,983,RC,77332,HCPCS,Outpatient,,,67.67,33.84,,60.9,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.72,155,,,Fee Schedule,155% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,35.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,144.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.66,144.19,
77333-RADIATION TREAT AID(S) INTERMEDIATE Profee,3565232,CDM,983,RC,77333,HCPCS,Outpatient,,,104.47,52.24,,94.02,90,,,percent of total billed charges,90% of total Billed charges,173.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.13,155,,,Fee Schedule,155% of CMS OPPS Rate,85.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.13,140,,,Fee Schedule,140% of CMS OPPS Rate,85.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.13,140,,,Fee Schedule,140% of CMS OPPS Rate,242.91,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,85.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.31,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,98.31,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.72,242.91,
77334-RADIATION TREATMENT AID(S) COMPLEX Profee,3565233,CDM,983,RC,77334,HCPCS,Outpatient,,,154.34,77.17,,138.91,90,,,percent of total billed charges,90% of total Billed charges,112.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,79.34,155,,,Fee Schedule,155% of CMS OPPS Rate,56.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.34,140,,,Fee Schedule,140% of CMS OPPS Rate,56.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.34,140,,,Fee Schedule,140% of CMS OPPS Rate,157.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,273.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.67,273.3,
77338-DESIGN MIC DEVICE FOR IMRT Profee,3565234,CDM,983,RC,77338,HCPCS,Outpatient,,,531.87,265.94,,478.68,90,,,percent of total billed charges,90% of total Billed charges,415.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.66,155,,,Fee Schedule,155% of CMS OPPS Rate,209.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,792.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,792.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,677.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,677.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,428.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.66,140,,,Fee Schedule,140% of CMS OPPS Rate,209.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.66,140,,,Fee Schedule,140% of CMS OPPS Rate,581.55,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,209.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,438.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,209.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,924.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,209.76,924.77,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,445.2,222.60,,400.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,356.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,400.68,90,,,Percent of total Billed charges,90% of total billed charges,151.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,431.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,409.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,284.31,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,350.16,78.65,,,percent of total billed charges,78.65% of total billed charges,397.7,89.33,,,percent of total billed charges,89.33% of total billed charges,400.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,311.64,70,,,percent of total billed charges,70% of total billed charges,400.68,90,,,percent of total billed charges,90% of total billed charges,422.94,95,,,percent of total billed charges,95% of total billed charges,422.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.87,86,,,percent of total billed charges,86% of total billed charges,356.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,431.84,97,,,percent of total billed charges,97% of total billed charges,400.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,431.84,97,,,percent of total billed charges,97% of total billed charges,414.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,431.84,
77431-TREATMENT MANAGEMENT 1-2 FRACTIONS,3400486,CDM,983,RC,77431,HCPCS,Outpatient,,,244.56,122.28,,220.1,90,,,percent of total billed charges,90% of total Billed charges,206.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,144.86,155,,,Fee Schedule,155% of CMS OPPS Rate,103.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,113.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,144.86,140,,,Fee Schedule,140% of CMS OPPS Rate,103.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.86,140,,,Fee Schedule,140% of CMS OPPS Rate,288.97,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.5,288.97,
77432-Sterotactic Radiation Treatment,4169511,CDM,333,RC,77432,HCPCS,Outpatient,,,1097.63,548.82,,987.87,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,878.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,987.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1064.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1009.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,700.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,863.31,78.65,,,percent of total billed charges,78.65% of total billed charges,980.53,89.33,,,percent of total billed charges,89.33% of total billed charges,987.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,768.34,70,,,percent of total billed charges,70% of total billed charges,987.87,90,,,percent of total billed charges,90% of total billed charges,1042.75,95,,,percent of total billed charges,95% of total billed charges,1042.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.96,86,,,percent of total billed charges,86% of total billed charges,878.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1064.7,97,,,percent of total billed charges,97% of total billed charges,987.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1064.7,97,,,percent of total billed charges,97% of total billed charges,1020.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1064.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.97,1064.7,
77435-SBRT MANAGEMENT Profee,3565384,CDM,983,RC,77435,HCPCS,Outpatient,,,1521.99,761.00,,1369.79,90,,,percent of total billed charges,90% of total Billed charges,1250.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,625.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,497.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,875.24,155,,,Fee Schedule,155% of CMS OPPS Rate,625.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,625.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1055.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,961.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,961.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,492.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,625.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1250.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1064.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,697.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,875.24,140,,,Fee Schedule,140% of CMS OPPS Rate,625.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,875.24,140,,,Fee Schedule,140% of CMS OPPS Rate,1750.97,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,625.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,625.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1307.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1307.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,492.57,1750.97,
77470-SPECIAL RAD TREATMENT Profee,3565553,CDM,983,RC,77470,HCPCS,Outpatient,,,303.92,151.96,,273.53,90,,,percent of total billed charges,90% of total Billed charges,53.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.96,155,,,Fee Schedule,155% of CMS OPPS Rate,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,140.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,140,,,Fee Schedule,140% of CMS OPPS Rate,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.96,140,,,Fee Schedule,140% of CMS OPPS Rate,75.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,495.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,285.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.54,495.96,
77470-SPECIAL RAD TREATMENT READ Profee,3565554,CDM,983,RC,77470,HCPCS,Outpatient,,,250.5,125.25,,225.45,90,,,percent of total billed charges,90% of total Billed charges,53.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.96,155,,,Fee Schedule,155% of CMS OPPS Rate,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,140.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.96,140,,,Fee Schedule,140% of CMS OPPS Rate,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.96,140,,,Fee Schedule,140% of CMS OPPS Rate,75.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,495.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,285.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.54,495.96,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,333,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,238.37,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.37,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,256.91,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,243.67,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,238.37,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,185.4,70,,,percent of total billed charges,70% of total billed charges,238.37,90,,,percent of total billed charges,90% of total billed charges,251.62,95,,,percent of total billed charges,95% of total billed charges,251.62,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,227.78,86,,,percent of total billed charges,86% of total billed charges,211.89,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,256.91,97,,,percent of total billed charges,97% of total billed charges,238.37,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.91,97,,,percent of total billed charges,97% of total billed charges,246.32,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,256.91,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77770-HDR Rdncl Ntrstl/Icav Brchtx - Pro Fee,4169514,CDM,983,RC,77770,HCPCS,Outpatient,,,236.49,118.25,,212.84,90,,,percent of total billed charges,90% of total Billed charges,426.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,245.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.61,155,,,Fee Schedule,155% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,546.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,278.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,597.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.84,597.48,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,342,RC,77771,HCPCS,Outpatient,,,511.39,255.70,,460.25,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.25,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,496.05,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,470.48,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,460.25,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,357.97,70,,,percent of total billed charges,70% of total billed charges,460.25,90,,,percent of total billed charges,90% of total billed charges,485.82,95,,,percent of total billed charges,95% of total billed charges,485.82,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,439.8,86,,,percent of total billed charges,86% of total billed charges,409.11,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,496.05,97,,,percent of total billed charges,97% of total billed charges,460.25,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,496.05,97,,,percent of total billed charges,97% of total billed charges,475.59,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,496.05,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
77771-HDR Rdncl Ntrstl/Icav Brchtx 2-12 Chnl - Pro Fee,4169515,CDM,983,RC,77771,HCPCS,Outpatient,,,456.6,228.30,,410.94,90,,,percent of total billed charges,90% of total Billed charges,699.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,456.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,492.34,155,,,Fee Schedule,155% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,975.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,519.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,456.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,979.75,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,628.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,979.75,
77772-HDR RDNCL NTRSTL/ICAV BRCHTX < 12,3537578,CDM,342,RC,77772,HCPCS,Outpatient,,,2147.98,1073.99,,1933.18,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1354.6,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1933.18,90,,,Percent of total Billed charges,90% of total billed charges,523.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2083.54,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1976.14,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1933.18,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.59,70,,,percent of total billed charges,70% of total billed charges,1933.18,90,,,percent of total billed charges,90% of total billed charges,2040.58,95,,,percent of total billed charges,95% of total billed charges,2040.58,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1847.26,86,,,percent of total billed charges,86% of total billed charges,1718.38,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2083.54,97,,,percent of total billed charges,97% of total billed charges,1933.18,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2083.54,97,,,percent of total billed charges,97% of total billed charges,1997.62,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2083.54,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,475.98,3518.47,
NM Brachytherapy Seed Implant,671978,CDM,342,RC,77778,HCPCS,Outpatient,,,2234.19,1117.10,,2010.77,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,836.63,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2010.77,90,,,Percent of total Billed charges,90% of total billed charges,202.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2167.16,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,2055.45,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2010.77,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.93,70,,,percent of total billed charges,70% of total billed charges,2010.77,90,,,percent of total billed charges,90% of total billed charges,2122.48,95,,,percent of total billed charges,95% of total billed charges,2122.48,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1921.4,86,,,percent of total billed charges,86% of total billed charges,1787.35,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2167.16,97,,,percent of total billed charges,97% of total billed charges,2010.77,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,2167.16,97,,,percent of total billed charges,97% of total billed charges,2077.8,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2167.16,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.95,3518.47,
77790-RADIATION HANDLING,3537579,CDM,342,RC,77790,HCPCS,Outpatient,,,40.89,20.45,,36.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.8,90,,,Percent of total Billed charges,90% of total billed charges,19.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,39.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,26.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,32.16,78.65,,,percent of total billed charges,78.65% of total billed charges,36.53,89.33,,,percent of total billed charges,89.33% of total billed charges,36.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.62,70,,,percent of total billed charges,70% of total billed charges,36.8,90,,,percent of total billed charges,90% of total billed charges,38.85,95,,,percent of total billed charges,95% of total billed charges,38.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.17,86,,,percent of total billed charges,86% of total billed charges,32.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.66,97,,,percent of total billed charges,97% of total billed charges,36.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.66,97,,,percent of total billed charges,97% of total billed charges,38.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,39.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,39.66,
NM Cardiac Shunt Study:Read,597279,CDM,972,RC,78428,HCPCS,Outpatient,,,435.14,217.57,,391.63,90,,,percent of total billed charges,90% of total Billed charges,249.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,171.71,155,,,Fee Schedule,155% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,149.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.71,140,,,Fee Schedule,140% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.71,140,,,Fee Schedule,140% of CMS OPPS Rate,349.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.05,391.63,
78451 - (26) Myocardial Spect SNGL Study at Rest or Stress,3899086,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,703.42,90,,,percent of total billed charges,90% of total Billed charges,450.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,309.22,155,,,Fee Schedule,155% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,640.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,398.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,631.36,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,367.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,658.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,220.87,703.42,
78451 - Myocardial Spect SNGL Study at Rest or Stress,3899088,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,703.42,90,,,percent of total billed charges,90% of total Billed charges,450.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,309.22,155,,,Fee Schedule,155% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,640.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,398.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,631.36,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,367.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,658.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,220.87,703.42,
NM Myocardial Rest or Stress Spect,603532,CDM,340,RC,78451,HCPCS,Outpatient,,,750.09,375.05,,675.08,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,590.23,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,675.08,90,,,Percent of total Billed charges,90% of total billed charges,209.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,727.59,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,690.08,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,675.08,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,525.06,70,,,percent of total billed charges,70% of total billed charges,675.08,90,,,percent of total billed charges,90% of total billed charges,712.59,95,,,percent of total billed charges,95% of total billed charges,712.59,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,645.08,86,,,percent of total billed charges,86% of total billed charges,600.07,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,727.59,97,,,percent of total billed charges,97% of total billed charges,675.08,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,727.59,97,,,percent of total billed charges,97% of total billed charges,697.58,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,727.59,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,190.19,6470.6,
78452 Ht muscle image spect mult,3428339,CDM,983,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,135.83,90,,,percent of total billed charges,90% of total Billed charges,301.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,340.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,211.29,155,,,Fee Schedule,155% of CMS OPPS Rate,150.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,793.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,892.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,892.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,638.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,638.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,390.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.29,140,,,Fee Schedule,140% of CMS OPPS Rate,150.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.29,140,,,Fee Schedule,140% of CMS OPPS Rate,422.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,150.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,340.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,636.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,921.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,921.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135.83,921.49,
78452-NM Myocardial EF Rest Stress Spect Add-on,4263188,CDM,340,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,135.83,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,853.13,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.83,90,,,Percent of total Billed charges,90% of total billed charges,306.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,146.39,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,138.85,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.83,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,105.64,70,,,percent of total billed charges,70% of total billed charges,135.83,90,,,percent of total billed charges,90% of total billed charges,143.37,95,,,percent of total billed charges,95% of total billed charges,143.37,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.79,86,,,percent of total billed charges,86% of total billed charges,120.74,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,146.39,97,,,percent of total billed charges,97% of total billed charges,135.83,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.39,97,,,percent of total billed charges,97% of total billed charges,140.36,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.39,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.64,6470.6,
NM Myocardial EF Rest Stress Spect,603531,CDM,340,RC,78452,HCPCS,Outpatient,,,150.92,75.46,,135.83,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,853.13,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.83,90,,,Percent of total Billed charges,90% of total billed charges,306.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,146.39,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,138.85,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.83,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,105.64,70,,,percent of total billed charges,70% of total billed charges,135.83,90,,,percent of total billed charges,90% of total billed charges,143.37,95,,,percent of total billed charges,95% of total billed charges,143.37,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.79,86,,,percent of total billed charges,86% of total billed charges,120.74,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,146.39,97,,,percent of total billed charges,97% of total billed charges,135.83,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.39,97,,,percent of total billed charges,97% of total billed charges,140.36,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.39,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.64,6470.6,
78466 - (26) MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUA,3997214,CDM,960,RC,78466,HCPCS,Outpatient,,,448.18,224.09,,403.36,90,,,percent of total billed charges,90% of total Billed charges,258.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,173.35,155,,,Fee Schedule,155% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,362.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,322.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,322.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.62,403.36,
Read,3348398,CDM,972,RC,78466,HCPCS,Outpatient,,,165.58,82.79,,149.02,90,,,percent of total billed charges,90% of total Billed charges,258.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,173.35,155,,,Fee Schedule,155% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,362.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,322.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,322.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.62,380.25,
NM Cardiac Eject Fract 1st pass rest,603526,CDM,340,RC,78468,HCPCS,Outpatient,,,435.45,217.73,,391.91,90,,,percent of total billed charges,90% of total Billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,357.65,250,,,Fee Schedule,250% of Fee Schedule Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,422.39,97,,,Percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,400.61,92,,,Percent of total billed charges,92% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1941.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2459.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,391.91,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.82,70,,,percent of total billed charges,70% of total billed charges,391.91,90,,,percent of total billed charges,90% of total billed charges,413.68,95,,,percent of total billed charges,95% of total billed charges,413.68,95,,,percent of total billed charges,95% of total billed charges,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.49,86,,,percent of total billed charges,86% of total billed charges,348.36,80,,,percent of total billed charges,80% of total billed charges,487.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.39,97,,,percent of total billed charges,97% of total billed charges,391.91,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.39,97,,,percent of total billed charges,97% of total billed charges,404.97,93,,,percent of total billed charges,93% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,422.39,97,,,percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,389.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,304.82,2459.48,
NM Tomo SPECT w/wo quantification,4061197,CDM,340,RC,78468,HCPCS,Outpatient,,,435.45,217.73,,391.91,90,,,percent of total billed charges,90% of total Billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,357.65,250,,,Fee Schedule,250% of Fee Schedule Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,391.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,422.39,97,,,Percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,400.61,92,,,Percent of total billed charges,92% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1941.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2459.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,391.91,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,304.82,70,,,percent of total billed charges,70% of total billed charges,391.91,90,,,percent of total billed charges,90% of total billed charges,413.68,95,,,percent of total billed charges,95% of total billed charges,413.68,95,,,percent of total billed charges,95% of total billed charges,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,374.49,86,,,percent of total billed charges,86% of total billed charges,348.36,80,,,percent of total billed charges,80% of total billed charges,487.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,422.39,97,,,percent of total billed charges,97% of total billed charges,391.91,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.39,97,,,percent of total billed charges,97% of total billed charges,404.97,93,,,percent of total billed charges,93% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,422.39,97,,,percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,389.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,304.82,2459.48,
NM Cardiac Wall Motion Study,645957,CDM,340,RC,78472,HCPCS,Outpatient,,,507.19,253.60,,456.47,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,392.13,250,,,Fee Schedule,250% of Fee Schedule Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.47,90,,,Percent of total Billed charges,90% of total billed charges,67.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,491.97,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,466.61,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.36,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.95,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,456.47,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,355.03,70,,,percent of total billed charges,70% of total billed charges,456.47,90,,,percent of total billed charges,90% of total billed charges,481.83,95,,,percent of total billed charges,95% of total billed charges,481.83,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,436.18,86,,,percent of total billed charges,86% of total billed charges,405.75,80,,,percent of total billed charges,80% of total billed charges,380.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,491.97,97,,,percent of total billed charges,97% of total billed charges,456.47,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.97,97,,,percent of total billed charges,97% of total billed charges,471.69,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.97,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61,1894.85,
NM Lung Scan Perfusion,603570,CDM,340,RC,78580,HCPCS,Outpatient,,,523.48,261.74,,471.13,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,437.8,250,,,Fee Schedule,250% of Fee Schedule Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,471.13,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,507.78,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,481.6,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.36,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.95,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,471.13,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,366.44,70,,,percent of total billed charges,70% of total billed charges,471.13,90,,,percent of total billed charges,90% of total billed charges,497.31,95,,,percent of total billed charges,95% of total billed charges,497.31,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,450.19,86,,,percent of total billed charges,86% of total billed charges,418.78,80,,,percent of total billed charges,80% of total billed charges,380.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,507.78,97,,,percent of total billed charges,97% of total billed charges,471.13,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,507.78,97,,,percent of total billed charges,97% of total billed charges,486.84,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,507.78,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1894.85,
NM Lung Scan Perf and Vent,603567,CDM,340,RC,78582,HCPCS,Outpatient,,,731.51,365.76,,658.36,90,,,percent of total billed charges,90% of total Billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,611.2,250,,,Fee Schedule,250% of Fee Schedule Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.36,90,,,Percent of total Billed charges,90% of total billed charges,218.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,709.56,97,,,Percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,672.99,92,,,Percent of total billed charges,92% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1941.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2459.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,658.36,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,512.06,70,,,percent of total billed charges,70% of total billed charges,658.36,90,,,percent of total billed charges,90% of total billed charges,694.93,95,,,percent of total billed charges,95% of total billed charges,694.93,95,,,percent of total billed charges,95% of total billed charges,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,629.1,86,,,percent of total billed charges,86% of total billed charges,585.21,80,,,percent of total billed charges,80% of total billed charges,487.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,709.56,97,,,percent of total billed charges,97% of total billed charges,658.36,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.56,97,,,percent of total billed charges,97% of total billed charges,680.3,93,,,percent of total billed charges,93% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.56,97,,,percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,389.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,198.81,2459.48,
NM Lung Differential Scan,603569,CDM,340,RC,78597,HCPCS,Outpatient,,,447.14,223.57,,402.43,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,358.78,250,,,Fee Schedule,250% of Fee Schedule Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,402.43,90,,,Percent of total Billed charges,90% of total billed charges,130.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,433.73,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,411.37,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.36,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.95,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,402.43,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,313,70,,,percent of total billed charges,70% of total billed charges,402.43,90,,,percent of total billed charges,90% of total billed charges,424.78,95,,,percent of total billed charges,95% of total billed charges,424.78,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,384.54,86,,,percent of total billed charges,86% of total billed charges,357.71,80,,,percent of total billed charges,80% of total billed charges,380.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,433.73,97,,,percent of total billed charges,97% of total billed charges,402.43,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,433.73,97,,,percent of total billed charges,97% of total billed charges,415.84,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,433.73,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.7,1894.85,
NM Lung Differential Scan Vent & Pref,603572,CDM,340,RC,78598,HCPCS,Outpatient,,,665.42,332.71,,598.88,90,,,percent of total billed charges,90% of total Billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,573,250,,,Fee Schedule,250% of Fee Schedule Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.88,90,,,Percent of total Billed charges,90% of total billed charges,211.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,645.46,97,,,Percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,612.19,92,,,Percent of total billed charges,92% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1941.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2459.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,598.88,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,465.79,70,,,percent of total billed charges,70% of total billed charges,598.88,90,,,percent of total billed charges,90% of total billed charges,632.15,95,,,percent of total billed charges,95% of total billed charges,632.15,95,,,percent of total billed charges,95% of total billed charges,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,572.26,86,,,percent of total billed charges,86% of total billed charges,532.34,80,,,percent of total billed charges,80% of total billed charges,487.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,645.46,97,,,percent of total billed charges,97% of total billed charges,598.88,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.46,97,,,percent of total billed charges,97% of total billed charges,618.84,93,,,percent of total billed charges,93% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,645.46,97,,,percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,389.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,192.34,2459.48,
NM Renal Scan with Diuretic,603516,CDM,340,RC,78708,HCPCS,Outpatient,,,419.71,209.86,,377.74,90,,,percent of total billed charges,90% of total Billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,256.93,250,,,Fee Schedule,250% of Fee Schedule Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.74,90,,,Percent of total Billed charges,90% of total billed charges,75.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,407.12,97,,,Percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,386.13,92,,,Percent of total billed charges,92% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1941.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2459.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,377.74,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,293.8,70,,,percent of total billed charges,70% of total billed charges,377.74,90,,,percent of total billed charges,90% of total billed charges,398.72,95,,,percent of total billed charges,95% of total billed charges,398.72,95,,,percent of total billed charges,95% of total billed charges,458.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,916.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,360.95,86,,,percent of total billed charges,86% of total billed charges,335.77,80,,,percent of total billed charges,80% of total billed charges,487.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,407.12,97,,,percent of total billed charges,97% of total billed charges,377.74,90,,,percent of total billed charges,90% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,407.12,97,,,percent of total billed charges,97% of total billed charges,390.33,93,,,percent of total billed charges,93% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,407.12,97,,,percent of total billed charges,97% of total billed charges,458.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.21,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,389.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69,2459.48,
Read,597089,CDM,972,RC,78740,HCPCS,Outpatient,,,192.18,96.09,,172.96,90,,,percent of total billed charges,90% of total Billed charges,316.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,218.23,155,,,Fee Schedule,155% of CMS OPPS Rate,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,412.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,293.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,293.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,181.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.23,140,,,Fee Schedule,140% of CMS OPPS Rate,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.23,140,,,Fee Schedule,140% of CMS OPPS Rate,443.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,424.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.4,443.77,
NM PYP no spect,3697192,CDM,341,RC,78800,HCPCS,Outpatient,,,555.44,277.72,,499.9,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,349.43,250,,,Fee Schedule,250% of Fee Schedule Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.9,90,,,Percent of total Billed charges,90% of total billed charges,60.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.78,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,511,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.36,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.95,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.9,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,388.81,70,,,percent of total billed charges,70% of total billed charges,499.9,90,,,percent of total billed charges,90% of total billed charges,527.67,95,,,percent of total billed charges,95% of total billed charges,527.67,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.68,86,,,percent of total billed charges,86% of total billed charges,444.35,80,,,percent of total billed charges,80% of total billed charges,380.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.78,97,,,percent of total billed charges,97% of total billed charges,499.9,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.78,97,,,percent of total billed charges,97% of total billed charges,516.56,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.78,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55,1894.85,
NM Breast Whole Body,603536,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,612.21,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,608.95,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.21,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,659.82,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.81,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,476.16,70,,,percent of total billed charges,70% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,585,86,,,percent of total billed charges,86% of total billed charges,544.18,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,659.82,97,,,percent of total billed charges,97% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.82,97,,,percent of total billed charges,97% of total billed charges,632.61,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,659.82,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,6470.6,
NM Tumor Loc Whole Body:NM Tumor Loc Whole Body,603544,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,612.21,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,608.95,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.21,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,659.82,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.81,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,476.16,70,,,percent of total billed charges,70% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,585,86,,,percent of total billed charges,86% of total billed charges,544.18,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,659.82,97,,,percent of total billed charges,97% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.82,97,,,percent of total billed charges,97% of total billed charges,632.61,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,659.82,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,6470.6,
NM WBC Imaging Whole Body,603546,CDM,340,RC,78802,HCPCS,Outpatient,,,680.23,340.12,,612.21,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,608.95,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.21,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,659.82,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.81,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,476.16,70,,,percent of total billed charges,70% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,646.22,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,585,86,,,percent of total billed charges,86% of total billed charges,544.18,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,659.82,97,,,percent of total billed charges,97% of total billed charges,612.21,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,659.82,97,,,percent of total billed charges,97% of total billed charges,632.61,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,659.82,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,6470.6,
Read,597073,CDM,972,RC,78802,HCPCS,Outpatient,,,272.09,136.05,,244.88,90,,,percent of total billed charges,90% of total Billed charges,449.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,109.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,308.39,155,,,Fee Schedule,155% of CMS OPPS Rate,220.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,593.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,422.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,422.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,268.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,440.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.39,140,,,Fee Schedule,140% of CMS OPPS Rate,220.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.39,140,,,Fee Schedule,140% of CMS OPPS Rate,628.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,220.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,258.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,593.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.98,628.71,
NM Brain Spect,603562,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM Liver Spect,603565,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM Musculoskeletal Spect,603558,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM PYP with spect,3697194,CDM,341,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM RBC Liver Spect,603566,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM Tumor Loc Spect,603545,CDM,340,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM WBC Imaging Whole Body Spect,3736901,CDM,320,RC,78803,HCPCS,Outpatient,,,837.56,418.78,,753.8,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,625.43,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.8,90,,,Percent of total Billed charges,90% of total billed charges,244.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.43,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,770.56,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,586.29,70,,,percent of total billed charges,70% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,795.68,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.3,86,,,percent of total billed charges,86% of total billed charges,670.05,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.43,97,,,percent of total billed charges,97% of total billed charges,753.8,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.43,97,,,percent of total billed charges,97% of total billed charges,778.93,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.43,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,222.19,6470.6,
NM Oral Isotope Therapy,3342270,CDM,340,RC,79005,HCPCS,Outpatient,,,336.37,168.19,,302.73,90,,,percent of total billed charges,90% of total Billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,106.38,250,,,Fee Schedule,250% of Fee Schedule Rate,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.73,90,,,Percent of total Billed charges,90% of total billed charges,41.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,326.28,97,,,Percent of total billed charges,97% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,309.46,92,,,Percent of total billed charges,92% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,602.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,226.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,961.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1217.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,302.73,90,,,percent of total billed charges,90% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,235.46,70,,,percent of total billed charges,70% of total billed charges,302.73,90,,,percent of total billed charges,90% of total billed charges,319.55,95,,,percent of total billed charges,95% of total billed charges,319.55,95,,,percent of total billed charges,95% of total billed charges,226.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,289.28,86,,,percent of total billed charges,86% of total billed charges,269.1,80,,,percent of total billed charges,80% of total billed charges,245.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,326.28,97,,,percent of total billed charges,97% of total billed charges,302.73,90,,,percent of total billed charges,90% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.28,97,,,percent of total billed charges,97% of total billed charges,312.82,93,,,percent of total billed charges,93% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,326.28,97,,,percent of total billed charges,97% of total billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,192.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.79,1217.46,
Read,597234,CDM,972,RC,79005,HCPCS,Outpatient,,,134.55,67.28,,121.1,90,,,percent of total billed charges,90% of total Billed charges,89.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.8,155,,,Fee Schedule,155% of CMS OPPS Rate,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.8,140,,,Fee Schedule,140% of CMS OPPS Rate,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.8,140,,,Fee Schedule,140% of CMS OPPS Rate,125.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.86,260.59,
Read,1225041,CDM,972,RC,79005,HCPCS,Outpatient,,,134.55,67.28,,121.1,90,,,percent of total billed charges,90% of total Billed charges,89.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.8,155,,,Fee Schedule,155% of CMS OPPS Rate,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.8,140,,,Fee Schedule,140% of CMS OPPS Rate,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.8,140,,,Fee Schedule,140% of CMS OPPS Rate,125.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.86,260.59,
Read,646054,CDM,972,RC,79101,HCPCS,Outpatient,,,146.47,73.24,,131.82,90,,,percent of total billed charges,90% of total Billed charges,93.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,65.66,155,,,Fee Schedule,155% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,281.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,213.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,213.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.66,140,,,Fee Schedule,140% of CMS OPPS Rate,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.66,140,,,Fee Schedule,140% of CMS OPPS Rate,131.25,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.51,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,280.51,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.9,281.2,
Smear Review Pathology,649497,CDM,300,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,49.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,44.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,49.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,51.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,35.45,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,43.66,78.65,,,percent of total billed charges,78.65% of total billed charges,49.59,89.33,,,percent of total billed charges,89.33% of total billed charges,49.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,38.86,70,,,percent of total billed charges,70% of total billed charges,49.96,90,,,percent of total billed charges,90% of total billed charges,52.73,95,,,percent of total billed charges,95% of total billed charges,52.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.74,86,,,percent of total billed charges,86% of total billed charges,44.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,53.84,97,,,percent of total billed charges,97% of total billed charges,49.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.84,97,,,percent of total billed charges,97% of total billed charges,51.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.45,53.84,
"Pathology Billing Cytopathology NG Thin Prep, with interpretation, except cervical or vaginal",646357,CDM,310,RC,88112,HCPCS,Outpatient,,,144.67,72.34,,130.2,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,115.74,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.2,90,,,Percent of total Billed charges,90% of total billed charges,45.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,140.33,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,133.1,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,130.2,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,101.27,70,,,percent of total billed charges,70% of total billed charges,130.2,90,,,percent of total billed charges,90% of total billed charges,137.44,95,,,percent of total billed charges,95% of total billed charges,137.44,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,124.42,86,,,percent of total billed charges,86% of total billed charges,115.74,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,140.33,97,,,percent of total billed charges,97% of total billed charges,130.2,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.33,97,,,percent of total billed charges,97% of total billed charges,134.54,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.33,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Pathology Billing Gyn Cytology with Pathologist Interpretation,295392,CDM,971,RC,88141,HCPCS,Outpatient,,,50.32,25.16,,45.29,90,,,percent of total billed charges,90% of total Billed charges,41.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.71,155,,,Fee Schedule,155% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,24.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,30.71,145,,,Fee Schedule,145% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.71,145,,,Fee Schedule,145% of CMS OPPS Rate,30.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.53,60.71,
Pathology Billing Surgical Pathology Level II Complexity,295348,CDM,310,RC,88302,HCPCS,Outpatient,,,69.93,34.97,,62.94,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,55.94,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.94,90,,,Percent of total Billed charges,90% of total billed charges,5.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,67.83,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,64.34,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,62.94,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,48.95,70,,,percent of total billed charges,70% of total billed charges,62.94,90,,,percent of total billed charges,90% of total billed charges,66.43,95,,,percent of total billed charges,95% of total billed charges,66.43,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.14,86,,,percent of total billed charges,86% of total billed charges,55.94,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,67.83,97,,,percent of total billed charges,97% of total billed charges,62.94,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.83,97,,,percent of total billed charges,97% of total billed charges,65.03,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.83,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5,121.68,
Pathology Billing Surgical Pathology Level III Complexity,295350,CDM,310,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,81.91,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,53.49,150,,,Fee Schedule,150% of Fee Schedule Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.91,90,,,Percent of total Billed charges,90% of total billed charges,7.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.28,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.91,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,70,,,percent of total billed charges,70% of total billed charges,81.91,90,,,percent of total billed charges,90% of total billed charges,86.46,95,,,percent of total billed charges,95% of total billed charges,86.46,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.27,86,,,percent of total billed charges,86% of total billed charges,72.81,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.28,97,,,percent of total billed charges,97% of total billed charges,81.91,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.28,97,,,percent of total billed charges,97% of total billed charges,84.64,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.28,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.5,244.43,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,310,RC,88305,HCPCS,Outpatient,,,191.73,95.87,,172.56,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,84.11,150,,,Fee Schedule,150% of Fee Schedule Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.56,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,185.98,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,176.39,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,172.56,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,134.21,70,,,percent of total billed charges,70% of total billed charges,172.56,90,,,percent of total billed charges,90% of total billed charges,182.14,95,,,percent of total billed charges,95% of total billed charges,182.14,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,164.89,86,,,percent of total billed charges,86% of total billed charges,153.38,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,185.98,97,,,percent of total billed charges,97% of total billed charges,172.56,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.98,97,,,percent of total billed charges,97% of total billed charges,178.31,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.98,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,244.43,
Pathology Billing Surgical Pathology Level IV Complexity,295352,CDM,310,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,84.11,150,,,Fee Schedule,150% of Fee Schedule Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.23,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,151.14,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,143.35,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,140.23,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,109.07,70,,,percent of total billed charges,70% of total billed charges,140.23,90,,,percent of total billed charges,90% of total billed charges,148.02,95,,,percent of total billed charges,95% of total billed charges,148.02,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,134,86,,,percent of total billed charges,86% of total billed charges,124.65,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,151.14,97,,,percent of total billed charges,97% of total billed charges,140.23,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.14,97,,,percent of total billed charges,97% of total billed charges,144.9,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,151.14,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,244.43,
Pathology Billing Surgical Pathology Level V Complexity,295354,CDM,310,RC,88307,HCPCS,Outpatient,,,618.39,309.20,,556.55,90,,,percent of total billed charges,90% of total Billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate,312.23,150,,,Fee Schedule,150% of Fee Schedule Rate,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.55,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,599.84,97,,,Percent of total billed charges,97% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate,568.92,92,,,Percent of total billed charges,92% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate,782.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1247.44,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1580.07,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,556.55,90,,,percent of total billed charges,90% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate,432.87,70,,,percent of total billed charges,70% of total billed charges,556.55,90,,,percent of total billed charges,90% of total billed charges,587.47,95,,,percent of total billed charges,95% of total billed charges,587.47,95,,,percent of total billed charges,95% of total billed charges,294.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,588.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,531.82,86,,,percent of total billed charges,86% of total billed charges,494.71,80,,,percent of total billed charges,80% of total billed charges,293.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,599.84,97,,,percent of total billed charges,97% of total billed charges,556.55,90,,,percent of total billed charges,90% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.84,97,,,percent of total billed charges,97% of total billed charges,575.1,93,,,percent of total billed charges,93% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,599.84,97,,,percent of total billed charges,97% of total billed charges,294.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.37,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,250.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,1580.07,
Pathology Billing Surgical Pathology Level V Complexity Profee,3549253,CDM,971,RC,88307,HCPCS,Outpatient,,,618.39,309.20,,556.55,90,,,percent of total billed charges,90% of total Billed charges,361.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.9,155,,,Fee Schedule,155% of CMS OPPS Rate,182.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,357,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,357,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,375.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,375.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,185.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.9,145,,,Fee Schedule,145% of CMS OPPS Rate,182.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.76,145,,,Fee Schedule,145% of CMS OPPS Rate,264.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,182.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,207,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,439.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,182.69,556.55,
Pathology Billing Decalcification,295360,CDM,310,RC,88311,HCPCS,Outpatient,,,13.38,6.69,,12.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.04,90,,,Percent of total Billed charges,90% of total billed charges,6.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,8.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,10.52,78.65,,,percent of total billed charges,78.65% of total billed charges,11.95,89.33,,,percent of total billed charges,89.33% of total billed charges,12.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.37,70,,,percent of total billed charges,70% of total billed charges,12.04,90,,,percent of total billed charges,90% of total billed charges,12.71,95,,,percent of total billed charges,95% of total billed charges,12.71,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.51,86,,,percent of total billed charges,86% of total billed charges,10.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.98,97,,,percent of total billed charges,97% of total billed charges,12.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.98,97,,,percent of total billed charges,97% of total billed charges,12.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.19,12.98,
Special Stain HELICO,605636,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Special Stain HELICO Profee,3549261,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,151.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,155,,,Fee Schedule,155% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.57,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,145,,,Fee Schedule,145% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.17,145,,,Fee Schedule,145% of CMS OPPS Rate,109.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71.57,219.17,
Special Stain Pneumocystis,1425138,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Pathology Billing IHC Additional Stain,3318836,CDM,310,RC,88341,HCPCS,Outpatient,,,63.38,31.69,,57.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,50.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,57.04,90,,,Percent of total Billed charges,90% of total billed charges,37.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,61.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,58.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,40.48,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,49.85,78.65,,,percent of total billed charges,78.65% of total billed charges,56.62,89.33,,,percent of total billed charges,89.33% of total billed charges,57.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.37,70,,,percent of total billed charges,70% of total billed charges,57.04,90,,,percent of total billed charges,90% of total billed charges,60.21,95,,,percent of total billed charges,95% of total billed charges,60.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,86,,,percent of total billed charges,86% of total billed charges,50.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.48,97,,,percent of total billed charges,97% of total billed charges,57.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.48,97,,,percent of total billed charges,97% of total billed charges,58.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.03,61.48,
Pathology Billing IHC Additional Stain Profee,3549247,CDM,971,RC,88341,HCPCS,Outpatient,,,184.47,92.24,,166.02,90,,,percent of total billed charges,90% of total Billed charges,103.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.95,155,,,Fee Schedule,155% of CMS OPPS Rate,51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,125.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,125.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.34,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.95,145,,,Fee Schedule,145% of CMS OPPS Rate,51,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.58,145,,,Fee Schedule,145% of CMS OPPS Rate,73.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51,166.02,
"Pathology Billing Immuno Cyto Chemistry, tissue,IP,ea ab",295366,CDM,310,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,193.28,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,121.11,150,,,Fee Schedule,150% of Fee Schedule Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.28,90,,,Percent of total Billed charges,90% of total billed charges,44.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,208.31,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,197.57,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,193.28,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,70,,,percent of total billed charges,70% of total billed charges,193.28,90,,,percent of total billed charges,90% of total billed charges,204.01,95,,,percent of total billed charges,95% of total billed charges,204.01,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.69,86,,,percent of total billed charges,86% of total billed charges,171.8,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,208.31,97,,,percent of total billed charges,97% of total billed charges,193.28,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.31,97,,,percent of total billed charges,97% of total billed charges,199.72,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,208.31,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.14,766.61,
Pathology Billing Archive tissue selection,1837101,CDM,310,RC,88363,HCPCS,Outpatient,,,51.88,25.94,,46.69,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,41.5,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.69,90,,,Percent of total Billed charges,90% of total billed charges,14.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,50.32,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,47.73,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,46.69,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,36.32,70,,,percent of total billed charges,70% of total billed charges,46.69,90,,,percent of total billed charges,90% of total billed charges,49.29,95,,,percent of total billed charges,95% of total billed charges,49.29,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.62,86,,,percent of total billed charges,86% of total billed charges,41.5,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,50.32,97,,,percent of total billed charges,97% of total billed charges,46.69,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.32,97,,,percent of total billed charges,97% of total billed charges,48.25,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.32,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.56,121.68,
90471-PF IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE,4321579,CDM,981,RC,90471,HCPCS,Outpatient,,,36.86,18.43,,33.17,90,,,percent of total billed charges,90% of total Billed charges,33.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,155,,,Fee Schedule,155% of CMS OPPS Rate,18.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,21.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.06,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,145,,,Fee Schedule,145% of CMS OPPS Rate,18.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.18,145,,,Fee Schedule,145% of CMS OPPS Rate,26.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,38.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.06,49.18,
AMB Admin Oral Immunization Charge -> First Vaccine 90473,3444233,CDM,771,RC,90473,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.92,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.1,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.85,328.92,
0.5 mL MenQuadfi Vaccine,4125120,CDM,636,RC,90619,HCPCS,Outpatient,,,399.39,199.70,,359.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,319.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,359.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,387.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,367.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,255.06,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,314.13,78.65,,,percent of total billed charges,78.65% of total billed charges,356.78,89.33,,,percent of total billed charges,89.33% of total billed charges,359.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,279.57,70,,,percent of total billed charges,70% of total billed charges,359.45,90,,,percent of total billed charges,90% of total billed charges,379.42,95,,,percent of total billed charges,95% of total billed charges,379.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.48,86,,,percent of total billed charges,86% of total billed charges,319.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,387.41,97,,,percent of total billed charges,97% of total billed charges,359.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,387.41,97,,,percent of total billed charges,97% of total billed charges,371.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.06,387.41,
91010- Esoph motil/stim/perfus/inter/rep,3431279,CDM,983,RC,91010,HCPCS,Outpatient,,,131.4,65.70,,118.26,90,,,percent of total billed charges,90% of total Billed charges,262.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,190.53,155,,,Fee Schedule,155% of CMS OPPS Rate,131.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,337.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,276.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,276.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.53,145,,,Fee Schedule,145% of CMS OPPS Rate,131.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.06,145,,,Fee Schedule,145% of CMS OPPS Rate,190.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,131.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,381.06,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,788.48,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,700.87,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.48,90,,,Percent of total Billed charges,90% of total billed charges,314.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,849.81,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,806,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,788.48,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,613.26,70,,,percent of total billed charges,70% of total billed charges,788.48,90,,,percent of total billed charges,90% of total billed charges,832.29,95,,,percent of total billed charges,95% of total billed charges,832.29,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,753.44,86,,,percent of total billed charges,86% of total billed charges,700.87,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,849.81,97,,,percent of total billed charges,97% of total billed charges,788.48,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.81,97,,,percent of total billed charges,97% of total billed charges,814.76,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,849.81,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.85,2356.78,
91035PF Gastroesophageal Reflux Test w/Mucosal Attached Tele,4281208,CDM,960,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,788.48,90,,,percent of total billed charges,90% of total Billed charges,690.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,351.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,812.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,650.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,650.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,383.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.88,145,,,Fee Schedule,145% of CMS OPPS Rate,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.82,145,,,Fee Schedule,145% of CMS OPPS Rate,484.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,482.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,777.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,777.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,334.4,1000.82,
ENDO CAPSULE ENDOSCOPY,3431296,CDM,983,RC,91110,HCPCS,Outpatient,,,1579.54,789.77,,1421.59,90,,,percent of total billed charges,90% of total Billed charges,1148.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,555.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,680.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,804.78,155,,,Fee Schedule,155% of CMS OPPS Rate,555.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1021.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,555.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1148.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1148.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1151.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1151.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,732.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1110.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,866.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,804.78,145,,,Fee Schedule,145% of CMS OPPS Rate,555.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1666.02,145,,,Fee Schedule,145% of CMS OPPS Rate,804.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,555.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,555.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1444.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,555.02,1666.02,
92018- Opthal exam/eval/gen anes/complete,3435581,CDM,962,RC,92018,HCPCS,Outpatient,,,273.16,136.58,,245.84,90,,,percent of total billed charges,90% of total Billed charges,264.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,191.59,155,,,Fee Schedule,155% of CMS OPPS Rate,132.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,210.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,210.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,191.59,145,,,Fee Schedule,145% of CMS OPPS Rate,132.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.18,145,,,Fee Schedule,145% of CMS OPPS Rate,191.59,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,132.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,132.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,245.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.5,384.18,
92019- Opthal exam/eval/gen anes/limited,3435582,CDM,962,RC,92019,HCPCS,Outpatient,,,143.16,71.58,,128.84,90,,,percent of total billed charges,90% of total Billed charges,137.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,98.96,155,,,Fee Schedule,155% of CMS OPPS Rate,68.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,98.96,145,,,Fee Schedule,145% of CMS OPPS Rate,68.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.69,145,,,Fee Schedule,145% of CMS OPPS Rate,98.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,116.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.5,198.69,
92100- Serial tonometry/intraoc pres/I&R,3435592,CDM,962,RC,92100,HCPCS,Outpatient,,,63.35,31.68,,57.02,90,,,percent of total billed charges,90% of total Billed charges,94.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,155,,,Fee Schedule,155% of CMS OPPS Rate,30.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.73,145,,,Fee Schedule,145% of CMS OPPS Rate,30.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.59,145,,,Fee Schedule,145% of CMS OPPS Rate,44.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,158.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.85,158.52,
92136- Opthal bio/intraoc lens power calc,3435593,CDM,510,RC,92136,HCPCS,Outpatient,,,46.11,23.06,,41.5,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,36.89,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.73,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,42.42,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,41.5,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,32.28,70,,,percent of total billed charges,70% of total billed charges,41.5,90,,,percent of total billed charges,90% of total billed charges,43.8,95,,,percent of total billed charges,95% of total billed charges,43.8,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,39.65,86,,,percent of total billed charges,86% of total billed charges,36.89,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,44.73,97,,,percent of total billed charges,97% of total billed charges,41.5,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.73,97,,,percent of total billed charges,97% of total billed charges,42.88,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.73,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.28,566.05,
92225- Opthalmoscopy/drawing/ext/I&R/ini,3435594,CDM,510,RC,92225,HCPCS,Outpatient,,,69.71,34.86,,62.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,55.77,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,62.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,64.13,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,44.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,54.83,78.65,,,percent of total billed charges,78.65% of total billed charges,62.27,89.33,,,percent of total billed charges,89.33% of total billed charges,62.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.8,70,,,percent of total billed charges,70% of total billed charges,62.74,90,,,percent of total billed charges,90% of total billed charges,66.22,95,,,percent of total billed charges,95% of total billed charges,66.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.95,86,,,percent of total billed charges,86% of total billed charges,55.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,67.62,97,,,percent of total billed charges,97% of total billed charges,62.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.62,97,,,percent of total billed charges,97% of total billed charges,64.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.52,67.62,
92226- Opthalmoscopy/drawing/ext/I&R/subs,3435595,CDM,510,RC,92226,HCPCS,Outpatient,,,64.09,32.05,,57.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,51.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,57.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,62.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,58.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,40.93,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,50.41,78.65,,,percent of total billed charges,78.65% of total billed charges,57.25,89.33,,,percent of total billed charges,89.33% of total billed charges,57.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.86,70,,,percent of total billed charges,70% of total billed charges,57.68,90,,,percent of total billed charges,90% of total billed charges,60.89,95,,,percent of total billed charges,95% of total billed charges,60.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.12,86,,,percent of total billed charges,86% of total billed charges,51.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,62.17,97,,,percent of total billed charges,97% of total billed charges,57.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,62.17,97,,,percent of total billed charges,97% of total billed charges,59.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,62.17,
92227- Remote image/analysis/rpt/MD sup,3431348,CDM,510,RC,92227,HCPCS,Outpatient,,,37.42,18.71,,33.68,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,29.94,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.68,90,,,Percent of total Billed charges,90% of total billed charges,9.79,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,36.3,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,34.43,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,33.68,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,26.19,70,,,percent of total billed charges,70% of total billed charges,33.68,90,,,percent of total billed charges,90% of total billed charges,35.55,95,,,percent of total billed charges,95% of total billed charges,35.55,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.18,86,,,percent of total billed charges,86% of total billed charges,29.94,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36.3,97,,,percent of total billed charges,97% of total billed charges,33.68,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.3,97,,,percent of total billed charges,97% of total billed charges,34.8,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,36.3,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.9,165.55,
92228- Remote image/monit/manage/MD I & R,3431349,CDM,510,RC,92228,HCPCS,Outpatient,,,30.32,15.16,,27.29,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,24.26,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.29,90,,,Percent of total Billed charges,90% of total billed charges,10.64,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,29.41,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,27.89,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,27.29,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,70,,,percent of total billed charges,70% of total billed charges,27.29,90,,,percent of total billed charges,90% of total billed charges,28.8,95,,,percent of total billed charges,95% of total billed charges,28.8,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.08,86,,,percent of total billed charges,86% of total billed charges,24.26,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,29.41,97,,,percent of total billed charges,97% of total billed charges,27.29,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.41,97,,,percent of total billed charges,97% of total billed charges,28.2,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.41,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.67,165.55,
92230- Fluorescein angioscopy w/I&R,3435596,CDM,510,RC,92230,HCPCS,Outpatient,,,236.49,118.25,,212.84,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,189.19,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.84,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,229.4,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,217.57,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.84,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,165.54,70,,,percent of total billed charges,70% of total billed charges,212.84,90,,,percent of total billed charges,90% of total billed charges,224.67,95,,,percent of total billed charges,95% of total billed charges,224.67,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,203.38,86,,,percent of total billed charges,86% of total billed charges,189.19,80,,,percent of total billed charges,80% of total billed charges,502.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,229.4,97,,,percent of total billed charges,97% of total billed charges,212.84,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.4,97,,,percent of total billed charges,97% of total billed charges,219.94,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,229.4,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,2356.78,
92235- Fluorescein angio/imaging/I&R,3435597,CDM,510,RC,92235,HCPCS,Outpatient,,,195.36,97.68,,175.82,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,156.29,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.82,90,,,Percent of total Billed charges,90% of total billed charges,30.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,189.5,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,179.73,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,175.82,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,136.75,70,,,percent of total billed charges,70% of total billed charges,175.82,90,,,percent of total billed charges,90% of total billed charges,185.59,95,,,percent of total billed charges,95% of total billed charges,185.59,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,168.01,86,,,percent of total billed charges,86% of total billed charges,156.29,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,189.5,97,,,percent of total billed charges,97% of total billed charges,175.82,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.5,97,,,percent of total billed charges,97% of total billed charges,181.68,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.5,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.3,1365.32,
92240- Indocyanine-green angio/image/I&R,3435598,CDM,510,RC,92240,HCPCS,Outpatient,,,343.01,171.51,,308.71,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,274.41,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,332.72,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,315.57,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,308.71,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,240.11,70,,,percent of total billed charges,70% of total billed charges,308.71,90,,,percent of total billed charges,90% of total billed charges,325.86,95,,,percent of total billed charges,95% of total billed charges,325.86,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,294.99,86,,,percent of total billed charges,86% of total billed charges,274.41,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,332.72,97,,,percent of total billed charges,97% of total billed charges,308.71,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.72,97,,,percent of total billed charges,97% of total billed charges,319,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,332.72,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.21,1365.32,
92265- Needle oculoelectromyography/I&R,3435601,CDM,510,RC,92265,HCPCS,Outpatient,,,95.87,47.94,,86.28,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,76.7,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.28,90,,,Percent of total Billed charges,90% of total billed charges,31.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.99,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,88.2,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.28,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,67.11,70,,,percent of total billed charges,70% of total billed charges,86.28,90,,,percent of total billed charges,90% of total billed charges,91.08,95,,,percent of total billed charges,95% of total billed charges,91.08,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,82.45,86,,,percent of total billed charges,86% of total billed charges,76.7,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,92.99,97,,,percent of total billed charges,97% of total billed charges,86.28,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.99,97,,,percent of total billed charges,97% of total billed charges,89.16,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.99,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.8,280.22,
92270- Electro-oculography w/I&R,3435602,CDM,510,RC,92270,HCPCS,Outpatient,,,156.19,78.10,,140.57,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,124.95,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.57,90,,,Percent of total Billed charges,90% of total billed charges,42.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,151.5,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,143.69,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,140.57,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,109.33,70,,,percent of total billed charges,70% of total billed charges,140.57,90,,,percent of total billed charges,90% of total billed charges,148.38,95,,,percent of total billed charges,95% of total billed charges,148.38,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,134.32,86,,,percent of total billed charges,86% of total billed charges,124.95,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,151.5,97,,,percent of total billed charges,97% of total billed charges,140.57,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.5,97,,,percent of total billed charges,97% of total billed charges,145.26,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,151.5,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.48,566.05,
92311- Fit/Rx/corneal lens/aphakia/1 eye,3435610,CDM,510,RC,92311,HCPCS,Outpatient,,,261.89,130.95,,235.7,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,209.51,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,254.03,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,240.94,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,235.7,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,183.32,70,,,percent of total billed charges,70% of total billed charges,235.7,90,,,percent of total billed charges,90% of total billed charges,248.8,95,,,percent of total billed charges,95% of total billed charges,248.8,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.23,86,,,percent of total billed charges,86% of total billed charges,209.51,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.03,97,,,percent of total billed charges,97% of total billed charges,235.7,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.03,97,,,percent of total billed charges,97% of total billed charges,243.56,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,254.03,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.32,1840.7,
92312- Fit/Rx/corneal lens/aphakia/OU,3435611,CDM,510,RC,92312,HCPCS,Outpatient,,,303.72,151.86,,273.35,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,242.98,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,294.61,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,279.42,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,273.35,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,212.6,70,,,percent of total billed charges,70% of total billed charges,273.35,90,,,percent of total billed charges,90% of total billed charges,288.53,95,,,percent of total billed charges,95% of total billed charges,288.53,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,261.2,86,,,percent of total billed charges,86% of total billed charges,242.98,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,294.61,97,,,percent of total billed charges,97% of total billed charges,273.35,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.61,97,,,percent of total billed charges,97% of total billed charges,282.46,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,294.61,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
92313- Fit/Rx/corneoscleral lens,3435612,CDM,510,RC,92313,HCPCS,Outpatient,,,246.07,123.04,,221.46,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,196.86,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,238.69,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,226.38,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,221.46,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,172.25,70,,,percent of total billed charges,70% of total billed charges,221.46,90,,,percent of total billed charges,90% of total billed charges,233.77,95,,,percent of total billed charges,95% of total billed charges,233.77,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,211.62,86,,,percent of total billed charges,86% of total billed charges,196.86,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,238.69,97,,,percent of total billed charges,97% of total billed charges,221.46,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.69,97,,,percent of total billed charges,97% of total billed charges,228.85,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.69,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
92315- Fit/Rx/tech/corn lens/aphakia/1 ey,3435614,CDM,510,RC,92315,HCPCS,Outpatient,,,198.87,99.44,,178.98,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,159.1,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,192.9,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,182.96,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,178.98,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,139.21,70,,,percent of total billed charges,70% of total billed charges,178.98,90,,,percent of total billed charges,90% of total billed charges,188.93,95,,,percent of total billed charges,95% of total billed charges,188.93,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,171.03,86,,,percent of total billed charges,86% of total billed charges,159.1,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,192.9,97,,,percent of total billed charges,97% of total billed charges,178.98,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.9,97,,,percent of total billed charges,97% of total billed charges,184.95,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,192.9,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
92316- Fit/Rx/tech/corneal lens/aphakia/O,3435615,CDM,510,RC,92316,HCPCS,Outpatient,,,246.86,123.43,,222.17,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,197.49,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.45,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,227.11,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,222.17,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,172.8,70,,,percent of total billed charges,70% of total billed charges,222.17,90,,,percent of total billed charges,90% of total billed charges,234.52,95,,,percent of total billed charges,95% of total billed charges,234.52,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,212.3,86,,,percent of total billed charges,86% of total billed charges,197.49,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,239.45,97,,,percent of total billed charges,97% of total billed charges,222.17,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.45,97,,,percent of total billed charges,97% of total billed charges,229.58,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,239.45,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,56.87,566.05,
92317- Fit/Rx/tech/corneoscleral lens,3435616,CDM,510,RC,92317,HCPCS,Outpatient,,,208.33,104.17,,187.5,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,166.66,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,202.08,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,191.66,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.5,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,145.83,70,,,percent of total billed charges,70% of total billed charges,187.5,90,,,percent of total billed charges,90% of total billed charges,197.91,95,,,percent of total billed charges,95% of total billed charges,197.91,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.16,86,,,percent of total billed charges,86% of total billed charges,166.66,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.08,97,,,percent of total billed charges,97% of total billed charges,187.5,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.08,97,,,percent of total billed charges,97% of total billed charges,193.75,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,202.08,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,202.08,
92325- Modify contact lens/med supervise,3435617,CDM,510,RC,92325,HCPCS,Outpatient,,,107.71,53.86,,96.94,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,86.17,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,104.48,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,99.09,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,96.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,75.4,70,,,percent of total billed charges,70% of total billed charges,96.94,90,,,percent of total billed charges,90% of total billed charges,102.32,95,,,percent of total billed charges,95% of total billed charges,102.32,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.63,86,,,percent of total billed charges,86% of total billed charges,86.17,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,104.48,97,,,percent of total billed charges,97% of total billed charges,96.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.48,97,,,percent of total billed charges,97% of total billed charges,100.17,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.48,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.4,566.05,
92326- Replacement of contact lens,3435618,CDM,510,RC,92326,HCPCS,Outpatient,,,91.9,45.95,,82.71,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,73.52,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,89.14,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,84.55,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,82.71,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,64.33,70,,,percent of total billed charges,70% of total billed charges,82.71,90,,,percent of total billed charges,90% of total billed charges,87.31,95,,,percent of total billed charges,95% of total billed charges,87.31,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,79.03,86,,,percent of total billed charges,86% of total billed charges,73.52,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,89.14,97,,,percent of total billed charges,97% of total billed charges,82.71,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.14,97,,,percent of total billed charges,97% of total billed charges,85.47,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,89.14,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
92502- Otolaryngologic exam/gen anesth,3435632,CDM,510,RC,92502,HCPCS,Outpatient,,,242.37,121.19,,218.13,90,,,percent of total billed charges,90% of total Billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,193.9,80,,,Percent of total Billed charges,80% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.13,90,,,Percent of total Billed charges,90% of total billed charges,43.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,235.1,97,,,Percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,222.98,92,,,Percent of total billed charges,92% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1758.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2227.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,218.13,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,169.66,70,,,percent of total billed charges,70% of total billed charges,218.13,90,,,percent of total billed charges,90% of total billed charges,230.25,95,,,percent of total billed charges,95% of total billed charges,230.25,95,,,percent of total billed charges,95% of total billed charges,414.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,829.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208.44,86,,,percent of total billed charges,86% of total billed charges,193.9,80,,,percent of total billed charges,80% of total billed charges,456.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,235.1,97,,,percent of total billed charges,97% of total billed charges,218.13,90,,,percent of total billed charges,90% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.1,97,,,percent of total billed charges,97% of total billed charges,225.4,93,,,percent of total billed charges,93% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,235.1,97,,,percent of total billed charges,97% of total billed charges,414.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,352.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.5,2227.05,
92504- Otolaryngo binocular microscopy,3435314,CDM,510,RC,92504,HCPCS,Outpatient,,,70.57,35.29,,63.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,64.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,45.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,55.5,78.65,,,percent of total billed charges,78.65% of total billed charges,63.04,89.33,,,percent of total billed charges,89.33% of total billed charges,63.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,49.4,70,,,percent of total billed charges,70% of total billed charges,63.51,90,,,percent of total billed charges,90% of total billed charges,67.04,95,,,percent of total billed charges,95% of total billed charges,67.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.69,86,,,percent of total billed charges,86% of total billed charges,56.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,68.45,97,,,percent of total billed charges,97% of total billed charges,63.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.45,97,,,percent of total billed charges,97% of total billed charges,65.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.07,68.45,
92507- Tx speech/lang/voice/aud/ea indiv,3435634,CDM,940,RC,92507,HCPCS,Outpatient,,,197,98.50,,177.3,90,,,percent of total billed charges,90% of total Billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,157.6,80,,,Percent of total Billed charges,80% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.3,90,,,Percent of total Billed charges,90% of total billed charges,23.87,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,191.09,97,,,Percent of total billed charges,97% of total billed charges,72.97,100,,,Fee Schedule,100% of CMS OPPS Rate,181.24,92,,,Percent of total billed charges,92% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,296.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,73.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.58,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,335.47,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,177.3,90,,,percent of total billed charges,90% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,137.9,70,,,percent of total billed charges,70% of total billed charges,177.3,90,,,percent of total billed charges,90% of total billed charges,187.15,95,,,percent of total billed charges,95% of total billed charges,187.15,95,,,percent of total billed charges,95% of total billed charges,73.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,169.42,86,,,percent of total billed charges,86% of total billed charges,157.6,80,,,percent of total billed charges,80% of total billed charges,85.47,111,,,Fee Schedule,111% of CMS OPPS Rate,191.09,97,,,percent of total billed charges,97% of total billed charges,177.3,90,,,percent of total billed charges,90% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.09,97,,,percent of total billed charges,97% of total billed charges,183.21,93,,,percent of total billed charges,93% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,97,,,percent of total billed charges,97% of total billed charges,73.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,62.19,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.7,361.58,
92508- Tx speech/lang/voice/aud/2 > indiv,3435635,CDM,510,RC,92508,HCPCS,Outpatient,,,59.88,29.94,,53.89,90,,,percent of total billed charges,90% of total Billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,47.9,80,,,Percent of total Billed charges,80% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.08,97,,,Percent of total billed charges,97% of total billed charges,22.34,100,,,Fee Schedule,100% of CMS OPPS Rate,55.09,92,,,Percent of total billed charges,92% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,90.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,102.67,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,53.89,90,,,percent of total billed charges,90% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,41.92,70,,,percent of total billed charges,70% of total billed charges,53.89,90,,,percent of total billed charges,90% of total billed charges,56.89,95,,,percent of total billed charges,95% of total billed charges,56.89,95,,,percent of total billed charges,95% of total billed charges,22.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,51.5,86,,,percent of total billed charges,86% of total billed charges,47.9,80,,,percent of total billed charges,80% of total billed charges,25.39,111,,,Fee Schedule,111% of CMS OPPS Rate,58.08,97,,,percent of total billed charges,97% of total billed charges,53.89,90,,,percent of total billed charges,90% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.08,97,,,percent of total billed charges,97% of total billed charges,55.69,93,,,percent of total billed charges,93% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.08,97,,,percent of total billed charges,97% of total billed charges,22.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.39,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.03,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.03,110.66,
92511-PF NASOPHARYNGOSCOPY W/ENDOSCOPE SPX,4321577,CDM,981,RC,92511,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,108.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.32,155,,,Fee Schedule,155% of CMS OPPS Rate,36.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,52.32,145,,,Fee Schedule,145% of CMS OPPS Rate,36.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.95,145,,,Fee Schedule,145% of CMS OPPS Rate,52.32,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,267.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.08,267.99,
92512- Nasal function studies,3435637,CDM,510,RC,92512,HCPCS,Outpatient,,,153.73,76.87,,138.36,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,122.98,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,149.12,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,141.43,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,138.36,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,107.61,70,,,percent of total billed charges,70% of total billed charges,138.36,90,,,percent of total billed charges,90% of total billed charges,146.04,95,,,percent of total billed charges,95% of total billed charges,146.04,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,132.21,86,,,percent of total billed charges,86% of total billed charges,122.98,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,149.12,97,,,percent of total billed charges,97% of total billed charges,138.36,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.12,97,,,percent of total billed charges,97% of total billed charges,142.97,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.12,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,107.61,1365.32,
92520- Laryngeal function studies,3435638,CDM,510,RC,92520,HCPCS,Outpatient,,,202.93,101.47,,182.64,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,162.34,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.84,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,186.7,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.64,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,142.05,70,,,percent of total billed charges,70% of total billed charges,182.64,90,,,percent of total billed charges,90% of total billed charges,192.78,95,,,percent of total billed charges,95% of total billed charges,192.78,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.52,86,,,percent of total billed charges,86% of total billed charges,162.34,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,196.84,97,,,percent of total billed charges,97% of total billed charges,182.64,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.84,97,,,percent of total billed charges,97% of total billed charges,188.72,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.84,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
92522- Speech Sound Production Evaluation,3514660,CDM,940,RC,92522,HCPCS,Outpatient,,,282.33,141.17,,254.1,90,,,percent of total billed charges,90% of total Billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,225.86,80,,,Percent of total Billed charges,80% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,273.86,97,,,Percent of total billed charges,97% of total billed charges,106.2,100,,,Fee Schedule,100% of CMS OPPS Rate,259.74,92,,,Percent of total billed charges,92% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,432.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,106.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,488.48,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,254.1,90,,,percent of total billed charges,90% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,197.63,70,,,percent of total billed charges,70% of total billed charges,254.1,90,,,percent of total billed charges,90% of total billed charges,268.21,95,,,percent of total billed charges,95% of total billed charges,268.21,95,,,percent of total billed charges,95% of total billed charges,106.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,242.8,86,,,percent of total billed charges,86% of total billed charges,225.86,80,,,percent of total billed charges,80% of total billed charges,99.79,111,,,Fee Schedule,111% of CMS OPPS Rate,273.86,97,,,percent of total billed charges,97% of total billed charges,254.1,90,,,percent of total billed charges,90% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.86,97,,,percent of total billed charges,97% of total billed charges,262.57,93,,,percent of total billed charges,93% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,273.86,97,,,percent of total billed charges,97% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,90.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,90.55,526.5,
SPEECH SOUND PRODUCTION EVALUATION,3430610,CDM,940,RC,92522,HCPCS,Outpatient,,,282.33,141.17,,254.1,90,,,percent of total billed charges,90% of total Billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,225.86,80,,,Percent of total Billed charges,80% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,273.86,97,,,Percent of total billed charges,97% of total billed charges,106.2,100,,,Fee Schedule,100% of CMS OPPS Rate,259.74,92,,,Percent of total billed charges,92% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,432.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,106.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,526.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,488.48,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,254.1,90,,,percent of total billed charges,90% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,197.63,70,,,percent of total billed charges,70% of total billed charges,254.1,90,,,percent of total billed charges,90% of total billed charges,268.21,95,,,percent of total billed charges,95% of total billed charges,268.21,95,,,percent of total billed charges,95% of total billed charges,106.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,242.8,86,,,percent of total billed charges,86% of total billed charges,225.86,80,,,percent of total billed charges,80% of total billed charges,99.79,111,,,Fee Schedule,111% of CMS OPPS Rate,273.86,97,,,percent of total billed charges,97% of total billed charges,254.1,90,,,percent of total billed charges,90% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.86,97,,,percent of total billed charges,97% of total billed charges,262.57,93,,,percent of total billed charges,93% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,273.86,97,,,percent of total billed charges,97% of total billed charges,106.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,90.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,90.55,526.5,
92540 Basic vestibular evaluation,3584883,CDM,960,RC,92540,HCPCS,Outpatient,,,78.47,39.24,,70.62,90,,,percent of total billed charges,90% of total Billed charges,57.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.34,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,158.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.34,145,,,Fee Schedule,145% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.13,145,,,Fee Schedule,145% of CMS OPPS Rate,40.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,163.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,163.08,
92542 Positional nystagmus test,3584884,CDM,960,RC,92542,HCPCS,Outpatient,,,10.59,5.30,,9.53,90,,,percent of total billed charges,90% of total Billed charges,7.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,5.68,155,,,Fee Schedule,155% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.68,145,,,Fee Schedule,145% of CMS OPPS Rate,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.44,145,,,Fee Schedule,145% of CMS OPPS Rate,5.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,43.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,3.92,67.84,
92548 Cdp-sot 6 cond w/i&r,3584885,CDM,960,RC,92548,HCPCS,Outpatient,,,35.04,17.52,,31.54,90,,,percent of total billed charges,90% of total Billed charges,25.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,155,,,Fee Schedule,155% of CMS OPPS Rate,12.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.94,145,,,Fee Schedule,145% of CMS OPPS Rate,12.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.05,145,,,Fee Schedule,145% of CMS OPPS Rate,17.94,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.37,180.75,
92550 - Tympanometry and reflux threshold measurements,3715336,CDM,510,RC,92550,HCPCS,Outpatient,,,57.3,28.65,,51.57,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,45.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.57,90,,,Percent of total Billed charges,90% of total billed charges,17.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,55.58,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,52.72,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,51.57,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.11,70,,,percent of total billed charges,70% of total billed charges,51.57,90,,,percent of total billed charges,90% of total billed charges,54.44,95,,,percent of total billed charges,95% of total billed charges,54.44,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,49.28,86,,,percent of total billed charges,86% of total billed charges,45.84,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,55.58,97,,,percent of total billed charges,97% of total billed charges,51.57,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.58,97,,,percent of total billed charges,97% of total billed charges,53.29,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55.58,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.25,708.98,
92597- Eval/use/fitting voice prosthesis,3435653,CDM,510,RC,92597,HCPCS,Outpatient,,,186.85,93.43,,168.17,90,,,percent of total billed charges,90% of total Billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,149.48,80,,,Percent of total Billed charges,80% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,181.24,97,,,Percent of total billed charges,97% of total billed charges,68.7,100,,,Fee Schedule,100% of CMS OPPS Rate,171.9,92,,,Percent of total billed charges,92% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,279.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,315.89,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,168.17,90,,,percent of total billed charges,90% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,130.8,70,,,percent of total billed charges,70% of total billed charges,168.17,90,,,percent of total billed charges,90% of total billed charges,177.51,95,,,percent of total billed charges,95% of total billed charges,177.51,95,,,percent of total billed charges,95% of total billed charges,68.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,160.69,86,,,percent of total billed charges,86% of total billed charges,149.48,80,,,percent of total billed charges,80% of total billed charges,79.55,111,,,Fee Schedule,111% of CMS OPPS Rate,181.24,97,,,percent of total billed charges,97% of total billed charges,168.17,90,,,percent of total billed charges,90% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.24,97,,,percent of total billed charges,97% of total billed charges,173.77,93,,,percent of total billed charges,93% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,181.24,97,,,percent of total billed charges,97% of total billed charges,68.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.89,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.56,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.56,340.48,
92607- Eval/speech-gen device/first hr,3435656,CDM,510,RC,92607,HCPCS,Outpatient,,,315.69,157.85,,284.12,90,,,percent of total billed charges,90% of total Billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,252.55,80,,,Percent of total Billed charges,80% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,306.22,97,,,Percent of total billed charges,97% of total billed charges,116.67,100,,,Fee Schedule,100% of CMS OPPS Rate,290.43,92,,,Percent of total billed charges,92% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,474.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,116.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,535.85,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,284.12,90,,,percent of total billed charges,90% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,220.98,70,,,percent of total billed charges,70% of total billed charges,284.12,90,,,percent of total billed charges,90% of total billed charges,299.91,95,,,percent of total billed charges,95% of total billed charges,299.91,95,,,percent of total billed charges,95% of total billed charges,116.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,271.49,86,,,percent of total billed charges,86% of total billed charges,252.55,80,,,percent of total billed charges,80% of total billed charges,137.5,111,,,Fee Schedule,111% of CMS OPPS Rate,306.22,97,,,percent of total billed charges,97% of total billed charges,284.12,90,,,percent of total billed charges,90% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.22,97,,,percent of total billed charges,97% of total billed charges,293.59,93,,,percent of total billed charges,93% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,306.22,97,,,percent of total billed charges,97% of total billed charges,116.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.86,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,99.33,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99.33,577.56,
92608- Eval/speech-gen device/add 30 min,3435657,CDM,510,RC,92608,HCPCS,Outpatient,,,124.88,62.44,,112.39,90,,,percent of total billed charges,90% of total Billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,99.9,80,,,Percent of total Billed charges,80% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,121.13,97,,,Percent of total billed charges,97% of total billed charges,45.75,100,,,Fee Schedule,100% of CMS OPPS Rate,114.89,92,,,Percent of total billed charges,92% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,186,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,210.24,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,112.39,90,,,percent of total billed charges,90% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,87.42,70,,,percent of total billed charges,70% of total billed charges,112.39,90,,,percent of total billed charges,90% of total billed charges,118.64,95,,,percent of total billed charges,95% of total billed charges,118.64,95,,,percent of total billed charges,95% of total billed charges,45.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.4,86,,,percent of total billed charges,86% of total billed charges,99.9,80,,,percent of total billed charges,80% of total billed charges,54.95,111,,,Fee Schedule,111% of CMS OPPS Rate,121.13,97,,,percent of total billed charges,97% of total billed charges,112.39,90,,,percent of total billed charges,90% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.13,97,,,percent of total billed charges,97% of total billed charges,116.14,93,,,percent of total billed charges,93% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.13,97,,,percent of total billed charges,97% of total billed charges,45.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.85,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.97,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.97,226.6,
92613- Endoscop eval/swallow/I & R only,3435661,CDM,510,RC,92613,HCPCS,Outpatient,,,95.02,47.51,,85.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,76.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,85.52,90,,,Percent of total Billed charges,90% of total billed charges,40.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,87.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,60.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,74.74,78.65,,,percent of total billed charges,78.65% of total billed charges,84.88,89.33,,,percent of total billed charges,89.33% of total billed charges,85.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.51,70,,,percent of total billed charges,70% of total billed charges,85.52,90,,,percent of total billed charges,90% of total billed charges,90.27,95,,,percent of total billed charges,95% of total billed charges,90.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.72,86,,,percent of total billed charges,86% of total billed charges,76.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,92.17,97,,,percent of total billed charges,97% of total billed charges,85.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,92.17,97,,,percent of total billed charges,97% of total billed charges,88.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.57,92.17,
92615- Laryngeal sens test/endo/I & R onl,3435663,CDM,510,RC,92615,HCPCS,Outpatient,,,85.29,42.65,,76.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,68.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,54.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,67.08,78.65,,,percent of total billed charges,78.65% of total billed charges,76.19,89.33,,,percent of total billed charges,89.33% of total billed charges,76.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.7,70,,,percent of total billed charges,70% of total billed charges,76.76,90,,,percent of total billed charges,90% of total billed charges,81.03,95,,,percent of total billed charges,95% of total billed charges,81.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.35,86,,,percent of total billed charges,86% of total billed charges,68.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.73,97,,,percent of total billed charges,97% of total billed charges,76.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.73,97,,,percent of total billed charges,97% of total billed charges,79.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,82.73,
92616- Endoscop eval/swallow/laryn sense,3435664,CDM,510,RC,92616,HCPCS,Outpatient,,,532.58,266.29,,479.32,90,,,percent of total billed charges,90% of total Billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,426.06,80,,,Percent of total Billed charges,80% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,479.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,516.6,97,,,Percent of total billed charges,97% of total billed charges,95.21,100,,,Fee Schedule,100% of CMS OPPS Rate,489.97,92,,,Percent of total billed charges,92% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,388.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,438.73,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,479.32,90,,,percent of total billed charges,90% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,372.81,70,,,percent of total billed charges,70% of total billed charges,479.32,90,,,percent of total billed charges,90% of total billed charges,505.95,95,,,percent of total billed charges,95% of total billed charges,505.95,95,,,percent of total billed charges,95% of total billed charges,95.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,458.02,86,,,percent of total billed charges,86% of total billed charges,426.06,80,,,percent of total billed charges,80% of total billed charges,110.32,111,,,Fee Schedule,111% of CMS OPPS Rate,516.6,97,,,percent of total billed charges,97% of total billed charges,479.32,90,,,percent of total billed charges,90% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,516.6,97,,,percent of total billed charges,97% of total billed charges,495.3,93,,,percent of total billed charges,93% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,516.6,97,,,percent of total billed charges,97% of total billed charges,95.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,81.33,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81.33,516.6,
92640- Analy/prog/aud brainstem implt/hr,3435666,CDM,510,RC,92640,HCPCS,Outpatient,,,284.18,142.09,,255.76,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,227.34,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,275.65,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,261.45,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,255.76,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,198.93,70,,,percent of total billed charges,70% of total billed charges,255.76,90,,,percent of total billed charges,90% of total billed charges,269.97,95,,,percent of total billed charges,95% of total billed charges,269.97,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,244.39,86,,,percent of total billed charges,86% of total billed charges,227.34,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,275.65,97,,,percent of total billed charges,97% of total billed charges,255.76,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.65,97,,,percent of total billed charges,97% of total billed charges,264.29,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,275.65,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,708.98,
"92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretat",3584893,CDM,960,RC,92652,HCPCS,Outpatient,,,282.81,141.41,,254.53,90,,,percent of total billed charges,90% of total Billed charges,216.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.74,155,,,Fee Schedule,155% of CMS OPPS Rate,106.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.74,145,,,Fee Schedule,145% of CMS OPPS Rate,106.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.2,145,,,Fee Schedule,145% of CMS OPPS Rate,154.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,314.2,
"92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report",3584894,CDM,960,RC,92653,HCPCS,Outpatient,,,210.02,105.01,,189.02,90,,,percent of total billed charges,90% of total Billed charges,160.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.9,155,,,Fee Schedule,155% of CMS OPPS Rate,79.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.01,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.9,145,,,Fee Schedule,145% of CMS OPPS Rate,79.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.93,145,,,Fee Schedule,145% of CMS OPPS Rate,114.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,79.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.01,232.93,
92920- PTCA Left Main,3560640,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92920- PTCA single major coronary,3430752,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92920-Coronary Angioplasty - CIRC,4197399,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty - LAD,4197401,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty - LT MAIN,4197415,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- DIAG,4197409,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- OM,4197405,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- PDA,4197413,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- PLB,4197411,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- RAMUS,4197407,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-Coronary Angioplasty- RCA,4197403,CDM,481,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.14,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1234.5,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.87,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,890.88,70,,,percent of total billed charges,70% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,1209.05,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.5,86,,,percent of total billed charges,86% of total billed charges,1018.14,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.5,97,,,percent of total billed charges,97% of total billed charges,1145.41,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.5,97,,,percent of total billed charges,97% of total billed charges,1183.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1234.5,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,890.88,25425.73,
92920-PF Coronary Angioplasty - CIRC,4197400,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty - LAD,4197402,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty - LT MAIN,4197416,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- DIAG,4197410,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- OM,4197406,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- PDA,4197414,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- PLB,4197412,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- RAMUS,4197408,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF Coronary Angioplasty- RCA,4197404,CDM,960,RC,92920,HCPCS,Outpatient,,,1272.68,636.34,,1145.41,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF PTCA - LM,3580901,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF PTCA CIRC,3580902,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF PTCA LAD,3580903,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF PTCA Left Main,3580900,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PF PTCA RCA,3580904,CDM,960,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,1060.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,761.18,155,,,Fee Schedule,155% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,787.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,885.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,461.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1049.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,716.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,761.18,145,,,Fee Schedule,145% of CMS OPPS Rate,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.36,145,,,Fee Schedule,145% of CMS OPPS Rate,761.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,504.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,524.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.79,1538.36,
92920-PTCA - LM,3552631,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92920-PTCA CIRC,3431979,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92920-PTCA LAD,3431980,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92920-PTCA RCA,3431981,CDM,481,RC,92920,HCPCS,Outpatient,,,1425.4,712.70,,1282.86,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.32,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1382.64,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1311.37,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,997.78,70,,,percent of total billed charges,70% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,1354.13,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1225.84,86,,,percent of total billed charges,86% of total billed charges,1140.32,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1382.64,97,,,percent of total billed charges,97% of total billed charges,1282.86,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1382.64,97,,,percent of total billed charges,97% of total billed charges,1325.62,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1382.64,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,997.78,25425.73,
92921-Coronary Angioplasty add vessel- CIRC,4197417,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- DIAG,4197427,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- LAD,4197419,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- LT MAIN,4197433,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- OM,4197423,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- PDA,4197431,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- PLB,4197429,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- RAMUS,4197425,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-Coronary Angioplasty add vessel- RCA,4197421,CDM,481,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,500.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,563.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,575.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,399.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,492.09,78.65,,,percent of total billed charges,78.65% of total billed charges,558.9,89.33,,,percent of total billed charges,89.33% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,437.96,70,,,percent of total billed charges,70% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,594.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,538.06,86,,,percent of total billed charges,86% of total billed charges,500.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,563.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,581.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,606.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.55,606.88,
92921-PF Coronary Angioplasty add vessel- CIRC,4197418,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- DIAG,4197428,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- LAD,4197420,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- LT MAIN,4197434,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- OM,4197424,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- PDA,4197432,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- PLB,4197430,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- RAMUS,4197426,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92921-PF Coronary Angioplasty add vessel- RCA,4197422,CDM,960,RC,92921,HCPCS,Outpatient,,,625.65,312.83,,563.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.7,563.09,
92924- Athrectomy sg cor/branch,3430754,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1529.24,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.33,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1648.19,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.23,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.41,70,,,percent of total billed charges,70% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.28,86,,,percent of total billed charges,86% of total billed charges,1359.33,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.19,97,,,percent of total billed charges,97% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.19,97,,,percent of total billed charges,97% of total billed charges,1580.22,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1648.19,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1189.41,51750.98,
92924-Ather/Rotablator LAD,3561395,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1529.24,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.33,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1648.19,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.23,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.41,70,,,percent of total billed charges,70% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.28,86,,,percent of total billed charges,86% of total billed charges,1359.33,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.19,97,,,percent of total billed charges,97% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.19,97,,,percent of total billed charges,97% of total billed charges,1580.22,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1648.19,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1189.41,51750.98,
92924-Ather/Rotablator RCA,3560658,CDM,481,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1529.24,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.33,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1648.19,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.23,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.41,70,,,percent of total billed charges,70% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,1614.2,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.28,86,,,percent of total billed charges,86% of total billed charges,1359.33,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.19,97,,,percent of total billed charges,97% of total billed charges,1529.24,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.19,97,,,percent of total billed charges,97% of total billed charges,1580.22,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1648.19,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1189.41,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-CIRC,4197345,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-DIAG,4197355,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-LAD,4197347,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-LT MAIN,4197361,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-OM,4197351,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-PDA,4197359,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-PLB,4197357,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-RAMUS,4197353,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-Coronary Atherectomy with coronary angioplasty-RCA,4197349,CDM,481,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.68,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1365.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1471.59,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.73,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.97,70,,,percent of total billed charges,70% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,1441.25,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.71,86,,,percent of total billed charges,86% of total billed charges,1213.68,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1471.59,97,,,percent of total billed charges,97% of total billed charges,1365.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.59,97,,,percent of total billed charges,97% of total billed charges,1410.9,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1471.59,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.97,51750.98,
92924-PF Ather/Rotablator LAD,3580907,CDM,960,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1529.24,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Ather/Rotablator RCA,3580906,CDM,960,RC,92924,HCPCS,Outpatient,,,1699.16,849.58,,1529.24,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-CIRC,4197346,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-DIAG,4197356,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-LAD,4197348,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-LT MAIN,4197362,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-OM,4197352,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-PDA,4197360,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-PLB,4197358,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-RAMUS,4197354,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92924-PF Coronary Atherectomy with coronary angioplasty-RCA,4197350,CDM,960,RC,92924,HCPCS,Outpatient,,,1517.1,758.55,,1365.39,90,,,percent of total billed charges,90% of total Billed charges,1266.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.14,155,,,Fee Schedule,155% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1056.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1056.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,549.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1255.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,898.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,854.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,910.14,145,,,Fee Schedule,145% of CMS OPPS Rate,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.6,145,,,Fee Schedule,145% of CMS OPPS Rate,910.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,599.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,627.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.06,1836.6,
92925 Percutaneous transluminal coronary atherectomy with c,3623286,CDM,510,RC,92925,HCPCS,Outpatient,,,808.89,404.45,,728,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,647.11,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,728,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,784.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,744.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,516.57,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,636.21,78.65,,,percent of total billed charges,78.65% of total billed charges,722.59,89.33,,,percent of total billed charges,89.33% of total billed charges,728,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,566.22,70,,,percent of total billed charges,70% of total billed charges,728,90,,,percent of total billed charges,90% of total billed charges,768.45,95,,,percent of total billed charges,95% of total billed charges,768.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.65,86,,,percent of total billed charges,86% of total billed charges,647.11,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,784.62,97,,,percent of total billed charges,97% of total billed charges,728,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,784.62,97,,,percent of total billed charges,97% of total billed charges,752.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.57,784.62,
92925-Coronary Atherectomy with coronary angioplasty add vessel-CIRC,4197301,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-DIAG,4197311,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-LAD,4197303,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-LT MAIN,4197317,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-OM,4197307,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-PDA,4197315,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-PLB,4197313,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-RAMUS,4197309,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-Coronary Atherectomy with coronary angioplasty add vessel-RCA,4197305,CDM,481,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,578.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,665.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,461.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,568.66,78.65,,,percent of total billed charges,78.65% of total billed charges,645.87,89.33,,,percent of total billed charges,89.33% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,506.1,70,,,percent of total billed charges,70% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,686.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.78,86,,,percent of total billed charges,86% of total billed charges,578.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,650.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,672.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.72,701.31,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-CIRC,4197302,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-DIAG,4197312,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-LAD,4197304,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-LT MAIN,4197318,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-OM,4197308,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-PDA,4197316,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-PLB,4197314,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-RAMUS,4197310,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92925-PF Coronary Atherectomy with coronary angioplasty add vessel-RCA,4197306,CDM,960,RC,92925,HCPCS,Outpatient,,,723,361.50,,650.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.9,650.7,
92928- Coronary stent/single cor art,3430756,CDM,481,RC,92928,HCPCS,Outpatient,,,1586.21,793.11,,1427.59,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.97,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1427.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1538.62,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1459.31,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1427.59,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1110.35,70,,,percent of total billed charges,70% of total billed charges,1427.59,90,,,percent of total billed charges,90% of total billed charges,1506.9,95,,,percent of total billed charges,95% of total billed charges,1506.9,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1364.14,86,,,percent of total billed charges,86% of total billed charges,1268.97,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1538.62,97,,,percent of total billed charges,97% of total billed charges,1427.59,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.62,97,,,percent of total billed charges,97% of total billed charges,1475.18,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1538.62,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1110.35,51750.98,
92928-Coronary Angioplasty with coronary stent- CIRC,4217108,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-Coronary Angioplasty with coronary stent- DIAG,4217135,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-Coronary Angioplasty with coronary stent- LAD,4217111,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-Coronary Angioplasty with coronary stent- LEFT MAIN,4217114,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-Coronary Angioplasty with coronary stent- RAMUS,4217120,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-Coronary Angioplasty with coronary stent- RCA,4217117,CDM,481,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92928-PF Coronary Angioplasty with coronary stent- CIRC,4217109,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
92928-PF Coronary Angioplasty with coronary stent- DIAG,4217136,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
92928-PF Coronary Angioplasty with coronary stent- LAD,4217112,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
92928-PF Coronary Angioplasty with coronary stent- LEFT MAIN,4217115,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
92928-PF Coronary Angioplasty with coronary stent- RAMUS,4217121,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
92928-PF Coronary Angioplasty with coronary stent- RCA,4217118,CDM,960,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,1182.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,849.21,155,,,Fee Schedule,155% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,876.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,985.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,985.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,930.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1171.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,837.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,797.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,849.21,145,,,Fee Schedule,145% of CMS OPPS Rate,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1714.09,145,,,Fee Schedule,145% of CMS OPPS Rate,849.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,560.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,585.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.97,1714.09,
Coronary Angioplasty with coronary stent- CIRC,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
Coronary Angioplasty with coronary stent- DIAG,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
Coronary Angioplasty with coronary stent- LAD,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
Coronary Angioplasty with coronary stent- LEFT MAIN,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
Coronary Angioplasty with coronary stent- RAMUS,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
Coronary Angioplasty with coronary stent- RCA,,,480,RC,92928,HCPCS,Outpatient,,,1241.6,620.80,,1117.44,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,993.28,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1117.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1204.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1142.27,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,869.12,70,,,percent of total billed charges,70% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,1179.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1067.78,86,,,percent of total billed charges,86% of total billed charges,993.28,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1204.35,97,,,percent of total billed charges,97% of total billed charges,1117.44,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1204.35,97,,,percent of total billed charges,97% of total billed charges,1154.69,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1204.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.12,51750.98,
92929 Percutaneous transcatheter placement of intracoronary,3623279,CDM,510,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929 PF -Coronary Angioplasty with coronary stent add vesse,4217133,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
92929-Coronary Angioplasty with coronary stent add vessel- C,4217123,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929-Coronary Angioplasty with coronary stent add vessel- D,4217138,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929-Coronary Angioplasty with coronary stent add vessel- L,4217126,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929-Coronary Angioplasty with coronary stent add vessel- L,4217129,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929-Coronary Angioplasty with coronary stent add vessel- R,4217132,CDM,481,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217124,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217127,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217130,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
92929-PF Coronary Angioplasty with coronary stent add vessel,4217139,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
Coronary Angioplasty with coronary stent add vessel- CIRC,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
Coronary Angioplasty with coronary stent add vessel- DIAG,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
Coronary Angioplasty with coronary stent add vessel- LAD,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
Coronary Angioplasty with coronary stent add vessel- LEFT MAIN,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
Coronary Angioplasty with coronary stent add vessel- RCA,,,480,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,715.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,731.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,507.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,625.03,78.65,,,percent of total billed charges,78.65% of total billed charges,709.89,89.33,,,percent of total billed charges,89.33% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.27,70,,,percent of total billed charges,70% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,754.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.42,86,,,percent of total billed charges,86% of total billed charges,635.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,715.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,739.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.49,770.83,
92933 - ATHERECTOMY W DES LC,4165504,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2542.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2859.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.23,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2923.36,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2224.29,70,,,percent of total billed charges,70% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.7,86,,,percent of total billed charges,86% of total billed charges,2542.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3082.23,97,,,percent of total billed charges,97% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3082.23,97,,,percent of total billed charges,97% of total billed charges,2955.13,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3082.23,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2224.29,83742.97,
92933 -ATHERECTOMY W DES LAD,4167144,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2542.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2859.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.23,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2923.36,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2224.29,70,,,percent of total billed charges,70% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.7,86,,,percent of total billed charges,86% of total billed charges,2542.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3082.23,97,,,percent of total billed charges,97% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3082.23,97,,,percent of total billed charges,97% of total billed charges,2955.13,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3082.23,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2224.29,83742.97,
92933- ATHERECTOMY W DES LT MAIN,4167146,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2542.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2859.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.23,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2923.36,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2224.29,70,,,percent of total billed charges,70% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.7,86,,,percent of total billed charges,86% of total billed charges,2542.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3082.23,97,,,percent of total billed charges,97% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3082.23,97,,,percent of total billed charges,97% of total billed charges,2955.13,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3082.23,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2224.29,83742.97,
92933- ATHERECTOMY W DES RAMUS,4167145,CDM,481,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2542.05,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2859.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3082.23,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2923.36,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2224.29,70,,,percent of total billed charges,70% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,3018.68,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2732.7,86,,,percent of total billed charges,86% of total billed charges,2542.05,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3082.23,97,,,percent of total billed charges,97% of total billed charges,2859.8,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3082.23,97,,,percent of total billed charges,97% of total billed charges,2955.13,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3082.23,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2224.29,83742.97,
92933- Athrectomy/stent sg cor/branch,3430758,CDM,510,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,1601.49,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.54,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1601.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1726.05,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1637.08,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1601.49,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.6,70,,,percent of total billed charges,70% of total billed charges,1601.49,90,,,percent of total billed charges,90% of total billed charges,1690.46,95,,,percent of total billed charges,95% of total billed charges,1690.46,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1530.31,86,,,percent of total billed charges,86% of total billed charges,1423.54,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1726.05,97,,,percent of total billed charges,97% of total billed charges,1601.49,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1726.05,97,,,percent of total billed charges,97% of total billed charges,1654.87,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1726.05,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1245.6,83742.97,
92933-Athrectomy W/PTA/Stent,3552627,CDM,481,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,1601.49,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.54,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1601.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1726.05,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1637.08,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1601.49,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1245.6,70,,,percent of total billed charges,70% of total billed charges,1601.49,90,,,percent of total billed charges,90% of total billed charges,1690.46,95,,,percent of total billed charges,95% of total billed charges,1690.46,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1530.31,86,,,percent of total billed charges,86% of total billed charges,1423.54,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1726.05,97,,,percent of total billed charges,97% of total billed charges,1601.49,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1726.05,97,,,percent of total billed charges,97% of total billed charges,1654.87,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1726.05,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1245.6,83742.97,
92933-Coronary Atherectomy with coronary stent- LT MAIN,4197379,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-CIRC,4197363,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-DIAG,4197373,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-LAD,4197365,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-OM,4197369,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-PDA,4197377,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-PLB,4197375,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-RAMUS,4197371,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-Coronary Atherectomy with coronary stent-RCA,4197367,CDM,481,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.02,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1541.12,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1461.68,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.15,70,,,percent of total billed charges,70% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,1509.34,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1366.35,86,,,percent of total billed charges,86% of total billed charges,1271.02,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1541.12,97,,,percent of total billed charges,97% of total billed charges,1429.9,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.12,97,,,percent of total billed charges,97% of total billed charges,1477.57,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1541.12,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1112.15,83742.97,
92933-PF ATHERECTOMY W DES LAD,4167147,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,2859.8,
92933-PF ATHERECTOMY W DES LC,4165505,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,2859.8,
92933-PF ATHERECTOMY W DES LT MAIN,4165506,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,2859.8,
92933-PF ATHERECTOMY W DES RAMUS,4167148,CDM,960,RC,92933,HCPCS,Outpatient,,,3177.56,1588.78,,2859.8,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,2859.8,
92933-PF Athrectomy W/PTA/Stent,3580909,CDM,960,RC,92933,HCPCS,Outpatient,,,1779.43,889.72,,1601.49,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent- LT MAIN,4197380,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-CIRC,4197364,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-DIAG,4197374,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-LAD,4197366,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-OM,4197370,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-PDA,4197378,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-PLB,4197376,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-RAMUS,4197372,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
92933-PF Coronary Atherectomy with coronary stent-RCA,4197368,CDM,960,RC,92933,HCPCS,Outpatient,,,1588.78,794.39,,1429.9,90,,,percent of total billed charges,90% of total Billed charges,1325.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,951.61,155,,,Fee Schedule,155% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,983.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1106.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1106.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1045.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,573.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1312.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,940.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,896.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,951.61,145,,,Fee Schedule,145% of CMS OPPS Rate,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1921.83,145,,,Fee Schedule,145% of CMS OPPS Rate,951.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,626.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.62,1921.83,
ATHERECTOMY W DES LAD,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1565.25,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.34,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1686.99,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.04,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.42,70,,,percent of total billed charges,70% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.69,86,,,percent of total billed charges,86% of total billed charges,1391.34,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1686.99,97,,,percent of total billed charges,97% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1686.99,97,,,percent of total billed charges,97% of total billed charges,1617.43,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1686.99,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1217.42,83742.97,
ATHERECTOMY W DES LC,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1565.25,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.34,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1686.99,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.04,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.42,70,,,percent of total billed charges,70% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.69,86,,,percent of total billed charges,86% of total billed charges,1391.34,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1686.99,97,,,percent of total billed charges,97% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1686.99,97,,,percent of total billed charges,97% of total billed charges,1617.43,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1686.99,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1217.42,83742.97,
ATHERECTOMY W DES LT MAIN,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1565.25,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.34,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1686.99,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.04,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.42,70,,,percent of total billed charges,70% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.69,86,,,percent of total billed charges,86% of total billed charges,1391.34,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1686.99,97,,,percent of total billed charges,97% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1686.99,97,,,percent of total billed charges,97% of total billed charges,1617.43,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1686.99,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1217.42,83742.97,
ATHERECTOMY W DES RAMUS,,,480,RC,92933,HCPCS,Outpatient,,,1739.17,869.59,,1565.25,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.34,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1686.99,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.04,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.42,70,,,percent of total billed charges,70% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,1652.21,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1495.69,86,,,percent of total billed charges,86% of total billed charges,1391.34,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1686.99,97,,,percent of total billed charges,97% of total billed charges,1565.25,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1686.99,97,,,percent of total billed charges,97% of total billed charges,1617.43,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1686.99,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1217.42,83742.97,
92934-Coronary Atherectomy with coronary stent  add vessel-DIAG,4197391,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent  add vessel-LT MAIN,4197397,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent  add vessel-PDA,4197395,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent  add vessel-PLB,4197393,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent  add vessel-RAMUS,4197389,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent add vessel-CIRC,4197381,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent add vessel-LAD,4197383,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent add vessel-OM,4197387,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-Coronary Atherectomy with coronary stent add vessel-RCA,4197385,CDM,481,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.53,78.65,,,percent of total billed charges,78.65% of total billed charges,647.99,89.33,,,percent of total billed charges,89.33% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.77,70,,,percent of total billed charges,70% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,689.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.83,86,,,percent of total billed charges,86% of total billed charges,580.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,652.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,674.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,703.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.24,703.62,
92934-PF Coronary Atherectomy with coronary stent  add vessel-DIAG,4197392,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent  add vessel-LT MAIN,4197398,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent  add vessel-PDA,4197396,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent  add vessel-PLB,4197394,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent  add vessel-RAMUS,4197390,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent add vessel-CIRC,4197382,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent add vessel-LAD,4197384,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent add vessel-OM,4197388,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92934-PF Coronary Atherectomy with coronary stent add vessel-RCA,4197386,CDM,960,RC,92934,HCPCS,Outpatient,,,725.38,362.69,,652.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.61,652.84,
92937- PCI of/through CABG single vessel,3430760,CDM,510,RC,92937,HCPCS,Outpatient,,,1584.51,792.26,,1426.06,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1267.61,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1536.97,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1457.75,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.16,70,,,percent of total billed charges,70% of total billed charges,1426.06,90,,,percent of total billed charges,90% of total billed charges,1505.28,95,,,percent of total billed charges,95% of total billed charges,1505.28,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1362.68,86,,,percent of total billed charges,86% of total billed charges,1267.61,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1536.97,97,,,percent of total billed charges,97% of total billed charges,1426.06,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1536.97,97,,,percent of total billed charges,97% of total billed charges,1473.59,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1536.97,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1109.16,51750.98,
92938 Percutaneous transluminal revascularization of or thro,3622807,CDM,510,RC,92938,HCPCS,Outpatient,,,793.82,396.91,,714.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,635.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,714.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,730.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,506.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,624.36,78.65,,,percent of total billed charges,78.65% of total billed charges,709.13,89.33,,,percent of total billed charges,89.33% of total billed charges,714.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,555.67,70,,,percent of total billed charges,70% of total billed charges,714.44,90,,,percent of total billed charges,90% of total billed charges,754.13,95,,,percent of total billed charges,95% of total billed charges,754.13,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,682.69,86,,,percent of total billed charges,86% of total billed charges,635.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,770.01,97,,,percent of total billed charges,97% of total billed charges,714.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,770.01,97,,,percent of total billed charges,97% of total billed charges,738.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.01,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.95,770.01,
92941- PCI total/subto occ/AMI/single cor,3430762,CDM,510,RC,92941,HCPCS,Outpatient,,,1782.85,891.43,,1604.57,90,,,percent of total billed charges,90% of total Billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1426.28,80,,,Percent of total Billed charges,80% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1604.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1729.36,97,,,Percent of total billed charges,97% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1640.22,92,,,Percent of total billed charges,92% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1604.57,90,,,percent of total billed charges,90% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248,70,,,percent of total billed charges,70% of total billed charges,1604.57,90,,,percent of total billed charges,90% of total billed charges,1693.71,95,,,percent of total billed charges,95% of total billed charges,1693.71,95,,,percent of total billed charges,95% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1533.25,86,,,percent of total billed charges,86% of total billed charges,1426.28,80,,,percent of total billed charges,80% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.36,97,,,percent of total billed charges,97% of total billed charges,1604.57,90,,,percent of total billed charges,90% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1729.36,97,,,percent of total billed charges,97% of total billed charges,1658.05,93,,,percent of total billed charges,93% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1729.36,97,,,percent of total billed charges,97% of total billed charges,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1782.85,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1248,1782.85,
92941-PF Prq Trluml Coronr Tot Occlus Revasc Mi One Vsl,4361225,CDM,960,RC,92941,HCPCS,Outpatient,,,1286.5,643.25,,1157.85,90,,,percent of total billed charges,90% of total Billed charges,1327.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,656.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.19,155,,,Fee Schedule,155% of CMS OPPS Rate,656.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,656.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,656.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1313.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,952.19,145,,,Fee Schedule,145% of CMS OPPS Rate,656.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1924.28,145,,,Fee Schedule,145% of CMS OPPS Rate,952.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,656.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,656.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1924.28,
92941-Prq Trluml Coronr Tot Occlus Revasc Mi One Vsl,4361224,CDM,481,RC,92941,HCPCS,Outpatient,,,1286.5,643.25,,1157.85,90,,,percent of total billed charges,90% of total Billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1029.2,80,,,Percent of total Billed charges,80% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1157.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1247.91,97,,,Percent of total billed charges,97% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1183.58,92,,,Percent of total billed charges,92% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1157.85,90,,,percent of total billed charges,90% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,900.55,70,,,percent of total billed charges,70% of total billed charges,1157.85,90,,,percent of total billed charges,90% of total billed charges,1222.18,95,,,percent of total billed charges,95% of total billed charges,1222.18,95,,,percent of total billed charges,95% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1106.39,86,,,percent of total billed charges,86% of total billed charges,1029.2,80,,,percent of total billed charges,80% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1247.91,97,,,percent of total billed charges,97% of total billed charges,1157.85,90,,,percent of total billed charges,90% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1247.91,97,,,percent of total billed charges,97% of total billed charges,1196.45,93,,,percent of total billed charges,93% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1247.91,97,,,percent of total billed charges,97% of total billed charges,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1286.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,900.55,1286.5,
92943 - PCI CTO DES LAD,4141219,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.69,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1432.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1544.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1464.74,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.48,70,,,percent of total billed charges,70% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1369.21,86,,,percent of total billed charges,86% of total billed charges,1273.69,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1544.35,97,,,percent of total billed charges,97% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.35,97,,,percent of total billed charges,97% of total billed charges,1480.66,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1544.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1114.48,51750.98,
92943 - PCI CTO DES LC,4141220,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.69,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1432.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1544.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1464.74,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.48,70,,,percent of total billed charges,70% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1369.21,86,,,percent of total billed charges,86% of total billed charges,1273.69,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1544.35,97,,,percent of total billed charges,97% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.35,97,,,percent of total billed charges,97% of total billed charges,1480.66,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1544.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1114.48,51750.98,
92943 - PCI CTO DES LT MAIN,4141223,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.69,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1432.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1544.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1464.74,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.48,70,,,percent of total billed charges,70% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1369.21,86,,,percent of total billed charges,86% of total billed charges,1273.69,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1544.35,97,,,percent of total billed charges,97% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.35,97,,,percent of total billed charges,97% of total billed charges,1480.66,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1544.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1114.48,51750.98,
92943 - PCI CTO DES RAMUS,4141221,CDM,481,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.69,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1432.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1544.35,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1464.74,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.48,70,,,percent of total billed charges,70% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,1512.5,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1369.21,86,,,percent of total billed charges,86% of total billed charges,1273.69,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1544.35,97,,,percent of total billed charges,97% of total billed charges,1432.9,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.35,97,,,percent of total billed charges,97% of total billed charges,1480.66,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1544.35,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1114.48,51750.98,
92943 - PF  PCI CTO DES RAMUS,4141225,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,1328.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.64,155,,,Fee Schedule,155% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,953.64,145,,,Fee Schedule,145% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.89,145,,,Fee Schedule,145% of CMS OPPS Rate,953.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1925.89,
92943 - PF PCI CTO DES LAD,4141227,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,1328.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.64,155,,,Fee Schedule,155% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,953.64,145,,,Fee Schedule,145% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.89,145,,,Fee Schedule,145% of CMS OPPS Rate,953.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1925.89,
92943 - PF PCI CTO DES LC,4141226,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,1328.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.64,155,,,Fee Schedule,155% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,953.64,145,,,Fee Schedule,145% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.89,145,,,Fee Schedule,145% of CMS OPPS Rate,953.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1925.89,
92943 - PF PCI CTO DES LT MAIN,4141224,CDM,960,RC,92943,HCPCS,Outpatient,,,1592.11,796.06,,1432.9,90,,,percent of total billed charges,90% of total Billed charges,1328.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.64,155,,,Fee Schedule,155% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,953.64,145,,,Fee Schedule,145% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.89,145,,,Fee Schedule,145% of CMS OPPS Rate,953.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1925.89,
92943- PCI of CTO single coronary,3430763,CDM,360,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,1604.84,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1426.53,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1604.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1729.67,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1640.51,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1604.84,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1248.21,70,,,percent of total billed charges,70% of total billed charges,1604.84,90,,,percent of total billed charges,90% of total billed charges,1694,95,,,percent of total billed charges,95% of total billed charges,1694,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1533.52,86,,,percent of total billed charges,86% of total billed charges,1426.53,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1729.67,97,,,percent of total billed charges,97% of total billed charges,1604.84,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1729.67,97,,,percent of total billed charges,97% of total billed charges,1658.34,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1729.67,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1248.21,51750.98,
92943-CTO-Revasc/PTCA,3552629,CDM,481,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,1604.84,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1426.53,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1604.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1729.67,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1640.51,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1604.84,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1248.21,70,,,percent of total billed charges,70% of total billed charges,1604.84,90,,,percent of total billed charges,90% of total billed charges,1694,95,,,percent of total billed charges,95% of total billed charges,1694,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1533.52,86,,,percent of total billed charges,86% of total billed charges,1426.53,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1729.67,97,,,percent of total billed charges,97% of total billed charges,1604.84,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1729.67,97,,,percent of total billed charges,97% of total billed charges,1658.34,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1729.67,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1248.21,51750.98,
92943-PF CTO-Revasc/PTCA,3580910,CDM,960,RC,92943,HCPCS,Outpatient,,,1783.16,891.58,,1604.84,90,,,percent of total billed charges,90% of total Billed charges,1328.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,953.64,155,,,Fee Schedule,155% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,985.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1107.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1107.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1046.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1315.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,942.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,897.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,953.64,145,,,Fee Schedule,145% of CMS OPPS Rate,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.89,145,,,Fee Schedule,145% of CMS OPPS Rate,953.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,657.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.8,1925.89,
"92944 - (PF) Percutaneous transluminal revascularization of chronic total occlusion, coronary artery",3635238,CDM,510,RC,92944,HCPCS,Outpatient,,,893.79,446.90,,804.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,715.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,804.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,866.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,822.29,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,570.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,702.99,78.65,,,percent of total billed charges,78.65% of total billed charges,798.44,89.33,,,percent of total billed charges,89.33% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,625.65,70,,,percent of total billed charges,70% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,849.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.66,86,,,percent of total billed charges,86% of total billed charges,715.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,866.98,97,,,percent of total billed charges,97% of total billed charges,804.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,866.98,97,,,percent of total billed charges,97% of total billed charges,831.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,866.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,570.79,866.98,
92944-CTO Revasc- additional vessel- DIAG,4197337,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- LAD,4197329,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- LT MAIN,4197343,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- OM,4197333,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- PDA,4197341,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- PLB,4197339,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- RAMUS,4197335,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-CTO Revasc- additional vessel- RCA,4197331,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92944-PF CTO Revasc- additional vessel- CIRC,4197328,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- DIAG,4197338,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- LAD,4197330,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- LT MAIN,4197344,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- OM,4197334,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- PDA,4197342,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- PLB,4197340,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- RAMUS,4197336,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
92944-PF CTO Revasc- additional vessel- RCA,4197332,CDM,960,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.82,818.46,
"CTO with PTA, Stent, artherectomy; add'l vessel",4197327,CDM,481,RC,92944,HCPCS,Outpatient,,,909.4,454.70,,818.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,727.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,818.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,836.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,580.76,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,715.26,78.65,,,percent of total billed charges,78.65% of total billed charges,812.38,89.33,,,percent of total billed charges,89.33% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.58,70,,,percent of total billed charges,70% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,863.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,782.08,86,,,percent of total billed charges,86% of total billed charges,727.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,818.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,845.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,580.76,882.12,
92950- Cardiopulmonary resuscitation,3430765,CDM,450,RC,92950,HCPCS,Outpatient,,,841.76,420.88,,757.58,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,673.41,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,757.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,816.51,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,774.42,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,757.58,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,589.23,70,,,percent of total billed charges,70% of total billed charges,757.58,90,,,percent of total billed charges,90% of total billed charges,799.67,95,,,percent of total billed charges,95% of total billed charges,799.67,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,723.91,86,,,percent of total billed charges,86% of total billed charges,673.41,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,816.51,97,,,percent of total billed charges,97% of total billed charges,757.58,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,816.51,97,,,percent of total billed charges,97% of total billed charges,782.84,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,816.51,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.21,1365.32,
92950-PF Cardiopulmonary Resuscitation,4321576,CDM,981,RC,92950,HCPCS,Outpatient,,,361.98,180.99,,325.78,90,,,percent of total billed charges,90% of total Billed charges,497.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.44,155,,,Fee Schedule,155% of CMS OPPS Rate,180.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,308.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,308.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,287.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,287.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,146.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,259.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,262.44,145,,,Fee Schedule,145% of CMS OPPS Rate,180.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,721.4,145,,,Fee Schedule,145% of CMS OPPS Rate,262.44,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,201.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,180.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,471.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,471.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146.23,721.4,
92953- Temporary transcutaneous pacing,3430926,CDM,480,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,2.53,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2.73,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.59,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2.53,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1.97,70,,,percent of total billed charges,70% of total billed charges,2.53,90,,,percent of total billed charges,90% of total billed charges,2.67,95,,,percent of total billed charges,95% of total billed charges,2.67,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2.42,86,,,percent of total billed charges,86% of total billed charges,2.25,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2.73,97,,,percent of total billed charges,97% of total billed charges,2.53,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.73,97,,,percent of total billed charges,97% of total billed charges,2.61,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2.73,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.97,2867.25,
92953-PF TEMPORARY TRANSCUTANEOUS PACING,4321575,CDM,981,RC,92953,HCPCS,Outpatient,,,2.12,1.06,,1.91,90,,,percent of total billed charges,90% of total Billed charges,2.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1.52,145,,,Fee Schedule,145% of CMS OPPS Rate,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.05,145,,,Fee Schedule,145% of CMS OPPS Rate,1.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,17.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1.05,17.68,
92953-TEMPORARY TRANSCUTANEOUS PACING,3431983,CDM,481,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,2.53,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2.73,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2.59,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2.53,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1.97,70,,,percent of total billed charges,70% of total billed charges,2.53,90,,,percent of total billed charges,90% of total billed charges,2.67,95,,,percent of total billed charges,95% of total billed charges,2.67,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2.42,86,,,percent of total billed charges,86% of total billed charges,2.25,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2.73,97,,,percent of total billed charges,97% of total billed charges,2.53,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.73,97,,,percent of total billed charges,97% of total billed charges,2.61,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2.73,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.97,2867.25,
"Transcutaneous PCNG, Temp",3428533,CDM,981,RC,92953,HCPCS,Outpatient,,,2.81,1.41,,2.53,90,,,percent of total billed charges,90% of total Billed charges,2.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1.52,145,,,Fee Schedule,145% of CMS OPPS Rate,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.05,145,,,Fee Schedule,145% of CMS OPPS Rate,1.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,17.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1.05,17.68,
92960- Cardioversion/elective/external,3430927,CDM,960,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,192.92,90,,,percent of total billed charges,90% of total Billed charges,252.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.95,155,,,Fee Schedule,155% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.95,145,,,Fee Schedule,145% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.62,145,,,Fee Schedule,145% of CMS OPPS Rate,151.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87,366.62,
92960-EXTERNAL ELECTIVE CARDIOVERSION,3431984,CDM,481,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,171.02,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,152.02,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.02,90,,,Percent of total Billed charges,90% of total billed charges,95.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.32,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,174.82,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.02,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,133.01,70,,,percent of total billed charges,70% of total billed charges,171.02,90,,,percent of total billed charges,90% of total billed charges,180.52,95,,,percent of total billed charges,95% of total billed charges,180.52,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.42,86,,,percent of total billed charges,86% of total billed charges,152.02,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.32,97,,,percent of total billed charges,97% of total billed charges,171.02,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.32,97,,,percent of total billed charges,97% of total billed charges,176.72,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.32,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87,2867.25,
92960-PF CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL,4321574,CDM,981,RC,92960,HCPCS,Outpatient,,,209.58,104.79,,188.62,90,,,percent of total billed charges,90% of total Billed charges,252.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.95,155,,,Fee Schedule,155% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.95,145,,,Fee Schedule,145% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.62,145,,,Fee Schedule,145% of CMS OPPS Rate,151.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87,366.62,
92960-PF EXTERNAL ELECTIVE CARDIOVERSION,3580911,CDM,960,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,171.02,90,,,percent of total billed charges,90% of total Billed charges,252.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.95,155,,,Fee Schedule,155% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.95,145,,,Fee Schedule,145% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.62,145,,,Fee Schedule,145% of CMS OPPS Rate,151.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87,366.62,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,192.92,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,171.48,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.92,90,,,Percent of total Billed charges,90% of total billed charges,95.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,207.92,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,197.2,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,192.92,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,150.05,70,,,percent of total billed charges,70% of total billed charges,192.92,90,,,percent of total billed charges,90% of total billed charges,203.63,95,,,percent of total billed charges,95% of total billed charges,203.63,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.34,86,,,percent of total billed charges,86% of total billed charges,171.48,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,207.92,97,,,percent of total billed charges,97% of total billed charges,192.92,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.92,97,,,percent of total billed charges,97% of total billed charges,199.35,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,207.92,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87,2867.25,
Ext Cardioversion - Elec,3428428,CDM,981,RC,92960,HCPCS,Outpatient,,,190.02,95.01,,171.02,90,,,percent of total billed charges,90% of total Billed charges,252.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.95,155,,,Fee Schedule,155% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.95,145,,,Fee Schedule,145% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.62,145,,,Fee Schedule,145% of CMS OPPS Rate,151.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87,366.62,
92961- Cardioversion/elective/internal,3430928,CDM,510,RC,92961,HCPCS,Outpatient,,,512.55,256.28,,461.3,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,410.04,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,461.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,497.17,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,471.55,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,461.3,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,358.79,70,,,percent of total billed charges,70% of total billed charges,461.3,90,,,percent of total billed charges,90% of total billed charges,486.92,95,,,percent of total billed charges,95% of total billed charges,486.92,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,440.79,86,,,percent of total billed charges,86% of total billed charges,410.04,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,497.17,97,,,percent of total billed charges,97% of total billed charges,461.3,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.17,97,,,percent of total billed charges,97% of total billed charges,476.67,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,497.17,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,358.79,2867.25,
92970- Cardioassist/circ assist/internal,3430929,CDM,510,RC,92970,HCPCS,Outpatient,,,510.86,255.43,,459.77,90,,,percent of total billed charges,90% of total Billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,408.69,80,,,Percent of total Billed charges,80% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,459.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,495.53,97,,,Percent of total billed charges,97% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,469.99,92,,,Percent of total billed charges,92% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,459.77,90,,,percent of total billed charges,90% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,357.6,70,,,percent of total billed charges,70% of total billed charges,459.77,90,,,percent of total billed charges,90% of total billed charges,485.32,95,,,percent of total billed charges,95% of total billed charges,485.32,95,,,percent of total billed charges,95% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,439.34,86,,,percent of total billed charges,86% of total billed charges,408.69,80,,,percent of total billed charges,80% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,495.53,97,,,percent of total billed charges,97% of total billed charges,459.77,90,,,percent of total billed charges,90% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,495.53,97,,,percent of total billed charges,97% of total billed charges,475.1,93,,,percent of total billed charges,93% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,495.53,97,,,percent of total billed charges,97% of total billed charges,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,510.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,357.6,510.86,
92971- Cardioassist/circ assist/external,3430930,CDM,510,RC,92971,HCPCS,Outpatient,,,267.31,133.66,,240.58,90,,,percent of total billed charges,90% of total Billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,213.85,80,,,Percent of total Billed charges,80% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,240.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,259.29,97,,,Percent of total billed charges,97% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,245.93,92,,,Percent of total billed charges,92% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,240.58,90,,,percent of total billed charges,90% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.12,70,,,percent of total billed charges,70% of total billed charges,240.58,90,,,percent of total billed charges,90% of total billed charges,253.94,95,,,percent of total billed charges,95% of total billed charges,253.94,95,,,percent of total billed charges,95% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,229.89,86,,,percent of total billed charges,86% of total billed charges,213.85,80,,,percent of total billed charges,80% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,259.29,97,,,percent of total billed charges,97% of total billed charges,240.58,90,,,percent of total billed charges,90% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,259.29,97,,,percent of total billed charges,97% of total billed charges,248.6,93,,,percent of total billed charges,93% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,259.29,97,,,percent of total billed charges,97% of total billed charges,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,267.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,187.12,267.31,
0715T-PF Shockwave additional vessel 1,4197322,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,486.16,
0715T-PF Shockwave additional vessel 2,4197324,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,486.16,
0715T-PF Shockwave additional vessel 3,4197326,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,486.16,
0715T-PF Shockwave- Primary Vessel,4197320,CDM,960,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.05,486.16,
0715T-Shockwave additional vessel 1,4197321,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,432.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,486.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,496.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,344.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,424.86,78.65,,,percent of total billed charges,78.65% of total billed charges,482.55,89.33,,,percent of total billed charges,89.33% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.13,70,,,percent of total billed charges,70% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.55,86,,,percent of total billed charges,86% of total billed charges,432.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,502.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.97,523.97,
0715T-Shockwave additional vessel 2,4197323,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,432.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,486.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,496.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,344.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,424.86,78.65,,,percent of total billed charges,78.65% of total billed charges,482.55,89.33,,,percent of total billed charges,89.33% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.13,70,,,percent of total billed charges,70% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.55,86,,,percent of total billed charges,86% of total billed charges,432.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,502.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.97,523.97,
0715T-Shockwave additional vessel 3,4197325,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,432.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,486.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,496.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,344.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,424.86,78.65,,,percent of total billed charges,78.65% of total billed charges,482.55,89.33,,,percent of total billed charges,89.33% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.13,70,,,percent of total billed charges,70% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.55,86,,,percent of total billed charges,86% of total billed charges,432.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,502.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.97,523.97,
0715T-Shockwave- Primary Vessel,4197319,CDM,481,RC,92972,HCPCS,Outpatient,,,540.18,270.09,,486.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,432.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,486.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,496.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,344.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,424.86,78.65,,,percent of total billed charges,78.65% of total billed charges,482.55,89.33,,,percent of total billed charges,89.33% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.13,70,,,percent of total billed charges,70% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,513.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.55,86,,,percent of total billed charges,86% of total billed charges,432.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,486.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,502.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,523.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.97,523.97,
92972-PF Shockwave - Primary Vessel,4361243,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,248.54,
92972-PF Shockwave additional vessel 1,4361237,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,248.54,
92972-PF Shockwave additional vessel 2,4361239,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,248.54,
92972-PF Shockwave additional vessel 3,4361241,CDM,960,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.85,248.54,
92972-Shockwave - Primary Vessel,4361242,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,254.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,176.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,217.21,78.65,,,percent of total billed charges,78.65% of total billed charges,246.7,89.33,,,percent of total billed charges,89.33% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.31,70,,,percent of total billed charges,70% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,86,,,percent of total billed charges,86% of total billed charges,220.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,256.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.36,267.88,
92972-Shockwave additional vessel 1,4361236,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,254.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,176.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,217.21,78.65,,,percent of total billed charges,78.65% of total billed charges,246.7,89.33,,,percent of total billed charges,89.33% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.31,70,,,percent of total billed charges,70% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,86,,,percent of total billed charges,86% of total billed charges,220.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,256.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.36,267.88,
92972-Shockwave additional vessel 2,4361238,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,254.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,176.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,217.21,78.65,,,percent of total billed charges,78.65% of total billed charges,246.7,89.33,,,percent of total billed charges,89.33% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.31,70,,,percent of total billed charges,70% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,86,,,percent of total billed charges,86% of total billed charges,220.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,256.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.36,267.88,
92972-Shockwave additional vessel 3,4361240,CDM,481,RC,92972,HCPCS,Outpatient,,,276.16,138.08,,248.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,254.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,176.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,217.21,78.65,,,percent of total billed charges,78.65% of total billed charges,246.7,89.33,,,percent of total billed charges,89.33% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.31,70,,,percent of total billed charges,70% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,262.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.5,86,,,percent of total billed charges,86% of total billed charges,220.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,248.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,256.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.36,267.88,
92973- Coronary thrombectomy/mechanical,3430931,CDM,481,RC,92973,HCPCS,Outpatient,,,475.36,237.68,,427.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,380.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,427.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,437.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,303.58,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,373.88,78.65,,,percent of total billed charges,78.65% of total billed charges,424.65,89.33,,,percent of total billed charges,89.33% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,332.75,70,,,percent of total billed charges,70% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,451.59,95,,,percent of total billed charges,95% of total billed charges,451.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.81,86,,,percent of total billed charges,86% of total billed charges,380.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,442.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.58,461.1,
92973-INTRACORONARY TRANSCATHER THROMBECT,3431985,CDM,481,RC,92973,HCPCS,Outpatient,,,475.36,237.68,,427.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,380.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,427.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,437.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,303.58,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,373.88,78.65,,,percent of total billed charges,78.65% of total billed charges,424.65,89.33,,,percent of total billed charges,89.33% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,332.75,70,,,percent of total billed charges,70% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,451.59,95,,,percent of total billed charges,95% of total billed charges,451.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.81,86,,,percent of total billed charges,86% of total billed charges,380.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,427.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,442.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.58,461.1,
Percutaneous Trasluminal Coronary Thrombectomy,646459,CDM,481,RC,92973,HCPCS,Outpatient,,,462.9,231.45,,416.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,370.32,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,416.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,449.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,425.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,295.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,364.08,78.65,,,percent of total billed charges,78.65% of total billed charges,413.52,89.33,,,percent of total billed charges,89.33% of total billed charges,416.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,324.03,70,,,percent of total billed charges,70% of total billed charges,416.61,90,,,percent of total billed charges,90% of total billed charges,439.76,95,,,percent of total billed charges,95% of total billed charges,439.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.09,86,,,percent of total billed charges,86% of total billed charges,370.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,449.01,97,,,percent of total billed charges,97% of total billed charges,416.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,449.01,97,,,percent of total billed charges,97% of total billed charges,430.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.01,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.62,449.01,
92974- Brachytherapy/transcath/coronary,3430932,CDM,510,RC,92974,HCPCS,Outpatient,,,433.99,217.00,,390.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,347.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,390.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,420.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,399.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,277.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,341.34,78.65,,,percent of total billed charges,78.65% of total billed charges,387.69,89.33,,,percent of total billed charges,89.33% of total billed charges,390.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,303.79,70,,,percent of total billed charges,70% of total billed charges,390.59,90,,,percent of total billed charges,90% of total billed charges,412.29,95,,,percent of total billed charges,95% of total billed charges,412.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.23,86,,,percent of total billed charges,86% of total billed charges,347.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,420.97,97,,,percent of total billed charges,97% of total billed charges,390.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,420.97,97,,,percent of total billed charges,97% of total billed charges,403.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.16,420.97,
92975- Coronary thrombolysis/IC infusion,3430933,CDM,510,RC,92975,HCPCS,Outpatient,,,1014.4,507.20,,912.96,90,,,percent of total billed charges,90% of total Billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,811.52,80,,,Percent of total Billed charges,80% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,912.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,983.97,97,,,Percent of total billed charges,97% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,933.25,92,,,Percent of total billed charges,92% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,912.96,90,,,percent of total billed charges,90% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,710.08,70,,,percent of total billed charges,70% of total billed charges,912.96,90,,,percent of total billed charges,90% of total billed charges,963.68,95,,,percent of total billed charges,95% of total billed charges,963.68,95,,,percent of total billed charges,95% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,872.38,86,,,percent of total billed charges,86% of total billed charges,811.52,80,,,percent of total billed charges,80% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,983.97,97,,,percent of total billed charges,97% of total billed charges,912.96,90,,,percent of total billed charges,90% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,983.97,97,,,percent of total billed charges,97% of total billed charges,943.39,93,,,percent of total billed charges,93% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,983.97,97,,,percent of total billed charges,97% of total billed charges,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1014.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,710.08,1014.4,
"92975-Coronary Thrombolysis; by intracoronary infusion, including coronary angiography",4271260,CDM,481,RC,92975,HCPCS,Outpatient,,,792.63,396.32,,713.37,90,,,percent of total billed charges,90% of total Billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,634.1,80,,,Percent of total Billed charges,80% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,768.85,97,,,Percent of total billed charges,97% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,729.22,92,,,Percent of total billed charges,92% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,713.37,90,,,percent of total billed charges,90% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,554.84,70,,,percent of total billed charges,70% of total billed charges,713.37,90,,,percent of total billed charges,90% of total billed charges,753,95,,,percent of total billed charges,95% of total billed charges,753,95,,,percent of total billed charges,95% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,681.66,86,,,percent of total billed charges,86% of total billed charges,634.1,80,,,percent of total billed charges,80% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,768.85,97,,,percent of total billed charges,97% of total billed charges,713.37,90,,,percent of total billed charges,90% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,768.85,97,,,percent of total billed charges,97% of total billed charges,737.15,93,,,percent of total billed charges,93% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,768.85,97,,,percent of total billed charges,97% of total billed charges,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,554.84,792.63,
"92975-PF Coronary Thrombolysis; by intracoronary infusion, including coronary angiography",4271261,CDM,960,RC,92975,HCPCS,Outpatient,,,792.63,396.32,,713.37,90,,,percent of total billed charges,90% of total Billed charges,755.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,373.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.11,155,,,Fee Schedule,155% of CMS OPPS Rate,373.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,698.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,373.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,785.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,785.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,593.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,593.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,305.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,747.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,507.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,542.11,145,,,Fee Schedule,145% of CMS OPPS Rate,373.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,1095.2,145,,,Fee Schedule,145% of CMS OPPS Rate,542.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,373.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,492.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,373.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,666.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,305.51,1095.2,
92977- Coronary thrombolysis/IV infusion,3430934,CDM,510,RC,92977,HCPCS,Outpatient,,,124.24,62.12,,111.82,90,,,percent of total billed charges,90% of total Billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate,99.39,80,,,Percent of total Billed charges,80% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.51,97,,,Percent of total billed charges,97% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate,114.3,92,,,Percent of total billed charges,92% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate,803.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,302.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1280.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1621.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.82,90,,,percent of total billed charges,90% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate,86.97,70,,,percent of total billed charges,70% of total billed charges,111.82,90,,,percent of total billed charges,90% of total billed charges,118.03,95,,,percent of total billed charges,95% of total billed charges,118.03,95,,,percent of total billed charges,95% of total billed charges,302.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,604.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.85,86,,,percent of total billed charges,86% of total billed charges,99.39,80,,,percent of total billed charges,80% of total billed charges,320.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.51,97,,,percent of total billed charges,97% of total billed charges,111.82,90,,,percent of total billed charges,90% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.51,97,,,percent of total billed charges,97% of total billed charges,115.54,93,,,percent of total billed charges,93% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120.51,97,,,percent of total billed charges,97% of total billed charges,302.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.1,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,256.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.97,1621.56,
92977-PF THROMBOLYSIS CORONARY INTRAVENOUS INFUSION,4321573,CDM,981,RC,92977,HCPCS,Outpatient,,,95.4,47.70,,85.86,90,,,percent of total billed charges,90% of total Billed charges,94.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.15,155,,,Fee Schedule,155% of CMS OPPS Rate,47.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,60.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.15,145,,,Fee Schedule,145% of CMS OPPS Rate,47.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.89,145,,,Fee Schedule,145% of CMS OPPS Rate,69.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,320.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.25,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,83.25,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.69,320.68,
92978 - PF Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3715284,CDM,510,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92978 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3621299,CDM,510,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92978 PF IVUS CIRC,3580912,CDM,960,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,537.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,397.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,397.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.58,537.66,
92978-IVUS CIRC,3431986,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92978-IVUS LAD,3431987,CDM,481,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92978-IVUS LEFT MAIN,3431988,CDM,481,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92978-IVUS RCA,3431989,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
IVUS -Ramus,3840968,CDM,480,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.58,90,,,Percent of total Billed charges,90% of total billed charges,165.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,245.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,198.89,78.65,,,percent of total billed charges,78.65% of total billed charges,225.89,89.33,,,percent of total billed charges,89.33% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.01,70,,,percent of total billed charges,70% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,240.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,86,,,percent of total billed charges,86% of total billed charges,202.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,227.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.28,97,,,percent of total billed charges,97% of total billed charges,235.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,245.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.13,245.28,
92979 - PF Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3715285,CDM,510,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3623711,CDM,510,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979- IVUS LAD Additional,3560639,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979-IVUS CIRC ADDITIONAL,3431990,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979-IVUS LAD ADDITIONAL,3431991,CDM,480,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979-IVUS LEFT MAIN ADD,3431992,CDM,481,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979-IVUS RCA ADDITIONAL,3431993,CDM,480,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,161.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,181.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,185.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158.69,78.65,,,percent of total billed charges,78.65% of total billed charges,180.24,89.33,,,percent of total billed charges,89.33% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.23,70,,,percent of total billed charges,70% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,191.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.51,86,,,percent of total billed charges,86% of total billed charges,161.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,181.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,187.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.85,195.71,
92979-PF IVUS LAD Additional,3580913,CDM,960,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,329.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,329.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,245.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,245.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,329.6,
92986- Perc valvuloplasty/aortic valve,3430940,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,3170.84,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2818.52,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3170.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3417.46,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3241.3,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2466.21,70,,,percent of total billed charges,70% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3029.91,86,,,percent of total billed charges,86% of total billed charges,2818.52,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3417.46,97,,,percent of total billed charges,97% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.46,97,,,percent of total billed charges,97% of total billed charges,3276.53,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3417.46,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2466.21,25425.73,
92986-Aortic Valvuloplasty,3431994,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,3170.84,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2818.52,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3170.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3417.46,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3241.3,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2466.21,70,,,percent of total billed charges,70% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3029.91,86,,,percent of total billed charges,86% of total billed charges,2818.52,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3417.46,97,,,percent of total billed charges,97% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.46,97,,,percent of total billed charges,97% of total billed charges,3276.53,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3417.46,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2466.21,25425.73,
92986-Balloon Valvuloplasty Aortic,3431995,CDM,481,RC,92986,HCPCS,Outpatient,,,3523.15,1761.58,,3170.84,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2818.52,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3170.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3417.46,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3241.3,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2466.21,70,,,percent of total billed charges,70% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,3346.99,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3029.91,86,,,percent of total billed charges,86% of total billed charges,2818.52,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3417.46,97,,,percent of total billed charges,97% of total billed charges,3170.84,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3417.46,97,,,percent of total billed charges,97% of total billed charges,3276.53,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3417.46,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2466.21,25425.73,
Balloon Valvuloplasty Aortic,,,480,RC,92986,HCPCS,Outpatient,,,3451.73,1725.87,,3106.56,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2761.38,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3106.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3348.18,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3175.59,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3106.56,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2416.21,70,,,percent of total billed charges,70% of total billed charges,3106.56,90,,,percent of total billed charges,90% of total billed charges,3279.14,95,,,percent of total billed charges,95% of total billed charges,3279.14,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2968.49,86,,,percent of total billed charges,86% of total billed charges,2761.38,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3348.18,97,,,percent of total billed charges,97% of total billed charges,3106.56,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3348.18,97,,,percent of total billed charges,97% of total billed charges,3210.11,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3348.18,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2416.21,25425.73,
92987- Perc valvuloplasty/mitral valve,3430941,CDM,510,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,3281.18,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2916.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3281.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3536.38,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3354.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.03,70,,,percent of total billed charges,70% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3135.35,86,,,percent of total billed charges,86% of total billed charges,2916.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3536.38,97,,,percent of total billed charges,97% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3536.38,97,,,percent of total billed charges,97% of total billed charges,3390.55,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3536.38,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2552.03,51750.98,
92987-Balloon Valuloplasty Mitral,3431996,CDM,481,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,3281.18,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2916.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3281.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3536.38,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3354.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.03,70,,,percent of total billed charges,70% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3135.35,86,,,percent of total billed charges,86% of total billed charges,2916.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3536.38,97,,,percent of total billed charges,97% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3536.38,97,,,percent of total billed charges,97% of total billed charges,3390.55,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3536.38,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2552.03,51750.98,
92987-Mitral Valvuloplasty,3431997,CDM,481,RC,92987,HCPCS,Outpatient,,,3645.75,1822.88,,3281.18,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2916.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3281.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3536.38,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3354.09,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.03,70,,,percent of total billed charges,70% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,3463.46,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3135.35,86,,,percent of total billed charges,86% of total billed charges,2916.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3536.38,97,,,percent of total billed charges,97% of total billed charges,3281.18,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3536.38,97,,,percent of total billed charges,97% of total billed charges,3390.55,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3536.38,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2552.03,51750.98,
Balloon Valuloplasty Mitral,,,480,RC,92987,HCPCS,Outpatient,,,3571.54,1785.77,,3214.39,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2857.23,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3214.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3464.39,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3285.82,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3214.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2500.08,70,,,percent of total billed charges,70% of total billed charges,3214.39,90,,,percent of total billed charges,90% of total billed charges,3392.96,95,,,percent of total billed charges,95% of total billed charges,3392.96,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3071.52,86,,,percent of total billed charges,86% of total billed charges,2857.23,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3464.39,97,,,percent of total billed charges,97% of total billed charges,3214.39,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3464.39,97,,,percent of total billed charges,97% of total billed charges,3321.53,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3464.39,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2500.08,51750.98,
92990- Perc balloon valvuloplas/pul valve,3430942,CDM,510,RC,92990,HCPCS,Outpatient,,,2898.8,1449.40,,2608.92,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2319.04,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2608.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2811.84,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2666.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2029.16,70,,,percent of total billed charges,70% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2492.97,86,,,percent of total billed charges,86% of total billed charges,2319.04,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2811.84,97,,,percent of total billed charges,97% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2811.84,97,,,percent of total billed charges,97% of total billed charges,2695.88,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2811.84,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2029.16,51750.98,
92990-Balloon Valvuloplasty Pulmonic,3431998,CDM,481,RC,92990,HCPCS,Outpatient,,,2898.8,1449.40,,2608.92,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2319.04,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2608.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2811.84,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2666.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2029.16,70,,,percent of total billed charges,70% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2492.97,86,,,percent of total billed charges,86% of total billed charges,2319.04,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2811.84,97,,,percent of total billed charges,97% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2811.84,97,,,percent of total billed charges,97% of total billed charges,2695.88,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2811.84,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2029.16,51750.98,
92990-Pulmonary Valvuloplasty,3431999,CDM,481,RC,92990,HCPCS,Outpatient,,,2898.8,1449.40,,2608.92,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2319.04,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2608.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2811.84,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2666.9,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2029.16,70,,,percent of total billed charges,70% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,2753.86,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2492.97,86,,,percent of total billed charges,86% of total billed charges,2319.04,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2811.84,97,,,percent of total billed charges,97% of total billed charges,2608.92,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2811.84,97,,,percent of total billed charges,97% of total billed charges,2695.88,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2811.84,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2029.16,51750.98,
Balloon Valvuloplasty Pulmonic,,,480,RC,92990,HCPCS,Outpatient,,,2846.18,1423.09,,2561.56,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2276.94,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2561.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2760.79,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,2618.49,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2561.56,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.33,70,,,percent of total billed charges,70% of total billed charges,2561.56,90,,,percent of total billed charges,90% of total billed charges,2703.87,95,,,percent of total billed charges,95% of total billed charges,2703.87,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2447.71,86,,,percent of total billed charges,86% of total billed charges,2276.94,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2760.79,97,,,percent of total billed charges,97% of total billed charges,2561.56,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2760.79,97,,,percent of total billed charges,97% of total billed charges,2646.95,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2760.79,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1992.33,51750.98,
92997- Pulm art angioplasty/init vessel,3430945,CDM,360,RC,92997,HCPCS,Outpatient,,,1706.32,853.16,,1535.69,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1365.06,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1535.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1655.13,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.81,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1535.69,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.42,70,,,percent of total billed charges,70% of total billed charges,1535.69,90,,,percent of total billed charges,90% of total billed charges,1621,95,,,percent of total billed charges,95% of total billed charges,1621,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1467.44,86,,,percent of total billed charges,86% of total billed charges,1365.06,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1655.13,97,,,percent of total billed charges,97% of total billed charges,1535.69,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1655.13,97,,,percent of total billed charges,97% of total billed charges,1586.88,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1655.13,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1194.42,51750.98,
92997-Pulmonary Angiography  w  Angioplasty,3432000,CDM,481,RC,92997,HCPCS,Outpatient,,,1706.32,853.16,,1535.69,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1365.06,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1535.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1655.13,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.81,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1535.69,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.42,70,,,percent of total billed charges,70% of total billed charges,1535.69,90,,,percent of total billed charges,90% of total billed charges,1621,95,,,percent of total billed charges,95% of total billed charges,1621,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1467.44,86,,,percent of total billed charges,86% of total billed charges,1365.06,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1655.13,97,,,percent of total billed charges,97% of total billed charges,1535.69,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1655.13,97,,,percent of total billed charges,97% of total billed charges,1586.88,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1655.13,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1194.42,51750.98,
Pulmonary Angiography  w  Angioplasty,,,480,RC,92997,HCPCS,Outpatient,,,1672.34,836.17,,1505.11,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1337.87,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1505.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1622.17,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.55,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1505.11,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.64,70,,,percent of total billed charges,70% of total billed charges,1505.11,90,,,percent of total billed charges,90% of total billed charges,1588.72,95,,,percent of total billed charges,95% of total billed charges,1588.72,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1438.21,86,,,percent of total billed charges,86% of total billed charges,1337.87,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1622.17,97,,,percent of total billed charges,97% of total billed charges,1505.11,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1622.17,97,,,percent of total billed charges,97% of total billed charges,1555.28,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1622.17,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1170.64,51750.98,
92998- Pulm art angioplasty/ea add vessel,3430946,CDM,510,RC,92998,HCPCS,Outpatient,,,852.98,426.49,,767.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,682.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,767.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,784.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,544.73,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,670.89,78.65,,,percent of total billed charges,78.65% of total billed charges,761.98,89.33,,,percent of total billed charges,89.33% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,597.09,70,,,percent of total billed charges,70% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,810.33,95,,,percent of total billed charges,95% of total billed charges,810.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.56,86,,,percent of total billed charges,86% of total billed charges,682.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,793.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.73,827.39,
92998-Pulmonary Angio w Angioplasty add,3432001,CDM,481,RC,92998,HCPCS,Outpatient,,,852.98,426.49,,767.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,682.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,767.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,784.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,544.73,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,670.89,78.65,,,percent of total billed charges,78.65% of total billed charges,761.98,89.33,,,percent of total billed charges,89.33% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,597.09,70,,,percent of total billed charges,70% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,810.33,95,,,percent of total billed charges,95% of total billed charges,810.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.56,86,,,percent of total billed charges,86% of total billed charges,682.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,767.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,793.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,544.73,827.39,
Pulmonary Angio w Angioplasty add,,,480,RC,92998,HCPCS,Outpatient,,,837.17,418.59,,753.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,669.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,753.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,812.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,770.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,534.64,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,658.45,78.65,,,percent of total billed charges,78.65% of total billed charges,747.86,89.33,,,percent of total billed charges,89.33% of total billed charges,753.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,586.02,70,,,percent of total billed charges,70% of total billed charges,753.45,90,,,percent of total billed charges,90% of total billed charges,795.31,95,,,percent of total billed charges,95% of total billed charges,795.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.97,86,,,percent of total billed charges,86% of total billed charges,669.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,812.05,97,,,percent of total billed charges,97% of total billed charges,753.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,812.05,97,,,percent of total billed charges,97% of total billed charges,778.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,812.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.64,812.05,
Clinic EKG,3527352,CDM,730,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,25.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,22.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,25.21,90,,,Percent of total Billed charges,90% of total billed charges,21.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,27.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,25.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,17.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,22.03,78.65,,,percent of total billed charges,78.65% of total billed charges,25.02,89.33,,,percent of total billed charges,89.33% of total billed charges,25.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.61,70,,,percent of total billed charges,70% of total billed charges,25.21,90,,,percent of total billed charges,90% of total billed charges,26.61,95,,,percent of total billed charges,95% of total billed charges,26.61,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.09,86,,,percent of total billed charges,86% of total billed charges,22.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.17,97,,,percent of total billed charges,97% of total billed charges,25.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.17,97,,,percent of total billed charges,97% of total billed charges,26.05,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.89,27.17,
Electrocardiogram with Magnet,1955109,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,25.21,90,,,percent of total billed charges,90% of total Billed charges,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.69,90,,,Percent of total Billed charges,90% of total billed charges,19.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.73,155,,,Fee Schedule,155% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,145,,,Fee Schedule,145% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.37,145,,,Fee Schedule,145% of CMS OPPS Rate,19.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,29.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.61,43.69,
EKG Pre/Post Unit,645285,CDM,730,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.34,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,20.85,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,19.77,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.34,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,70,,,percent of total billed charges,70% of total billed charges,19.34,90,,,percent of total billed charges,90% of total billed charges,20.42,95,,,percent of total billed charges,95% of total billed charges,20.42,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.48,86,,,percent of total billed charges,86% of total billed charges,17.19,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.85,97,,,percent of total billed charges,97% of total billed charges,19.34,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.85,97,,,percent of total billed charges,97% of total billed charges,19.99,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,20.85,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,280.22,
EKG-Inpatient,617637,CDM,730,RC,93005,HCPCS,Outpatient,,,14.52,7.26,,13.07,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.62,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.07,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14.08,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,13.36,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13.07,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,10.16,70,,,percent of total billed charges,70% of total billed charges,13.07,90,,,percent of total billed charges,90% of total billed charges,13.79,95,,,percent of total billed charges,95% of total billed charges,13.79,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12.49,86,,,percent of total billed charges,86% of total billed charges,11.62,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14.08,97,,,percent of total billed charges,97% of total billed charges,13.07,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.08,97,,,percent of total billed charges,97% of total billed charges,13.5,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14.08,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.16,280.22,
PAT EKG,653557,CDM,730,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.19,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.34,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,20.85,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,19.77,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.34,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,15.04,70,,,percent of total billed charges,70% of total billed charges,19.34,90,,,percent of total billed charges,90% of total billed charges,20.42,95,,,percent of total billed charges,95% of total billed charges,20.42,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.48,86,,,percent of total billed charges,86% of total billed charges,17.19,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.85,97,,,percent of total billed charges,97% of total billed charges,19.34,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.85,97,,,percent of total billed charges,97% of total billed charges,19.99,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,20.85,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,280.22,
93010-EKG Interpretation,3561120,CDM,960,RC,93010,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,11.5,155,,,Fee Schedule,155% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,11.5,145,,,Fee Schedule,145% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.2,145,,,Fee Schedule,145% of CMS OPPS Rate,11.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.56,23.2,
93010-PF ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY,4321508,CDM,981,RC,93010,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,11.5,155,,,Fee Schedule,155% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,11.5,145,,,Fee Schedule,145% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.2,145,,,Fee Schedule,145% of CMS OPPS Rate,11.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.56,23.2,
93016- Cardio stress/supervision only,3430950,CDM,960,RC,93016,HCPCS,Outpatient,,,56.25,28.13,,50.63,90,,,percent of total billed charges,90% of total Billed charges,41.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.49,155,,,Fee Schedule,155% of CMS OPPS Rate,20.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,23.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,29.49,145,,,Fee Schedule,145% of CMS OPPS Rate,20.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.16,145,,,Fee Schedule,145% of CMS OPPS Rate,29.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,36.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.8,60.16,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,68.26,34.13,,61.43,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,54.61,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.43,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.21,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,62.8,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.43,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,47.78,70,,,percent of total billed charges,70% of total billed charges,61.43,90,,,percent of total billed charges,90% of total billed charges,64.85,95,,,percent of total billed charges,95% of total billed charges,64.85,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.7,86,,,percent of total billed charges,86% of total billed charges,54.61,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,66.21,97,,,percent of total billed charges,97% of total billed charges,61.43,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.21,97,,,percent of total billed charges,97% of total billed charges,63.48,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.21,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1365.32,
93018- CV stress test/interp/report only,3430952,CDM,960,RC,93018,HCPCS,Outpatient,,,27.73,13.87,,24.96,90,,,percent of total billed charges,90% of total Billed charges,27.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.58,155,,,Fee Schedule,155% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,15.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,19.58,145,,,Fee Schedule,145% of CMS OPPS Rate,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.96,145,,,Fee Schedule,145% of CMS OPPS Rate,19.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,18.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,24.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.96,39.96,
93040- ECG/1-3 leads/w interp & report,3430954,CDM,510,RC,93040,HCPCS,Outpatient,,,31.8,15.90,,28.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.62,90,,,Percent of total Billed charges,90% of total billed charges,14.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,30.85,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,29.26,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.31,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,25.01,78.65,,,percent of total billed charges,78.65% of total billed charges,28.41,89.33,,,percent of total billed charges,89.33% of total billed charges,28.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.26,70,,,percent of total billed charges,70% of total billed charges,28.62,90,,,percent of total billed charges,90% of total billed charges,30.21,95,,,percent of total billed charges,95% of total billed charges,30.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.35,86,,,percent of total billed charges,86% of total billed charges,25.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.85,97,,,percent of total billed charges,97% of total billed charges,28.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.85,97,,,percent of total billed charges,97% of total billed charges,29.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.85,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.76,30.85,
93042- ECG/1-3 leads/interp & report only,3430956,CDM,510,RC,93042,HCPCS,Outpatient,,,18.06,9.03,,16.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.45,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,16.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,14.2,78.65,,,percent of total billed charges,78.65% of total billed charges,16.13,89.33,,,percent of total billed charges,89.33% of total billed charges,16.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.64,70,,,percent of total billed charges,70% of total billed charges,16.25,90,,,percent of total billed charges,90% of total billed charges,17.16,95,,,percent of total billed charges,95% of total billed charges,17.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.53,86,,,percent of total billed charges,86% of total billed charges,14.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.52,97,,,percent of total billed charges,97% of total billed charges,16.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.52,97,,,percent of total billed charges,97% of total billed charges,16.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.53,17.52,
93224- Xtrnl Ecg Less than 48 Hr Record Scan Stor w/Phy R+I,3430957,CDM,960,RC,93224,HCPCS,Outpatient,,,133.96,66.98,,120.56,90,,,percent of total billed charges,90% of total Billed charges,133.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.11,90,,,Percent of total Billed charges,90% of total billed charges,93.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.98,155,,,Fee Schedule,155% of CMS OPPS Rate,65.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.98,145,,,Fee Schedule,145% of CMS OPPS Rate,65.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.27,145,,,Fee Schedule,145% of CMS OPPS Rate,94.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,144.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.5,224.15,
CL Holter Monitor 24-48 hour,3430958,CDM,731,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,29.92,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.92,90,,,Percent of total Billed charges,90% of total billed charges,20.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,32.24,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.92,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,70,,,percent of total billed charges,70% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.59,86,,,percent of total billed charges,86% of total billed charges,26.59,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,32.24,97,,,percent of total billed charges,97% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.24,97,,,percent of total billed charges,97% of total billed charges,30.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.24,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.25,566.05,
Holter Monitor Scanning,604597,CDM,731,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,29.92,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.92,90,,,Percent of total Billed charges,90% of total billed charges,20.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,32.24,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.92,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,70,,,percent of total billed charges,70% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.59,86,,,percent of total billed charges,86% of total billed charges,26.59,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,32.24,97,,,percent of total billed charges,97% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.24,97,,,percent of total billed charges,97% of total billed charges,30.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.24,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.25,566.05,
93226- Holter/to 48 hrs/scan analy/w rpt,3430959,CDM,960,RC,93226,HCPCS,Outpatient,,,64.36,32.18,,57.92,90,,,percent of total billed charges,90% of total Billed charges,64.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.83,155,,,Fee Schedule,155% of CMS OPPS Rate,31.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.83,145,,,Fee Schedule,145% of CMS OPPS Rate,31.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.22,145,,,Fee Schedule,145% of CMS OPPS Rate,45.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.73,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.73,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.61,94.22,
93227- Holter/to 48 hrs/review/interp,3430960,CDM,960,RC,93227,HCPCS,Outpatient,,,36.38,18.19,,32.74,90,,,percent of total billed charges,90% of total Billed charges,35.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.69,155,,,Fee Schedule,155% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,27.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,25.69,145,,,Fee Schedule,145% of CMS OPPS Rate,17.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.88,145,,,Fee Schedule,145% of CMS OPPS Rate,25.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,43.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.72,52.39,
93228- MCT/rec/to 30 days/interp/rept,3430961,CDM,730,RC,93228,HCPCS,Outpatient,,,49.86,24.93,,44.87,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,39.89,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.84,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,39.22,78.65,,,percent of total billed charges,78.65% of total billed charges,44.54,89.33,,,percent of total billed charges,89.33% of total billed charges,44.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.9,70,,,percent of total billed charges,70% of total billed charges,44.87,90,,,percent of total billed charges,90% of total billed charges,47.37,95,,,percent of total billed charges,95% of total billed charges,47.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.88,86,,,percent of total billed charges,86% of total billed charges,39.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.36,97,,,percent of total billed charges,97% of total billed charges,44.87,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.36,97,,,percent of total billed charges,97% of total billed charges,46.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.84,48.36,
93229- MCT to 30 days/tech support,3430962,CDM,731,RC,93229,HCPCS,Outpatient,,,2083.74,1041.87,,1875.37,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1666.99,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1875.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2021.23,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1917.04,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1875.37,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.62,70,,,percent of total billed charges,70% of total billed charges,1875.37,90,,,percent of total billed charges,90% of total billed charges,1979.55,95,,,percent of total billed charges,95% of total billed charges,1979.55,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1792.02,86,,,percent of total billed charges,86% of total billed charges,1666.99,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2021.23,97,,,percent of total billed charges,97% of total billed charges,1875.37,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2021.23,97,,,percent of total billed charges,97% of total billed charges,1937.88,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2021.23,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,2021.23,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,21.88,10.94,,19.69,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,17.5,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.22,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.69,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,70,,,percent of total billed charges,70% of total billed charges,19.69,90,,,percent of total billed charges,90% of total billed charges,20.79,95,,,percent of total billed charges,95% of total billed charges,20.79,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.82,86,,,percent of total billed charges,86% of total billed charges,17.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,21.22,97,,,percent of total billed charges,97% of total billed charges,19.69,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.22,97,,,percent of total billed charges,97% of total billed charges,20.35,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.22,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.32,165.55,
93244 - External electrocardiographic recording for more than 48 hours up to 7 days by continuous rh,3635239,CDM,510,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,41.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,36.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.75,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.46,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.28,78.65,,,percent of total billed charges,78.65% of total billed charges,41.21,89.33,,,percent of total billed charges,89.33% of total billed charges,41.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.29,70,,,percent of total billed charges,70% of total billed charges,41.52,90,,,percent of total billed charges,90% of total billed charges,43.82,95,,,percent of total billed charges,95% of total billed charges,43.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.67,86,,,percent of total billed charges,86% of total billed charges,36.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.75,97,,,percent of total billed charges,97% of total billed charges,41.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.75,97,,,percent of total billed charges,97% of total billed charges,42.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.75,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.46,44.75,
93244 CardioKey 48hrs to 7days,3594862,CDM,960,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,41.52,90,,,percent of total billed charges,90% of total Billed charges,46.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,155,,,Fee Schedule,155% of CMS OPPS Rate,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,145,,,Fee Schedule,145% of CMS OPPS Rate,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.45,145,,,Fee Schedule,145% of CMS OPPS Rate,32.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,67.45,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,21.88,10.94,,19.69,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,17.5,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.22,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,20.13,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.69,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,15.32,70,,,percent of total billed charges,70% of total billed charges,19.69,90,,,percent of total billed charges,90% of total billed charges,20.79,95,,,percent of total billed charges,95% of total billed charges,20.79,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.82,86,,,percent of total billed charges,86% of total billed charges,17.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,21.22,97,,,percent of total billed charges,97% of total billed charges,19.69,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.22,97,,,percent of total billed charges,97% of total billed charges,20.35,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.22,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.32,280.22,
93248 - External electrocardiographic recording for more than 7 days up to 15 days by continuous rhy,3635240,CDM,960,RC,93248,HCPCS,Outpatient,,,50.8,25.40,,45.72,90,,,percent of total billed charges,90% of total Billed charges,51.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,155,,,Fee Schedule,155% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,145,,,Fee Schedule,145% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.12,145,,,Fee Schedule,145% of CMS OPPS Rate,36.29,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,74.12,
93248 CardioKey 7days to 15 days,3594863,CDM,960,RC,93248,HCPCS,Outpatient,,,50.8,25.40,,45.72,90,,,percent of total billed charges,90% of total Billed charges,51.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,155,,,Fee Schedule,155% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.29,145,,,Fee Schedule,145% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.12,145,,,Fee Schedule,145% of CMS OPPS Rate,36.29,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.24,74.12,
93260-Programming device evaluation (in person) with iterative adjustment of the implantable device,3783565,CDM,510,RC,93260,HCPCS,Outpatient,,,84.01,42.01,,75.61,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,67.21,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,81.49,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,77.29,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,75.61,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.81,70,,,percent of total billed charges,70% of total billed charges,75.61,90,,,percent of total billed charges,90% of total billed charges,79.81,95,,,percent of total billed charges,95% of total billed charges,79.81,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,72.25,86,,,percent of total billed charges,86% of total billed charges,67.21,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,81.49,97,,,percent of total billed charges,97% of total billed charges,75.61,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.49,97,,,percent of total billed charges,97% of total billed charges,78.13,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.49,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"93261-Interrogation device evaluation (in person) with analysis, review and report by a physician or",3783563,CDM,510,RC,93261,HCPCS,Outpatient,,,83.21,41.61,,74.89,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,66.57,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.71,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,76.55,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.89,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.25,70,,,percent of total billed charges,70% of total billed charges,74.89,90,,,percent of total billed charges,90% of total billed charges,79.05,95,,,percent of total billed charges,95% of total billed charges,79.05,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.56,86,,,percent of total billed charges,86% of total billed charges,66.57,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.71,97,,,percent of total billed charges,97% of total billed charges,74.89,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.71,97,,,percent of total billed charges,97% of total billed charges,77.39,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.71,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,81.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,155,,,Fee Schedule,155% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,145,,,Fee Schedule,145% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.84,145,,,Fee Schedule,145% of CMS OPPS Rate,50.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,118.84,
93264-CardioMems Recalibration.,4131431,CDM,481,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,57.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,66.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,46.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,56.74,78.65,,,percent of total billed charges,78.65% of total billed charges,64.44,89.33,,,percent of total billed charges,89.33% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,70,,,percent of total billed charges,70% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,68.53,95,,,percent of total billed charges,95% of total billed charges,68.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.04,86,,,percent of total billed charges,86% of total billed charges,57.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,67.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.07,69.98,
93264-CAVA MONITOR WRLESS PULM ART PRESS,3430963,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,81.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,155,,,Fee Schedule,155% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,145,,,Fee Schedule,145% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.84,145,,,Fee Schedule,145% of CMS OPPS Rate,50.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,118.84,
93264-PF CardioMems Recalibration,4131346,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,81.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,155,,,Fee Schedule,155% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,145,,,Fee Schedule,145% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.84,145,,,Fee Schedule,145% of CMS OPPS Rate,50.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,118.84,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,57.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,66.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,46.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,56.74,78.65,,,percent of total billed charges,78.65% of total billed charges,64.44,89.33,,,percent of total billed charges,89.33% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.5,70,,,percent of total billed charges,70% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,68.53,95,,,percent of total billed charges,95% of total billed charges,68.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.04,86,,,percent of total billed charges,86% of total billed charges,57.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,64.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,67.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.07,69.98,
93268- Event recorder/to 30 days/global,3430964,CDM,731,RC,93268,HCPCS,Outpatient,,,439.96,219.98,,395.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,351.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,395.96,90,,,Percent of total Billed charges,90% of total billed charges,92.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,426.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,404.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,280.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,346.04,78.65,,,percent of total billed charges,78.65% of total billed charges,393.02,89.33,,,percent of total billed charges,89.33% of total billed charges,395.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,307.97,70,,,percent of total billed charges,70% of total billed charges,395.96,90,,,percent of total billed charges,90% of total billed charges,417.96,95,,,percent of total billed charges,95% of total billed charges,417.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.37,86,,,percent of total billed charges,86% of total billed charges,351.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,426.76,97,,,percent of total billed charges,97% of total billed charges,395.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,426.76,97,,,percent of total billed charges,97% of total billed charges,409.16,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,426.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.78,426.76,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,731,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,13.76,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.76,90,,,Percent of total Billed charges,90% of total billed charges,16.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14.83,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.07,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13.76,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,10.7,70,,,percent of total billed charges,70% of total billed charges,13.76,90,,,percent of total billed charges,90% of total billed charges,14.53,95,,,percent of total billed charges,95% of total billed charges,14.53,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.15,86,,,percent of total billed charges,86% of total billed charges,12.23,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14.83,97,,,percent of total billed charges,97% of total billed charges,13.76,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,97,,,percent of total billed charges,97% of total billed charges,14.22,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14.83,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.7,170.62,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,13.76,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.76,90,,,Percent of total Billed charges,90% of total billed charges,16.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14.83,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,14.07,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13.76,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,10.7,70,,,percent of total billed charges,70% of total billed charges,13.76,90,,,percent of total billed charges,90% of total billed charges,14.53,95,,,percent of total billed charges,95% of total billed charges,14.53,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.15,86,,,percent of total billed charges,86% of total billed charges,12.23,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14.83,97,,,percent of total billed charges,97% of total billed charges,13.76,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,97,,,percent of total billed charges,97% of total billed charges,14.22,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14.83,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.7,170.62,
93272- Event rec/to 30 days/review/interp,3430966,CDM,960,RC,93272,HCPCS,Outpatient,,,48.12,24.06,,43.31,90,,,percent of total billed charges,90% of total Billed charges,47.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.97,155,,,Fee Schedule,155% of CMS OPPS Rate,23.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.97,145,,,Fee Schedule,145% of CMS OPPS Rate,23.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.01,145,,,Fee Schedule,145% of CMS OPPS Rate,33.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,41.62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.29,69.01,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,61.33,30.67,,55.2,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,49.06,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.2,90,,,Percent of total Billed charges,90% of total billed charges,11.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,59.49,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,56.42,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,55.2,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,42.93,70,,,percent of total billed charges,70% of total billed charges,55.2,90,,,percent of total billed charges,90% of total billed charges,58.26,95,,,percent of total billed charges,95% of total billed charges,58.26,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,52.74,86,,,percent of total billed charges,86% of total billed charges,49.06,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,59.49,97,,,percent of total billed charges,97% of total billed charges,55.2,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.49,97,,,percent of total billed charges,97% of total billed charges,57.04,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.49,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.54,170.62,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,65.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.12,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.39,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,70.47,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,66.84,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,65.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,70,,,percent of total billed charges,70% of total billed charges,65.39,90,,,percent of total billed charges,90% of total billed charges,69.02,95,,,percent of total billed charges,95% of total billed charges,69.02,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.48,86,,,percent of total billed charges,86% of total billed charges,58.12,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70.47,97,,,percent of total billed charges,97% of total billed charges,65.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.47,97,,,percent of total billed charges,97% of total billed charges,67.56,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.47,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,170.62,
93280-In Person programming/eval W/adjustments to test function of the device and select optimal pro,4271187,CDM,481,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,65.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.12,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.39,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,70.47,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,66.84,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,65.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.86,70,,,percent of total billed charges,70% of total billed charges,65.39,90,,,percent of total billed charges,90% of total billed charges,69.02,95,,,percent of total billed charges,95% of total billed charges,69.02,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.48,86,,,percent of total billed charges,86% of total billed charges,58.12,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70.47,97,,,percent of total billed charges,97% of total billed charges,65.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.47,97,,,percent of total billed charges,97% of total billed charges,67.56,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.47,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,170.62,
93280-PF In Person programming/eval W/adjustments to test function of the device and select optimal,4271188,CDM,960,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,65.39,90,,,percent of total billed charges,90% of total Billed charges,77.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,54.71,155,,,Fee Schedule,155% of CMS OPPS Rate,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,100.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,100.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,145,,,Fee Schedule,145% of CMS OPPS Rate,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.71,145,,,Fee Schedule,145% of CMS OPPS Rate,54.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,91.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.73,111.71,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,81.54,40.77,,73.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.23,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.39,90,,,Percent of total Billed charges,90% of total billed charges,15.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,79.09,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,75.02,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,57.08,70,,,percent of total billed charges,70% of total billed charges,73.39,90,,,percent of total billed charges,90% of total billed charges,77.46,95,,,percent of total billed charges,95% of total billed charges,77.46,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.12,86,,,percent of total billed charges,86% of total billed charges,65.23,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,79.09,97,,,percent of total billed charges,97% of total billed charges,73.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.09,97,,,percent of total billed charges,97% of total billed charges,75.83,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.09,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.11,170.62,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,80.92,40.46,,72.83,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,64.74,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.83,90,,,Percent of total Billed charges,90% of total billed charges,13.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.49,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.45,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.83,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,70,,,percent of total billed charges,70% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.59,86,,,percent of total billed charges,86% of total billed charges,64.74,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.49,97,,,percent of total billed charges,97% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.49,97,,,percent of total billed charges,97% of total billed charges,75.26,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.49,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.64,170.62,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,109.86,54.93,,98.87,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,87.89,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.87,90,,,Percent of total Billed charges,90% of total billed charges,15.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,106.56,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,101.07,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,98.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,76.9,70,,,percent of total billed charges,70% of total billed charges,98.87,90,,,percent of total billed charges,90% of total billed charges,104.37,95,,,percent of total billed charges,95% of total billed charges,104.37,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,94.48,86,,,percent of total billed charges,86% of total billed charges,87.89,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,106.56,97,,,percent of total billed charges,97% of total billed charges,98.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.56,97,,,percent of total billed charges,97% of total billed charges,102.17,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,106.56,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.53,170.62,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,119.19,59.60,,107.27,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,95.35,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.27,90,,,Percent of total Billed charges,90% of total billed charges,18.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,115.61,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,109.65,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,107.27,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,83.43,70,,,percent of total billed charges,70% of total billed charges,107.27,90,,,percent of total billed charges,90% of total billed charges,113.23,95,,,percent of total billed charges,95% of total billed charges,113.23,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.5,86,,,percent of total billed charges,86% of total billed charges,95.35,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,115.61,97,,,percent of total billed charges,97% of total billed charges,107.27,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.61,97,,,percent of total billed charges,97% of total billed charges,110.85,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.61,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.63,170.62,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,49.93,24.97,,44.94,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,39.94,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.94,90,,,Percent of total Billed charges,90% of total billed charges,10.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,48.43,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,45.94,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.94,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,34.95,70,,,percent of total billed charges,70% of total billed charges,44.94,90,,,percent of total billed charges,90% of total billed charges,47.43,95,,,percent of total billed charges,95% of total billed charges,47.43,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.94,86,,,percent of total billed charges,86% of total billed charges,39.94,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,48.43,97,,,percent of total billed charges,97% of total billed charges,44.94,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.43,97,,,percent of total billed charges,97% of total billed charges,46.43,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.43,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.7,170.62,
93286- PPM eval/peri-proc/sng/dual/multi,3430975,CDM,510,RC,93286,HCPCS,Outpatient,,,77.7,38.85,,69.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,62.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,71.48,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,49.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,61.11,78.65,,,percent of total billed charges,78.65% of total billed charges,69.41,89.33,,,percent of total billed charges,89.33% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.39,70,,,percent of total billed charges,70% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.82,86,,,percent of total billed charges,86% of total billed charges,62.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,72.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.62,75.37,
Pre/Post MRI Pacemaker Interrogation,4231171,CDM,480,RC,93286,HCPCS,Outpatient,,,31.08,15.54,,27.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,19.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.45,78.65,,,percent of total billed charges,78.65% of total billed charges,27.76,89.33,,,percent of total billed charges,89.33% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.76,70,,,percent of total billed charges,70% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,29.53,95,,,percent of total billed charges,95% of total billed charges,29.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.73,86,,,percent of total billed charges,86% of total billed charges,24.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,28.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,30.15,
Pre/Post MRI Pacemaker Interrogation,4231197,CDM,480,RC,93286,HCPCS,Outpatient,,,31.08,15.54,,27.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,19.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.45,78.65,,,percent of total billed charges,78.65% of total billed charges,27.76,89.33,,,percent of total billed charges,89.33% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.76,70,,,percent of total billed charges,70% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,29.53,95,,,percent of total billed charges,95% of total billed charges,29.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.73,86,,,percent of total billed charges,86% of total billed charges,24.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,27.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,28.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.85,30.15,
93287- ICD eval/peri-proc/sng/dual/multi,3430976,CDM,510,RC,93287,HCPCS,Outpatient,,,77.7,38.85,,69.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,62.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,71.48,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,49.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,61.11,78.65,,,percent of total billed charges,78.65% of total billed charges,69.41,89.33,,,percent of total billed charges,89.33% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.39,70,,,percent of total billed charges,70% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.82,86,,,percent of total billed charges,86% of total billed charges,62.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,72.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.62,75.37,
Pre/Post MRI Defibrillator Interrogation,4231172,CDM,480,RC,93287,HCPCS,Outpatient,,,46.72,23.36,,42.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.84,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.75,78.65,,,percent of total billed charges,78.65% of total billed charges,41.74,89.33,,,percent of total billed charges,89.33% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.7,70,,,percent of total billed charges,70% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,44.38,95,,,percent of total billed charges,95% of total billed charges,44.38,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,86,,,percent of total billed charges,86% of total billed charges,37.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,43.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.84,45.32,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,40.34,20.17,,36.31,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,32.27,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.31,90,,,Percent of total Billed charges,90% of total billed charges,10.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,39.13,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,37.11,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,36.31,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,28.24,70,,,percent of total billed charges,70% of total billed charges,36.31,90,,,percent of total billed charges,90% of total billed charges,38.32,95,,,percent of total billed charges,95% of total billed charges,38.32,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.69,86,,,percent of total billed charges,86% of total billed charges,32.27,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.13,97,,,percent of total billed charges,97% of total billed charges,36.31,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.13,97,,,percent of total billed charges,97% of total billed charges,37.52,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,39.13,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.91,170.62,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,71.59,35.80,,64.43,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,57.27,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.43,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,69.44,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.86,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.11,70,,,percent of total billed charges,70% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.57,86,,,percent of total billed charges,86% of total billed charges,57.27,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,69.44,97,,,percent of total billed charges,97% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.44,97,,,percent of total billed charges,97% of total billed charges,66.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.44,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,170.62,
93289-ICD Generator Testing,3432004,CDM,481,RC,93289,HCPCS,Outpatient,,,71.59,35.80,,64.43,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,57.27,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.43,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,69.44,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.86,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.11,70,,,percent of total billed charges,70% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.57,86,,,percent of total billed charges,86% of total billed charges,57.27,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,69.44,97,,,percent of total billed charges,97% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.44,97,,,percent of total billed charges,97% of total billed charges,66.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.44,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,170.62,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,71.59,35.80,,64.43,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,57.27,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.43,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,69.44,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.86,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,50.11,70,,,percent of total billed charges,70% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,68.01,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.57,86,,,percent of total billed charges,86% of total billed charges,57.27,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,69.44,97,,,percent of total billed charges,97% of total billed charges,64.43,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.44,97,,,percent of total billed charges,97% of total billed charges,66.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.44,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,170.62,
93290- Internal card mon/interr/in person,3430979,CDM,510,RC,93290,HCPCS,Outpatient,,,81.64,40.82,,73.48,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.31,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.48,90,,,Percent of total Billed charges,90% of total billed charges,8.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,79.19,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,75.11,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.48,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,57.15,70,,,percent of total billed charges,70% of total billed charges,73.48,90,,,percent of total billed charges,90% of total billed charges,77.56,95,,,percent of total billed charges,95% of total billed charges,77.56,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.21,86,,,percent of total billed charges,86% of total billed charges,65.31,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,79.19,97,,,percent of total billed charges,97% of total billed charges,73.48,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.19,97,,,percent of total billed charges,97% of total billed charges,75.93,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.19,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.54,170.62,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,34.98,17.49,,31.48,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,27.98,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.48,90,,,Percent of total Billed charges,90% of total billed charges,13.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33.93,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,32.18,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,31.48,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,24.49,70,,,percent of total billed charges,70% of total billed charges,31.48,90,,,percent of total billed charges,90% of total billed charges,33.23,95,,,percent of total billed charges,95% of total billed charges,33.23,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30.08,86,,,percent of total billed charges,86% of total billed charges,27.98,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33.93,97,,,percent of total billed charges,97% of total billed charges,31.48,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.93,97,,,percent of total billed charges,97% of total billed charges,32.53,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33.93,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.98,121.68,
93292- Wearable defib sys/inter/in person,3430981,CDM,510,RC,93292,HCPCS,Outpatient,,,73.74,36.87,,66.37,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,58.99,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.37,90,,,Percent of total Billed charges,90% of total billed charges,7.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,71.53,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,67.84,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,66.37,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,51.62,70,,,percent of total billed charges,70% of total billed charges,66.37,90,,,percent of total billed charges,90% of total billed charges,70.05,95,,,percent of total billed charges,95% of total billed charges,70.05,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,63.42,86,,,percent of total billed charges,86% of total billed charges,58.99,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,71.53,97,,,percent of total billed charges,97% of total billed charges,66.37,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.53,97,,,percent of total billed charges,97% of total billed charges,68.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.53,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.76,170.62,
93293- TTM/90 day/PPM/sg/dual/mult,3430982,CDM,732,RC,93293,HCPCS,Outpatient,,,77.7,38.85,,69.93,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,62.16,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.93,90,,,Percent of total Billed charges,90% of total billed charges,24.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,75.37,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,71.48,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.93,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,54.39,70,,,percent of total billed charges,70% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,73.82,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.82,86,,,percent of total billed charges,86% of total billed charges,62.16,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,75.37,97,,,percent of total billed charges,97% of total billed charges,69.93,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.37,97,,,percent of total billed charges,97% of total billed charges,72.26,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.37,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.3,170.62,
93294- PM remote eval/90 day/sg/dual/mult,3430983,CDM,960,RC,93294,HCPCS,Outpatient,,,59.11,29.56,,53.2,90,,,percent of total billed charges,90% of total Billed charges,58.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.11,155,,,Fee Schedule,155% of CMS OPPS Rate,29.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,42.11,145,,,Fee Schedule,145% of CMS OPPS Rate,29.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.94,145,,,Fee Schedule,145% of CMS OPPS Rate,42.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.91,84.94,
93295- ICD remote eval/90 day/sg/dual/mul,3430984,CDM,960,RC,93295,HCPCS,Outpatient,,,73.35,36.68,,66.02,90,,,percent of total billed charges,90% of total Billed charges,72.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,51.52,145,,,Fee Schedule,145% of CMS OPPS Rate,35.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.56,145,,,Fee Schedule,145% of CMS OPPS Rate,51.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.53,106.63,
93296- PM remote trans/90 day/tech review,3430985,CDM,480,RC,93296,HCPCS,Outpatient,,,38.63,19.32,,34.77,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.77,90,,,Percent of total Billed charges,90% of total billed charges,21.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,37.47,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,35.54,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,27.04,70,,,percent of total billed charges,70% of total billed charges,34.77,90,,,percent of total billed charges,90% of total billed charges,36.7,95,,,percent of total billed charges,95% of total billed charges,36.7,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33.22,86,,,percent of total billed charges,86% of total billed charges,30.9,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37.47,97,,,percent of total billed charges,97% of total billed charges,34.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.47,97,,,percent of total billed charges,97% of total billed charges,35.93,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.47,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.99,170.62,
93297- ICM remote eval/30 day,3430986,CDM,510,RC,93297,HCPCS,Outpatient,,,68.85,34.43,,61.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,55.08,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,63.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,43.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,54.15,78.65,,,percent of total billed charges,78.65% of total billed charges,61.5,89.33,,,percent of total billed charges,89.33% of total billed charges,61.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.2,70,,,percent of total billed charges,70% of total billed charges,61.97,90,,,percent of total billed charges,90% of total billed charges,65.41,95,,,percent of total billed charges,95% of total billed charges,65.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.21,86,,,percent of total billed charges,86% of total billed charges,55.08,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,66.78,97,,,percent of total billed charges,97% of total billed charges,61.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.78,97,,,percent of total billed charges,97% of total billed charges,64.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.97,66.78,
93298- ILR remote eval/30 day,3430987,CDM,960,RC,93298,HCPCS,Outpatient,,,49.31,24.66,,44.38,90,,,percent of total billed charges,90% of total Billed charges,51.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.9,155,,,Fee Schedule,155% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,31.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.9,145,,,Fee Schedule,145% of CMS OPPS Rate,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.43,145,,,Fee Schedule,145% of CMS OPPS Rate,36.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,74.43,
93303- TTE/congenital anomalies/complete,3430989,CDM,510,RC,93303,HCPCS,Outpatient,,,385.17,192.59,,346.65,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,308.14,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.65,90,,,Percent of total Billed charges,90% of total billed charges,104.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,373.61,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,354.36,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,346.65,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,269.62,70,,,percent of total billed charges,70% of total billed charges,346.65,90,,,percent of total billed charges,90% of total billed charges,365.91,95,,,percent of total billed charges,95% of total billed charges,365.91,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,331.25,86,,,percent of total billed charges,86% of total billed charges,308.14,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,373.61,97,,,percent of total billed charges,97% of total billed charges,346.65,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.61,97,,,percent of total billed charges,97% of total billed charges,358.21,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.61,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95,2452.82,
93304- TTE/congen/anom/follow up/limited,3430990,CDM,510,RC,93304,HCPCS,Outpatient,,,288.83,144.42,,259.95,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,231.06,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.95,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,280.17,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,265.72,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,259.95,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,202.18,70,,,percent of total billed charges,70% of total billed charges,259.95,90,,,percent of total billed charges,90% of total billed charges,274.39,95,,,percent of total billed charges,95% of total billed charges,274.39,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,248.39,86,,,percent of total billed charges,86% of total billed charges,231.06,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,280.17,97,,,percent of total billed charges,97% of total billed charges,259.95,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.17,97,,,percent of total billed charges,97% of total billed charges,268.61,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.17,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,2452.82,
"93306- Transthoracic Echo (TTE) Complete, w/2D, Doppler & Color (PRO FEE)",3430991,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.49,155,,,Fee Schedule,155% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.49,145,,,Fee Schedule,145% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.3,145,,,Fee Schedule,145% of CMS OPPS Rate,163.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.75,331.3,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.54,2452.82,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.54,2452.82,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.54,2452.82,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.54,2452.82,
93307- TTE/2D/M-mode/w/o spec/color dop,3430993,CDM,483,RC,93307,HCPCS,Outpatient,,,226.47,113.24,,203.82,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,181.18,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.82,90,,,Percent of total Billed charges,90% of total billed charges,104.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,219.68,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,208.35,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,203.82,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,158.53,70,,,percent of total billed charges,70% of total billed charges,203.82,90,,,percent of total billed charges,90% of total billed charges,215.15,95,,,percent of total billed charges,95% of total billed charges,215.15,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,194.76,86,,,percent of total billed charges,86% of total billed charges,181.18,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,219.68,97,,,percent of total billed charges,97% of total billed charges,203.82,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.68,97,,,percent of total billed charges,97% of total billed charges,210.62,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,219.68,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95,1138.43,
CVS Charge 2D Echo,645298,CDM,483,RC,93307,HCPCS,Outpatient,,,329.64,164.82,,296.68,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,263.71,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,296.68,90,,,Percent of total Billed charges,90% of total billed charges,104.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,319.75,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,303.27,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,296.68,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,230.75,70,,,percent of total billed charges,70% of total billed charges,296.68,90,,,percent of total billed charges,90% of total billed charges,313.16,95,,,percent of total billed charges,95% of total billed charges,313.16,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,283.49,86,,,percent of total billed charges,86% of total billed charges,263.71,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,319.75,97,,,percent of total billed charges,97% of total billed charges,296.68,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.75,97,,,percent of total billed charges,97% of total billed charges,306.57,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,319.75,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95,1138.43,
93308 - Limited Echocardiogram Pro Fee,3635415,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.59,70,,,percent of total billed charges,70% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.5,86,,,percent of total billed charges,86% of total billed charges,39.54,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.94,97,,,percent of total billed charges,97% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,97,,,percent of total billed charges,97% of total billed charges,45.96,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1138.43,
93308-Dobutamine Valve Study,4061205,CDM,482,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.59,70,,,percent of total billed charges,70% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.5,86,,,percent of total billed charges,86% of total billed charges,39.54,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.94,97,,,percent of total billed charges,97% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,97,,,percent of total billed charges,97% of total billed charges,45.96,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1138.43,
93308-PF Dobutamine Valve Study,4061208,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
93308-PF ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD,4321509,CDM,981,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.59,70,,,percent of total billed charges,70% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.5,86,,,percent of total billed charges,86% of total billed charges,39.54,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.94,97,,,percent of total billed charges,97% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,97,,,percent of total billed charges,97% of total billed charges,45.96,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1138.43,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.59,70,,,percent of total billed charges,70% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.5,86,,,percent of total billed charges,86% of total billed charges,39.54,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.94,97,,,percent of total billed charges,97% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,97,,,percent of total billed charges,97% of total billed charges,45.96,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1138.43,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.54,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,45.47,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,34.59,70,,,percent of total billed charges,70% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,46.95,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,42.5,86,,,percent of total billed charges,86% of total billed charges,39.54,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.94,97,,,percent of total billed charges,97% of total billed charges,44.48,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,97,,,percent of total billed charges,97% of total billed charges,45.96,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1138.43,
93312- TEE/2D/probe place/image/int/rep,3430995,CDM,483,RC,93312,HCPCS,Outpatient,,,316.46,158.23,,284.81,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,253.17,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.81,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,306.97,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,291.14,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,284.81,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,221.52,70,,,percent of total billed charges,70% of total billed charges,284.81,90,,,percent of total billed charges,90% of total billed charges,300.64,95,,,percent of total billed charges,95% of total billed charges,300.64,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,272.16,86,,,percent of total billed charges,86% of total billed charges,253.17,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,306.97,97,,,percent of total billed charges,97% of total billed charges,284.81,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.97,97,,,percent of total billed charges,97% of total billed charges,294.31,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.97,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.93,2452.82,
"93312- Transesophageal Echo (TEE) 2D, Includes Probe Plcmt, Image Acq, I&R (PRO FEE)",3430996,CDM,483,RC,93312,HCPCS,Outpatient,,,316.46,158.23,,284.81,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,253.17,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.81,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,306.97,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,291.14,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,284.81,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,221.52,70,,,percent of total billed charges,70% of total billed charges,284.81,90,,,percent of total billed charges,90% of total billed charges,300.64,95,,,percent of total billed charges,95% of total billed charges,300.64,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,272.16,86,,,percent of total billed charges,86% of total billed charges,253.17,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,306.97,97,,,percent of total billed charges,97% of total billed charges,284.81,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.97,97,,,percent of total billed charges,97% of total billed charges,294.31,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.97,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.93,2452.82,
Echocardiogram Transeso,604557,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,520.03,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,462.25,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.03,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,560.48,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,531.59,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,404.47,70,,,percent of total billed charges,70% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.92,86,,,percent of total billed charges,86% of total billed charges,462.25,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,560.48,97,,,percent of total billed charges,97% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,560.48,97,,,percent of total billed charges,97% of total billed charges,537.36,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.48,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.93,2452.82,
Echocardiogram Transeso in OR,1345096,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,520.03,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,462.25,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.03,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,560.48,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,531.59,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,404.47,70,,,percent of total billed charges,70% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.92,86,,,percent of total billed charges,86% of total billed charges,462.25,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,560.48,97,,,percent of total billed charges,97% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,560.48,97,,,percent of total billed charges,97% of total billed charges,537.36,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.48,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.93,2452.82,
MCNH Echo Transthoracic TTE Limited,3805224,CDM,483,RC,93312,HCPCS,Outpatient,,,577.81,288.91,,520.03,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,462.25,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.03,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,560.48,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,531.59,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,404.47,70,,,percent of total billed charges,70% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,548.92,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.92,86,,,percent of total billed charges,86% of total billed charges,462.25,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,560.48,97,,,percent of total billed charges,97% of total billed charges,520.03,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,560.48,97,,,percent of total billed charges,97% of total billed charges,537.36,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.48,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.93,2452.82,
93313- TEE/probe place only,3430997,CDM,510,RC,93313,HCPCS,Outpatient,,,30.07,15.04,,27.06,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,24.06,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.17,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,27.66,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,27.06,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,21.05,70,,,percent of total billed charges,70% of total billed charges,27.06,90,,,percent of total billed charges,90% of total billed charges,28.57,95,,,percent of total billed charges,95% of total billed charges,28.57,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,25.86,86,,,percent of total billed charges,86% of total billed charges,24.06,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,29.17,97,,,percent of total billed charges,97% of total billed charges,27.06,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.17,97,,,percent of total billed charges,97% of total billed charges,27.97,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.17,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.05,2452.82,
93314- TEE/image acquisition/int/rep only,3430998,CDM,510,RC,93314,HCPCS,Outpatient,,,334.62,167.31,,301.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,267.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,301.16,90,,,Percent of total Billed charges,90% of total billed charges,146.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,324.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,307.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,213.7,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,263.19,78.65,,,percent of total billed charges,78.65% of total billed charges,298.92,89.33,,,percent of total billed charges,89.33% of total billed charges,301.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.23,70,,,percent of total billed charges,70% of total billed charges,301.16,90,,,percent of total billed charges,90% of total billed charges,317.89,95,,,percent of total billed charges,95% of total billed charges,317.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.77,86,,,percent of total billed charges,86% of total billed charges,267.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,324.58,97,,,percent of total billed charges,97% of total billed charges,301.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,324.58,97,,,percent of total billed charges,97% of total billed charges,311.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,324.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.93,324.58,
93315- TEE/congen/prob plac/image/int/rep,3430999,CDM,510,RC,93315,HCPCS,Outpatient,,,329.33,164.67,,296.4,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,263.46,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,296.4,90,,,Percent of total Billed charges,90% of total billed charges,290.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,319.45,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,302.98,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,296.4,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,230.53,70,,,percent of total billed charges,70% of total billed charges,296.4,90,,,percent of total billed charges,90% of total billed charges,312.86,95,,,percent of total billed charges,95% of total billed charges,312.86,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,283.22,86,,,percent of total billed charges,86% of total billed charges,263.46,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,319.45,97,,,percent of total billed charges,97% of total billed charges,296.4,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.45,97,,,percent of total billed charges,97% of total billed charges,306.28,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,264,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,319.45,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,230.53,2452.82,
93316- TEE/congenital/probe place only,3431000,CDM,510,RC,93316,HCPCS,Outpatient,,,69.41,34.71,,62.47,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,55.53,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.47,90,,,Percent of total Billed charges,90% of total billed charges,46.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,67.33,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,63.86,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,62.47,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,48.59,70,,,percent of total billed charges,70% of total billed charges,62.47,90,,,percent of total billed charges,90% of total billed charges,65.94,95,,,percent of total billed charges,95% of total billed charges,65.94,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,59.69,86,,,percent of total billed charges,86% of total billed charges,55.53,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,67.33,97,,,percent of total billed charges,97% of total billed charges,62.47,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.33,97,,,percent of total billed charges,97% of total billed charges,64.55,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.33,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.28,2452.82,
93317- TEE/congenital/image/int/rep only,3431001,CDM,510,RC,93317,HCPCS,Outpatient,,,232.48,116.24,,209.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,185.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,209.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,213.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,148.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,182.85,78.65,,,percent of total billed charges,78.65% of total billed charges,207.68,89.33,,,percent of total billed charges,89.33% of total billed charges,209.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,162.74,70,,,percent of total billed charges,70% of total billed charges,209.23,90,,,percent of total billed charges,90% of total billed charges,220.86,95,,,percent of total billed charges,95% of total billed charges,220.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.93,86,,,percent of total billed charges,86% of total billed charges,185.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.51,97,,,percent of total billed charges,97% of total billed charges,209.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.51,97,,,percent of total billed charges,97% of total billed charges,216.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.47,225.51,
93318- TEE/real time 2D/image/cont mon,3431002,CDM,480,RC,93318,HCPCS,Outpatient,,,268.72,134.36,,241.85,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,214.98,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,247.22,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,241.85,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,188.1,70,,,percent of total billed charges,70% of total billed charges,241.85,90,,,percent of total billed charges,90% of total billed charges,255.28,95,,,percent of total billed charges,95% of total billed charges,255.28,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.1,86,,,percent of total billed charges,86% of total billed charges,214.98,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,260.66,97,,,percent of total billed charges,97% of total billed charges,241.85,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.66,97,,,percent of total billed charges,97% of total billed charges,249.91,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,260.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,188.1,2452.82,
3D Echocardiographic imaging and postprocessing during TEE o,3938898,CDM,483,RC,93319,HCPCS,Outpatient,,,135.18,67.59,,121.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,108.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,121.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,131.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,124.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,86.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,106.32,78.65,,,percent of total billed charges,78.65% of total billed charges,120.76,89.33,,,percent of total billed charges,89.33% of total billed charges,121.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,94.63,70,,,percent of total billed charges,70% of total billed charges,121.66,90,,,percent of total billed charges,90% of total billed charges,128.42,95,,,percent of total billed charges,95% of total billed charges,128.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.25,86,,,percent of total billed charges,86% of total billed charges,108.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,131.12,97,,,percent of total billed charges,97% of total billed charges,121.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,131.12,97,,,percent of total billed charges,97% of total billed charges,125.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.33,131.12,
93319 - 3D Echo Img Cgen Car Anomol,4113120,CDM,972,RC,93319,HCPCS,Outpatient,,,133.42,66.71,,120.08,90,,,percent of total billed charges,90% of total Billed charges,79.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.23,155,,,Fee Schedule,155% of CMS OPPS Rate,23.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.23,145,,,Fee Schedule,145% of CMS OPPS Rate,23.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.71,145,,,Fee Schedule,145% of CMS OPPS Rate,34.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.61,120.08,
93320 (26) - Doppler Echo Spectral Display,4113123,CDM,972,RC,93320,HCPCS,Outpatient,,,112.86,56.43,,101.57,90,,,percent of total billed charges,90% of total Billed charges,59.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.62,90,,,Percent of total Billed charges,90% of total billed charges,60.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.02,155,,,Fee Schedule,155% of CMS OPPS Rate,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.02,145,,,Fee Schedule,145% of CMS OPPS Rate,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.67,145,,,Fee Schedule,145% of CMS OPPS Rate,42.02,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,72.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.98,133.62,
93320- Doppler echo spectral display,3431003,CDM,483,RC,93320,HCPCS,Outpatient,,,80.07,40.04,,72.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.06,90,,,Percent of total Billed charges,90% of total billed charges,45.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,62.98,78.65,,,percent of total billed charges,78.65% of total billed charges,71.53,89.33,,,percent of total billed charges,89.33% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.05,70,,,percent of total billed charges,70% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,76.07,95,,,percent of total billed charges,95% of total billed charges,76.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.86,86,,,percent of total billed charges,86% of total billed charges,64.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.67,97,,,percent of total billed charges,97% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.67,97,,,percent of total billed charges,97% of total billed charges,74.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,77.67,
93320-Spectral Doppler,3554696,CDM,481,RC,93320,HCPCS,Outpatient,,,80.07,40.04,,72.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.06,90,,,Percent of total Billed charges,90% of total billed charges,45.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,62.98,78.65,,,percent of total billed charges,78.65% of total billed charges,71.53,89.33,,,percent of total billed charges,89.33% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.05,70,,,percent of total billed charges,70% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,76.07,95,,,percent of total billed charges,95% of total billed charges,76.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.86,86,,,percent of total billed charges,86% of total billed charges,64.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.67,97,,,percent of total billed charges,97% of total billed charges,72.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.67,97,,,percent of total billed charges,97% of total billed charges,74.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,77.67,
Spectral Doppler,3558607,CDM,483,RC,93320,HCPCS,Outpatient,,,122.11,61.06,,109.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,97.69,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,109.9,90,,,Percent of total Billed charges,90% of total billed charges,45.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,118.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,112.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,77.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,96.04,78.65,,,percent of total billed charges,78.65% of total billed charges,109.08,89.33,,,percent of total billed charges,89.33% of total billed charges,109.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,85.48,70,,,percent of total billed charges,70% of total billed charges,109.9,90,,,percent of total billed charges,90% of total billed charges,116,95,,,percent of total billed charges,95% of total billed charges,116,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.01,86,,,percent of total billed charges,86% of total billed charges,97.69,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,118.45,97,,,percent of total billed charges,97% of total billed charges,109.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,118.45,97,,,percent of total billed charges,97% of total billed charges,113.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,118.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.39,118.45,
93321- Dop echo/pulse/cont wave/spec/lim,3431005,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,41.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.98,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.68,78.65,,,percent of total billed charges,78.65% of total billed charges,41.66,89.33,,,percent of total billed charges,89.33% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.65,70,,,percent of total billed charges,70% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,86,,,percent of total billed charges,86% of total billed charges,37.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,43.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,45.24,
93321 Doppler echo pulsed wave,4061246,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,41.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.98,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.68,78.65,,,percent of total billed charges,78.65% of total billed charges,41.66,89.33,,,percent of total billed charges,89.33% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.65,70,,,percent of total billed charges,70% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,86,,,percent of total billed charges,86% of total billed charges,37.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,43.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,45.24,
"93321(26)- Doppler Echo, Limited or F/U (PRO FEE)",3431004,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,41.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.98,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.68,78.65,,,percent of total billed charges,78.65% of total billed charges,41.66,89.33,,,percent of total billed charges,89.33% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.65,70,,,percent of total billed charges,70% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,86,,,percent of total billed charges,86% of total billed charges,37.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,43.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,45.24,
93321-Limited or Follow Up TEE,3556733,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,41.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.98,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.68,78.65,,,percent of total billed charges,78.65% of total billed charges,41.66,89.33,,,percent of total billed charges,89.33% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.65,70,,,percent of total billed charges,70% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,86,,,percent of total billed charges,86% of total billed charges,37.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,43.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,45.24,
Limited Spectral Doppler,3558606,CDM,483,RC,93321,HCPCS,Outpatient,,,46.64,23.32,,41.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.98,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.68,78.65,,,percent of total billed charges,78.65% of total billed charges,41.66,89.33,,,percent of total billed charges,89.33% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.65,70,,,percent of total billed charges,70% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,44.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,86,,,percent of total billed charges,86% of total billed charges,37.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,41.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.24,97,,,percent of total billed charges,97% of total billed charges,43.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,45.24,
93325 - Color Flow Mapping Pro Fee,3635416,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.79,155,,,Fee Schedule,155% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.79,145,,,Fee Schedule,145% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.57,145,,,Fee Schedule,145% of CMS OPPS Rate,8.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.45,105.78,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.77,78.65,,,percent of total billed charges,78.65% of total billed charges,5.41,89.33,,,percent of total billed charges,89.33% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.24,70,,,percent of total billed charges,70% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,86,,,percent of total billed charges,86% of total billed charges,4.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,5.88,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.77,78.65,,,percent of total billed charges,78.65% of total billed charges,5.41,89.33,,,percent of total billed charges,89.33% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.24,70,,,percent of total billed charges,70% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,86,,,percent of total billed charges,86% of total billed charges,4.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,5.88,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.77,78.65,,,percent of total billed charges,78.65% of total billed charges,5.41,89.33,,,percent of total billed charges,89.33% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.24,70,,,percent of total billed charges,70% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,5.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.21,86,,,percent of total billed charges,86% of total billed charges,4.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,5.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.87,5.88,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2452.82,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2452.82,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2452.82,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2452.82,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,109.19,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.84,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,132.4,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,125.57,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,95.54,70,,,percent of total billed charges,70% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,129.67,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,117.38,86,,,percent of total billed charges,86% of total billed charges,109.19,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,132.4,97,,,percent of total billed charges,97% of total billed charges,122.84,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.4,97,,,percent of total billed charges,97% of total billed charges,126.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.4,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2452.82,
93351- TTE/rest/stress/2D/M-mode/cont ECG,3431009,CDM,483,RC,93351,HCPCS,Outpatient,,,359.72,179.86,,323.75,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.78,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.93,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.94,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,323.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,251.8,70,,,percent of total billed charges,70% of total billed charges,323.75,90,,,percent of total billed charges,90% of total billed charges,341.73,95,,,percent of total billed charges,95% of total billed charges,341.73,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,309.36,86,,,percent of total billed charges,86% of total billed charges,287.78,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,348.93,97,,,percent of total billed charges,97% of total billed charges,323.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.93,97,,,percent of total billed charges,97% of total billed charges,334.54,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.93,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.8,2452.82,
CL Dobutamine Stress Echocardiogram,3334935,CDM,483,RC,93351,HCPCS,Outpatient,,,359.72,179.86,,323.75,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,287.78,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.93,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,330.94,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,323.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,251.8,70,,,percent of total billed charges,70% of total billed charges,323.75,90,,,percent of total billed charges,90% of total billed charges,341.73,95,,,percent of total billed charges,95% of total billed charges,341.73,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,309.36,86,,,percent of total billed charges,86% of total billed charges,287.78,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,348.93,97,,,percent of total billed charges,97% of total billed charges,323.75,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.93,97,,,percent of total billed charges,97% of total billed charges,334.54,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.93,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.8,2452.82,
Dobutamine Stress Echo,3569308,CDM,483,RC,93351,HCPCS,Outpatient,,,560.85,280.43,,504.77,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,448.68,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,504.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,544.02,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,515.98,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,504.77,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,392.6,70,,,percent of total billed charges,70% of total billed charges,504.77,90,,,percent of total billed charges,90% of total billed charges,532.81,95,,,percent of total billed charges,95% of total billed charges,532.81,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,482.33,86,,,percent of total billed charges,86% of total billed charges,448.68,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,544.02,97,,,percent of total billed charges,97% of total billed charges,504.77,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,544.02,97,,,percent of total billed charges,97% of total billed charges,521.59,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544.02,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,388.42,2452.82,
"Stress Echo, Complete",1259040,CDM,483,RC,93351,HCPCS,Outpatient,,,560.85,280.43,,504.77,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,448.68,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,504.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,544.02,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,515.98,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,504.77,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,392.6,70,,,percent of total billed charges,70% of total billed charges,504.77,90,,,percent of total billed charges,90% of total billed charges,532.81,95,,,percent of total billed charges,95% of total billed charges,532.81,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,482.33,86,,,percent of total billed charges,86% of total billed charges,448.68,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,544.02,97,,,percent of total billed charges,97% of total billed charges,504.77,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,544.02,97,,,percent of total billed charges,97% of total billed charges,521.59,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,544.02,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,388.42,2452.82,
93355-Structural Heart TEE,3554695,CDM,481,RC,93355,HCPCS,Outpatient,,,593.93,296.97,,534.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,475.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,534.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,546.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,379.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,467.14,78.65,,,percent of total billed charges,78.65% of total billed charges,530.57,89.33,,,percent of total billed charges,89.33% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,415.75,70,,,percent of total billed charges,70% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,564.23,95,,,percent of total billed charges,95% of total billed charges,564.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.78,86,,,percent of total billed charges,86% of total billed charges,475.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,552.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.3,576.11,
Structural Heart TEE,3569306,CDM,483,RC,93355,HCPCS,Outpatient,,,593.93,296.97,,534.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,475.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,534.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,546.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,379.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,467.14,78.65,,,percent of total billed charges,78.65% of total billed charges,530.57,89.33,,,percent of total billed charges,89.33% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,415.75,70,,,percent of total billed charges,70% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,564.23,95,,,percent of total billed charges,95% of total billed charges,564.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,510.78,86,,,percent of total billed charges,86% of total billed charges,475.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,534.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,552.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,379.3,576.11,
93356-PF Myocardial Strain Imaging,3818894,CDM,960,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,20.97,90,,,percent of total billed charges,90% of total Billed charges,34.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.41,155,,,Fee Schedule,155% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.41,145,,,Fee Schedule,145% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.2,145,,,Fee Schedule,145% of CMS OPPS Rate,16.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,54.71,
Myocardial Strain Imaging,3818893,CDM,483,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,20.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,18.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,20.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,14.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,18.33,78.65,,,percent of total billed charges,78.65% of total billed charges,20.81,89.33,,,percent of total billed charges,89.33% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.31,70,,,percent of total billed charges,70% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,22.14,95,,,percent of total billed charges,95% of total billed charges,22.14,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.04,86,,,percent of total billed charges,86% of total billed charges,18.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,21.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,22.6,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,20.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,18.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,20.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,14.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,18.33,78.65,,,percent of total billed charges,78.65% of total billed charges,20.81,89.33,,,percent of total billed charges,89.33% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.31,70,,,percent of total billed charges,70% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,22.14,95,,,percent of total billed charges,95% of total billed charges,22.14,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.04,86,,,percent of total billed charges,86% of total billed charges,18.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,20.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,21.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.88,22.6,
93451- Rt heart cath/O2 sats/CO,3430767,CDM,481,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,1648.4,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1465.25,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1776.61,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1685.04,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1648.4,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1282.09,70,,,percent of total billed charges,70% of total billed charges,1648.4,90,,,percent of total billed charges,90% of total billed charges,1739.98,95,,,percent of total billed charges,95% of total billed charges,1739.98,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1575.14,86,,,percent of total billed charges,86% of total billed charges,1465.25,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1776.61,97,,,percent of total billed charges,97% of total billed charges,1648.4,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1776.61,97,,,percent of total billed charges,97% of total billed charges,1703.35,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1776.61,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1282.09,14422.86,
93451-PF RIGHT HEART CATH,3580915,CDM,960,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,1648.4,90,,,percent of total billed charges,90% of total Billed charges,1335.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,647.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.48,155,,,Fee Schedule,155% of CMS OPPS Rate,647.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1310.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1474.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1474.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1139.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1139.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,646.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1294.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,841.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,938.48,145,,,Fee Schedule,145% of CMS OPPS Rate,647.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1937.14,145,,,Fee Schedule,145% of CMS OPPS Rate,938.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,647.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,686.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,647.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1281.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1281.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,646.25,1937.14,
93451-RIGHT HEART CATH,3432005,CDM,481,RC,93451,HCPCS,Outpatient,,,1831.56,915.78,,1648.4,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1465.25,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1776.61,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1685.04,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1648.4,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1282.09,70,,,percent of total billed charges,70% of total billed charges,1648.4,90,,,percent of total billed charges,90% of total billed charges,1739.98,95,,,percent of total billed charges,95% of total billed charges,1739.98,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1575.14,86,,,percent of total billed charges,86% of total billed charges,1465.25,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1776.61,97,,,percent of total billed charges,97% of total billed charges,1648.4,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1776.61,97,,,percent of total billed charges,97% of total billed charges,1703.35,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1776.61,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1282.09,14422.86,
93452- Lt heart cath/LV gram,3430769,CDM,510,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,1495.64,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.46,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1611.97,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.87,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.64,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.27,70,,,percent of total billed charges,70% of total billed charges,1495.64,90,,,percent of total billed charges,90% of total billed charges,1578.73,95,,,percent of total billed charges,95% of total billed charges,1578.73,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.17,86,,,percent of total billed charges,86% of total billed charges,1329.46,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1611.97,97,,,percent of total billed charges,97% of total billed charges,1495.64,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1611.97,97,,,percent of total billed charges,97% of total billed charges,1545.49,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1611.97,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.27,14422.86,
"93452-LHC, LV only",3560666,CDM,481,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,1495.64,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.46,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1611.97,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.87,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.64,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.27,70,,,percent of total billed charges,70% of total billed charges,1495.64,90,,,percent of total billed charges,90% of total billed charges,1578.73,95,,,percent of total billed charges,95% of total billed charges,1578.73,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.17,86,,,percent of total billed charges,86% of total billed charges,1329.46,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1611.97,97,,,percent of total billed charges,97% of total billed charges,1495.64,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1611.97,97,,,percent of total billed charges,97% of total billed charges,1545.49,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1611.97,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.27,14422.86,
"93452-PF LHC, LV only",3580916,CDM,960,RC,93452,HCPCS,Outpatient,,,1661.82,830.91,,1495.64,90,,,percent of total billed charges,90% of total Billed charges,1212.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,587.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,851.86,155,,,Fee Schedule,155% of CMS OPPS Rate,587.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1418.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,587.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1595.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1595.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1254.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1254.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,715.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1174.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,796.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,851.86,145,,,Fee Schedule,145% of CMS OPPS Rate,587.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1757.95,145,,,Fee Schedule,145% of CMS OPPS Rate,851.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,587.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,766.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,587.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1422.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1422.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,587.49,1757.95,
"93453- RHC w LHC, LV only",3560648,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1864.75,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1657.55,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1864.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2009.78,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.18,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1450.36,70,,,percent of total billed charges,70% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1781.87,86,,,percent of total billed charges,86% of total billed charges,1657.55,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2009.78,97,,,percent of total billed charges,97% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.78,97,,,percent of total billed charges,97% of total billed charges,1926.9,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2009.78,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1450.36,14422.86,
93453- Rt/Lt heart cath w/LV,3430770,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1864.75,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1657.55,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1864.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2009.78,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.18,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1450.36,70,,,percent of total billed charges,70% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1781.87,86,,,percent of total billed charges,86% of total billed charges,1657.55,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2009.78,97,,,percent of total billed charges,97% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.78,97,,,percent of total billed charges,97% of total billed charges,1926.9,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2009.78,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1450.36,14422.86,
"93453-PF RHC w LHC, LV only",3580917,CDM,960,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1864.75,90,,,percent of total billed charges,90% of total Billed charges,1512.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,733.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1063.98,155,,,Fee Schedule,155% of CMS OPPS Rate,733.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1827.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,733.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2055.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2055.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1619.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1619.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,935.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,733.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1467.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1063.98,145,,,Fee Schedule,145% of CMS OPPS Rate,733.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,2193.69,145,,,Fee Schedule,145% of CMS OPPS Rate,1063.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,733.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1003,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,733.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1861.7,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1861.7,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,733.78,2193.69,
"93453-RHC w LHC, LV only",3554698,CDM,481,RC,93453,HCPCS,Outpatient,,,2071.94,1035.97,,1864.75,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1657.55,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1864.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2009.78,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.18,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1450.36,70,,,percent of total billed charges,70% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,1968.34,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1781.87,86,,,percent of total billed charges,86% of total billed charges,1657.55,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2009.78,97,,,percent of total billed charges,97% of total billed charges,1864.75,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.78,97,,,percent of total billed charges,97% of total billed charges,1926.9,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2009.78,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1450.36,14422.86,
93454- Coronary angiogram,3430771,CDM,481,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,390.47,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,473.45,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,449.04,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,341.66,70,,,percent of total billed charges,70% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,419.76,86,,,percent of total billed charges,86% of total billed charges,390.47,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.45,97,,,percent of total billed charges,97% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.45,97,,,percent of total billed charges,97% of total billed charges,453.92,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473.45,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,341.66,14422.86,
93454-CORONARY ANGIOGRAM ONLY NO LHC,3432006,CDM,481,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,390.47,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,473.45,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,449.04,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,341.66,70,,,percent of total billed charges,70% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,419.76,86,,,percent of total billed charges,86% of total billed charges,390.47,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.45,97,,,percent of total billed charges,97% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.45,97,,,percent of total billed charges,97% of total billed charges,453.92,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473.45,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,341.66,14422.86,
93454-PF CORONARY ANGIOGRAM ONLY NO LHC,3580918,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,976.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,155,,,Fee Schedule,155% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1599.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,737.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,145,,,Fee Schedule,145% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.46,145,,,Fee Schedule,145% of CMS OPPS Rate,707.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,790.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1467.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,439.28,1599.06,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,390.47,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,473.45,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,449.04,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,341.66,70,,,percent of total billed charges,70% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,463.69,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,419.76,86,,,percent of total billed charges,86% of total billed charges,390.47,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.45,97,,,percent of total billed charges,97% of total billed charges,439.28,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.45,97,,,percent of total billed charges,97% of total billed charges,453.92,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,473.45,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,341.66,14422.86,
93455- Coronary angiogram/w grafts,3430772,CDM,481,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,1636.35,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1454.54,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1636.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1763.62,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1672.72,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1636.35,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.72,70,,,percent of total billed charges,70% of total billed charges,1636.35,90,,,percent of total billed charges,90% of total billed charges,1727.26,95,,,percent of total billed charges,95% of total billed charges,1727.26,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1563.63,86,,,percent of total billed charges,86% of total billed charges,1454.54,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1763.62,97,,,percent of total billed charges,97% of total billed charges,1636.35,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1763.62,97,,,percent of total billed charges,97% of total billed charges,1690.9,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1763.62,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1272.72,14422.86,
93455-CORONARY ANGIO W/GRAFTS ONLY NO LHC,3432007,CDM,481,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,1636.35,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1454.54,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1636.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1763.62,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1672.72,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1636.35,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.72,70,,,percent of total billed charges,70% of total billed charges,1636.35,90,,,percent of total billed charges,90% of total billed charges,1727.26,95,,,percent of total billed charges,95% of total billed charges,1727.26,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1563.63,86,,,percent of total billed charges,86% of total billed charges,1454.54,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1763.62,97,,,percent of total billed charges,97% of total billed charges,1636.35,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1763.62,97,,,percent of total billed charges,97% of total billed charges,1690.9,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1763.62,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1272.72,14422.86,
93455-PF CORONARY ANGIO W/GRAFTS ONLY NO LHC,3580919,CDM,960,RC,93455,HCPCS,Outpatient,,,1818.17,909.09,,1636.35,90,,,percent of total billed charges,90% of total Billed charges,1328.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,645.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.53,155,,,Fee Schedule,155% of CMS OPPS Rate,645.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1615.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,645.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1817.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1817.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1431.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1431.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,860.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,645.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1290.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,896.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.53,145,,,Fee Schedule,145% of CMS OPPS Rate,645.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1926.86,145,,,Fee Schedule,145% of CMS OPPS Rate,935.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,645.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,921.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,645.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1711.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1711.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,645.19,1926.86,
93456- Rt Heart Cath w/cors,3430773,CDM,481,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,1829.63,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1626.34,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1829.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1971.93,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1870.29,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1829.63,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.04,70,,,percent of total billed charges,70% of total billed charges,1829.63,90,,,percent of total billed charges,90% of total billed charges,1931.27,95,,,percent of total billed charges,95% of total billed charges,1931.27,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1748.31,86,,,percent of total billed charges,86% of total billed charges,1626.34,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1971.93,97,,,percent of total billed charges,97% of total billed charges,1829.63,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1971.93,97,,,percent of total billed charges,97% of total billed charges,1890.62,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1971.93,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1423.04,14422.86,
93456-PF RHC w/COR only,3680917,CDM,960,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,1829.63,90,,,percent of total billed charges,90% of total Billed charges,1484.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,720.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.55,155,,,Fee Schedule,155% of CMS OPPS Rate,720.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1799.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,720.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2023.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2023.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1594.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1594.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,933.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1440.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,996.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1044.55,145,,,Fee Schedule,145% of CMS OPPS Rate,720.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,2152.99,145,,,Fee Schedule,145% of CMS OPPS Rate,1044.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,720.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,989.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,720.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1836.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,720.38,2152.99,
93456-RHC w/COR only,3680915,CDM,481,RC,93456,HCPCS,Outpatient,,,2032.92,1016.46,,1829.63,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1626.34,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1829.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1971.93,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1870.29,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1829.63,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.04,70,,,percent of total billed charges,70% of total billed charges,1829.63,90,,,percent of total billed charges,90% of total billed charges,1931.27,95,,,percent of total billed charges,95% of total billed charges,1931.27,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1748.31,86,,,percent of total billed charges,86% of total billed charges,1626.34,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1971.93,97,,,percent of total billed charges,97% of total billed charges,1829.63,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1971.93,97,,,percent of total billed charges,97% of total billed charges,1890.62,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1971.93,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1423.04,14422.86,
93457- Rt heart cath w/cors/grafts,3430774,CDM,510,RC,93457,HCPCS,Outpatient,,,2191.16,1095.58,,1972.04,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1752.93,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1972.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2125.43,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2015.87,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1972.04,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1533.81,70,,,percent of total billed charges,70% of total billed charges,1972.04,90,,,percent of total billed charges,90% of total billed charges,2081.6,95,,,percent of total billed charges,95% of total billed charges,2081.6,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1884.4,86,,,percent of total billed charges,86% of total billed charges,1752.93,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2125.43,97,,,percent of total billed charges,97% of total billed charges,1972.04,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2125.43,97,,,percent of total billed charges,97% of total billed charges,2037.78,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2125.43,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1533.81,14422.86,
93457-PF Right Heart Cath with coronary angiography and bypass grafts- No LHC,4271190,CDM,960,RC,93457,HCPCS,Outpatient,,,2373.76,1186.88,,2136.38,90,,,percent of total billed charges,90% of total Billed charges,1599.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,776.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.26,155,,,Fee Schedule,155% of CMS OPPS Rate,776.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1992.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,776.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2241.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2241.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1767.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1767.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1051.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,776.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1552.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1095.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1125.26,145,,,Fee Schedule,145% of CMS OPPS Rate,776.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,2319.99,145,,,Fee Schedule,145% of CMS OPPS Rate,1125.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,776.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1120.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,776.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,2080.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2080.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,776.04,2319.99,
93457-Right Heart Cath with coronary angiography and bypass grafts- No LHC,4271189,CDM,481,RC,93457,HCPCS,Outpatient,,,2373.76,1186.88,,2136.38,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.01,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2136.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2302.55,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2183.86,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2136.38,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1661.63,70,,,percent of total billed charges,70% of total billed charges,2136.38,90,,,percent of total billed charges,90% of total billed charges,2255.07,95,,,percent of total billed charges,95% of total billed charges,2255.07,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2041.43,86,,,percent of total billed charges,86% of total billed charges,1899.01,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2302.55,97,,,percent of total billed charges,97% of total billed charges,2136.38,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2302.55,97,,,percent of total billed charges,97% of total billed charges,2207.6,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2302.55,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1661.63,14422.86,
93458- Lt Heart cath/LV/cors,3430775,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1671.43,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.71,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1671.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1801.43,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1708.57,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1300,70,,,percent of total billed charges,70% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1597.14,86,,,percent of total billed charges,86% of total billed charges,1485.71,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1801.43,97,,,percent of total billed charges,97% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1801.43,97,,,percent of total billed charges,97% of total billed charges,1727.14,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1801.43,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1300,14422.86,
"93458-LEFT HEART CATH, LV, COR",3432008,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1671.43,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.71,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1671.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1801.43,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1708.57,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1300,70,,,percent of total billed charges,70% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1597.14,86,,,percent of total billed charges,86% of total billed charges,1485.71,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1801.43,97,,,percent of total billed charges,97% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1801.43,97,,,percent of total billed charges,97% of total billed charges,1727.14,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1801.43,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1300,14422.86,
"93458-PF LEFT HEART CATH, LV, COR",3580920,CDM,960,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1671.43,90,,,percent of total billed charges,90% of total Billed charges,1357.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,659.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.81,155,,,Fee Schedule,155% of CMS OPPS Rate,659.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1664.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,659.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1872.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1872.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1476.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1476.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,890.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1318.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,913.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.81,145,,,Fee Schedule,145% of CMS OPPS Rate,659.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1968.42,145,,,Fee Schedule,145% of CMS OPPS Rate,955.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,659.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,953.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,659.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1770.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1770.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,659.18,1968.42,
93458-Selective Coronary Angio (SCA) w/Left Heart Cath (LHC),3430777,CDM,481,RC,93458,HCPCS,Outpatient,,,1857.14,928.57,,1671.43,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1485.71,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1671.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1801.43,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1708.57,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1300,70,,,percent of total billed charges,70% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,1764.28,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1597.14,86,,,percent of total billed charges,86% of total billed charges,1485.71,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1801.43,97,,,percent of total billed charges,97% of total billed charges,1671.43,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1801.43,97,,,percent of total billed charges,97% of total billed charges,1727.14,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1801.43,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1300,14422.86,
93459- Lt Heart cath/LV/cors/grafts,3430778,CDM,481,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,1760.98,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.31,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1760.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1897.94,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1800.11,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1760.98,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.65,70,,,percent of total billed charges,70% of total billed charges,1760.98,90,,,percent of total billed charges,90% of total billed charges,1858.81,95,,,percent of total billed charges,95% of total billed charges,1858.81,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1682.71,86,,,percent of total billed charges,86% of total billed charges,1565.31,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1897.94,97,,,percent of total billed charges,97% of total billed charges,1760.98,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1897.94,97,,,percent of total billed charges,97% of total billed charges,1819.68,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1897.94,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1369.65,14422.86,
"93459-LEFT HEART CATH, LV ,COR, SVG, IMA",3432009,CDM,481,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,1760.98,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.31,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1760.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1897.94,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1800.11,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1760.98,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.65,70,,,percent of total billed charges,70% of total billed charges,1760.98,90,,,percent of total billed charges,90% of total billed charges,1858.81,95,,,percent of total billed charges,95% of total billed charges,1858.81,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1682.71,86,,,percent of total billed charges,86% of total billed charges,1565.31,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1897.94,97,,,percent of total billed charges,97% of total billed charges,1760.98,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1897.94,97,,,percent of total billed charges,97% of total billed charges,1819.68,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1897.94,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1369.65,14422.86,
"93459-PF LEFT HEART CATH, LV ,COR, SVG, IMA",3580921,CDM,960,RC,93459,HCPCS,Outpatient,,,1956.64,978.32,,1760.98,90,,,percent of total billed charges,90% of total Billed charges,1430.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,694.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.94,155,,,Fee Schedule,155% of CMS OPPS Rate,694.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1812.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,694.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2038.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2038.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1610.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1610.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,982.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1388.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.94,145,,,Fee Schedule,145% of CMS OPPS Rate,694.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2073.79,145,,,Fee Schedule,145% of CMS OPPS Rate,1006.94,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,694.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1053.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,694.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1955.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1955.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,694.44,2073.79,
93460- Rt & Lt Heart cath/LV/cors,3430779,CDM,481,RC,93460,HCPCS,Outpatient,,,2167.46,1083.73,,1950.71,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1733.97,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1950.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2102.44,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1994.06,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1950.71,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1517.22,70,,,percent of total billed charges,70% of total billed charges,1950.71,90,,,percent of total billed charges,90% of total billed charges,2059.09,95,,,percent of total billed charges,95% of total billed charges,2059.09,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1864.02,86,,,percent of total billed charges,86% of total billed charges,1733.97,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2102.44,97,,,percent of total billed charges,97% of total billed charges,1950.71,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2102.44,97,,,percent of total billed charges,97% of total billed charges,2015.74,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2102.44,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1517.22,14422.86,
"93460-R & L HEART CATH, LV,COR",3432010,CDM,481,RC,93460,HCPCS,Outpatient,,,2167.46,1083.73,,1950.71,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1733.97,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1950.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2102.44,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1994.06,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1950.71,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1517.22,70,,,percent of total billed charges,70% of total billed charges,1950.71,90,,,percent of total billed charges,90% of total billed charges,2059.09,95,,,percent of total billed charges,95% of total billed charges,2059.09,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1864.02,86,,,percent of total billed charges,86% of total billed charges,1733.97,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2102.44,97,,,percent of total billed charges,97% of total billed charges,1950.71,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2102.44,97,,,percent of total billed charges,97% of total billed charges,2015.74,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2102.44,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1517.22,14422.86,
Left and Right Heart Cath,3437578,CDM,960,RC,93460,HCPCS,Outpatient,,,3012.94,1506.47,,2711.65,90,,,percent of total billed charges,90% of total Billed charges,1583.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,768.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.69,155,,,Fee Schedule,155% of CMS OPPS Rate,768.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2005.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,768.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2255.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2255.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1782.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1782.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1051.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1537.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1077.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1114.69,145,,,Fee Schedule,145% of CMS OPPS Rate,768.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2296.5,145,,,Fee Schedule,145% of CMS OPPS Rate,1114.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,768.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1128.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,768.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2092.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2092.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,768.75,2711.65,
93461- Rt & Lt Heart cath/LV/cors/grafts,3430780,CDM,481,RC,93461,HCPCS,Outpatient,,,2387.6,1193.80,,2148.84,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.08,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2148.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2315.97,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2196.59,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2148.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.32,70,,,percent of total billed charges,70% of total billed charges,2148.84,90,,,percent of total billed charges,90% of total billed charges,2268.22,95,,,percent of total billed charges,95% of total billed charges,2268.22,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2053.34,86,,,percent of total billed charges,86% of total billed charges,1910.08,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2315.97,97,,,percent of total billed charges,97% of total billed charges,2148.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2315.97,97,,,percent of total billed charges,97% of total billed charges,2220.47,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2315.97,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1671.32,14422.86,
"93461-PF R & L HEART CATH,LV,COR,SVG,IMA",3580922,CDM,960,RC,93461,HCPCS,Outpatient,,,2387.6,1193.80,,2148.84,90,,,percent of total billed charges,90% of total Billed charges,1745.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,847.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.76,155,,,Fee Schedule,155% of CMS OPPS Rate,847.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2244.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,847.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2524.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2524.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1994.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1994.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1205.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1694.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1211.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1228.76,145,,,Fee Schedule,145% of CMS OPPS Rate,847.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2530.6,145,,,Fee Schedule,145% of CMS OPPS Rate,1228.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,847.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1291.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,847.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2397.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2397.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,847.42,2530.6,
"93461-R & L HEART CATH,LV,COR,SVG,IMA",3432011,CDM,481,RC,93461,HCPCS,Outpatient,,,2387.6,1193.80,,2148.84,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.08,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2148.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2315.97,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2196.59,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2148.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.32,70,,,percent of total billed charges,70% of total billed charges,2148.84,90,,,percent of total billed charges,90% of total billed charges,2268.22,95,,,percent of total billed charges,95% of total billed charges,2268.22,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2053.34,86,,,percent of total billed charges,86% of total billed charges,1910.08,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2315.97,97,,,percent of total billed charges,97% of total billed charges,2148.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2315.97,97,,,percent of total billed charges,97% of total billed charges,2220.47,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2315.97,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1671.32,14422.86,
93462- Lt Heart Cath by transseptal punc,3430781,CDM,510,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,506.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,450.53,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,506.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,518.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,359.65,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,442.94,78.65,,,percent of total billed charges,78.65% of total billed charges,503.08,89.33,,,percent of total billed charges,89.33% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,394.21,70,,,percent of total billed charges,70% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,535,95,,,percent of total billed charges,95% of total billed charges,535,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.32,86,,,percent of total billed charges,86% of total billed charges,450.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,523.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.65,546.27,
93462-Transseptal Puncture,3432012,CDM,481,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,506.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,450.53,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,506.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,518.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,359.65,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,442.94,78.65,,,percent of total billed charges,78.65% of total billed charges,503.08,89.33,,,percent of total billed charges,89.33% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,394.21,70,,,percent of total billed charges,70% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,535,95,,,percent of total billed charges,95% of total billed charges,535,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.32,86,,,percent of total billed charges,86% of total billed charges,450.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,506.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,523.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.65,546.27,
Transseptal Puncture,3427173,CDM,960,RC,93462,HCPCS,Outpatient,,,563.16,281.58,,506.84,90,,,percent of total billed charges,90% of total Billed charges,418.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,300.21,155,,,Fee Schedule,155% of CMS OPPS Rate,207.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,375.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,328.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,328.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,169.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,296.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,300.21,145,,,Fee Schedule,145% of CMS OPPS Rate,207.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.26,145,,,Fee Schedule,145% of CMS OPPS Rate,300.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,207.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,684.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,207.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,342.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,163.61,684.84,
93463- Pharma admin/hemo before/dur/after,3430782,CDM,481,RC,93463,HCPCS,Outpatient,,,258.85,129.43,,232.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,207.08,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,232.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,238.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,165.31,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,203.59,78.65,,,percent of total billed charges,78.65% of total billed charges,231.23,89.33,,,percent of total billed charges,89.33% of total billed charges,232.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,181.2,70,,,percent of total billed charges,70% of total billed charges,232.97,90,,,percent of total billed charges,90% of total billed charges,245.91,95,,,percent of total billed charges,95% of total billed charges,245.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.61,86,,,percent of total billed charges,86% of total billed charges,207.08,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,251.08,97,,,percent of total billed charges,97% of total billed charges,232.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.08,97,,,percent of total billed charges,97% of total billed charges,240.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.31,251.08,
93463-Pharmacological RHC,3432026,CDM,481,RC,93463,HCPCS,Outpatient,,,258.81,129.41,,232.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,207.05,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,232.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,238.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,165.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,203.56,78.65,,,percent of total billed charges,78.65% of total billed charges,231.2,89.33,,,percent of total billed charges,89.33% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,181.17,70,,,percent of total billed charges,70% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,245.87,95,,,percent of total billed charges,95% of total billed charges,245.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.58,86,,,percent of total billed charges,86% of total billed charges,207.05,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,240.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.28,251.05,
Pharmacological RHC,,,480,RC,93463,HCPCS,Outpatient,,,258.81,129.41,,232.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,207.05,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,232.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,238.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,165.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,203.56,78.65,,,percent of total billed charges,78.65% of total billed charges,231.2,89.33,,,percent of total billed charges,89.33% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,181.17,70,,,percent of total billed charges,70% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,245.87,95,,,percent of total billed charges,95% of total billed charges,245.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.58,86,,,percent of total billed charges,86% of total billed charges,207.05,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,232.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,240.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.28,251.05,
93464- Physio ex study/hemo before/after,3430783,CDM,510,RC,93464,HCPCS,Outpatient,,,322.46,161.23,,290.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,257.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,290.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,312.79,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,296.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,205.93,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,253.62,78.65,,,percent of total billed charges,78.65% of total billed charges,288.06,89.33,,,percent of total billed charges,89.33% of total billed charges,290.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.72,70,,,percent of total billed charges,70% of total billed charges,290.21,90,,,percent of total billed charges,90% of total billed charges,306.34,95,,,percent of total billed charges,95% of total billed charges,306.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.32,86,,,percent of total billed charges,86% of total billed charges,257.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,312.79,97,,,percent of total billed charges,97% of total billed charges,290.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,312.79,97,,,percent of total billed charges,97% of total billed charges,299.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.79,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.93,312.79,
93503- Inser/place/flo dir cath/Swan-Ganz,3431011,CDM,510,RC,93503,HCPCS,Outpatient,,,235.8,117.90,,212.22,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,188.64,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.73,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.94,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.22,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.06,70,,,percent of total billed charges,70% of total billed charges,212.22,90,,,percent of total billed charges,90% of total billed charges,224.01,95,,,percent of total billed charges,95% of total billed charges,224.01,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.79,86,,,percent of total billed charges,86% of total billed charges,188.64,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.73,97,,,percent of total billed charges,97% of total billed charges,212.22,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.73,97,,,percent of total billed charges,97% of total billed charges,219.29,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,228.73,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.06,7253.45,
93503-Swan Ganz Insertion only,3432013,CDM,481,RC,93503,HCPCS,Outpatient,,,235.8,117.90,,212.22,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,188.64,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.73,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,216.94,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,212.22,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.06,70,,,percent of total billed charges,70% of total billed charges,212.22,90,,,percent of total billed charges,90% of total billed charges,224.01,95,,,percent of total billed charges,95% of total billed charges,224.01,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,202.79,86,,,percent of total billed charges,86% of total billed charges,188.64,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,228.73,97,,,percent of total billed charges,97% of total billed charges,212.22,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.73,97,,,percent of total billed charges,97% of total billed charges,219.29,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,228.73,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.06,7253.45,
Swan Ganz Insertion only,,,480,RC,93503,HCPCS,Outpatient,,,230.95,115.48,,207.86,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,184.76,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.02,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,212.47,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,207.86,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,161.67,70,,,percent of total billed charges,70% of total billed charges,207.86,90,,,percent of total billed charges,90% of total billed charges,219.4,95,,,percent of total billed charges,95% of total billed charges,219.4,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,198.62,86,,,percent of total billed charges,86% of total billed charges,184.76,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,224.02,97,,,percent of total billed charges,97% of total billed charges,207.86,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.02,97,,,percent of total billed charges,97% of total billed charges,214.78,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224.02,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,161.67,7253.45,
93505- Endomyocardial biopsy,3431012,CDM,510,RC,93505,HCPCS,Outpatient,,,1048.44,524.22,,943.6,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,838.75,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.6,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1016.99,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,943.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,733.91,70,,,percent of total billed charges,70% of total billed charges,943.6,90,,,percent of total billed charges,90% of total billed charges,996.02,95,,,percent of total billed charges,95% of total billed charges,996.02,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,901.66,86,,,percent of total billed charges,86% of total billed charges,838.75,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1016.99,97,,,percent of total billed charges,97% of total billed charges,943.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1016.99,97,,,percent of total billed charges,97% of total billed charges,975.05,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1016.99,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,14522.85,
93505-Myocardial Biopsy,3432014,CDM,481,RC,93505,HCPCS,Outpatient,,,1048.44,524.22,,943.6,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,838.75,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.6,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1016.99,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,943.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,733.91,70,,,percent of total billed charges,70% of total billed charges,943.6,90,,,percent of total billed charges,90% of total billed charges,996.02,95,,,percent of total billed charges,95% of total billed charges,996.02,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,901.66,86,,,percent of total billed charges,86% of total billed charges,838.75,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1016.99,97,,,percent of total billed charges,97% of total billed charges,943.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1016.99,97,,,percent of total billed charges,97% of total billed charges,975.05,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1016.99,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,14522.85,
Myocardial Biopsy,,,480,RC,93505,HCPCS,Outpatient,,,1572.7,786.35,,1415.43,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1258.16,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.43,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1525.52,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1446.88,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1415.43,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1100.89,70,,,percent of total billed charges,70% of total billed charges,1415.43,90,,,percent of total billed charges,90% of total billed charges,1494.07,95,,,percent of total billed charges,95% of total billed charges,1494.07,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1352.52,86,,,percent of total billed charges,86% of total billed charges,1258.16,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1525.52,97,,,percent of total billed charges,97% of total billed charges,1415.43,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1525.52,97,,,percent of total billed charges,97% of total billed charges,1462.61,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1525.52,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,14522.85,
93530- Right Heart Cath (RHC) Only 93530,3430785,CDM,510,RC,93530,HCPCS,Outpatient,,,2237.5,1118.75,,2013.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1790,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2013.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2170.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2058.5,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1428.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1759.84,78.65,,,percent of total billed charges,78.65% of total billed charges,1998.79,89.33,,,percent of total billed charges,89.33% of total billed charges,2013.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1566.25,70,,,percent of total billed charges,70% of total billed charges,2013.75,90,,,percent of total billed charges,90% of total billed charges,2125.63,95,,,percent of total billed charges,95% of total billed charges,2125.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1924.25,86,,,percent of total billed charges,86% of total billed charges,1790,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2170.38,97,,,percent of total billed charges,97% of total billed charges,2013.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2170.38,97,,,percent of total billed charges,97% of total billed charges,2080.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2170.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1428.92,2946.49,
93531- Rt ht/retrograde Lt ht/congen anom,3431015,CDM,510,RC,93531,HCPCS,Outpatient,,,5954.32,2977.16,,5358.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4763.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5358.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5775.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5477.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3802.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4683.2,78.65,,,percent of total billed charges,78.65% of total billed charges,5319.09,89.33,,,percent of total billed charges,89.33% of total billed charges,5358.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4168.02,70,,,percent of total billed charges,70% of total billed charges,5358.89,90,,,percent of total billed charges,90% of total billed charges,5656.6,95,,,percent of total billed charges,95% of total billed charges,5656.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5120.72,86,,,percent of total billed charges,86% of total billed charges,4763.46,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5775.69,97,,,percent of total billed charges,97% of total billed charges,5358.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5775.69,97,,,percent of total billed charges,97% of total billed charges,5537.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5775.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2946.49,5775.69,
93532- Rt ht/tran sep Lt ht/intact septum,3431016,CDM,510,RC,93532,HCPCS,Outpatient,,,1494.62,747.31,,1345.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1195.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1345.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1449.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1375.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,954.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1175.55,78.65,,,percent of total billed charges,78.65% of total billed charges,1335.17,89.33,,,percent of total billed charges,89.33% of total billed charges,1345.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1046.23,70,,,percent of total billed charges,70% of total billed charges,1345.16,90,,,percent of total billed charges,90% of total billed charges,1419.89,95,,,percent of total billed charges,95% of total billed charges,1419.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1285.37,86,,,percent of total billed charges,86% of total billed charges,1195.7,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1449.78,97,,,percent of total billed charges,97% of total billed charges,1345.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1449.78,97,,,percent of total billed charges,97% of total billed charges,1390,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1449.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,954.5,2946.49,
93533- Rt ht/trans sep Lt ht/septal open,3431017,CDM,510,RC,93533,HCPCS,Outpatient,,,997.35,498.68,,897.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,797.88,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,897.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,967.43,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,917.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,636.93,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,784.44,78.65,,,percent of total billed charges,78.65% of total billed charges,890.95,89.33,,,percent of total billed charges,89.33% of total billed charges,897.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,698.15,70,,,percent of total billed charges,70% of total billed charges,897.62,90,,,percent of total billed charges,90% of total billed charges,947.48,95,,,percent of total billed charges,95% of total billed charges,947.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,857.72,86,,,percent of total billed charges,86% of total billed charges,797.88,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,967.43,97,,,percent of total billed charges,97% of total billed charges,897.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,967.43,97,,,percent of total billed charges,97% of total billed charges,927.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,967.43,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.93,2946.49,
93561- Cath w/thermodilution/card ouput,3431023,CDM,510,RC,93561,HCPCS,Outpatient,,,177.65,88.83,,159.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,142.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,159.89,90,,,Percent of total Billed charges,90% of total billed charges,33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,172.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,163.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,113.45,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,139.73,78.65,,,percent of total billed charges,78.65% of total billed charges,158.7,89.33,,,percent of total billed charges,89.33% of total billed charges,159.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,124.36,70,,,percent of total billed charges,70% of total billed charges,159.89,90,,,percent of total billed charges,90% of total billed charges,168.77,95,,,percent of total billed charges,95% of total billed charges,168.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,86,,,percent of total billed charges,86% of total billed charges,142.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,172.32,97,,,percent of total billed charges,97% of total billed charges,159.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.32,97,,,percent of total billed charges,97% of total billed charges,165.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30,172.32,
93562- Subseq measure of CO w thermodilut,3431024,CDM,510,RC,93562,HCPCS,Outpatient,,,133.66,66.83,,120.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,106.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,120.29,90,,,Percent of total Billed charges,90% of total billed charges,22.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,129.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,122.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,85.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,105.13,78.65,,,percent of total billed charges,78.65% of total billed charges,119.4,89.33,,,percent of total billed charges,89.33% of total billed charges,120.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.56,70,,,percent of total billed charges,70% of total billed charges,120.29,90,,,percent of total billed charges,90% of total billed charges,126.98,95,,,percent of total billed charges,95% of total billed charges,126.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.95,86,,,percent of total billed charges,86% of total billed charges,106.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,129.65,97,,,percent of total billed charges,97% of total billed charges,120.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.65,97,,,percent of total billed charges,97% of total billed charges,124.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,129.65,
93563- Cath inj/S&I/rept congenital heart,3430787,CDM,510,RC,93563,HCPCS,Outpatient,,,154.7,77.35,,139.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,123.76,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,139.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,150.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,142.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,98.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,121.67,78.65,,,percent of total billed charges,78.65% of total billed charges,138.2,89.33,,,percent of total billed charges,89.33% of total billed charges,139.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,108.29,70,,,percent of total billed charges,70% of total billed charges,139.23,90,,,percent of total billed charges,90% of total billed charges,146.97,95,,,percent of total billed charges,95% of total billed charges,146.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.04,86,,,percent of total billed charges,86% of total billed charges,123.76,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,150.06,97,,,percent of total billed charges,97% of total billed charges,139.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,150.06,97,,,percent of total billed charges,97% of total billed charges,143.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.79,150.06,
93564- Cath inj/S&I/rep congen hrt grafts,3430788,CDM,510,RC,93564,HCPCS,Outpatient,,,162.35,81.18,,146.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,129.88,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,146.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,149.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,103.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,127.69,78.65,,,percent of total billed charges,78.65% of total billed charges,145.03,89.33,,,percent of total billed charges,89.33% of total billed charges,146.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,113.65,70,,,percent of total billed charges,70% of total billed charges,146.12,90,,,percent of total billed charges,90% of total billed charges,154.23,95,,,percent of total billed charges,95% of total billed charges,154.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.62,86,,,percent of total billed charges,86% of total billed charges,129.88,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,157.48,97,,,percent of total billed charges,97% of total billed charges,146.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.48,97,,,percent of total billed charges,97% of total billed charges,150.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.68,157.48,
93565- Cath inj/S&I/rept LV or LA angio,3430789,CDM,510,RC,93565,HCPCS,Outpatient,,,124.88,62.44,,112.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,99.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,112.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,121.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,114.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,79.75,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,98.22,78.65,,,percent of total billed charges,78.65% of total billed charges,111.56,89.33,,,percent of total billed charges,89.33% of total billed charges,112.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,87.42,70,,,percent of total billed charges,70% of total billed charges,112.39,90,,,percent of total billed charges,90% of total billed charges,118.64,95,,,percent of total billed charges,95% of total billed charges,118.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.4,86,,,percent of total billed charges,86% of total billed charges,99.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,121.13,97,,,percent of total billed charges,97% of total billed charges,112.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,121.13,97,,,percent of total billed charges,97% of total billed charges,116.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.75,121.13,
93566- RV or RA angio w cath,3430790,CDM,510,RC,93566,HCPCS,Outpatient,,,324.03,162.02,,291.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,259.22,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,291.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,314.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,298.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,206.93,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,254.86,78.65,,,percent of total billed charges,78.65% of total billed charges,289.46,89.33,,,percent of total billed charges,89.33% of total billed charges,291.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,226.82,70,,,percent of total billed charges,70% of total billed charges,291.63,90,,,percent of total billed charges,90% of total billed charges,307.83,95,,,percent of total billed charges,95% of total billed charges,307.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.67,86,,,percent of total billed charges,86% of total billed charges,259.22,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,314.31,97,,,percent of total billed charges,97% of total billed charges,291.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,314.31,97,,,percent of total billed charges,97% of total billed charges,301.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.93,314.31,
93566-Injection procedure during cardiac cath for selective RV or RA angiography,4271191,CDM,481,RC,93566,HCPCS,Outpatient,,,56.14,28.07,,50.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,44.91,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,51.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,35.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,44.16,78.65,,,percent of total billed charges,78.65% of total billed charges,50.15,89.33,,,percent of total billed charges,89.33% of total billed charges,50.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.3,70,,,percent of total billed charges,70% of total billed charges,50.53,90,,,percent of total billed charges,90% of total billed charges,53.33,95,,,percent of total billed charges,95% of total billed charges,53.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.28,86,,,percent of total billed charges,86% of total billed charges,44.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,54.46,97,,,percent of total billed charges,97% of total billed charges,50.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.46,97,,,percent of total billed charges,97% of total billed charges,52.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.85,54.46,
93566-PF Injection procedure during cardiac cath for selective RV or RA angiography,4271192,CDM,960,RC,93566,HCPCS,Outpatient,,,56.14,28.07,,50.53,90,,,percent of total billed charges,90% of total Billed charges,82.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.38,145,,,Fee Schedule,145% of CMS OPPS Rate,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.78,145,,,Fee Schedule,145% of CMS OPPS Rate,38.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,306.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,283.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.47,306.7,
93567- Supra valv aortography inj/w cath,3430791,CDM,481,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,251.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,223.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,251.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,256.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,178.39,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,219.7,78.65,,,percent of total billed charges,78.65% of total billed charges,249.53,89.33,,,percent of total billed charges,89.33% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.53,70,,,percent of total billed charges,70% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,265.36,95,,,percent of total billed charges,95% of total billed charges,265.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.22,86,,,percent of total billed charges,86% of total billed charges,223.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,259.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.39,270.95,
93567-PF SUPRAVALVULAR AORTOGRAM WITH CATH,3580923,CDM,960,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,251.4,90,,,percent of total billed charges,90% of total Billed charges,143.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.1,155,,,Fee Schedule,155% of CMS OPPS Rate,38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.1,145,,,Fee Schedule,145% of CMS OPPS Rate,38,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.41,145,,,Fee Schedule,145% of CMS OPPS Rate,55.1,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,163.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.35,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.35,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38,251.4,
93567-SUPRAVALVULAR AORTOGRAM WITH CATH,3432015,CDM,481,RC,93567,HCPCS,Outpatient,,,279.33,139.67,,251.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,223.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,251.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,256.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,178.39,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,219.7,78.65,,,percent of total billed charges,78.65% of total billed charges,249.53,89.33,,,percent of total billed charges,89.33% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,195.53,70,,,percent of total billed charges,70% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,265.36,95,,,percent of total billed charges,95% of total billed charges,265.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.22,86,,,percent of total billed charges,86% of total billed charges,223.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,251.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,259.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.39,270.95,
93568- Pulmonary angio w cath,3430792,CDM,510,RC,93568,HCPCS,Outpatient,,,308.35,154.18,,277.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,246.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,277.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,283.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,196.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,242.52,78.65,,,percent of total billed charges,78.65% of total billed charges,275.45,89.33,,,percent of total billed charges,89.33% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.85,70,,,percent of total billed charges,70% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,292.93,95,,,percent of total billed charges,95% of total billed charges,292.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.18,86,,,percent of total billed charges,86% of total billed charges,246.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,286.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.92,299.1,
93568-Pulmonary Angiography during Cath,3432016,CDM,481,RC,93568,HCPCS,Outpatient,,,308.35,154.18,,277.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,246.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,277.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,283.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,196.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,242.52,78.65,,,percent of total billed charges,78.65% of total billed charges,275.45,89.33,,,percent of total billed charges,89.33% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.85,70,,,percent of total billed charges,70% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,292.93,95,,,percent of total billed charges,95% of total billed charges,292.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.18,86,,,percent of total billed charges,86% of total billed charges,246.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,277.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,286.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.92,299.1,
Pulmonary Angiography (Cardiology),3316233,CDM,960,RC,93568,HCPCS,Outpatient,,,124.58,62.29,,112.12,90,,,percent of total billed charges,90% of total Billed charges,162.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.15,155,,,Fee Schedule,155% of CMS OPPS Rate,47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,74.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.15,145,,,Fee Schedule,145% of CMS OPPS Rate,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.26,145,,,Fee Schedule,145% of CMS OPPS Rate,68.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.59,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,256.59,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.36,256.59,
Pulmonary Angiography during Cath,3427257,CDM,960,RC,93568,HCPCS,Outpatient,,,124.58,62.29,,112.12,90,,,percent of total billed charges,90% of total Billed charges,162.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.15,155,,,Fee Schedule,155% of CMS OPPS Rate,47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,74.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.15,145,,,Fee Schedule,145% of CMS OPPS Rate,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.26,145,,,Fee Schedule,145% of CMS OPPS Rate,68.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.59,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,256.59,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.36,256.59,
93571- FFR w/cath/initial vessel,3431025,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93571-FFR RAMUS,4179744,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93571-PF FFR RAMUS,4179745,CDM,960,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,387.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,435.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,435.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,364.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,364.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,231.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.21,435.55,
93571-PRESSURE WIRE/FFR CIRC,3432017,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93571-PRESSURE WIRE/FFR LAD,3432018,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93571-PRESSURE WIRE/FFR LM,3432019,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93571-PRESSURE WIRE/FFR RCA,3432020,CDM,481,RC,93571,HCPCS,Outpatient,,,192.45,96.23,,173.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,173.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,177.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,122.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,151.37,78.65,,,percent of total billed charges,78.65% of total billed charges,171.92,89.33,,,percent of total billed charges,89.33% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.72,70,,,percent of total billed charges,70% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,182.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.51,86,,,percent of total billed charges,86% of total billed charges,153.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,173.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,178.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.9,186.68,
93572- FFR w/cath/each add vessel,3431026,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,127.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,127.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,130.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,78.65,,,percent of total billed charges,78.65% of total billed charges,126.59,89.33,,,percent of total billed charges,89.33% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,70,,,percent of total billed charges,70% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.87,86,,,percent of total billed charges,86% of total billed charges,113.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,131.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.5,137.46,
93572-ADDL PRESSURE WIRE/FFR LC,3432021,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,127.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,127.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,130.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,78.65,,,percent of total billed charges,78.65% of total billed charges,126.59,89.33,,,percent of total billed charges,89.33% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,70,,,percent of total billed charges,70% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.87,86,,,percent of total billed charges,86% of total billed charges,113.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,131.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.5,137.46,
93572-ADDL PRESSURE WIRE/FFR LD,3432022,CDM,480,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,127.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,127.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,130.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,78.65,,,percent of total billed charges,78.65% of total billed charges,126.59,89.33,,,percent of total billed charges,89.33% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,70,,,percent of total billed charges,70% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.87,86,,,percent of total billed charges,86% of total billed charges,113.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,131.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.5,137.46,
93572-ADDL PRESSURE WIRE/FFR RC,3432023,CDM,481,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,127.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,127.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,130.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,78.65,,,percent of total billed charges,78.65% of total billed charges,126.59,89.33,,,percent of total billed charges,89.33% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,70,,,percent of total billed charges,70% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.87,86,,,percent of total billed charges,86% of total billed charges,113.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,131.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.5,137.46,
93572-FFR RAMUS ADDITIONAL,4179746,CDM,481,RC,93572,HCPCS,Outpatient,,,253.06,126.53,,227.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,202.45,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,232.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,161.61,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,199.04,78.65,,,percent of total billed charges,78.65% of total billed charges,226.06,89.33,,,percent of total billed charges,89.33% of total billed charges,227.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.14,70,,,percent of total billed charges,70% of total billed charges,227.75,90,,,percent of total billed charges,90% of total billed charges,240.41,95,,,percent of total billed charges,95% of total billed charges,240.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.63,86,,,percent of total billed charges,86% of total billed charges,202.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,245.47,97,,,percent of total billed charges,97% of total billed charges,227.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,245.47,97,,,percent of total billed charges,97% of total billed charges,235.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.61,245.47,
93572-PF RMAUS ADDITIONAL,4179747,CDM,960,RC,93572,HCPCS,Outpatient,,,253.06,126.53,,227.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,234.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,210.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,210.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.35,234.31,
93572-Pressue Wire FF R Additional,3560653,CDM,481,RC,93572,HCPCS,Outpatient,,,141.71,70.86,,127.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,127.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,130.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.5,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,111.46,78.65,,,percent of total billed charges,78.65% of total billed charges,126.59,89.33,,,percent of total billed charges,89.33% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.2,70,,,percent of total billed charges,70% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,134.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.87,86,,,percent of total billed charges,86% of total billed charges,113.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,127.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,131.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.5,137.46,
93573-PF Pulmonary Artery (ies) injection  during heart catheterization,4271240,CDM,960,RC,93573,HCPCS,Outpatient,,,130.3,65.15,,117.27,90,,,percent of total billed charges,90% of total Billed charges,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.1,155,,,Fee Schedule,155% of CMS OPPS Rate,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.1,145,,,Fee Schedule,145% of CMS OPPS Rate,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.1,145,,,Fee Schedule,145% of CMS OPPS Rate,89.1,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.09,122.9,
93573-Pulmonary Artery (ies) injection  during heart catheterization,4271239,CDM,481,RC,93573,HCPCS,Outpatient,,,130.3,65.15,,117.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,104.24,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,117.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,126.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,119.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,83.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,102.48,78.65,,,percent of total billed charges,78.65% of total billed charges,116.4,89.33,,,percent of total billed charges,89.33% of total billed charges,117.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,91.21,70,,,percent of total billed charges,70% of total billed charges,117.27,90,,,percent of total billed charges,90% of total billed charges,123.79,95,,,percent of total billed charges,95% of total billed charges,123.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.06,86,,,percent of total billed charges,86% of total billed charges,104.24,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,126.39,97,,,percent of total billed charges,97% of total billed charges,117.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,126.39,97,,,percent of total billed charges,97% of total billed charges,121.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.21,126.39,
93580- ASD closure/transcath/w implant,3431027,CDM,480,RC,93580,HCPCS,Outpatient,,,2612.6,1306.30,,2351.34,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2090.08,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2351.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2534.22,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2403.59,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.82,70,,,percent of total billed charges,70% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2246.84,86,,,percent of total billed charges,86% of total billed charges,2090.08,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2534.22,97,,,percent of total billed charges,97% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2534.22,97,,,percent of total billed charges,97% of total billed charges,2429.72,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2534.22,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1828.82,83742.97,
93580-ASD Closure,3432024,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.30,,2351.34,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2090.08,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2351.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2534.22,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2403.59,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.82,70,,,percent of total billed charges,70% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2246.84,86,,,percent of total billed charges,86% of total billed charges,2090.08,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2534.22,97,,,percent of total billed charges,97% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2534.22,97,,,percent of total billed charges,97% of total billed charges,2429.72,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2534.22,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1828.82,83742.97,
93580-PFO Closure,3432025,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.30,,2351.34,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2090.08,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2351.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2534.22,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2403.59,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.82,70,,,percent of total billed charges,70% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2246.84,86,,,percent of total billed charges,86% of total billed charges,2090.08,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2534.22,97,,,percent of total billed charges,97% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2534.22,97,,,percent of total billed charges,97% of total billed charges,2429.72,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2534.22,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1828.82,83742.97,
93580-Transcatheter closure of congenital defect with implant,3560651,CDM,481,RC,93580,HCPCS,Outpatient,,,2612.6,1306.30,,2351.34,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2090.08,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2351.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2534.22,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2403.59,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.82,70,,,percent of total billed charges,70% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,2481.97,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2246.84,86,,,percent of total billed charges,86% of total billed charges,2090.08,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2534.22,97,,,percent of total billed charges,97% of total billed charges,2351.34,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2534.22,97,,,percent of total billed charges,97% of total billed charges,2429.72,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2534.22,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1828.82,83742.97,
ASD Closure,,,480,RC,93580,HCPCS,Outpatient,,,2561.42,1280.71,,2305.28,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.14,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2305.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2484.58,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2356.51,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2305.28,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1792.99,70,,,percent of total billed charges,70% of total billed charges,2305.28,90,,,percent of total billed charges,90% of total billed charges,2433.35,95,,,percent of total billed charges,95% of total billed charges,2433.35,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2202.82,86,,,percent of total billed charges,86% of total billed charges,2049.14,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2484.58,97,,,percent of total billed charges,97% of total billed charges,2305.28,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.58,97,,,percent of total billed charges,97% of total billed charges,2382.12,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2484.58,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1792.99,83742.97,
PFO Closure,,,480,RC,93580,HCPCS,Outpatient,,,2561.42,1280.71,,2305.28,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2049.14,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2305.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2484.58,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2356.51,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2305.28,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1792.99,70,,,percent of total billed charges,70% of total billed charges,2305.28,90,,,percent of total billed charges,90% of total billed charges,2433.35,95,,,percent of total billed charges,95% of total billed charges,2433.35,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2202.82,86,,,percent of total billed charges,86% of total billed charges,2049.14,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2484.58,97,,,percent of total billed charges,97% of total billed charges,2305.28,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2484.58,97,,,percent of total billed charges,97% of total billed charges,2382.12,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2484.58,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1792.99,83742.97,
93581- VSD closure/transcath/implant,3431028,CDM,510,RC,93581,HCPCS,Outpatient,,,3566.93,1783.47,,3210.24,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2853.54,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3210.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3459.92,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,3281.58,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3210.24,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2496.85,70,,,percent of total billed charges,70% of total billed charges,3210.24,90,,,percent of total billed charges,90% of total billed charges,3388.58,95,,,percent of total billed charges,95% of total billed charges,3388.58,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3067.56,86,,,percent of total billed charges,86% of total billed charges,2853.54,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3459.92,97,,,percent of total billed charges,97% of total billed charges,3210.24,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,3459.92,97,,,percent of total billed charges,97% of total billed charges,3317.24,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3459.92,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2496.85,83742.97,
93583-Septal Ablation,3432027,CDM,481,RC,93583,HCPCS,Outpatient,,,1993.6,996.80,,1794.24,90,,,percent of total billed charges,90% of total Billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.88,80,,,Percent of total Billed charges,80% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1794.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1933.79,97,,,Percent of total billed charges,97% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1834.11,92,,,Percent of total billed charges,92% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1794.24,90,,,percent of total billed charges,90% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1395.52,70,,,percent of total billed charges,70% of total billed charges,1794.24,90,,,percent of total billed charges,90% of total billed charges,1893.92,95,,,percent of total billed charges,95% of total billed charges,1893.92,95,,,percent of total billed charges,95% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1714.5,86,,,percent of total billed charges,86% of total billed charges,1594.88,80,,,percent of total billed charges,80% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.79,97,,,percent of total billed charges,97% of total billed charges,1794.24,90,,,percent of total billed charges,90% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1933.79,97,,,percent of total billed charges,97% of total billed charges,1854.05,93,,,percent of total billed charges,93% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1933.79,97,,,percent of total billed charges,97% of total billed charges,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1993.6,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1395.52,1993.6,
Septal Ablation,,,480,RC,93583,HCPCS,Outpatient,,,1950.72,975.36,,1755.65,90,,,percent of total billed charges,90% of total Billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1560.58,80,,,Percent of total Billed charges,80% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1755.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1892.2,97,,,Percent of total billed charges,97% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1794.66,92,,,Percent of total billed charges,92% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1755.65,90,,,percent of total billed charges,90% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1365.5,70,,,percent of total billed charges,70% of total billed charges,1755.65,90,,,percent of total billed charges,90% of total billed charges,1853.18,95,,,percent of total billed charges,95% of total billed charges,1853.18,95,,,percent of total billed charges,95% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1677.62,86,,,percent of total billed charges,86% of total billed charges,1560.58,80,,,percent of total billed charges,80% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1892.2,97,,,percent of total billed charges,97% of total billed charges,1755.65,90,,,percent of total billed charges,90% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1892.2,97,,,percent of total billed charges,97% of total billed charges,1814.17,93,,,percent of total billed charges,93% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1892.2,97,,,percent of total billed charges,97% of total billed charges,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1950.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1365.5,1950.72,
93590-Perivalvular Plug,3432028,CDM,481,RC,93590,HCPCS,Outpatient,,,2811.26,1405.63,,2530.13,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2249.01,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2530.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2726.92,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.36,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2530.13,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1967.88,70,,,percent of total billed charges,70% of total billed charges,2530.13,90,,,percent of total billed charges,90% of total billed charges,2670.7,95,,,percent of total billed charges,95% of total billed charges,2670.7,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2417.68,86,,,percent of total billed charges,86% of total billed charges,2249.01,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2726.92,97,,,percent of total billed charges,97% of total billed charges,2530.13,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2726.92,97,,,percent of total billed charges,97% of total billed charges,2614.47,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2726.92,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1967.88,83742.97,
Perivalvular Plug,,,480,RC,93590,HCPCS,Outpatient,,,2751.58,1375.79,,2476.42,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.26,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2476.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2669.03,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2531.45,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2476.42,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.11,70,,,percent of total billed charges,70% of total billed charges,2476.42,90,,,percent of total billed charges,90% of total billed charges,2614,95,,,percent of total billed charges,95% of total billed charges,2614,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2366.36,86,,,percent of total billed charges,86% of total billed charges,2201.26,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2669.03,97,,,percent of total billed charges,97% of total billed charges,2476.42,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2669.03,97,,,percent of total billed charges,97% of total billed charges,2558.97,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2669.03,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1926.11,83742.97,
93591-Perivalvular Plug,3432029,CDM,481,RC,93591,HCPCS,Outpatient,,,2322.47,1161.24,,2090.22,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1857.98,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2090.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2252.8,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,2136.67,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2090.22,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1625.73,70,,,percent of total billed charges,70% of total billed charges,2090.22,90,,,percent of total billed charges,90% of total billed charges,2206.35,95,,,percent of total billed charges,95% of total billed charges,2206.35,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1997.32,86,,,percent of total billed charges,86% of total billed charges,1857.98,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2252.8,97,,,percent of total billed charges,97% of total billed charges,2090.22,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2252.8,97,,,percent of total billed charges,97% of total billed charges,2159.9,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2252.8,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1625.73,83742.97,
93591-PF Perivalvular Plug,3580924,CDM,960,RC,93591,HCPCS,Outpatient,,,2322.47,1161.24,,2090.22,90,,,percent of total billed charges,90% of total Billed charges,1728.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,854.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1239.32,155,,,Fee Schedule,155% of CMS OPPS Rate,854.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1323.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1488.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1488.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1367.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1367.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,880.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1709.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1230.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,997.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1239.32,145,,,Fee Schedule,145% of CMS OPPS Rate,854.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,2505.63,145,,,Fee Schedule,145% of CMS OPPS Rate,1239.32,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,854.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1121.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,854.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,854.7,2505.63,
93592-Perivalvular Plug,3432030,CDM,481,RC,93592,HCPCS,Outpatient,,,1026.63,513.32,,923.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,821.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,923.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,995.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,944.5,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,655.63,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,807.47,78.65,,,percent of total billed charges,78.65% of total billed charges,917.11,89.33,,,percent of total billed charges,89.33% of total billed charges,923.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,718.64,70,,,percent of total billed charges,70% of total billed charges,923.97,90,,,percent of total billed charges,90% of total billed charges,975.3,95,,,percent of total billed charges,95% of total billed charges,975.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,882.9,86,,,percent of total billed charges,86% of total billed charges,821.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,995.83,97,,,percent of total billed charges,97% of total billed charges,923.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,995.83,97,,,percent of total billed charges,97% of total billed charges,954.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,995.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.63,995.83,
93592-PF Perivalvular Plug,3580925,CDM,960,RC,93592,HCPCS,Outpatient,,,1026.63,513.32,,923.97,90,,,percent of total billed charges,90% of total Billed charges,764.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.88,155,,,Fee Schedule,155% of CMS OPPS Rate,378.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,378.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,654.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,654.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,602.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,602.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,387.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,757.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,541.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,439.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,548.88,145,,,Fee Schedule,145% of CMS OPPS Rate,378.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1108.64,145,,,Fee Schedule,145% of CMS OPPS Rate,548.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,378.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,494.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,378.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.54,1108.64,
93595 (26) - L Hrt Cath Chd Img Cath Trgt Zon Nml/Abnl Nt Cnj,4169604,CDM,960,RC,93595,HCPCS,Outpatient,,,626.01,313.01,,563.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.8,563.41,
"93596-PF R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",4348481,CDM,960,RC,93596,HCPCS,Outpatient,,,601.2,300.60,,541.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.36,541.08,
"93596-R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",4127773,CDM,481,RC,93596,HCPCS,Outpatient,,,601.2,300.60,,541.08,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,480.96,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,541.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,583.16,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,553.1,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,541.08,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,420.84,70,,,percent of total billed charges,70% of total billed charges,541.08,90,,,percent of total billed charges,90% of total billed charges,571.14,95,,,percent of total billed charges,95% of total billed charges,571.14,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.03,86,,,percent of total billed charges,86% of total billed charges,480.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,583.16,97,,,percent of total billed charges,97% of total billed charges,541.08,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.16,97,,,percent of total billed charges,97% of total billed charges,559.12,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,583.16,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,420.84,14422.86,
"R&L Heart Cath for Congen Hrt Dfct, Norm Natv Connect",,,480,RC,93596,HCPCS,Outpatient,,,601.2,300.60,,541.08,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,480.96,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,541.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,583.16,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,553.1,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,541.08,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,420.84,70,,,percent of total billed charges,70% of total billed charges,541.08,90,,,percent of total billed charges,90% of total billed charges,571.14,95,,,percent of total billed charges,95% of total billed charges,571.14,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.03,86,,,percent of total billed charges,86% of total billed charges,480.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,583.16,97,,,percent of total billed charges,97% of total billed charges,541.08,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.16,97,,,percent of total billed charges,97% of total billed charges,559.12,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,583.16,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,420.84,14422.86,
93600- Bundle of HIS recording,3431029,CDM,510,RC,93600,HCPCS,Outpatient,,,312.63,156.32,,281.37,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,250.1,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.37,90,,,Percent of total Billed charges,90% of total billed charges,133.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,303.25,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,287.62,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,281.37,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,218.84,70,,,percent of total billed charges,70% of total billed charges,281.37,90,,,percent of total billed charges,90% of total billed charges,297,95,,,percent of total billed charges,95% of total billed charges,297,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,268.86,86,,,percent of total billed charges,86% of total billed charges,250.1,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,303.25,97,,,percent of total billed charges,97% of total billed charges,281.37,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,303.25,97,,,percent of total billed charges,97% of total billed charges,290.75,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.25,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.5,32823,
93600-Bundle of His Recording,4271193,CDM,481,RC,93600,HCPCS,Outpatient,,,491.84,245.92,,442.66,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,393.47,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.66,90,,,Percent of total Billed charges,90% of total billed charges,133.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,477.08,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,452.49,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,442.66,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,344.29,70,,,percent of total billed charges,70% of total billed charges,442.66,90,,,percent of total billed charges,90% of total billed charges,467.25,95,,,percent of total billed charges,95% of total billed charges,467.25,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,422.98,86,,,percent of total billed charges,86% of total billed charges,393.47,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,477.08,97,,,percent of total billed charges,97% of total billed charges,442.66,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.08,97,,,percent of total billed charges,97% of total billed charges,457.41,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,477.08,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.5,32823,
93600-PF Bundle of His Recording,4271194,CDM,960,RC,93600,HCPCS,Outpatient,,,491.84,245.92,,442.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,354.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,294.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,294.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.5,442.66,
93602- Intra-atrial recording,3431030,CDM,510,RC,93602,HCPCS,Outpatient,,,308.69,154.35,,277.82,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,246.95,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.82,90,,,Percent of total Billed charges,90% of total billed charges,125.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.43,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,283.99,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.82,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,216.08,70,,,percent of total billed charges,70% of total billed charges,277.82,90,,,percent of total billed charges,90% of total billed charges,293.26,95,,,percent of total billed charges,95% of total billed charges,293.26,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.47,86,,,percent of total billed charges,86% of total billed charges,246.95,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.43,97,,,percent of total billed charges,97% of total billed charges,277.82,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.43,97,,,percent of total billed charges,97% of total billed charges,287.08,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,114,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.43,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114,32823,
93602-Intra-Atrial Recording,4271195,CDM,481,RC,93602,HCPCS,Outpatient,,,360.4,180.20,,324.36,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,288.32,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.36,90,,,Percent of total Billed charges,90% of total billed charges,125.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,349.59,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,331.57,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,324.36,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,252.28,70,,,percent of total billed charges,70% of total billed charges,324.36,90,,,percent of total billed charges,90% of total billed charges,342.38,95,,,percent of total billed charges,95% of total billed charges,342.38,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,309.94,86,,,percent of total billed charges,86% of total billed charges,288.32,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,349.59,97,,,percent of total billed charges,97% of total billed charges,324.36,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.59,97,,,percent of total billed charges,97% of total billed charges,335.17,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,114,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,349.59,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114,32823,
93602-PF Intra-Atrial Recording,4271196,CDM,960,RC,93602,HCPCS,Outpatient,,,360.4,180.20,,324.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,288.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,288.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,243.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,243.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.84,324.36,
93603- Right ventricular recording,3431031,CDM,510,RC,93603,HCPCS,Outpatient,,,308.69,154.35,,277.82,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,246.95,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.43,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,283.99,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.82,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,216.08,70,,,percent of total billed charges,70% of total billed charges,277.82,90,,,percent of total billed charges,90% of total billed charges,293.26,95,,,percent of total billed charges,95% of total billed charges,293.26,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.47,86,,,percent of total billed charges,86% of total billed charges,246.95,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.43,97,,,percent of total billed charges,97% of total billed charges,277.82,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.43,97,,,percent of total billed charges,97% of total billed charges,287.08,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,299.43,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.08,5445.8,
93603-PF RV Recording,4271263,CDM,960,RC,93603,HCPCS,Outpatient,,,477,238.50,,429.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,330.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,275.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,275.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.82,429.3,
93603-RV Recording,4271262,CDM,481,RC,93603,HCPCS,Outpatient,,,477,238.50,,429.3,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,381.6,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,462.69,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,438.84,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,429.3,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,333.9,70,,,percent of total billed charges,70% of total billed charges,429.3,90,,,percent of total billed charges,90% of total billed charges,453.15,95,,,percent of total billed charges,95% of total billed charges,453.15,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,410.22,86,,,percent of total billed charges,86% of total billed charges,381.6,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,462.69,97,,,percent of total billed charges,97% of total billed charges,429.3,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.69,97,,,percent of total billed charges,97% of total billed charges,443.61,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,462.69,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,333.9,5445.8,
93609- Intra vent and/or atrial map/tachy,3431032,CDM,480,RC,93609,HCPCS,Outpatient,,,734.83,367.42,,661.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,587.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,661.35,90,,,Percent of total Billed charges,90% of total billed charges,257.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,712.79,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,676.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,469.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,577.96,78.65,,,percent of total billed charges,78.65% of total billed charges,656.44,89.33,,,percent of total billed charges,89.33% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,514.38,70,,,percent of total billed charges,70% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,698.09,95,,,percent of total billed charges,95% of total billed charges,698.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.95,86,,,percent of total billed charges,86% of total billed charges,587.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.79,97,,,percent of total billed charges,97% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,712.79,97,,,percent of total billed charges,97% of total billed charges,683.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,712.79,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,712.79,
93609-CARDIAC MAPPING,3432031,CDM,481,RC,93609,HCPCS,Outpatient,,,734.83,367.42,,661.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,587.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,661.35,90,,,Percent of total Billed charges,90% of total billed charges,257.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,712.79,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,676.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,469.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,577.96,78.65,,,percent of total billed charges,78.65% of total billed charges,656.44,89.33,,,percent of total billed charges,89.33% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,514.38,70,,,percent of total billed charges,70% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,698.09,95,,,percent of total billed charges,95% of total billed charges,698.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.95,86,,,percent of total billed charges,86% of total billed charges,587.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.79,97,,,percent of total billed charges,97% of total billed charges,661.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,712.79,97,,,percent of total billed charges,97% of total billed charges,683.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,712.79,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234,712.79,
93610- Intra-atrial pacing,3431033,CDM,510,RC,93610,HCPCS,Outpatient,,,436.32,218.16,,392.69,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,349.06,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.69,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,423.23,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,401.41,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,392.69,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,305.42,70,,,percent of total billed charges,70% of total billed charges,392.69,90,,,percent of total billed charges,90% of total billed charges,414.5,95,,,percent of total billed charges,95% of total billed charges,414.5,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,375.24,86,,,percent of total billed charges,86% of total billed charges,349.06,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,423.23,97,,,percent of total billed charges,97% of total billed charges,392.69,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.23,97,,,percent of total billed charges,97% of total billed charges,405.78,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,423.23,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,32823,
93610-Intra-Atrial Pacing,4271197,CDM,481,RC,93610,HCPCS,Outpatient,,,511.98,255.99,,460.78,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,409.58,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.78,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,496.62,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,471.02,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,460.78,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,358.39,70,,,percent of total billed charges,70% of total billed charges,460.78,90,,,percent of total billed charges,90% of total billed charges,486.38,95,,,percent of total billed charges,95% of total billed charges,486.38,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,440.3,86,,,percent of total billed charges,86% of total billed charges,409.58,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,496.62,97,,,percent of total billed charges,97% of total billed charges,460.78,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,496.62,97,,,percent of total billed charges,97% of total billed charges,476.14,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,496.62,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,32823,
93610-PF Intra-Atrial Pacing,4271198,CDM,960,RC,93610,HCPCS,Outpatient,,,511.98,255.99,,460.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,389.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,389.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,331.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,331.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,179.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,249.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.51,460.78,
93612- Intraventricular pacing,3431034,CDM,510,RC,93612,HCPCS,Outpatient,,,432.83,216.42,,389.55,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,346.26,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.55,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,419.85,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,398.2,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,389.55,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,302.98,70,,,percent of total billed charges,70% of total billed charges,389.55,90,,,percent of total billed charges,90% of total billed charges,411.19,95,,,percent of total billed charges,95% of total billed charges,411.19,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,372.23,86,,,percent of total billed charges,86% of total billed charges,346.26,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,419.85,97,,,percent of total billed charges,97% of total billed charges,389.55,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,419.85,97,,,percent of total billed charges,97% of total billed charges,402.53,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,419.85,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,32823,
93612-IntraVentricular Pacing,4271199,CDM,481,RC,93612,HCPCS,Outpatient,,,507.74,253.87,,456.97,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,406.19,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,492.51,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,467.12,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,456.97,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,355.42,70,,,percent of total billed charges,70% of total billed charges,456.97,90,,,percent of total billed charges,90% of total billed charges,482.35,95,,,percent of total billed charges,95% of total billed charges,482.35,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,436.66,86,,,percent of total billed charges,86% of total billed charges,406.19,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,492.51,97,,,percent of total billed charges,97% of total billed charges,456.97,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.51,97,,,percent of total billed charges,97% of total billed charges,472.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,492.51,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,32823,
93612-PF IntraVentricular Pacing,4271200,CDM,960,RC,93612,HCPCS,Outpatient,,,507.74,253.87,,456.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,400.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,400.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,342.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,342.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.95,456.97,
3 D Mapping,,,480,RC,93613,HCPCS,Outpatient,,,771.84,385.92,,694.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,617.47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,694.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,748.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,710.09,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,492.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,607.07,78.65,,,percent of total billed charges,78.65% of total billed charges,689.5,89.33,,,percent of total billed charges,89.33% of total billed charges,694.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,540.29,70,,,percent of total billed charges,70% of total billed charges,694.66,90,,,percent of total billed charges,90% of total billed charges,733.25,95,,,percent of total billed charges,95% of total billed charges,733.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,663.78,86,,,percent of total billed charges,86% of total billed charges,617.47,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,748.68,97,,,percent of total billed charges,97% of total billed charges,694.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,748.68,97,,,percent of total billed charges,97% of total billed charges,717.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,748.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.91,748.68,
93613- Electrophysiologic/3D mapping,3431035,CDM,480,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,712.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,633.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,727.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,505.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,622.36,78.65,,,percent of total billed charges,78.65% of total billed charges,706.86,89.33,,,percent of total billed charges,89.33% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,553.9,70,,,percent of total billed charges,70% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.5,86,,,percent of total billed charges,86% of total billed charges,633.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,735.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.33,767.54,
93613-3 D Mapping,3432032,CDM,480,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,712.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,633.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,727.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,505.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,622.36,78.65,,,percent of total billed charges,78.65% of total billed charges,706.86,89.33,,,percent of total billed charges,89.33% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,553.9,70,,,percent of total billed charges,70% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.5,86,,,percent of total billed charges,86% of total billed charges,633.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,735.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.33,767.54,
"93613-3D MAPPING, INTRACARDIAC",3432033,CDM,481,RC,93613,HCPCS,Outpatient,,,791.28,395.64,,712.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,633.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,727.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,505.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,622.36,78.65,,,percent of total billed charges,78.65% of total billed charges,706.86,89.33,,,percent of total billed charges,89.33% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,553.9,70,,,percent of total billed charges,70% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,751.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.5,86,,,percent of total billed charges,86% of total billed charges,633.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,712.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,735.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,767.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.33,767.54,
93615- Esop rec/ECG at/w w/o ven/w/o pace,3431036,CDM,510,RC,93615,HCPCS,Outpatient,,,96.38,48.19,,86.74,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,77.1,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.74,90,,,Percent of total Billed charges,90% of total billed charges,21.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93.49,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,88.67,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.74,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,67.47,70,,,percent of total billed charges,70% of total billed charges,86.74,90,,,percent of total billed charges,90% of total billed charges,91.56,95,,,percent of total billed charges,95% of total billed charges,91.56,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,82.89,86,,,percent of total billed charges,86% of total billed charges,77.1,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,93.49,97,,,percent of total billed charges,97% of total billed charges,86.74,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.49,97,,,percent of total billed charges,97% of total billed charges,89.63,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.49,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.5,5445.8,
93616- Esoph rec/ECG atr/w w/o ven/w/pace,3431037,CDM,510,RC,93616,HCPCS,Outpatient,,,152.48,76.24,,137.23,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,121.98,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.23,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,147.91,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,140.28,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,137.23,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,106.74,70,,,percent of total billed charges,70% of total billed charges,137.23,90,,,percent of total billed charges,90% of total billed charges,144.86,95,,,percent of total billed charges,95% of total billed charges,144.86,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,131.13,86,,,percent of total billed charges,86% of total billed charges,121.98,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,147.91,97,,,percent of total billed charges,97% of total billed charges,137.23,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.91,97,,,percent of total billed charges,97% of total billed charges,141.81,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,147.91,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,5445.8,
93618- Induction arrhythmia/elec pacing,3431038,CDM,510,RC,93618,HCPCS,Outpatient,,,582.21,291.11,,523.99,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,465.77,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.99,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,564.74,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,535.63,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,523.99,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,407.55,70,,,percent of total billed charges,70% of total billed charges,523.99,90,,,percent of total billed charges,90% of total billed charges,553.1,95,,,percent of total billed charges,95% of total billed charges,553.1,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,500.7,86,,,percent of total billed charges,86% of total billed charges,465.77,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,564.74,97,,,percent of total billed charges,97% of total billed charges,523.99,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,564.74,97,,,percent of total billed charges,97% of total billed charges,541.46,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,564.74,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,5445.8,
93618-Induction of Arrhythmia By Electrical Pacing,4271201,CDM,481,RC,93618,HCPCS,Outpatient,,,879.8,439.90,,791.82,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,703.84,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.82,90,,,Percent of total Billed charges,90% of total billed charges,206.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,853.41,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,809.42,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,791.82,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,615.86,70,,,percent of total billed charges,70% of total billed charges,791.82,90,,,percent of total billed charges,90% of total billed charges,835.81,95,,,percent of total billed charges,95% of total billed charges,835.81,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,756.63,86,,,percent of total billed charges,86% of total billed charges,703.84,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,853.41,97,,,percent of total billed charges,97% of total billed charges,791.82,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,853.41,97,,,percent of total billed charges,97% of total billed charges,818.21,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,853.41,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,187.5,5445.8,
93618-PF Induction of Arrhythmia By Electrical Pacing,4271202,CDM,960,RC,93618,HCPCS,Outpatient,,,879.8,439.90,,791.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,583.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,655.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,655.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,563.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,563.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,303.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.5,791.82,
93619- Comp EP eval w/o ind of arrhythmia,3431039,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,930.2,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,826.84,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1002.54,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,950.87,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,723.49,70,,,percent of total billed charges,70% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.85,86,,,percent of total billed charges,86% of total billed charges,826.84,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.54,97,,,percent of total billed charges,97% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.54,97,,,percent of total billed charges,97% of total billed charges,961.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1002.54,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.49,32823,
93619-Atrial Fibrillation,3432034,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,930.2,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,826.84,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1002.54,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,950.87,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,723.49,70,,,percent of total billed charges,70% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.85,86,,,percent of total billed charges,86% of total billed charges,826.84,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.54,97,,,percent of total billed charges,97% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.54,97,,,percent of total billed charges,97% of total billed charges,961.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1002.54,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.49,32823,
93619-Atrial Flutter,3432035,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,930.2,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,826.84,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1002.54,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,950.87,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,723.49,70,,,percent of total billed charges,70% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.85,86,,,percent of total billed charges,86% of total billed charges,826.84,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.54,97,,,percent of total billed charges,97% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.54,97,,,percent of total billed charges,97% of total billed charges,961.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1002.54,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.49,32823,
93619-Atrial Tachycardia,3432036,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,930.2,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,826.84,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1002.54,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,950.87,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,723.49,70,,,percent of total billed charges,70% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.85,86,,,percent of total billed charges,86% of total billed charges,826.84,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.54,97,,,percent of total billed charges,97% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.54,97,,,percent of total billed charges,97% of total billed charges,961.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1002.54,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.49,32823,
93619-EPS W/O INDUCTION OR ATTEMPT,3432037,CDM,481,RC,93619,HCPCS,Outpatient,,,1033.55,516.78,,930.2,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,826.84,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1002.54,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,950.87,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,723.49,70,,,percent of total billed charges,70% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,981.87,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.85,86,,,percent of total billed charges,86% of total billed charges,826.84,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.54,97,,,percent of total billed charges,97% of total billed charges,930.2,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.54,97,,,percent of total billed charges,97% of total billed charges,961.2,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1002.54,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,723.49,32823,
93620- Comp EP eval w/induc of arrhythmia,3431040,CDM,480,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93620-Atrial Fibrillation,3432038,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93620-Atrial Flutter,3432039,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93620-Atrial Tachycardia,3432040,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93620-EPS w Induction or Attempted Induction,3560652,CDM,481,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93620-EPS WITH INDUCTION OR ATTEMPT,3432041,CDM,480,RC,93620,HCPCS,Outpatient,,,1661.92,830.96,,1495.73,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.54,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1612.06,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.97,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.34,70,,,percent of total billed charges,70% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,1578.82,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.25,86,,,percent of total billed charges,86% of total billed charges,1329.54,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.06,97,,,percent of total billed charges,97% of total billed charges,1495.73,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.06,97,,,percent of total billed charges,97% of total billed charges,1545.59,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1612.06,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1163.34,32823,
93621- EP eval/comp/lt atrial pace/record,3431041,CDM,480,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,222.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,197.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,157.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.33,78.65,,,percent of total billed charges,78.65% of total billed charges,220.72,89.33,,,percent of total billed charges,89.33% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.96,70,,,percent of total billed charges,70% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.49,86,,,percent of total billed charges,86% of total billed charges,197.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,229.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.79,239.67,
"93621-CS, LA PACE RECORD",3432042,CDM,480,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,222.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,197.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,157.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.33,78.65,,,percent of total billed charges,78.65% of total billed charges,220.72,89.33,,,percent of total billed charges,89.33% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.96,70,,,percent of total billed charges,70% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.49,86,,,percent of total billed charges,86% of total billed charges,197.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,229.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.79,239.67,
93621-Record from CS,3432043,CDM,481,RC,93621,HCPCS,Outpatient,,,247.08,123.54,,222.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,197.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,157.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.33,78.65,,,percent of total billed charges,78.65% of total billed charges,220.72,89.33,,,percent of total billed charges,89.33% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.96,70,,,percent of total billed charges,70% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,234.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.49,86,,,percent of total billed charges,86% of total billed charges,197.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,222.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,229.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.79,239.67,
93622- LV pacing/recording,3431042,CDM,510,RC,93622,HCPCS,Outpatient,,,455.67,227.84,,410.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,364.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,410.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,442,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,419.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,291,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,358.39,78.65,,,percent of total billed charges,78.65% of total billed charges,407.06,89.33,,,percent of total billed charges,89.33% of total billed charges,410.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,318.97,70,,,percent of total billed charges,70% of total billed charges,410.1,90,,,percent of total billed charges,90% of total billed charges,432.89,95,,,percent of total billed charges,95% of total billed charges,432.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.88,86,,,percent of total billed charges,86% of total billed charges,364.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,442,97,,,percent of total billed charges,97% of total billed charges,410.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,442,97,,,percent of total billed charges,97% of total billed charges,423.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291,442,
"93622-Comp. EP with induction or attempted induction with RA, RV, HIS and LV pace and recording",4271203,CDM,481,RC,93622,HCPCS,Outpatient,,,710.2,355.10,,639.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,568.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,639.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,688.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,653.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,453.55,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,558.59,78.65,,,percent of total billed charges,78.65% of total billed charges,634.43,89.33,,,percent of total billed charges,89.33% of total billed charges,639.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,497.14,70,,,percent of total billed charges,70% of total billed charges,639.18,90,,,percent of total billed charges,90% of total billed charges,674.69,95,,,percent of total billed charges,95% of total billed charges,674.69,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,610.77,86,,,percent of total billed charges,86% of total billed charges,568.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,688.89,97,,,percent of total billed charges,97% of total billed charges,639.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,688.89,97,,,percent of total billed charges,97% of total billed charges,660.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,688.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.55,688.89,
"93622-PF Comp. EP with induction or attempted induction with RA, RV, HIS and LV pace and recording",4271204,CDM,960,RC,93622,HCPCS,Outpatient,,,710.2,355.10,,639.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,408.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,408.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,345.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,345.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,220,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220,699.84,
93623- Program stim/pace/IV drug inf,3431043,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,231.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,205.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,236.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,163.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,201.92,78.65,,,percent of total billed charges,78.65% of total billed charges,229.34,89.33,,,percent of total billed charges,89.33% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.71,70,,,percent of total billed charges,70% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.79,86,,,percent of total billed charges,86% of total billed charges,205.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,238.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,249.03,
93623-EP Study Drug Infusion,3432044,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,231.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,205.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,236.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,163.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,201.92,78.65,,,percent of total billed charges,78.65% of total billed charges,229.34,89.33,,,percent of total billed charges,89.33% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.71,70,,,percent of total billed charges,70% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.79,86,,,percent of total billed charges,86% of total billed charges,205.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,238.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,249.03,
93623-PROGM STIM AFTER DRUG INF,3432045,CDM,480,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,231.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,205.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,236.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,163.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,201.92,78.65,,,percent of total billed charges,78.65% of total billed charges,229.34,89.33,,,percent of total billed charges,89.33% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.71,70,,,percent of total billed charges,70% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.79,86,,,percent of total billed charges,86% of total billed charges,205.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,238.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,249.03,
93623-Program Stim after Drug Inf,3560654,CDM,481,RC,93623,HCPCS,Outpatient,,,256.73,128.37,,231.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,205.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,236.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,163.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,201.92,78.65,,,percent of total billed charges,78.65% of total billed charges,229.34,89.33,,,percent of total billed charges,89.33% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.71,70,,,percent of total billed charges,70% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,243.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.79,86,,,percent of total billed charges,86% of total billed charges,205.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,231.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,238.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,249.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.95,249.03,
93624- EP follow-up study w/induction,3431044,CDM,510,RC,93624,HCPCS,Outpatient,,,641.94,320.97,,577.75,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,513.55,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,577.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,622.68,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,590.58,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,577.75,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,449.36,70,,,percent of total billed charges,70% of total billed charges,577.75,90,,,percent of total billed charges,90% of total billed charges,609.84,95,,,percent of total billed charges,95% of total billed charges,609.84,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,552.07,86,,,percent of total billed charges,86% of total billed charges,513.55,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,622.68,97,,,percent of total billed charges,97% of total billed charges,577.75,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.68,97,,,percent of total billed charges,97% of total billed charges,597,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,622.68,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,449.36,32823,
93631- Intraop epicard/endocard/pace/map,3431045,CDM,510,RC,93631,HCPCS,Outpatient,,,1060.17,530.09,,954.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,848.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,954.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1028.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,975.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,677.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,833.85,78.65,,,percent of total billed charges,78.65% of total billed charges,947.07,89.33,,,percent of total billed charges,89.33% of total billed charges,954.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,742.12,70,,,percent of total billed charges,70% of total billed charges,954.15,90,,,percent of total billed charges,90% of total billed charges,1007.16,95,,,percent of total billed charges,95% of total billed charges,1007.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,911.75,86,,,percent of total billed charges,86% of total billed charges,848.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1028.36,97,,,percent of total billed charges,97% of total billed charges,954.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1028.36,97,,,percent of total billed charges,97% of total billed charges,985.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1028.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.05,1028.36,
93640- EP eval sng/dual/ICD leads/implant,3431046,CDM,480,RC,93640,HCPCS,Outpatient,,,474.18,237.09,,426.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,379.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,426.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,436.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,302.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,372.95,78.65,,,percent of total billed charges,78.65% of total billed charges,423.59,89.33,,,percent of total billed charges,89.33% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,331.93,70,,,percent of total billed charges,70% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,450.47,95,,,percent of total billed charges,95% of total billed charges,450.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.79,86,,,percent of total billed charges,86% of total billed charges,379.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,440.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,459.95,
93640-TESTING OF ICD LEAD AT INSERT/REPL,3432046,CDM,480,RC,93640,HCPCS,Outpatient,,,474.18,237.09,,426.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,379.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,426.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,436.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,302.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,372.95,78.65,,,percent of total billed charges,78.65% of total billed charges,423.59,89.33,,,percent of total billed charges,89.33% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,331.93,70,,,percent of total billed charges,70% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,450.47,95,,,percent of total billed charges,95% of total billed charges,450.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.79,86,,,percent of total billed charges,86% of total billed charges,379.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,426.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,440.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,302.82,459.95,
93641-PF TESTING OF ICD GENER AT INSERT/REPL,3580926,CDM,960,RC,93641,HCPCS,Outpatient,,,826.76,413.38,,744.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,763.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,859.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,859.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,866.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,866.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,377.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,715,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.63,866.9,
93641-TESTING OF ICD GENER AT INSERT/REPL,3432047,CDM,481,RC,93641,HCPCS,Outpatient,,,826.76,413.38,,744.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,661.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,744.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,801.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,760.62,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,527.99,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,650.26,78.65,,,percent of total billed charges,78.65% of total billed charges,738.56,89.33,,,percent of total billed charges,89.33% of total billed charges,744.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,578.73,70,,,percent of total billed charges,70% of total billed charges,744.08,90,,,percent of total billed charges,90% of total billed charges,785.42,95,,,percent of total billed charges,95% of total billed charges,785.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.01,86,,,percent of total billed charges,86% of total billed charges,661.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,801.96,97,,,percent of total billed charges,97% of total billed charges,744.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,801.96,97,,,percent of total billed charges,97% of total billed charges,768.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,801.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.99,801.96,
93642- EP eval/single/dual ICD,3437842,CDM,983,RC,93642,HCPCS,Outpatient,,,192.51,96.26,,173.26,90,,,percent of total billed charges,90% of total Billed charges,144.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.17,155,,,Fee Schedule,155% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,504.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,504.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,276.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.17,145,,,Fee Schedule,145% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.12,145,,,Fee Schedule,145% of CMS OPPS Rate,105.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,650,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,614.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,614.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.53,650,
"93642-Eval of single or dual pacing ICD. Incl. DFTs, induction of arrthymia, evaluation, programming",4271205,CDM,481,RC,93642,HCPCS,Outpatient,,,681.09,340.55,,612.98,90,,,percent of total billed charges,90% of total Billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,544.87,80,,,Percent of total Billed charges,80% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,660.66,97,,,Percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,626.6,92,,,Percent of total billed charges,92% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2696.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4299.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5445.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,612.98,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,476.76,70,,,percent of total billed charges,70% of total billed charges,612.98,90,,,percent of total billed charges,90% of total billed charges,647.04,95,,,percent of total billed charges,95% of total billed charges,647.04,95,,,percent of total billed charges,95% of total billed charges,1014.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2029.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,585.74,86,,,percent of total billed charges,86% of total billed charges,544.87,80,,,percent of total billed charges,80% of total billed charges,1021.01,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,660.66,97,,,percent of total billed charges,97% of total billed charges,612.98,90,,,percent of total billed charges,90% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.66,97,,,percent of total billed charges,97% of total billed charges,633.41,93,,,percent of total billed charges,93% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,660.66,97,,,percent of total billed charges,97% of total billed charges,1014.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,862.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,476.76,5445.8,
"93642-PF Eval of single or dual pacing ICD. Incl. DFTs, induction of arrthymia, evaluation, programm",4271206,CDM,960,RC,93642,HCPCS,Outpatient,,,681.09,340.55,,612.98,90,,,percent of total billed charges,90% of total Billed charges,144.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.17,155,,,Fee Schedule,155% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,504.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,504.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,276.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.17,145,,,Fee Schedule,145% of CMS OPPS Rate,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.12,145,,,Fee Schedule,145% of CMS OPPS Rate,105.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,650,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,614.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,614.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.53,650,
93644 - Ephys Eval SubQ Implantable Defibrillator,4201243,CDM,983,RC,93644,HCPCS,Outpatient,,,297.92,148.96,,268.13,90,,,percent of total billed charges,90% of total Billed charges,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64,155,,,Fee Schedule,155% of CMS OPPS Rate,44.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,283.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,286.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,286.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,212.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64,145,,,Fee Schedule,145% of CMS OPPS Rate,44.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.04,145,,,Fee Schedule,145% of CMS OPPS Rate,64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,320.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,320.63,
93650- Ablation AV Node,3560647,CDM,481,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,952.97,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1072.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1155.47,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.91,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,833.85,70,,,percent of total billed charges,70% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1024.44,86,,,percent of total billed charges,86% of total billed charges,952.97,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1155.47,97,,,percent of total billed charges,97% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.47,97,,,percent of total billed charges,97% of total billed charges,1107.83,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1155.47,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,833.85,32823,
93650- Ablation AV node/conduction,3431047,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,1173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,545.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,842.74,155,,,Fee Schedule,155% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1057.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1057.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,479.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1162.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,782.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,842.74,145,,,Fee Schedule,145% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1701.65,145,,,Fee Schedule,145% of CMS OPPS Rate,842.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,790.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,976.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,479.79,1701.65,
93650-ABLATION AV NODE,3432048,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,952.97,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1072.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1155.47,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.91,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,833.85,70,,,percent of total billed charges,70% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1024.44,86,,,percent of total billed charges,86% of total billed charges,952.97,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1155.47,97,,,percent of total billed charges,97% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.47,97,,,percent of total billed charges,97% of total billed charges,1107.83,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1155.47,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,833.85,32823,
93650-AV Nodal Ablation,3432049,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,952.97,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1072.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1155.47,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.91,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,833.85,70,,,percent of total billed charges,70% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1024.44,86,,,percent of total billed charges,86% of total billed charges,952.97,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1155.47,97,,,percent of total billed charges,97% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.47,97,,,percent of total billed charges,97% of total billed charges,1107.83,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1155.47,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,833.85,32823,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,952.97,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1072.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1155.47,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.91,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,833.85,70,,,percent of total billed charges,70% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1024.44,86,,,percent of total billed charges,86% of total billed charges,952.97,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1155.47,97,,,percent of total billed charges,97% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.47,97,,,percent of total billed charges,97% of total billed charges,1107.83,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1155.47,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,833.85,32823,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,952.97,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1072.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1155.47,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1095.91,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,833.85,70,,,percent of total billed charges,70% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,1131.65,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1024.44,86,,,percent of total billed charges,86% of total billed charges,952.97,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1155.47,97,,,percent of total billed charges,97% of total billed charges,1072.09,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.47,97,,,percent of total billed charges,97% of total billed charges,1107.83,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1155.47,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,833.85,32823,
93653- Ablation SVT,3560646,CDM,481,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,2009.9,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1786.58,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2166.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2054.56,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.25,70,,,percent of total billed charges,70% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1920.57,86,,,percent of total billed charges,86% of total billed charges,1786.58,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2166.22,97,,,percent of total billed charges,97% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2166.22,97,,,percent of total billed charges,97% of total billed charges,2076.89,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2166.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1563.25,114474.27,
93653- Comp EP/SVT ablat/single atr focus,3430793,CDM,480,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,2009.9,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1786.58,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2166.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2054.56,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.25,70,,,percent of total billed charges,70% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1920.57,86,,,percent of total billed charges,86% of total billed charges,1786.58,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2166.22,97,,,percent of total billed charges,97% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2166.22,97,,,percent of total billed charges,97% of total billed charges,2076.89,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2166.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1563.25,114474.27,
"93653-ABLATION SVT,ATRIAL AV NODE PATHWAY",3432050,CDM,480,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,2009.9,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1786.58,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2166.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2054.56,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.25,70,,,percent of total billed charges,70% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1920.57,86,,,percent of total billed charges,86% of total billed charges,1786.58,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2166.22,97,,,percent of total billed charges,97% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2166.22,97,,,percent of total billed charges,97% of total billed charges,2076.89,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2166.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1563.25,114474.27,
93653-SVT Ablation,3432051,CDM,481,RC,93653,HCPCS,Outpatient,,,2233.22,1116.61,,2009.9,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1786.58,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2009.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2166.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2054.56,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.25,70,,,percent of total billed charges,70% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,2121.56,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1920.57,86,,,percent of total billed charges,86% of total billed charges,1786.58,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2166.22,97,,,percent of total billed charges,97% of total billed charges,2009.9,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2166.22,97,,,percent of total billed charges,97% of total billed charges,2076.89,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2166.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1563.25,114474.27,
SVT Ablation,,,480,RC,93653,HCPCS,Outpatient,,,2217.55,1108.78,,1995.8,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1774.04,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1995.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2151.02,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2040.15,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1995.8,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1552.29,70,,,percent of total billed charges,70% of total billed charges,1995.8,90,,,percent of total billed charges,90% of total billed charges,2106.67,95,,,percent of total billed charges,95% of total billed charges,2106.67,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1907.09,86,,,percent of total billed charges,86% of total billed charges,1774.04,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2151.02,97,,,percent of total billed charges,97% of total billed charges,1995.8,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2151.02,97,,,percent of total billed charges,97% of total billed charges,2062.32,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2151.02,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1552.29,114474.27,
93654- Comp EP/VT tx/3Dmap/LV pace/rec,3430794,CDM,480,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2689.07,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2390.29,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2689.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2898.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2748.83,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.5,70,,,percent of total billed charges,70% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2569.56,86,,,percent of total billed charges,86% of total billed charges,2390.29,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2898.22,97,,,percent of total billed charges,97% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2898.22,97,,,percent of total billed charges,97% of total billed charges,2778.71,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2898.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2091.5,114474.27,
93654-ABLATION VT,3432052,CDM,480,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2689.07,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2390.29,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2689.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2898.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2748.83,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.5,70,,,percent of total billed charges,70% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2569.56,86,,,percent of total billed charges,86% of total billed charges,2390.29,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2898.22,97,,,percent of total billed charges,97% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2898.22,97,,,percent of total billed charges,97% of total billed charges,2778.71,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2898.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2091.5,114474.27,
93654-Vtach Ablation,3432053,CDM,481,RC,93654,HCPCS,Outpatient,,,2987.86,1493.93,,2689.07,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2390.29,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2689.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2898.22,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2748.83,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.5,70,,,percent of total billed charges,70% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,2838.47,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2569.56,86,,,percent of total billed charges,86% of total billed charges,2390.29,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2898.22,97,,,percent of total billed charges,97% of total billed charges,2689.07,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2898.22,97,,,percent of total billed charges,97% of total billed charges,2778.71,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2898.22,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2091.5,114474.27,
Vtach Ablation,,,480,RC,93654,HCPCS,Outpatient,,,2673.25,1336.63,,2405.93,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2138.6,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2405.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2593.05,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2459.39,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2405.93,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,1871.28,70,,,percent of total billed charges,70% of total billed charges,2405.93,90,,,percent of total billed charges,90% of total billed charges,2539.59,95,,,percent of total billed charges,95% of total billed charges,2539.59,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2299,86,,,percent of total billed charges,86% of total billed charges,2138.6,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2593.05,97,,,percent of total billed charges,97% of total billed charges,2405.93,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2593.05,97,,,percent of total billed charges,97% of total billed charges,2486.12,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2593.05,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1871.28,114474.27,
93655-Additional Tachycardia Mechanism,3554699,CDM,481,RC,93655,HCPCS,Outpatient,,,834.41,417.21,,750.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,667.53,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,750.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,809.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,767.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,532.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,656.28,78.65,,,percent of total billed charges,78.65% of total billed charges,745.39,89.33,,,percent of total billed charges,89.33% of total billed charges,750.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,584.09,70,,,percent of total billed charges,70% of total billed charges,750.97,90,,,percent of total billed charges,90% of total billed charges,792.69,95,,,percent of total billed charges,95% of total billed charges,792.69,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.59,86,,,percent of total billed charges,86% of total billed charges,667.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,809.38,97,,,percent of total billed charges,97% of total billed charges,750.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,809.38,97,,,percent of total billed charges,97% of total billed charges,776,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.87,809.38,
93655-PF Additional Tachycardia Mechanism,3580927,CDM,960,RC,93655,HCPCS,Outpatient,,,834.41,417.21,,750.97,90,,,percent of total billed charges,90% of total Billed charges,620.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,327.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,444.82,155,,,Fee Schedule,155% of CMS OPPS Rate,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,762.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,668.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,668.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,349.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,601.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,568.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,444.82,145,,,Fee Schedule,145% of CMS OPPS Rate,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.78,145,,,Fee Schedule,145% of CMS OPPS Rate,444.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,380.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.77,899.78,
93656 - AFIB ABLATION,3432054,CDM,481,RC,93656,HCPCS,Outpatient,,,2996.31,1498.16,,2696.68,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2397.05,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2696.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2906.42,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2756.61,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2696.68,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2097.42,70,,,percent of total billed charges,70% of total billed charges,2696.68,90,,,percent of total billed charges,90% of total billed charges,2846.49,95,,,percent of total billed charges,95% of total billed charges,2846.49,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2576.83,86,,,percent of total billed charges,86% of total billed charges,2397.05,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2906.42,97,,,percent of total billed charges,97% of total billed charges,2696.68,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2906.42,97,,,percent of total billed charges,97% of total billed charges,2786.57,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2906.42,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2097.42,114474.27,
93656- Comp EP/ Afib ablat/pul vein iso,3430795,CDM,481,RC,93656,HCPCS,Outpatient,,,2996.31,1498.16,,2696.68,90,,,percent of total billed charges,90% of total Billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2397.05,80,,,Percent of total Billed charges,80% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2696.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2906.42,97,,,Percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2756.61,92,,,Percent of total billed charges,92% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,56690.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90375.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,114474.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2696.68,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,2097.42,70,,,percent of total billed charges,70% of total billed charges,2696.68,90,,,percent of total billed charges,90% of total billed charges,2846.49,95,,,percent of total billed charges,95% of total billed charges,2846.49,95,,,percent of total billed charges,95% of total billed charges,21327.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42654.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2576.83,86,,,percent of total billed charges,86% of total billed charges,2397.05,80,,,percent of total billed charges,80% of total billed charges,21127.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2906.42,97,,,percent of total billed charges,97% of total billed charges,2696.68,90,,,percent of total billed charges,90% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2906.42,97,,,percent of total billed charges,97% of total billed charges,2786.57,93,,,percent of total billed charges,93% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2906.42,97,,,percent of total billed charges,97% of total billed charges,21327.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,21327.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18128.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2097.42,114474.27,
Atrial Fibrillation,3427167,CDM,960,RC,93656,HCPCS,Outpatient,,,2514.72,1257.36,,2263.25,90,,,percent of total billed charges,90% of total Billed charges,2075.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,948.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,874.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1375.98,155,,,Fee Schedule,155% of CMS OPPS Rate,948.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1785.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,948.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2008.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2008.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1758.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1758.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,932.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,948.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1897.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1582.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1493.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1375.98,145,,,Fee Schedule,145% of CMS OPPS Rate,948.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,3009.72,145,,,Fee Schedule,145% of CMS OPPS Rate,1375.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,948.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,874.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1016.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,948.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.5,3009.72,
93657- Addl linear or focal intracard cath ablatn L or R atrium,3569421,CDM,510,RC,93657,HCPCS,Outpatient,,,833.62,416.81,,750.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,666.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,750.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,808.61,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,766.93,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,532.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,655.66,78.65,,,percent of total billed charges,78.65% of total billed charges,744.69,89.33,,,percent of total billed charges,89.33% of total billed charges,750.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,583.53,70,,,percent of total billed charges,70% of total billed charges,750.26,90,,,percent of total billed charges,90% of total billed charges,791.94,95,,,percent of total billed charges,95% of total billed charges,791.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.91,86,,,percent of total billed charges,86% of total billed charges,666.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,808.61,97,,,percent of total billed charges,97% of total billed charges,750.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,808.61,97,,,percent of total billed charges,97% of total billed charges,775.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.61,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,532.37,808.61,
93657-Additional linear or focal catheter ablation of LA or RA for TX of Afib after PVI,4271207,CDM,481,RC,93657,HCPCS,Outpatient,,,650.37,325.19,,585.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,520.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,585.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,630.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,598.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,415.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,511.53,78.65,,,percent of total billed charges,78.65% of total billed charges,580.99,89.33,,,percent of total billed charges,89.33% of total billed charges,585.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,455.26,70,,,percent of total billed charges,70% of total billed charges,585.33,90,,,percent of total billed charges,90% of total billed charges,617.85,95,,,percent of total billed charges,95% of total billed charges,617.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,559.32,86,,,percent of total billed charges,86% of total billed charges,520.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,630.86,97,,,percent of total billed charges,97% of total billed charges,585.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,630.86,97,,,percent of total billed charges,97% of total billed charges,604.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.34,630.86,
93657-PF Additional linear or focal catheter ablation of LA or RA for TX of Afib after PVI,4271208,CDM,960,RC,93657,HCPCS,Outpatient,,,650.37,325.19,,585.33,90,,,percent of total billed charges,90% of total Billed charges,620.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,327.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,444.82,155,,,Fee Schedule,155% of CMS OPPS Rate,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,306.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,762.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,762.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,667.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,667.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,349.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,613.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,601.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,568.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,444.82,145,,,Fee Schedule,145% of CMS OPPS Rate,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.35,145,,,Fee Schedule,145% of CMS OPPS Rate,444.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,306.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.77,899.35,
93660- Tilt table/cont ECG/BP mon,3431049,CDM,480,RC,93660,HCPCS,Outpatient,,,159.19,79.60,,143.27,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,127.35,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,154.41,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,146.45,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.27,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,111.43,70,,,percent of total billed charges,70% of total billed charges,143.27,90,,,percent of total billed charges,90% of total billed charges,151.23,95,,,percent of total billed charges,95% of total billed charges,151.23,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,136.9,86,,,percent of total billed charges,86% of total billed charges,127.35,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,154.41,97,,,percent of total billed charges,97% of total billed charges,143.27,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.41,97,,,percent of total billed charges,97% of total billed charges,148.05,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.41,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111.43,2356.78,
93660-TILT TABLE TESTING,3432055,CDM,481,RC,93660,HCPCS,Outpatient,,,159.19,79.60,,143.27,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,127.35,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,154.41,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,146.45,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.27,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,111.43,70,,,percent of total billed charges,70% of total billed charges,143.27,90,,,percent of total billed charges,90% of total billed charges,151.23,95,,,percent of total billed charges,95% of total billed charges,151.23,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,136.9,86,,,percent of total billed charges,86% of total billed charges,127.35,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,154.41,97,,,percent of total billed charges,97% of total billed charges,143.27,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.41,97,,,percent of total billed charges,97% of total billed charges,148.05,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.41,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111.43,2356.78,
Tilt Table Test,604553,CDM,480,RC,93660,HCPCS,Outpatient,,,396.58,198.29,,356.92,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,317.26,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,384.68,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,364.85,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,356.92,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,277.61,70,,,percent of total billed charges,70% of total billed charges,356.92,90,,,percent of total billed charges,90% of total billed charges,376.75,95,,,percent of total billed charges,95% of total billed charges,376.75,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,341.06,86,,,percent of total billed charges,86% of total billed charges,317.26,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,384.68,97,,,percent of total billed charges,97% of total billed charges,356.92,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.68,97,,,percent of total billed charges,97% of total billed charges,368.82,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,384.68,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,277.61,2356.78,
93662- IC echo/w therap/diag interven,3431050,CDM,480,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,208.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,208.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,212.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,147.66,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,181.85,78.65,,,percent of total billed charges,78.65% of total billed charges,206.54,89.33,,,percent of total billed charges,89.33% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.85,70,,,percent of total billed charges,70% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.84,86,,,percent of total billed charges,86% of total billed charges,184.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,215.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.66,224.27,
93662-ICE-INTRACARDIAC ECHOCARDIOGRAPHY,3432056,CDM,481,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,208.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,208.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,212.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,147.66,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,181.85,78.65,,,percent of total billed charges,78.65% of total billed charges,206.54,89.33,,,percent of total billed charges,89.33% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.85,70,,,percent of total billed charges,70% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.84,86,,,percent of total billed charges,86% of total billed charges,184.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,215.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.66,224.27,
93662-Intracardiac Echocardiography,3432057,CDM,480,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,208.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,208.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,212.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,147.66,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,181.85,78.65,,,percent of total billed charges,78.65% of total billed charges,206.54,89.33,,,percent of total billed charges,89.33% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.85,70,,,percent of total billed charges,70% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,219.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.84,86,,,percent of total billed charges,86% of total billed charges,184.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,208.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,215.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.66,224.27,
93662-PF ICE-INTRACARDIAC ECHOCARDIOGRAPHY,3611084,CDM,960,RC,93662,HCPCS,Outpatient,,,231.21,115.61,,208.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,263.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,263.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,512.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,512.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.09,512.63,
93668- PAD rehab/per session,3431051,CDM,480,RC,93668,HCPCS,Outpatient,,,32.68,16.34,,29.41,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,26.14,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31.7,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,30.07,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.41,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,22.88,70,,,percent of total billed charges,70% of total billed charges,29.41,90,,,percent of total billed charges,90% of total billed charges,31.05,95,,,percent of total billed charges,95% of total billed charges,31.05,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.1,86,,,percent of total billed charges,86% of total billed charges,26.14,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31.7,97,,,percent of total billed charges,97% of total billed charges,29.41,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.7,97,,,percent of total billed charges,97% of total billed charges,30.39,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.7,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.36,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.88,280.2,
93724- PPM antitac eval/reprog/interp/rec,3431053,CDM,510,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,98.33,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,87.41,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.33,90,,,Percent of total Billed charges,90% of total billed charges,48.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,105.98,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,100.52,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,98.33,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,76.48,70,,,percent of total billed charges,70% of total billed charges,98.33,90,,,percent of total billed charges,90% of total billed charges,103.8,95,,,percent of total billed charges,95% of total billed charges,103.8,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,93.96,86,,,percent of total billed charges,86% of total billed charges,87.41,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,105.98,97,,,percent of total billed charges,97% of total billed charges,98.33,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.98,97,,,percent of total billed charges,97% of total billed charges,101.61,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.98,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.32,1348.7,
93724-NIPS Procedure,3644934,CDM,481,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,98.33,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,87.41,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.33,90,,,Percent of total Billed charges,90% of total billed charges,48.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,105.98,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,100.52,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,98.33,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,76.48,70,,,percent of total billed charges,70% of total billed charges,98.33,90,,,percent of total billed charges,90% of total billed charges,103.8,95,,,percent of total billed charges,95% of total billed charges,103.8,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,93.96,86,,,percent of total billed charges,86% of total billed charges,87.41,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,105.98,97,,,percent of total billed charges,97% of total billed charges,98.33,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.98,97,,,percent of total billed charges,97% of total billed charges,101.61,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.98,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.32,1348.7,
93724-PF NIPS Procedure,3644935,CDM,960,RC,93724,HCPCS,Outpatient,,,109.26,54.63,,98.33,90,,,percent of total billed charges,90% of total Billed charges,81.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,295.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.93,155,,,Fee Schedule,155% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,414.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,414.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,267.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,145,,,Fee Schedule,145% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.51,145,,,Fee Schedule,145% of CMS OPPS Rate,58.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,505.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,440.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.64,505.02,
NIPS Procedure,,,480,RC,93724,HCPCS,Outpatient,,,715.11,357.56,,643.6,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,572.09,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,643.6,90,,,Percent of total Billed charges,90% of total billed charges,48.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,693.66,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,657.9,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,643.6,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,500.58,70,,,percent of total billed charges,70% of total billed charges,643.6,90,,,percent of total billed charges,90% of total billed charges,679.35,95,,,percent of total billed charges,95% of total billed charges,679.35,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,614.99,86,,,percent of total billed charges,86% of total billed charges,572.09,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,693.66,97,,,percent of total billed charges,97% of total billed charges,643.6,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,693.66,97,,,percent of total billed charges,97% of total billed charges,665.05,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,693.66,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.32,1348.7,
93745- Init set up/prog/inst/wearable ICD,3431056,CDM,510,RC,93745,HCPCS,Outpatient,,,193.87,96.94,,174.48,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,155.1,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,188.05,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,178.36,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,174.48,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,135.71,70,,,percent of total billed charges,70% of total billed charges,174.48,90,,,percent of total billed charges,90% of total billed charges,184.18,95,,,percent of total billed charges,95% of total billed charges,184.18,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,166.73,86,,,percent of total billed charges,86% of total billed charges,155.1,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,188.05,97,,,percent of total billed charges,97% of total billed charges,174.48,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.05,97,,,percent of total billed charges,97% of total billed charges,180.3,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,188.05,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135.71,1348.7,
93750- VAD interr/in person/program/rept,3431057,CDM,510,RC,93750,HCPCS,Outpatient,,,130.09,65.05,,117.08,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,104.07,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.08,90,,,Percent of total Billed charges,90% of total billed charges,39.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.19,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,119.68,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.08,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,91.06,70,,,percent of total billed charges,70% of total billed charges,117.08,90,,,percent of total billed charges,90% of total billed charges,123.59,95,,,percent of total billed charges,95% of total billed charges,123.59,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,111.88,86,,,percent of total billed charges,86% of total billed charges,104.07,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.19,97,,,percent of total billed charges,97% of total billed charges,117.08,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.19,97,,,percent of total billed charges,97% of total billed charges,120.98,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.19,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.14,486.58,
93784- Amb BP mon/rec 24 hr>/interp/rept,3431059,CDM,510,RC,93784,HCPCS,Outpatient,,,112.51,56.26,,101.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,90.01,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,101.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,103.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,71.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,88.49,78.65,,,percent of total billed charges,78.65% of total billed charges,100.51,89.33,,,percent of total billed charges,89.33% of total billed charges,101.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.76,70,,,percent of total billed charges,70% of total billed charges,101.26,90,,,percent of total billed charges,90% of total billed charges,106.88,95,,,percent of total billed charges,95% of total billed charges,106.88,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.76,86,,,percent of total billed charges,86% of total billed charges,90.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,109.13,97,,,percent of total billed charges,97% of total billed charges,101.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.13,97,,,percent of total billed charges,97% of total billed charges,104.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.85,109.13,
93786- Amb BP mon/24 hrs> record only,3431060,CDM,510,RC,93786,HCPCS,Outpatient,,,53.21,26.61,,47.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,42.57,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.61,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,48.95,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,47.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,37.25,70,,,percent of total billed charges,70% of total billed charges,47.89,90,,,percent of total billed charges,90% of total billed charges,50.55,95,,,percent of total billed charges,95% of total billed charges,50.55,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45.76,86,,,percent of total billed charges,86% of total billed charges,42.57,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.61,97,,,percent of total billed charges,97% of total billed charges,47.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.61,97,,,percent of total billed charges,97% of total billed charges,49.49,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.61,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.25,566.05,
93788- AMB BP mon/24 hrs> scan/rept only,3431061,CDM,510,RC,93788,HCPCS,Outpatient,,,12.16,6.08,,10.94,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9.73,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.8,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8.51,70,,,percent of total billed charges,70% of total billed charges,10.94,90,,,percent of total billed charges,90% of total billed charges,11.55,95,,,percent of total billed charges,95% of total billed charges,11.55,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10.46,86,,,percent of total billed charges,86% of total billed charges,9.73,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11.8,97,,,percent of total billed charges,97% of total billed charges,10.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.8,97,,,percent of total billed charges,97% of total billed charges,11.31,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.8,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.51,566.05,
93790- Amb BP mon/24 hrs/interp/rept only,3431062,CDM,510,RC,93790,HCPCS,Outpatient,,,47.12,23.56,,42.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,43.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,30.09,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,37.06,78.65,,,percent of total billed charges,78.65% of total billed charges,42.09,89.33,,,percent of total billed charges,89.33% of total billed charges,42.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.98,70,,,percent of total billed charges,70% of total billed charges,42.41,90,,,percent of total billed charges,90% of total billed charges,44.76,95,,,percent of total billed charges,95% of total billed charges,44.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.52,86,,,percent of total billed charges,86% of total billed charges,37.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.71,97,,,percent of total billed charges,97% of total billed charges,42.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.71,97,,,percent of total billed charges,97% of total billed charges,43.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.09,45.71,
INR Monitoring- Home,3561523,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,25.85,90,,,percent of total billed charges,90% of total Billed charges,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,155,,,Fee Schedule,155% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,145,,,Fee Schedule,145% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.47,145,,,Fee Schedule,145% of CMS OPPS Rate,15.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,31.47,
INR POC,3444194,CDM,300,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,25.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,22.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,25.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,26.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,18.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,22.59,78.65,,,percent of total billed charges,78.65% of total billed charges,25.66,89.33,,,percent of total billed charges,89.33% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,70,,,percent of total billed charges,70% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,27.28,95,,,percent of total billed charges,95% of total billed charges,27.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,86,,,percent of total billed charges,86% of total billed charges,22.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,26.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.34,27.86,
Prothrombin and INR POC,3444204,CDM,300,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,25.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,22.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,25.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,26.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,18.34,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,22.59,78.65,,,percent of total billed charges,78.65% of total billed charges,25.66,89.33,,,percent of total billed charges,89.33% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,70,,,percent of total billed charges,70% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,27.28,95,,,percent of total billed charges,95% of total billed charges,27.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.7,86,,,percent of total billed charges,86% of total billed charges,22.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,25.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,26.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.34,27.86,
93797- OP card rehab w/o cont ECG monitor,3431063,CDM,943,RC,93797,HCPCS,Outpatient,,,41.67,20.84,,37.5,90,,,percent of total billed charges,90% of total Billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,33.34,80,,,Percent of total Billed charges,80% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,40.42,97,,,Percent of total billed charges,97% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,38.34,92,,,Percent of total billed charges,92% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,289.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,585.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.5,90,,,percent of total billed charges,90% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,29.17,70,,,percent of total billed charges,70% of total billed charges,37.5,90,,,percent of total billed charges,90% of total billed charges,39.59,95,,,percent of total billed charges,95% of total billed charges,39.59,95,,,percent of total billed charges,95% of total billed charges,109.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.84,86,,,percent of total billed charges,86% of total billed charges,33.34,80,,,percent of total billed charges,80% of total billed charges,113.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,40.42,97,,,percent of total billed charges,97% of total billed charges,37.5,90,,,percent of total billed charges,90% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.42,97,,,percent of total billed charges,97% of total billed charges,38.75,93,,,percent of total billed charges,93% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.42,97,,,percent of total billed charges,97% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,92.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.17,585.35,
93798- OP card rehab w/ECG mon/q session,3431064,CDM,943,RC,93798,HCPCS,Outpatient,,,64.3,32.15,,57.87,90,,,percent of total billed charges,90% of total Billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,51.44,80,,,Percent of total Billed charges,80% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,62.37,97,,,Percent of total billed charges,97% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,59.16,92,,,Percent of total billed charges,92% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,289.88,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,462.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,585.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,57.87,90,,,percent of total billed charges,90% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,45.01,70,,,percent of total billed charges,70% of total billed charges,57.87,90,,,percent of total billed charges,90% of total billed charges,61.09,95,,,percent of total billed charges,95% of total billed charges,61.09,95,,,percent of total billed charges,95% of total billed charges,109.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,55.3,86,,,percent of total billed charges,86% of total billed charges,51.44,80,,,percent of total billed charges,80% of total billed charges,113.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,62.37,97,,,percent of total billed charges,97% of total billed charges,57.87,90,,,percent of total billed charges,90% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.37,97,,,percent of total billed charges,97% of total billed charges,59.8,93,,,percent of total billed charges,93% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.37,97,,,percent of total billed charges,97% of total billed charges,109.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,92.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.01,585.35,
93799-iFR,4305231,CDM,481,RC,93799,HCPCS,Outpatient,,,151.54,75.77,,136.39,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,121.23,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,146.99,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,139.42,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,136.39,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,106.08,70,,,percent of total billed charges,70% of total billed charges,136.39,90,,,percent of total billed charges,90% of total billed charges,143.96,95,,,percent of total billed charges,95% of total billed charges,143.96,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,130.32,86,,,percent of total billed charges,86% of total billed charges,121.23,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,146.99,97,,,percent of total billed charges,97% of total billed charges,136.39,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.99,97,,,percent of total billed charges,97% of total billed charges,140.93,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.99,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,106.08,708.98,
93880 - (26) Duplex scan of extracranial arteries; complete,3898953,CDM,983,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.28,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.67,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,70.82,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.89,70,,,percent of total billed charges,70% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.2,86,,,percent of total billed charges,86% of total billed charges,61.58,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.67,97,,,percent of total billed charges,97% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.67,97,,,percent of total billed charges,97% of total billed charges,71.59,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.67,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.89,1138.43,
93880-CL Carotid Duplex Complete BILAT,3432058,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
93880-CL Carotid Duplex Complete LT,3432059,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
93880-CL Carotid Duplex Complete RT,3432060,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.28,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.67,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,70.82,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.89,70,,,percent of total billed charges,70% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.2,86,,,percent of total billed charges,86% of total billed charges,61.58,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.67,97,,,percent of total billed charges,97% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.67,97,,,percent of total billed charges,97% of total billed charges,71.59,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.67,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.89,1138.43,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.28,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.67,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,70.82,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.89,70,,,percent of total billed charges,70% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.2,86,,,percent of total billed charges,86% of total billed charges,61.58,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.67,97,,,percent of total billed charges,97% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.67,97,,,percent of total billed charges,97% of total billed charges,71.59,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.67,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.89,1138.43,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.58,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.28,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.67,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,70.82,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.89,70,,,percent of total billed charges,70% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,73.13,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.2,86,,,percent of total billed charges,86% of total billed charges,61.58,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.67,97,,,percent of total billed charges,97% of total billed charges,69.28,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.67,97,,,percent of total billed charges,97% of total billed charges,71.59,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.67,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.89,1138.43,
Read,3575287,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
US Carotids Bilat:Read,596599,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
93882-CL Carotid Duplex Limited BILAT,3432061,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Carotid Duplex Limited LT,3432062,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Carotid Duplex Limited RT,3432063,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Limited Carotid Post Proc LT,3432064,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Limited Carotid Post Proc RT,3432065,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Limited Carotid Post Procedure BILAT,3432066,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Limited Carotid Post Procedure LT,3432067,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93882-CL Limited Carotid Post Procedure RT,3432068,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,521.04,
SCMP US Carotid:Read,3575233,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
US Carotid Unilat Lt:Read,596605,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
US Carotid Unilat Rt:Read,596602,CDM,972,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93922-CL US Lower Extrem Art Limited BILAT,3432069,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
93922-CL US Lower Extrem Art Limited RT,3432070,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
93922-CL US Lower Extrem Arterial Limited LT,3432071,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
CL US Lower Extrem Art Limited BILAT,3427502,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
CL US Lower Extrem Art Limited RT,3427506,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
CL US Lower Extrem Arterial Limited LT,3427504,CDM,921,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,19.46,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.89,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.59,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,22.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.02,70,,,percent of total billed charges,70% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,23.1,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.92,86,,,percent of total billed charges,86% of total billed charges,19.46,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.59,97,,,percent of total billed charges,97% of total billed charges,21.89,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.59,97,,,percent of total billed charges,97% of total billed charges,22.62,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.59,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.02,566.05,
Read,3575289,CDM,972,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,48.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.26,155,,,Fee Schedule,155% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,114.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,114.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,145,,,Fee Schedule,145% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.53,145,,,Fee Schedule,145% of CMS OPPS Rate,35.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.89,151.1,
93923 - (26) Non-Invasive Physiologic Study Extremity 3 Lvls,3897032,CDM,983,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
93923-CL Lower Extrem Art Physiologic BILAT,3432072,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL Lower Extrem Art Physiologic LT,3432073,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL Lower Extrem Art Physiologic RT,3432074,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL Lower Periph Art Duplex wo Exer BILAT,3432075,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL Lower Periph Art Duplex wo Exer LT,3432076,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL Lower Periph Art Duplex wo Exer RT,3432077,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL US Lower Extrem Art Comp w ABI BILAT,3432078,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL US Lower Extrem Art Complete LT,3432079,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923-CL US Lower Extrem Art Complete RT,3432080,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
Read,3569752,CDM,972,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
SCSN US Arterial w Seg Pressures BILAT,3575259,CDM,972,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
US ABI Complete,3345454,CDM,921,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.1,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31.19,70,,,percent of total billed charges,70% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,42.33,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.32,86,,,percent of total billed charges,86% of total billed charges,35.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.22,97,,,percent of total billed charges,97% of total billed charges,40.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.22,97,,,percent of total billed charges,97% of total billed charges,41.44,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.19,708.98,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,1365.32,
93924-CL Lower Periph Art Duplex w Exer BILAT,3432081,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
93924-CL Lower Periph Art Duplex w Exer LT,3432082,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
93924-CL Lower Periph Art Duplex w Exer RT,3432083,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,1365.32,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,1365.32,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,1365.32,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,38.9,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.77,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.17,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,44.74,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,34.04,70,,,percent of total billed charges,70% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,46.2,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.82,86,,,percent of total billed charges,86% of total billed charges,38.9,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.17,97,,,percent of total billed charges,97% of total billed charges,43.77,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.17,97,,,percent of total billed charges,97% of total billed charges,45.23,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.17,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.04,1365.32,
SCSN US Arterial w Exercise RT Interp,3575269,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
SCSN US Arterials w Exercise Bilat Interp,3575265,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
SCSN US Arterials w Exercise LT Interp,3575267,CDM,972,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
US Lower Ext Arterial Bilat Limited:Read,3374595,CDM,972,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,439.6,90,,,percent of total billed charges,90% of total Billed charges,361.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,258.56,155,,,Fee Schedule,155% of CMS OPPS Rate,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,515.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.56,145,,,Fee Schedule,145% of CMS OPPS Rate,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.89,145,,,Fee Schedule,145% of CMS OPPS Rate,258.56,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,497.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146.81,524.89,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
93926 (26) Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620983,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
93926-CL Femoral Groin Artery BILAT,3432084,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
93926-CL Femoral Groin Artery LT,3432085,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
93926-CL Femoral Groin Artery RT,3432086,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
Read,3374599,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
Read,3374603,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
Read,3575243,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
SCSN US Arterial w Seg Pressures LT,3575263,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
US Duplex Limited Lower,3345452,CDM,921,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
US Lower Ext Arterial Lt Complete:Read,3374597,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
US Lower Ext Arterial Rt Complete:Read,3374601,CDM,510,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,37.69,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.4,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,70,,,percent of total billed charges,70% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,44.75,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.51,86,,,percent of total billed charges,86% of total billed charges,37.69,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45.7,97,,,percent of total billed charges,97% of total billed charges,42.4,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.7,97,,,percent of total billed charges,97% of total billed charges,43.81,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.98,521.04,
US Lower Ext Arterial Rt Limited:Read,630811,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
US Upper Ext Arterial Bilat Complete-Read,3351993,CDM,972,RC,93930,HCPCS,Outpatient,,,378.7,189.35,,340.83,90,,,percent of total billed charges,90% of total Billed charges,281.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,201.51,155,,,Fee Schedule,155% of CMS OPPS Rate,138.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,419.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,278.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,278.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.51,145,,,Fee Schedule,145% of CMS OPPS Rate,138.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,407.97,145,,,Fee Schedule,145% of CMS OPPS Rate,201.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,138.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,397.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,397.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,138.97,419.02,
Read,3351997,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
Read,3352001,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
Read,3352003,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
93970 26 Duplex scan of extremity veins including response,3621410,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
Read,596573,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,1257041,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3352011,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3370918,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3370921,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3569776,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3569782,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3569788,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
US Extremity Complete Bilat Lower for DVT:Read,3347590,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
US Extremity Complete Bilat Upper for DVT:Read,3347592,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
US Lower Ext Arterial Bilat Complete-Read,3374593,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93971 - PF Duplex scan of extremity veins including responses to compression and other maneuvers; un,3641198,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
93971 (26) Duplex scan of extremity veins including responses to compression and other maneuvers; un,3620981,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Periph Venous US Lower LT,3432094,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Periph Venous US Lower RT,3432095,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Periph Venous US Upper LT,3432096,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Periph Venous US Upper RT,3432097,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Upper Periph Arterial Duplex LT,3432098,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL Upper Periph Arterial Duplex RT,3432099,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Vein Map Mark Lower Extrem LT,3432100,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Vein Map Mark Lower Extrem RT,3432101,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Vein Map Mark Upper Extrem LT,3432102,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Vein Map Mark Upper Extrem RT,3432103,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Venous Insuff Lower Extrem LT,3432104,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Venous Insuff Lower Extrem RT,3432105,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Venous Insuff Upper Extrem LT,3432106,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-CL US Venous Insuff Upper Extrem RT,3432107,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
93971-PF DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY,4321510,CDM,981,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL Periph Venous US Lower RT,3427535,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL Periph Venous US Upper LT,3427538,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL Periph Venous US Upper RT,3427569,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL Upper Periph Arterial Duplex LT,3427572,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,921,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.92,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.16,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,41.13,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,39.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,29.68,70,,,percent of total billed charges,70% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,40.28,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.46,86,,,percent of total billed charges,86% of total billed charges,33.92,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,41.13,97,,,percent of total billed charges,97% of total billed charges,38.16,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.13,97,,,percent of total billed charges,97% of total billed charges,39.43,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.13,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,521.04,
Read,596567,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,1257043,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,1257045,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3352009,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3352013,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3352015,CDM,972,RC,93971,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,268.56,
Read,3352017,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3352019,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3352021,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,,,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3370951,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3370953,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3575295,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3575297,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
US Extremity Vein Unilat Lt Lower for DVT:Read,3347594,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
US Extremity Vein Unilat Lt Upper for DVT:Read,3347596,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
US Extremity Vein Unilat Rt Lower for DVT:Read,3347598,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
US Extremity Vein Unilat Rt Upper for DVT:Read,3347600,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
WHC US Extremity Vein Lt:Read,2198106,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
US Duplex Abd Pelvic Retro Complete:Read,596592,CDM,972,RC,93975,HCPCS,Outpatient,,,111,55.50,,99.9,90,,,percent of total billed charges,90% of total Billed charges,222,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.95,155,,,Fee Schedule,155% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,562.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.95,145,,,Fee Schedule,145% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.9,145,,,Fee Schedule,145% of CMS OPPS Rate,160.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,598.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99.9,598.14,
US Renal Artery:Read,1225049,CDM,972,RC,93975,HCPCS,Outpatient,,,111,55.50,,99.9,90,,,percent of total billed charges,90% of total Billed charges,222,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.95,155,,,Fee Schedule,155% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,562.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.95,145,,,Fee Schedule,145% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.9,145,,,Fee Schedule,145% of CMS OPPS Rate,160.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,598.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99.9,598.14,
US Duplex Aorta IVC Complete:Read,596586,CDM,972,RC,93978,HCPCS,Outpatient,,,77.95,38.98,,70.16,90,,,percent of total billed charges,90% of total Billed charges,155.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.03,155,,,Fee Schedule,155% of CMS OPPS Rate,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,255.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,255.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.03,145,,,Fee Schedule,145% of CMS OPPS Rate,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.06,145,,,Fee Schedule,145% of CMS OPPS Rate,113.03,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.17,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,387.17,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.16,387.17,
93985-CL US Ext AVF Comp Bilat Upper Pre-Op Wavelinq,3432108,CDM,960,RC,93985,HCPCS,Outpatient,,,508.97,254.49,,458.07,90,,,percent of total billed charges,90% of total Billed charges,376.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.86,155,,,Fee Schedule,155% of CMS OPPS Rate,184.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,358.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,358.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,235.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.86,145,,,Fee Schedule,145% of CMS OPPS Rate,184.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.37,145,,,Fee Schedule,145% of CMS OPPS Rate,267.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,184.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,282.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.73,545.37,
93986-CL US Ext AVF Comp Upper Pre-Op Wavelinq LT,3432109,CDM,960,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,269.18,90,,,percent of total billed charges,90% of total Billed charges,221.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.01,155,,,Fee Schedule,155% of CMS OPPS Rate,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.01,145,,,Fee Schedule,145% of CMS OPPS Rate,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.09,145,,,Fee Schedule,145% of CMS OPPS Rate,158.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,143.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.97,321.09,
93986-CL US Ext AVF Comp Upper Pre-Op Wavelinq RT,3432110,CDM,960,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,269.18,90,,,percent of total billed charges,90% of total Billed charges,221.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.01,155,,,Fee Schedule,155% of CMS OPPS Rate,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.01,145,,,Fee Schedule,145% of CMS OPPS Rate,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.09,145,,,Fee Schedule,145% of CMS OPPS Rate,158.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,143.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.97,321.09,
93990-CL US Ext AVF Comp Upper for AVF Wavelinq LT,3432111,CDM,960,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,266.34,90,,,percent of total billed charges,90% of total Billed charges,219.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.75,155,,,Fee Schedule,155% of CMS OPPS Rate,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,315.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.75,145,,,Fee Schedule,145% of CMS OPPS Rate,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.1,145,,,Fee Schedule,145% of CMS OPPS Rate,156.75,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92.49,351.81,
93990-CL US Ext AVF Comp Upper for AVF Wavelinq RT,3432112,CDM,960,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,266.34,90,,,percent of total billed charges,90% of total Billed charges,219.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.75,155,,,Fee Schedule,155% of CMS OPPS Rate,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,315.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.75,145,,,Fee Schedule,145% of CMS OPPS Rate,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.1,145,,,Fee Schedule,145% of CMS OPPS Rate,156.75,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92.49,351.81,
94002-PF-VENT MGMT INPAT INIT DAY,4321572,CDM,981,RC,94002,HCPCS,Outpatient,,,180.94,90.47,,162.85,90,,,percent of total billed charges,90% of total Billed charges,182.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.17,155,,,Fee Schedule,155% of CMS OPPS Rate,90.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,140.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,140.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.17,145,,,Fee Schedule,145% of CMS OPPS Rate,90.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.48,145,,,Fee Schedule,145% of CMS OPPS Rate,131.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,90.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,90.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,156.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.75,264.48,
94004-PF VENT MGMT NF PER DAY,4321571,CDM,981,RC,94004,HCPCS,Outpatient,,,93.3,46.65,,83.97,90,,,percent of total billed charges,90% of total Billed charges,94.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,155,,,Fee Schedule,155% of CMS OPPS Rate,46.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.63,145,,,Fee Schedule,145% of CMS OPPS Rate,46.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.82,145,,,Fee Schedule,145% of CMS OPPS Rate,67.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.54,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,81.54,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.3,136.82,
Clinic Spirometry without,3435735,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
Peak Expiratory Flow,617712,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
Peak Flow POC,3444203,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
Spirometry POC,3444207,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
94013- Measure lung vol/inf/child thro 2y,3435679,CDM,510,RC,94013,HCPCS,Outpatient,,,51.62,25.81,,46.46,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,41.3,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.07,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,47.49,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,46.46,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,36.13,70,,,percent of total billed charges,70% of total billed charges,46.46,90,,,percent of total billed charges,90% of total billed charges,49.04,95,,,percent of total billed charges,95% of total billed charges,49.04,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.39,86,,,percent of total billed charges,86% of total billed charges,41.3,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,50.07,97,,,percent of total billed charges,97% of total billed charges,46.46,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.07,97,,,percent of total billed charges,97% of total billed charges,48.01,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.07,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.13,2356.78,
94014- Pt init/spiromet rec/30 day,3435680,CDM,960,RC,94014,HCPCS,Outpatient,,,135.65,67.83,,122.09,90,,,percent of total billed charges,90% of total Billed charges,101.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.47,155,,,Fee Schedule,155% of CMS OPPS Rate,50.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.47,145,,,Fee Schedule,145% of CMS OPPS Rate,50.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.42,145,,,Fee Schedule,145% of CMS OPPS Rate,73.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,78.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.72,147.42,
94016- Pt init/spiromet rec/review/interp,3435682,CDM,960,RC,94016,HCPCS,Outpatient,,,64.28,32.14,,57.85,90,,,percent of total billed charges,90% of total Billed charges,47.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.39,155,,,Fee Schedule,155% of CMS OPPS Rate,23.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.39,145,,,Fee Schedule,145% of CMS OPPS Rate,23.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.43,145,,,Fee Schedule,145% of CMS OPPS Rate,34.39,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,41.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.61,69.43,
94060 - (PF) Spirometry/pre/post bronchodilator,4237109,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,40.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.33,90,,,Percent of total Billed charges,90% of total billed charges,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,145,,,Fee Schedule,145% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.13,145,,,Fee Schedule,145% of CMS OPPS Rate,29.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.35,100.36,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.31,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.35,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,19.78,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,70,,,percent of total billed charges,70% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.54,86,,,percent of total billed charges,86% of total billed charges,16.31,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,19.78,97,,,percent of total billed charges,97% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.78,97,,,percent of total billed charges,97% of total billed charges,18.96,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.78,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1365.32,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.31,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.35,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,19.78,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,70,,,percent of total billed charges,70% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.54,86,,,percent of total billed charges,86% of total billed charges,16.31,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,19.78,97,,,percent of total billed charges,97% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.78,97,,,percent of total billed charges,97% of total billed charges,18.96,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.78,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1365.32,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.31,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.35,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,19.78,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,70,,,percent of total billed charges,70% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.54,86,,,percent of total billed charges,86% of total billed charges,16.31,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,19.78,97,,,percent of total billed charges,97% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.78,97,,,percent of total billed charges,97% of total billed charges,18.96,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.78,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1365.32,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.31,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.35,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,19.78,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,18.76,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,14.27,70,,,percent of total billed charges,70% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,19.37,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.54,86,,,percent of total billed charges,86% of total billed charges,16.31,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,19.78,97,,,percent of total billed charges,97% of total billed charges,18.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.78,97,,,percent of total billed charges,97% of total billed charges,18.96,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.78,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1365.32,
94070- Bronchospasm provocation eval,3435683,CDM,510,RC,94070,HCPCS,Outpatient,,,79.27,39.64,,71.34,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,63.42,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.34,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,76.89,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.93,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,71.34,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,55.49,70,,,percent of total billed charges,70% of total billed charges,71.34,90,,,percent of total billed charges,90% of total billed charges,75.31,95,,,percent of total billed charges,95% of total billed charges,75.31,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.17,86,,,percent of total billed charges,86% of total billed charges,63.42,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,76.89,97,,,percent of total billed charges,97% of total billed charges,71.34,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.89,97,,,percent of total billed charges,97% of total billed charges,73.72,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.89,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1365.32,
94200- Max breathing cap/max volunt vent,3435685,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,29.57,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,90,,,Percent of total Billed charges,90% of total billed charges,5.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,31.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,30.23,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23,70,,,percent of total billed charges,70% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.26,86,,,percent of total billed charges,86% of total billed charges,26.29,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31.87,97,,,percent of total billed charges,97% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.87,97,,,percent of total billed charges,97% of total billed charges,30.56,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.4,280.22,
"Clinic Full PFT with spirometry, MVV,Lung Volumes and diffusion capacity",3435731,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,29.57,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,90,,,Percent of total Billed charges,90% of total billed charges,5.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,31.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,30.23,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23,70,,,percent of total billed charges,70% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.26,86,,,percent of total billed charges,86% of total billed charges,26.29,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31.87,97,,,percent of total billed charges,97% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.87,97,,,percent of total billed charges,97% of total billed charges,30.56,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.4,280.22,
Clinic MVV,3979027,CDM,460,RC,94200,HCPCS,Outpatient,,,32.86,16.43,,29.57,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,26.29,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,90,,,Percent of total Billed charges,90% of total billed charges,5.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,31.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,30.23,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,23,70,,,percent of total billed charges,70% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,31.22,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.26,86,,,percent of total billed charges,86% of total billed charges,26.29,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31.87,97,,,percent of total billed charges,97% of total billed charges,29.57,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.87,97,,,percent of total billed charges,97% of total billed charges,30.56,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.4,280.22,
94375- Respiratory flow volume loop,3435689,CDM,460,RC,94375,HCPCS,Outpatient,,,56.38,28.19,,50.74,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,45.1,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.74,90,,,Percent of total Billed charges,90% of total billed charges,19.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,54.69,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,51.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,50.74,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,39.47,70,,,percent of total billed charges,70% of total billed charges,50.74,90,,,percent of total billed charges,90% of total billed charges,53.56,95,,,percent of total billed charges,95% of total billed charges,53.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,48.49,86,,,percent of total billed charges,86% of total billed charges,45.1,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,54.69,97,,,percent of total billed charges,97% of total billed charges,50.74,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.69,97,,,percent of total billed charges,97% of total billed charges,52.43,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,54.69,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.04,1365.32,
94450- Breathing response to hypoxia,3435691,CDM,510,RC,94450,HCPCS,Outpatient,,,108.8,54.40,,97.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,87.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.92,90,,,Percent of total Billed charges,90% of total billed charges,28.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,105.54,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,100.1,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,97.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,76.16,70,,,percent of total billed charges,70% of total billed charges,97.92,90,,,percent of total billed charges,90% of total billed charges,103.36,95,,,percent of total billed charges,95% of total billed charges,103.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,93.57,86,,,percent of total billed charges,86% of total billed charges,87.04,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,105.54,97,,,percent of total billed charges,97% of total billed charges,97.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.54,97,,,percent of total billed charges,97% of total billed charges,101.18,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.54,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.56,1365.32,
94452- High altitude sim test/int/rpt,3435692,CDM,510,RC,94452,HCPCS,Outpatient,,,81.64,40.82,,73.48,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,65.31,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.19,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,75.11,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,57.15,70,,,percent of total billed charges,70% of total billed charges,73.48,90,,,percent of total billed charges,90% of total billed charges,77.56,95,,,percent of total billed charges,95% of total billed charges,77.56,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.21,86,,,percent of total billed charges,86% of total billed charges,65.31,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,79.19,97,,,percent of total billed charges,97% of total billed charges,73.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.19,97,,,percent of total billed charges,97% of total billed charges,75.93,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.19,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.15,566.05,
94453- High altitude sim test/int/rpt/O2,3435693,CDM,510,RC,94453,HCPCS,Outpatient,,,112.44,56.22,,101.2,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,89.95,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.07,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,103.44,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,101.2,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,78.71,70,,,percent of total billed charges,70% of total billed charges,101.2,90,,,percent of total billed charges,90% of total billed charges,106.82,95,,,percent of total billed charges,95% of total billed charges,106.82,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,96.7,86,,,percent of total billed charges,86% of total billed charges,89.95,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,109.07,97,,,percent of total billed charges,97% of total billed charges,101.2,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.07,97,,,percent of total billed charges,97% of total billed charges,104.57,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,109.07,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.71,566.05,
94610- Intrapul surfactant admin/ET tube,3435694,CDM,510,RC,94610,HCPCS,Outpatient,,,145.9,72.95,,131.31,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,116.72,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.52,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,134.23,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,131.31,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,102.13,70,,,percent of total billed charges,70% of total billed charges,131.31,90,,,percent of total billed charges,90% of total billed charges,138.61,95,,,percent of total billed charges,95% of total billed charges,138.61,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,125.47,86,,,percent of total billed charges,86% of total billed charges,116.72,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,141.52,97,,,percent of total billed charges,97% of total billed charges,131.31,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.52,97,,,percent of total billed charges,97% of total billed charges,135.69,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.52,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.13,933.58,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.73,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.82,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,70,,,percent of total billed charges,70% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.96,86,,,percent of total billed charges,86% of total billed charges,35.31,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.82,97,,,percent of total billed charges,97% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.82,97,,,percent of total billed charges,97% of total billed charges,41.05,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.82,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,566.05,
94618 - (PF) Pulmonary Stress Test - 6 min Walk,4237108,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.35,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,48.42,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.73,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.82,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,70,,,percent of total billed charges,70% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.96,86,,,percent of total billed charges,86% of total billed charges,35.31,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.82,97,,,percent of total billed charges,97% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.82,97,,,percent of total billed charges,97% of total billed charges,41.05,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.82,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,566.05,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.73,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.82,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,70,,,percent of total billed charges,70% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.96,86,,,percent of total billed charges,86% of total billed charges,35.31,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.82,97,,,percent of total billed charges,97% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.82,97,,,percent of total billed charges,97% of total billed charges,41.05,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.82,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,566.05,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.31,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.73,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.82,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.61,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,30.9,70,,,percent of total billed charges,70% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,41.93,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.96,86,,,percent of total billed charges,86% of total billed charges,35.31,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.82,97,,,percent of total billed charges,97% of total billed charges,39.73,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.82,97,,,percent of total billed charges,97% of total billed charges,41.05,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.82,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,566.05,
94621- Pulmonary stress testing/complex,3435696,CDM,460,RC,94621,HCPCS,Outpatient,,,203.39,101.70,,183.05,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,162.71,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.05,90,,,Percent of total Billed charges,90% of total billed charges,69.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,197.29,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,187.12,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,183.05,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,142.37,70,,,percent of total billed charges,70% of total billed charges,183.05,90,,,percent of total billed charges,90% of total billed charges,193.22,95,,,percent of total billed charges,95% of total billed charges,193.22,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.92,86,,,percent of total billed charges,86% of total billed charges,162.71,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,197.29,97,,,percent of total billed charges,97% of total billed charges,183.05,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,197.29,97,,,percent of total billed charges,97% of total billed charges,189.15,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.29,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.56,1365.32,
PFT for PAT,617693,CDM,460,RC,94621,HCPCS,Outpatient,,,203.39,101.70,,183.05,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,162.71,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.05,90,,,Percent of total Billed charges,90% of total billed charges,69.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,197.29,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,187.12,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,183.05,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,142.37,70,,,percent of total billed charges,70% of total billed charges,183.05,90,,,percent of total billed charges,90% of total billed charges,193.22,95,,,percent of total billed charges,95% of total billed charges,193.22,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.92,86,,,percent of total billed charges,86% of total billed charges,162.71,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,197.29,97,,,percent of total billed charges,97% of total billed charges,183.05,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,197.29,97,,,percent of total billed charges,97% of total billed charges,189.15,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.29,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.56,1365.32,
Pulmonary Stress Test Study II,617696,CDM,460,RC,94621,HCPCS,Outpatient,,,374.39,187.20,,336.95,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,299.51,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,336.95,90,,,Percent of total Billed charges,90% of total billed charges,69.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,363.16,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,344.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,336.95,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,262.07,70,,,percent of total billed charges,70% of total billed charges,336.95,90,,,percent of total billed charges,90% of total billed charges,355.67,95,,,percent of total billed charges,95% of total billed charges,355.67,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,321.98,86,,,percent of total billed charges,86% of total billed charges,299.51,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,363.16,97,,,percent of total billed charges,97% of total billed charges,336.95,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,363.16,97,,,percent of total billed charges,97% of total billed charges,348.18,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,363.16,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.56,1365.32,
AMB Admin INH Charge -> INH Treatment 94640,3574936,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.27,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,70,,,percent of total billed charges,70% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.69,86,,,percent of total billed charges,86% of total billed charges,21.1,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.59,97,,,percent of total billed charges,97% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.59,97,,,percent of total billed charges,97% of total billed charges,24.53,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.47,933.58,
INHELATION TX-AERO/NEB/ MDI/IPPB,3428470,CDM,981,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,17.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.6,155,,,Fee Schedule,155% of CMS OPPS Rate,8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,23.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.6,145,,,Fee Schedule,145% of CMS OPPS Rate,8,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.97,145,,,Fee Schedule,145% of CMS OPPS Rate,11.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.51,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28.51,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8,28.51,
RT CHARGE Aerosol Therapy -> Initial,3438247,CDM,940,RC,94640,HCPCS,Outpatient,,,21.23,10.62,,19.11,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,16.98,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.11,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.86,70,,,percent of total billed charges,70% of total billed charges,19.11,90,,,percent of total billed charges,90% of total billed charges,20.17,95,,,percent of total billed charges,95% of total billed charges,20.17,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.26,86,,,percent of total billed charges,86% of total billed charges,16.98,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.59,97,,,percent of total billed charges,97% of total billed charges,19.11,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.59,97,,,percent of total billed charges,97% of total billed charges,19.74,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.86,933.58,
RT CHARGE Aerosol Therapy -> Subsequent,3438246,CDM,940,RC,94640,HCPCS,Outpatient,,,21.23,10.62,,19.11,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,16.98,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,19.53,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19.11,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,14.86,70,,,percent of total billed charges,70% of total billed charges,19.11,90,,,percent of total billed charges,90% of total billed charges,20.17,95,,,percent of total billed charges,95% of total billed charges,20.17,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.26,86,,,percent of total billed charges,86% of total billed charges,16.98,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.59,97,,,percent of total billed charges,97% of total billed charges,19.11,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.59,97,,,percent of total billed charges,97% of total billed charges,19.74,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.86,933.58,
94662- CNP ventilation/initiation/mngt,3431740,CDM,410,RC,94662,HCPCS,Outpatient,,,95.05,47.53,,85.55,90,,,percent of total billed charges,90% of total Billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,76.04,80,,,Percent of total Billed charges,80% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.55,90,,,Percent of total Billed charges,90% of total billed charges,37.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.2,97,,,Percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,87.45,92,,,Percent of total billed charges,92% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2142.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2714.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,85.55,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,66.54,70,,,percent of total billed charges,70% of total billed charges,85.55,90,,,percent of total billed charges,90% of total billed charges,90.3,95,,,percent of total billed charges,95% of total billed charges,90.3,95,,,percent of total billed charges,95% of total billed charges,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81.74,86,,,percent of total billed charges,86% of total billed charges,76.04,80,,,percent of total billed charges,80% of total billed charges,480.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,92.2,97,,,percent of total billed charges,97% of total billed charges,85.55,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.2,97,,,percent of total billed charges,97% of total billed charges,88.4,93,,,percent of total billed charges,93% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.2,97,,,percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,429.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33.9,2714.08,
94680- O2 uptake/exp gas analy/simple,3435705,CDM,510,RC,94680,HCPCS,Outpatient,,,93.48,46.74,,84.13,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,74.78,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.13,90,,,Percent of total Billed charges,90% of total billed charges,16.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.68,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,86,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.13,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,65.44,70,,,percent of total billed charges,70% of total billed charges,84.13,90,,,percent of total billed charges,90% of total billed charges,88.81,95,,,percent of total billed charges,95% of total billed charges,88.81,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.39,86,,,percent of total billed charges,86% of total billed charges,74.78,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.68,97,,,percent of total billed charges,97% of total billed charges,84.13,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.68,97,,,percent of total billed charges,97% of total billed charges,86.94,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.68,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15,708.98,
94681- O2 uptake/CO2 output/% O2 extrated,3435706,CDM,510,RC,94681,HCPCS,Outpatient,,,90.33,45.17,,81.3,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,72.26,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.3,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.62,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,83.1,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.3,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,63.23,70,,,percent of total billed charges,70% of total billed charges,81.3,90,,,percent of total billed charges,90% of total billed charges,85.81,95,,,percent of total billed charges,95% of total billed charges,85.81,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77.68,86,,,percent of total billed charges,86% of total billed charges,72.26,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,87.62,97,,,percent of total billed charges,97% of total billed charges,81.3,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.62,97,,,percent of total billed charges,97% of total billed charges,84.01,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.62,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,1365.32,
94690- O2 uptake/rest/indirect,3435707,CDM,510,RC,94690,HCPCS,Outpatient,,,92.71,46.36,,83.44,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.44,90,,,Percent of total Billed charges,90% of total billed charges,4.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,89.93,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,85.29,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,83.44,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,64.9,70,,,percent of total billed charges,70% of total billed charges,83.44,90,,,percent of total billed charges,90% of total billed charges,88.07,95,,,percent of total billed charges,95% of total billed charges,88.07,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,79.73,86,,,percent of total billed charges,86% of total billed charges,74.17,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,89.93,97,,,percent of total billed charges,97% of total billed charges,83.44,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.93,97,,,percent of total billed charges,97% of total billed charges,86.22,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,89.93,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.5,280.22,
94726 - (26) Plethysmography Lung Volumes w/wo airway resist,3896956,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
94726 - PF Plethysmography/lung volume,3715330,CDM,510,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,19.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,23.06,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,21.87,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,16.64,70,,,percent of total billed charges,70% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,22.58,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.44,86,,,percent of total billed charges,86% of total billed charges,19.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.06,97,,,percent of total billed charges,97% of total billed charges,21.39,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.06,97,,,percent of total billed charges,97% of total billed charges,22.11,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.06,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.64,1365.32,
94727- Gas Dilution Washout for determin Lung Volume,3435710,CDM,460,RC,94727,HCPCS,Outpatient,,,74.54,37.27,,67.09,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,59.63,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.09,90,,,Percent of total Billed charges,90% of total billed charges,24.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,72.3,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,68.58,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,67.09,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,52.18,70,,,percent of total billed charges,70% of total billed charges,67.09,90,,,percent of total billed charges,90% of total billed charges,70.81,95,,,percent of total billed charges,95% of total billed charges,70.81,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,64.1,86,,,percent of total billed charges,86% of total billed charges,59.63,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,72.3,97,,,percent of total billed charges,97% of total billed charges,67.09,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.3,97,,,percent of total billed charges,97% of total billed charges,69.32,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,72.3,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.94,708.98,
94728- Airway resist/impulse oscillometry,3435711,CDM,510,RC,94728,HCPCS,Outpatient,,,64.28,32.14,,57.85,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,51.42,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.85,90,,,Percent of total Billed charges,90% of total billed charges,24.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,62.35,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,59.14,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,57.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,45,70,,,percent of total billed charges,70% of total billed charges,57.85,90,,,percent of total billed charges,90% of total billed charges,61.07,95,,,percent of total billed charges,95% of total billed charges,61.07,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,55.28,86,,,percent of total billed charges,86% of total billed charges,51.42,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,62.35,97,,,percent of total billed charges,97% of total billed charges,57.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.35,97,,,percent of total billed charges,97% of total billed charges,59.78,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,62.35,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.94,1365.32,
94729 - (PF) Diffusing capacity/CO2/add on,4237110,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.67,155,,,Fee Schedule,155% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.67,145,,,Fee Schedule,145% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.33,145,,,Fee Schedule,145% of CMS OPPS Rate,25.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,80.27,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.93,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,17.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,13.92,78.65,,,percent of total billed charges,78.65% of total billed charges,15.81,89.33,,,percent of total billed charges,89.33% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.39,70,,,percent of total billed charges,70% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,86,,,percent of total billed charges,86% of total billed charges,14.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,16.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,17.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,36.43,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.93,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,17.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,13.92,78.65,,,percent of total billed charges,78.65% of total billed charges,15.81,89.33,,,percent of total billed charges,89.33% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.39,70,,,percent of total billed charges,70% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,86,,,percent of total billed charges,86% of total billed charges,14.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,16.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,17.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,36.43,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.93,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,17.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,13.92,78.65,,,percent of total billed charges,78.65% of total billed charges,15.81,89.33,,,percent of total billed charges,89.33% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.39,70,,,percent of total billed charges,70% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,86,,,percent of total billed charges,86% of total billed charges,14.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,16.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,17.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,36.43,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.93,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,17.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,11.3,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,13.92,78.65,,,percent of total billed charges,78.65% of total billed charges,15.81,89.33,,,percent of total billed charges,89.33% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.39,70,,,percent of total billed charges,70% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,16.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.22,86,,,percent of total billed charges,86% of total billed charges,14.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,15.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,97,,,percent of total billed charges,97% of total billed charges,16.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,17.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.3,36.43,
94762- Noninv ear/pulse ox/cont/overnight,3435716,CDM,460,RC,94762,HCPCS,Outpatient,,,45.81,22.91,,41.23,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,36.65,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.15,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,41.23,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,32.07,70,,,percent of total billed charges,70% of total billed charges,41.23,90,,,percent of total billed charges,90% of total billed charges,43.52,95,,,percent of total billed charges,95% of total billed charges,43.52,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,39.4,86,,,percent of total billed charges,86% of total billed charges,36.65,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,44.44,97,,,percent of total billed charges,97% of total billed charges,41.23,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.44,97,,,percent of total billed charges,97% of total billed charges,42.6,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.07,708.98,
94780- Car seat/bed test/airway/neonate,3437843,CDM,983,RC,94780,HCPCS,Outpatient,,,127.54,63.77,,114.79,90,,,percent of total billed charges,90% of total Billed charges,71.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.67,155,,,Fee Schedule,155% of CMS OPPS Rate,23.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,25.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.67,145,,,Fee Schedule,145% of CMS OPPS Rate,23.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.21,145,,,Fee Schedule,145% of CMS OPPS Rate,33.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.66,114.79,
94781- Car seat/bed test/airway integ/neonate/nrsg obs/rec/interp/ad 30 min,3435723,CDM,510,RC,94781,HCPCS,Outpatient,,,49.9,24.95,,44.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,39.92,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,39.25,78.65,,,percent of total billed charges,78.65% of total billed charges,44.58,89.33,,,percent of total billed charges,89.33% of total billed charges,44.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.93,70,,,percent of total billed charges,70% of total billed charges,44.91,90,,,percent of total billed charges,90% of total billed charges,47.41,95,,,percent of total billed charges,95% of total billed charges,47.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,86,,,percent of total billed charges,86% of total billed charges,39.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.4,97,,,percent of total billed charges,97% of total billed charges,44.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.4,97,,,percent of total billed charges,97% of total billed charges,46.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.87,48.4,
Clinic MEP,3979029,CDM,960,RC,94799,HCPCS,Outpatient,,,688.77,344.39,,619.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,619.89,
Clinic MIP,3979028,CDM,960,RC,94799,HCPCS,Outpatient,,,688.77,344.39,,619.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20,619.89,
"95044- Allg patch or app, # of tests",3428645,CDM,920,RC,95044,HCPCS,Outpatient,,,9.31,4.66,,8.38,90,,,percent of total billed charges,90% of total Billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,7.45,80,,,Percent of total Billed charges,80% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.38,90,,,Percent of total Billed charges,90% of total billed charges,5.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9.03,97,,,Percent of total billed charges,97% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,92,,,Percent of total billed charges,92% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.84,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8.38,90,,,percent of total billed charges,90% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,6.52,70,,,percent of total billed charges,70% of total billed charges,8.38,90,,,percent of total billed charges,90% of total billed charges,8.84,95,,,percent of total billed charges,95% of total billed charges,8.84,95,,,percent of total billed charges,95% of total billed charges,848.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8.01,86,,,percent of total billed charges,86% of total billed charges,7.45,80,,,percent of total billed charges,80% of total billed charges,939.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9.03,97,,,percent of total billed charges,97% of total billed charges,8.38,90,,,percent of total billed charges,90% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.03,97,,,percent of total billed charges,97% of total billed charges,8.66,93,,,percent of total billed charges,93% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9.03,97,,,percent of total billed charges,97% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.36,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.74,4555.22,
95115 - PF Immunotherapy One Injection,4311915,CDM,960,RC,95115,HCPCS,Outpatient,,,21.08,10.54,,18.97,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.45,90,,,Percent of total Billed charges,90% of total billed charges,3.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.88,155,,,Fee Schedule,155% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,145,,,Fee Schedule,145% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.1,145,,,Fee Schedule,145% of CMS OPPS Rate,12.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,15.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,3.5,25.1,
95115- Professional services for allergen immunotherapy not including provision of allergenic extrac,3715131,CDM,510,RC,95115,HCPCS,Outpatient,,,22.42,11.21,,20.18,90,,,percent of total billed charges,90% of total Billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,17.94,80,,,Percent of total Billed charges,80% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.75,97,,,Percent of total billed charges,97% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,20.63,92,,,Percent of total billed charges,92% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,102.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,20.18,90,,,percent of total billed charges,90% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,15.69,70,,,percent of total billed charges,70% of total billed charges,20.18,90,,,percent of total billed charges,90% of total billed charges,21.3,95,,,percent of total billed charges,95% of total billed charges,21.3,95,,,percent of total billed charges,95% of total billed charges,38.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,19.28,86,,,percent of total billed charges,86% of total billed charges,17.94,80,,,percent of total billed charges,80% of total billed charges,39.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,21.75,97,,,percent of total billed charges,97% of total billed charges,20.18,90,,,percent of total billed charges,90% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.75,97,,,percent of total billed charges,97% of total billed charges,20.85,93,,,percent of total billed charges,93% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.75,97,,,percent of total billed charges,97% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.48,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.69,206.55,
"95117 - PF Immunotherapy Injections, 2 or more",4311916,CDM,960,RC,95117,HCPCS,Outpatient,,,24.55,12.28,,22.1,90,,,percent of total billed charges,90% of total Billed charges,20.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.19,90,,,Percent of total Billed charges,90% of total billed charges,7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.78,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.25,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,18.25,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7,29.78,
95117- Professional services for allergen immunotherapy not including provision of allergenic extrac,3715132,CDM,510,RC,95117,HCPCS,Outpatient,,,27.15,13.58,,24.44,90,,,percent of total billed charges,90% of total Billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,21.72,80,,,Percent of total Billed charges,80% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.34,97,,,Percent of total billed charges,97% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,24.98,92,,,Percent of total billed charges,92% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,102.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,24.44,90,,,percent of total billed charges,90% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,19.01,70,,,percent of total billed charges,70% of total billed charges,24.44,90,,,percent of total billed charges,90% of total billed charges,25.79,95,,,percent of total billed charges,95% of total billed charges,25.79,95,,,percent of total billed charges,95% of total billed charges,38.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.35,86,,,percent of total billed charges,86% of total billed charges,21.72,80,,,percent of total billed charges,80% of total billed charges,39.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,26.34,97,,,percent of total billed charges,97% of total billed charges,24.44,90,,,percent of total billed charges,90% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.34,97,,,percent of total billed charges,97% of total billed charges,25.25,93,,,percent of total billed charges,93% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.34,97,,,percent of total billed charges,97% of total billed charges,38.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.48,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.01,206.55,
95249 ? Ambulatory CGM >72 hours; Pt Prov EQP,4279406,CDM,983,RC,95249,HCPCS,Outpatient,,,113.61,56.81,,102.25,90,,,percent of total billed charges,90% of total Billed charges,105.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.71,155,,,Fee Schedule,155% of CMS OPPS Rate,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.71,145,,,Fee Schedule,145% of CMS OPPS Rate,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.86,145,,,Fee Schedule,145% of CMS OPPS Rate,77.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,152.86,
95249 ? CGM Patient Provided Equipment,4279414,CDM,983,RC,95249,HCPCS,Outpatient,,,113.61,56.81,,102.25,90,,,percent of total billed charges,90% of total Billed charges,105.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.71,155,,,Fee Schedule,155% of CMS OPPS Rate,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.71,145,,,Fee Schedule,145% of CMS OPPS Rate,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,152.86,145,,,Fee Schedule,145% of CMS OPPS Rate,77.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.14,152.86,
95250 - Ambulatory CGM >72 hours; Phys/QHP EQP,4241825,CDM,983,RC,95250,HCPCS,Outpatient,,,269.3,134.65,,242.37,90,,,percent of total billed charges,90% of total Billed charges,257.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,184.19,155,,,Fee Schedule,155% of CMS OPPS Rate,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,183.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.19,145,,,Fee Schedule,145% of CMS OPPS Rate,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.45,145,,,Fee Schedule,145% of CMS OPPS Rate,184.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.26,373.45,
95250 ? CGM Physician Provided Equipment,4279415,CDM,983,RC,95250,HCPCS,Outpatient,,,269.3,134.65,,242.37,90,,,percent of total billed charges,90% of total Billed charges,257.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,184.19,155,,,Fee Schedule,155% of CMS OPPS Rate,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,183.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,126.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.19,145,,,Fee Schedule,145% of CMS OPPS Rate,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.45,145,,,Fee Schedule,145% of CMS OPPS Rate,184.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,248.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.26,373.45,
"95251 - Ambulatory CGM >72 hours; Analysis, Interpretation &",4241826,CDM,983,RC,95251,HCPCS,Outpatient,,,71.23,35.62,,64.11,90,,,percent of total billed charges,90% of total Billed charges,67.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,48.71,155,,,Fee Schedule,155% of CMS OPPS Rate,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,48.71,145,,,Fee Schedule,145% of CMS OPPS Rate,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.28,145,,,Fee Schedule,145% of CMS OPPS Rate,48.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,72.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.9,98.28,
95251 ? CGM Analysis and Report,4279416,CDM,983,RC,95251,HCPCS,Outpatient,,,71.23,35.62,,64.11,90,,,percent of total billed charges,90% of total Billed charges,67.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,48.71,155,,,Fee Schedule,155% of CMS OPPS Rate,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,48.71,145,,,Fee Schedule,145% of CMS OPPS Rate,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.28,145,,,Fee Schedule,145% of CMS OPPS Rate,48.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,72.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.9,98.28,
95717- PF EEG PHYS/QHP 2-12 HR WITHOUT VIDEO,4348528,CDM,986,RC,95717,HCPCS,Outpatient,,,199.7,99.85,,179.73,90,,,percent of total billed charges,90% of total Billed charges,197.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.65,155,,,Fee Schedule,155% of CMS OPPS Rate,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,109.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.65,145,,,Fee Schedule,145% of CMS OPPS Rate,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.81,145,,,Fee Schedule,145% of CMS OPPS Rate,141.65,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.87,285.81,
95718- PF EEG PHYS/QHP 2-12 HR WITH VEEG,4348529,CDM,986,RC,95718,HCPCS,Outpatient,,,253.18,126.59,,227.86,90,,,percent of total billed charges,90% of total Billed charges,260.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.79,155,,,Fee Schedule,155% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,145.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.79,145,,,Fee Schedule,145% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.36,145,,,Fee Schedule,145% of CMS OPPS Rate,185.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.82,378.36,
95719- PF EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR WO VID,4348530,CDM,986,RC,95719,HCPCS,Outpatient,,,302.1,151.05,,271.89,90,,,percent of total billed charges,90% of total Billed charges,305.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.4,155,,,Fee Schedule,155% of CMS OPPS Rate,151.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,238.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,238.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,212.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,171.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.4,145,,,Fee Schedule,145% of CMS OPPS Rate,151.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,443,145,,,Fee Schedule,145% of CMS OPPS Rate,219.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,151.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,151.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.69,443,
95720- PF EEG PHYS/QHP EA INCR>12HR<26HR AFTER 24HR W/VEEG,4348531,CDM,986,RC,95720,HCPCS,Outpatient,,,389.68,194.84,,350.71,90,,,percent of total billed charges,90% of total Billed charges,402.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.35,155,,,Fee Schedule,155% of CMS OPPS Rate,198.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,286.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,286.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,313.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,313.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,179.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,224.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.35,145,,,Fee Schedule,145% of CMS OPPS Rate,198.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.05,145,,,Fee Schedule,145% of CMS OPPS Rate,287.35,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,198.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,232.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.4,584.05,
95721- PF EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/O VIDEO,4348532,CDM,986,RC,95721,HCPCS,Outpatient,,,388.8,194.40,,349.92,90,,,percent of total billed charges,90% of total Billed charges,401.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.88,155,,,Fee Schedule,155% of CMS OPPS Rate,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,316.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,316.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,285.88,145,,,Fee Schedule,145% of CMS OPPS Rate,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.81,145,,,Fee Schedule,145% of CMS OPPS Rate,285.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,234.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.03,581.81,
95722- PF EEG COMPLETE STD PHYS/QHP>36 HR<60 HR W/VEEG,4348533,CDM,986,RC,95722,HCPCS,Outpatient,,,472.24,236.12,,425.02,90,,,percent of total billed charges,90% of total Billed charges,489.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,240.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.61,155,,,Fee Schedule,155% of CMS OPPS Rate,240.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,240.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,349.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,349.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,383.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,383.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,340.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,275.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,348.61,145,,,Fee Schedule,145% of CMS OPPS Rate,240.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.59,145,,,Fee Schedule,145% of CMS OPPS Rate,348.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,240.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,284.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,240.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219,709.59,
95723- PF EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/O VIDEO,4348534,CDM,986,RC,95723,HCPCS,Outpatient,,,471.78,235.89,,424.6,90,,,percent of total billed charges,90% of total Billed charges,492.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.81,155,,,Fee Schedule,155% of CMS OPPS Rate,241.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,392.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,392.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,346.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,281.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,349.81,145,,,Fee Schedule,145% of CMS OPPS Rate,241.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,713.73,145,,,Fee Schedule,145% of CMS OPPS Rate,349.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,241.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,290.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,241.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.11,713.73,
95724- PF EEG COMPLETE STD PHYS/QHP>60 HR<84 HR W/VEEG,4348535,CDM,986,RC,95724,HCPCS,Outpatient,,,593.66,296.83,,534.29,90,,,percent of total billed charges,90% of total Billed charges,620.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,304.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.35,155,,,Fee Schedule,155% of CMS OPPS Rate,304.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,395.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,445.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,489.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,489.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,279.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,608.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,433.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,350.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,441.35,145,,,Fee Schedule,145% of CMS OPPS Rate,304.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.49,145,,,Fee Schedule,145% of CMS OPPS Rate,441.35,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,304.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,304.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.15,899.49,
95725- PF EEG COMPLETE STD PHYS/QHP>84 HR W/O VID,4348538,CDM,986,RC,95725,HCPCS,Outpatient,,,544.16,272.08,,489.74,90,,,percent of total billed charges,90% of total Billed charges,563.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,275.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.43,155,,,Fee Schedule,155% of CMS OPPS Rate,275.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,275.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,447.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,447.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,253.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,550.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,393.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,320.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,399.43,145,,,Fee Schedule,145% of CMS OPPS Rate,275.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,817.05,145,,,Fee Schedule,145% of CMS OPPS Rate,399.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,275.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,331.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,275.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.85,817.05,
95726- PF EEG COMPLETE STD PHYS/QHP>84 HR W/VEEG,4348539,CDM,986,RC,95726,HCPCS,Outpatient,,,760.48,380.24,,684.43,90,,,percent of total billed charges,90% of total Billed charges,788.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,386.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.66,155,,,Fee Schedule,155% of CMS OPPS Rate,386.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,386.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,562.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,619.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,619.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,352.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,547.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,443.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,560.66,145,,,Fee Schedule,145% of CMS OPPS Rate,386.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1142.83,145,,,Fee Schedule,145% of CMS OPPS Rate,560.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,386.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,459.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,386.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.78,1142.83,
95800- Sleep study/unattended/w recording,3435907,CDM,921,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,70.7,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,76.19,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,72.27,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,54.99,70,,,percent of total billed charges,70% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,67.55,86,,,percent of total billed charges,86% of total billed charges,62.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,76.19,97,,,percent of total billed charges,97% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.19,97,,,percent of total billed charges,97% of total billed charges,73.05,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.19,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.99,708.98,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,70.7,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,76.19,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,72.27,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,54.99,70,,,percent of total billed charges,70% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,67.55,86,,,percent of total billed charges,86% of total billed charges,62.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,76.19,97,,,percent of total billed charges,97% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.19,97,,,percent of total billed charges,97% of total billed charges,73.05,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.19,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.99,708.98,
Nocturnal Study,604506,CDM,920,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,70.7,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,62.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,76.19,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,72.27,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,54.99,70,,,percent of total billed charges,70% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,74.62,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,67.55,86,,,percent of total billed charges,86% of total billed charges,62.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,76.19,97,,,percent of total billed charges,97% of total billed charges,70.7,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.19,97,,,percent of total billed charges,97% of total billed charges,73.05,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.19,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.99,708.98,
95801- Sleep study/unattend/rec HR/sat/RR,3435908,CDM,510,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,72.83,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,64.74,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.49,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,74.45,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,70,,,percent of total billed charges,70% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.59,86,,,percent of total billed charges,86% of total billed charges,64.74,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.49,97,,,percent of total billed charges,97% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.49,97,,,percent of total billed charges,97% of total billed charges,75.26,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,78.49,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,56.64,566.05,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,72.83,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,64.74,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.49,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,74.45,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,56.64,70,,,percent of total billed charges,70% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,76.87,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.59,86,,,percent of total billed charges,86% of total billed charges,64.74,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.49,97,,,percent of total billed charges,97% of total billed charges,72.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.49,97,,,percent of total billed charges,97% of total billed charges,75.26,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,78.49,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,56.64,566.05,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,113.34,56.67,,102.01,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,90.67,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.01,90,,,Percent of total Billed charges,90% of total billed charges,221.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,109.94,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,104.27,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,102.01,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,79.34,70,,,percent of total billed charges,70% of total billed charges,102.01,90,,,percent of total billed charges,90% of total billed charges,107.67,95,,,percent of total billed charges,95% of total billed charges,107.67,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,97.47,86,,,percent of total billed charges,86% of total billed charges,90.67,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,109.94,97,,,percent of total billed charges,97% of total billed charges,102.01,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.94,97,,,percent of total billed charges,97% of total billed charges,105.41,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109.94,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79.34,2356.78,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,87.09,43.55,,78.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,69.67,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,84.48,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,80.12,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,78.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,60.96,70,,,percent of total billed charges,70% of total billed charges,78.38,90,,,percent of total billed charges,90% of total billed charges,82.74,95,,,percent of total billed charges,95% of total billed charges,82.74,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,74.9,86,,,percent of total billed charges,86% of total billed charges,69.67,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,84.48,97,,,percent of total billed charges,97% of total billed charges,78.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.48,97,,,percent of total billed charges,97% of total billed charges,80.99,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.48,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60.96,708.98,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,753.51,376.76,,678.16,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,602.81,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,678.16,90,,,Percent of total Billed charges,90% of total billed charges,310.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,730.9,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,693.23,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,678.16,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,527.46,70,,,percent of total billed charges,70% of total billed charges,678.16,90,,,percent of total billed charges,90% of total billed charges,715.83,95,,,percent of total billed charges,95% of total billed charges,715.83,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,648.02,86,,,percent of total billed charges,86% of total billed charges,602.81,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,730.9,97,,,percent of total billed charges,97% of total billed charges,678.16,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.9,97,,,percent of total billed charges,97% of total billed charges,700.76,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,730.9,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281.99,2356.78,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,164.64,82.32,,148.18,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,131.71,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.18,90,,,Percent of total Billed charges,90% of total billed charges,301.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,159.7,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,151.47,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.18,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,115.25,70,,,percent of total billed charges,70% of total billed charges,148.18,90,,,percent of total billed charges,90% of total billed charges,156.41,95,,,percent of total billed charges,95% of total billed charges,156.41,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,141.59,86,,,percent of total billed charges,86% of total billed charges,131.71,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,159.7,97,,,percent of total billed charges,97% of total billed charges,148.18,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.7,97,,,percent of total billed charges,97% of total billed charges,153.12,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159.7,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,115.25,4555.21,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,234.54,117.27,,211.09,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,187.63,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.09,90,,,Percent of total Billed charges,90% of total billed charges,297.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,227.5,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,215.78,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,211.09,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,164.18,70,,,percent of total billed charges,70% of total billed charges,211.09,90,,,percent of total billed charges,90% of total billed charges,222.81,95,,,percent of total billed charges,95% of total billed charges,222.81,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,201.7,86,,,percent of total billed charges,86% of total billed charges,187.63,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,227.5,97,,,percent of total billed charges,97% of total billed charges,211.09,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.5,97,,,percent of total billed charges,97% of total billed charges,218.12,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.5,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,164.18,4555.21,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,244.18,122.09,,219.76,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,195.34,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.76,90,,,Percent of total Billed charges,90% of total billed charges,569.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,236.85,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,224.65,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,219.76,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,170.93,70,,,percent of total billed charges,70% of total billed charges,219.76,90,,,percent of total billed charges,90% of total billed charges,231.97,95,,,percent of total billed charges,95% of total billed charges,231.97,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,209.99,86,,,percent of total billed charges,86% of total billed charges,195.34,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,236.85,97,,,percent of total billed charges,97% of total billed charges,219.76,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.85,97,,,percent of total billed charges,97% of total billed charges,227.09,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.85,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,170.93,4555.21,
95812 PF EEG Extended Monitoring 41-60mins,4315920,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,552.56,90,,,percent of total billed charges,90% of total Billed charges,509.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,367.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,259.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,319.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.17,145,,,Fee Schedule,145% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,738.96,145,,,Fee Schedule,145% of CMS OPPS Rate,367.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,621.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,621.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.48,738.96,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,552.56,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,491.17,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.56,90,,,Percent of total Billed charges,90% of total billed charges,42.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.54,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,564.84,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.56,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,429.77,70,,,percent of total billed charges,70% of total billed charges,552.56,90,,,percent of total billed charges,90% of total billed charges,583.26,95,,,percent of total billed charges,95% of total billed charges,583.26,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,528.01,86,,,percent of total billed charges,86% of total billed charges,491.17,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.54,97,,,percent of total billed charges,97% of total billed charges,552.56,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.54,97,,,percent of total billed charges,97% of total billed charges,570.98,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.54,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.93,1365.32,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,740,RC,95812,HCPCS,Outpatient,,,681.91,340.96,,613.72,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,545.53,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,613.72,90,,,Percent of total Billed charges,90% of total billed charges,42.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,661.45,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,627.36,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,613.72,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,477.34,70,,,percent of total billed charges,70% of total billed charges,613.72,90,,,percent of total billed charges,90% of total billed charges,647.81,95,,,percent of total billed charges,95% of total billed charges,647.81,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,586.44,86,,,percent of total billed charges,86% of total billed charges,545.53,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,661.45,97,,,percent of total billed charges,97% of total billed charges,613.72,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.45,97,,,percent of total billed charges,97% of total billed charges,634.18,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,661.45,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.93,1365.32,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,740,RC,95813,HCPCS,Outpatient,,,805.85,402.93,,725.27,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,644.68,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,725.27,90,,,Percent of total Billed charges,90% of total billed charges,48.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,781.67,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,741.38,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,725.27,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,564.1,70,,,percent of total billed charges,70% of total billed charges,725.27,90,,,percent of total billed charges,90% of total billed charges,765.56,95,,,percent of total billed charges,95% of total billed charges,765.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,693.03,86,,,percent of total billed charges,86% of total billed charges,644.68,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,781.67,97,,,percent of total billed charges,97% of total billed charges,725.27,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,781.67,97,,,percent of total billed charges,97% of total billed charges,749.44,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,781.67,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.45,1365.32,
95813 PF EEG Extended Monitoring 61-119mins,4315855,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,689.15,90,,,percent of total billed charges,90% of total Billed charges,604.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,116.87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,436.89,155,,,Fee Schedule,155% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.89,145,,,Fee Schedule,145% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.28,145,,,Fee Schedule,145% of CMS OPPS Rate,436.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,660.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,116.87,876.28,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,689.15,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,612.58,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,689.15,90,,,Percent of total Billed charges,90% of total billed charges,48.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,742.75,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,704.46,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,689.15,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,536,70,,,percent of total billed charges,70% of total billed charges,689.15,90,,,percent of total billed charges,90% of total billed charges,727.43,95,,,percent of total billed charges,95% of total billed charges,727.43,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,658.52,86,,,percent of total billed charges,86% of total billed charges,612.58,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,742.75,97,,,percent of total billed charges,97% of total billed charges,689.15,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.75,97,,,percent of total billed charges,97% of total billed charges,712.12,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,742.75,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.45,1365.32,
95816 - PF EEG Includes Recording Awake and Drowsy,4315856,CDM,960,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,102.38,90,,,percent of total billed charges,90% of total Billed charges,227.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.95,155,,,Fee Schedule,155% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,499.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,487.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,487.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,289.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.95,145,,,Fee Schedule,145% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.9,145,,,Fee Schedule,145% of CMS OPPS Rate,164.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,281.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,578.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,578.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,578.75,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,102.38,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,91.01,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.38,90,,,Percent of total Billed charges,90% of total billed charges,14.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,110.35,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,104.66,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,102.38,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,79.63,70,,,percent of total billed charges,70% of total billed charges,102.38,90,,,percent of total billed charges,90% of total billed charges,108.07,95,,,percent of total billed charges,95% of total billed charges,108.07,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,97.83,86,,,percent of total billed charges,86% of total billed charges,91.01,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,110.35,97,,,percent of total billed charges,97% of total billed charges,102.38,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.35,97,,,percent of total billed charges,97% of total billed charges,105.8,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.35,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.5,1365.32,
95819 - PF EEG Includes Recording Awake and Asleep,4315921,CDM,960,RC,95819,HCPCS,Outpatient,,,785.9,392.95,,707.31,90,,,percent of total billed charges,90% of total Billed charges,685.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,339.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,593.26,90,,,Percent of total Billed charges,90% of total billed charges,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,491.83,155,,,Fee Schedule,155% of CMS OPPS Rate,339.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,339.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,593.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,593.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,577.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,577.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.83,145,,,Fee Schedule,145% of CMS OPPS Rate,339.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,993.82,145,,,Fee Schedule,145% of CMS OPPS Rate,491.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,339.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,339.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,661.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,993.82,
95822 - (26) Electroencephalogram (EEG); recording in coma or sleep only,3899091,CDM,983,RC,95822,HCPCS,Outpatient,,,111.91,55.96,,100.72,90,,,percent of total billed charges,90% of total Billed charges,223.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.27,155,,,Fee Schedule,155% of CMS OPPS Rate,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.27,145,,,Fee Schedule,145% of CMS OPPS Rate,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.54,145,,,Fee Schedule,145% of CMS OPPS Rate,162.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,594.15,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,111.91,55.96,,100.72,90,,,percent of total billed charges,90% of total Billed charges,223.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.27,155,,,Fee Schedule,155% of CMS OPPS Rate,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,223.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.27,145,,,Fee Schedule,145% of CMS OPPS Rate,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.54,145,,,Fee Schedule,145% of CMS OPPS Rate,162.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,594.15,
95824 - (26) Electroencephalogram (EEG); cerebral death evaluation only,3899093,CDM,983,RC,95824,HCPCS,Outpatient,,,100.94,50.47,,90.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,139.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,317.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,317.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,317.09,
95824 - Electroencephalogram (EEG); cerebral death evaluation only,3800935,CDM,983,RC,95824,HCPCS,Outpatient,,,100.94,50.47,,90.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,139.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,317.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,317.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25,317.09,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,510,RC,95860,HCPCS,Outpatient,,,150.34,75.17,,135.31,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,120.27,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.31,90,,,Percent of total Billed charges,90% of total billed charges,19.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.83,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,138.31,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.31,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.24,70,,,percent of total billed charges,70% of total billed charges,135.31,90,,,percent of total billed charges,90% of total billed charges,142.82,95,,,percent of total billed charges,95% of total billed charges,142.82,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.29,86,,,percent of total billed charges,86% of total billed charges,120.27,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.83,97,,,percent of total billed charges,97% of total billed charges,135.31,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.83,97,,,percent of total billed charges,97% of total billed charges,139.82,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.83,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.5,566.05,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,510,RC,95861,HCPCS,Outpatient,,,198.53,99.27,,178.68,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,158.82,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.68,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,192.57,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,182.65,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,178.68,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,138.97,70,,,percent of total billed charges,70% of total billed charges,178.68,90,,,percent of total billed charges,90% of total billed charges,188.6,95,,,percent of total billed charges,95% of total billed charges,188.6,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,170.74,86,,,percent of total billed charges,86% of total billed charges,158.82,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,192.57,97,,,percent of total billed charges,97% of total billed charges,178.68,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.57,97,,,percent of total billed charges,97% of total billed charges,184.63,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,192.57,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,566.05,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,510,RC,95863,HCPCS,Outpatient,,,276.68,138.34,,249.01,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,221.34,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.01,90,,,Percent of total Billed charges,90% of total billed charges,27.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,268.38,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,254.55,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,249.01,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,193.68,70,,,percent of total billed charges,70% of total billed charges,249.01,90,,,percent of total billed charges,90% of total billed charges,262.85,95,,,percent of total billed charges,95% of total billed charges,262.85,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,237.94,86,,,percent of total billed charges,86% of total billed charges,221.34,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,268.38,97,,,percent of total billed charges,97% of total billed charges,249.01,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.38,97,,,percent of total billed charges,97% of total billed charges,257.31,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,268.38,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25,708.98,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,510,RC,95864,HCPCS,Outpatient,,,320.11,160.06,,288.1,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,256.09,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.1,90,,,Percent of total Billed charges,90% of total billed charges,31.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,310.51,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,294.5,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,288.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,224.08,70,,,percent of total billed charges,70% of total billed charges,288.1,90,,,percent of total billed charges,90% of total billed charges,304.1,95,,,percent of total billed charges,95% of total billed charges,304.1,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,275.29,86,,,percent of total billed charges,86% of total billed charges,256.09,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,310.51,97,,,percent of total billed charges,97% of total billed charges,288.1,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.51,97,,,percent of total billed charges,97% of total billed charges,297.7,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.51,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29,708.98,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,510,RC,95869,HCPCS,Outpatient,,,189.03,94.52,,170.13,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,151.22,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.13,90,,,Percent of total Billed charges,90% of total billed charges,8.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,183.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,173.91,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.13,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.32,70,,,percent of total billed charges,70% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,162.57,86,,,percent of total billed charges,86% of total billed charges,151.22,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.36,97,,,percent of total billed charges,97% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.36,97,,,percent of total billed charges,97% of total billed charges,175.8,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.79,708.98,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,510,RC,95870,HCPCS,Outpatient,,,158.23,79.12,,142.41,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,126.58,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.41,90,,,Percent of total Billed charges,90% of total billed charges,18.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,153.48,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,145.57,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,142.41,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,110.76,70,,,percent of total billed charges,70% of total billed charges,142.41,90,,,percent of total billed charges,90% of total billed charges,150.32,95,,,percent of total billed charges,95% of total billed charges,150.32,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,136.08,86,,,percent of total billed charges,86% of total billed charges,126.58,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,153.48,97,,,percent of total billed charges,97% of total billed charges,142.41,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.48,97,,,percent of total billed charges,97% of total billed charges,147.15,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.48,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.26,566.05,
95873- Electric stim/w chemodenervation,3435482,CDM,510,RC,95873,HCPCS,Outpatient,,,134.25,67.13,,120.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,107.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,120.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,130.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,123.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,85.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,105.59,78.65,,,percent of total billed charges,78.65% of total billed charges,119.93,89.33,,,percent of total billed charges,89.33% of total billed charges,120.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.98,70,,,percent of total billed charges,70% of total billed charges,120.83,90,,,percent of total billed charges,90% of total billed charges,127.54,95,,,percent of total billed charges,95% of total billed charges,127.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.46,86,,,percent of total billed charges,86% of total billed charges,107.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,130.22,97,,,percent of total billed charges,97% of total billed charges,120.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,130.22,97,,,percent of total billed charges,97% of total billed charges,124.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.74,130.22,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,143.71,71.86,,129.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,114.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,129.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,132.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,91.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,113.03,78.65,,,percent of total billed charges,78.65% of total billed charges,128.38,89.33,,,percent of total billed charges,89.33% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,100.6,70,,,percent of total billed charges,70% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,136.52,95,,,percent of total billed charges,95% of total billed charges,136.52,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.59,86,,,percent of total billed charges,86% of total billed charges,114.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,133.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.78,139.4,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,143.71,71.86,,129.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,114.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,129.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,132.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,91.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,113.03,78.65,,,percent of total billed charges,78.65% of total billed charges,128.38,89.33,,,percent of total billed charges,89.33% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,100.6,70,,,percent of total billed charges,70% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,136.52,95,,,percent of total billed charges,95% of total billed charges,136.52,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.59,86,,,percent of total billed charges,86% of total billed charges,114.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,129.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,133.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.78,139.4,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,510,RC,95885,HCPCS,Outpatient,,,108.99,54.50,,98.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,87.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,98.09,90,,,Percent of total Billed charges,90% of total billed charges,30.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,105.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,100.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,69.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,85.72,78.65,,,percent of total billed charges,78.65% of total billed charges,97.36,89.33,,,percent of total billed charges,89.33% of total billed charges,98.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,76.29,70,,,percent of total billed charges,70% of total billed charges,98.09,90,,,percent of total billed charges,90% of total billed charges,103.54,95,,,percent of total billed charges,95% of total billed charges,103.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.73,86,,,percent of total billed charges,86% of total billed charges,87.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,105.72,97,,,percent of total billed charges,97% of total billed charges,98.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,105.72,97,,,percent of total billed charges,97% of total billed charges,101.36,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,105.72,
95886- Needle electromyography/ea ext/com,3435486,CDM,510,RC,95886,HCPCS,Outpatient,,,130.28,65.14,,117.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,104.22,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,117.25,90,,,Percent of total Billed charges,90% of total billed charges,32.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,119.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,83.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,102.47,78.65,,,percent of total billed charges,78.65% of total billed charges,116.38,89.33,,,percent of total billed charges,89.33% of total billed charges,117.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,91.2,70,,,percent of total billed charges,70% of total billed charges,117.25,90,,,percent of total billed charges,90% of total billed charges,123.77,95,,,percent of total billed charges,95% of total billed charges,123.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.04,86,,,percent of total billed charges,86% of total billed charges,104.22,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,126.37,97,,,percent of total billed charges,97% of total billed charges,117.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,126.37,97,,,percent of total billed charges,97% of total billed charges,121.16,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,126.37,
95887- Needle electromyography/non-ext,3435487,CDM,510,RC,95887,HCPCS,Outpatient,,,116.08,58.04,,104.47,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,92.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,104.47,90,,,Percent of total Billed charges,90% of total billed charges,32.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,112.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,106.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,74.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,91.3,78.65,,,percent of total billed charges,78.65% of total billed charges,103.7,89.33,,,percent of total billed charges,89.33% of total billed charges,104.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,81.26,70,,,percent of total billed charges,70% of total billed charges,104.47,90,,,percent of total billed charges,90% of total billed charges,110.28,95,,,percent of total billed charges,95% of total billed charges,110.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.83,86,,,percent of total billed charges,86% of total billed charges,92.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,112.6,97,,,percent of total billed charges,97% of total billed charges,104.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,112.6,97,,,percent of total billed charges,97% of total billed charges,107.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,112.6,
95907- Nerve conduction study/1-2 study,3435491,CDM,510,RC,95907,HCPCS,Outpatient,,,92.71,46.36,,83.44,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,74.17,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.44,90,,,Percent of total Billed charges,90% of total billed charges,34.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,89.93,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,85.29,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,83.44,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,64.9,70,,,percent of total billed charges,70% of total billed charges,83.44,90,,,percent of total billed charges,90% of total billed charges,88.07,95,,,percent of total billed charges,95% of total billed charges,88.07,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,79.73,86,,,percent of total billed charges,86% of total billed charges,74.17,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,89.93,97,,,percent of total billed charges,97% of total billed charges,83.44,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.93,97,,,percent of total billed charges,97% of total billed charges,86.22,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,89.93,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.48,708.98,
95908- Nerve conduction study/3-4 study,3435492,CDM,510,RC,95908,HCPCS,Outpatient,,,114.8,57.40,,103.32,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,91.84,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.32,90,,,Percent of total Billed charges,90% of total billed charges,41.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,111.36,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,105.62,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,103.32,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,80.36,70,,,percent of total billed charges,70% of total billed charges,103.32,90,,,percent of total billed charges,90% of total billed charges,109.06,95,,,percent of total billed charges,95% of total billed charges,109.06,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,98.73,86,,,percent of total billed charges,86% of total billed charges,91.84,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,111.36,97,,,percent of total billed charges,97% of total billed charges,103.32,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.36,97,,,percent of total billed charges,97% of total billed charges,106.76,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.36,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.94,1365.32,
95909- Nerve conduction study/5-6 study,3435493,CDM,510,RC,95909,HCPCS,Outpatient,,,137.7,68.85,,123.93,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,110.16,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.93,90,,,Percent of total Billed charges,90% of total billed charges,50.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,133.57,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,126.68,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,123.93,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,96.39,70,,,percent of total billed charges,70% of total billed charges,123.93,90,,,percent of total billed charges,90% of total billed charges,130.82,95,,,percent of total billed charges,95% of total billed charges,130.82,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,118.42,86,,,percent of total billed charges,86% of total billed charges,110.16,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,133.57,97,,,percent of total billed charges,97% of total billed charges,123.93,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.57,97,,,percent of total billed charges,97% of total billed charges,128.06,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.57,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.76,1365.32,
95910- Nerve conduction study/7-8 study,3435494,CDM,510,RC,95910,HCPCS,Outpatient,,,174.83,87.42,,157.35,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,139.86,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.35,90,,,Percent of total Billed charges,90% of total billed charges,64.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,169.59,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,160.84,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,157.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,122.38,70,,,percent of total billed charges,70% of total billed charges,157.35,90,,,percent of total billed charges,90% of total billed charges,166.09,95,,,percent of total billed charges,95% of total billed charges,166.09,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,150.35,86,,,percent of total billed charges,86% of total billed charges,139.86,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,169.59,97,,,percent of total billed charges,97% of total billed charges,157.35,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.59,97,,,percent of total billed charges,97% of total billed charges,162.59,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,169.59,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.99,1365.32,
95911- Nerve conduction study/9-10 study,3435495,CDM,510,RC,95911,HCPCS,Outpatient,,,200.89,100.45,,180.8,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,160.71,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.8,90,,,Percent of total Billed charges,90% of total billed charges,75.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,194.86,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,184.82,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,180.8,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,140.62,70,,,percent of total billed charges,70% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,172.77,86,,,percent of total billed charges,86% of total billed charges,160.71,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,194.86,97,,,percent of total billed charges,97% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.86,97,,,percent of total billed charges,97% of total billed charges,186.83,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.86,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,68.54,2356.78,
95912- Nerve conduction study/11-12 study,3435496,CDM,510,RC,95912,HCPCS,Outpatient,,,225.67,112.84,,203.1,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,180.54,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.1,90,,,Percent of total Billed charges,90% of total billed charges,85.31,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.9,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,207.62,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,203.1,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,157.97,70,,,percent of total billed charges,70% of total billed charges,203.1,90,,,percent of total billed charges,90% of total billed charges,214.39,95,,,percent of total billed charges,95% of total billed charges,214.39,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,194.08,86,,,percent of total billed charges,86% of total billed charges,180.54,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.9,97,,,percent of total billed charges,97% of total billed charges,203.1,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.9,97,,,percent of total billed charges,97% of total billed charges,209.87,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.9,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77.55,2356.78,
95913- Nerve conduction studies/13 >,3435497,CDM,510,RC,95913,HCPCS,Outpatient,,,250.13,125.07,,225.12,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,200.1,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.12,90,,,Percent of total Billed charges,90% of total billed charges,95.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,242.63,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,230.12,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225.12,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,175.09,70,,,percent of total billed charges,70% of total billed charges,225.12,90,,,percent of total billed charges,90% of total billed charges,237.62,95,,,percent of total billed charges,95% of total billed charges,237.62,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215.11,86,,,percent of total billed charges,86% of total billed charges,200.1,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,242.63,97,,,percent of total billed charges,97% of total billed charges,225.12,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.63,97,,,percent of total billed charges,97% of total billed charges,232.62,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.63,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.86,2356.78,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,510,RC,95937,HCPCS,Outpatient,,,172.45,86.23,,155.21,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,137.96,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.21,90,,,Percent of total Billed charges,90% of total billed charges,13.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.28,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,158.65,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,155.21,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,120.72,70,,,percent of total billed charges,70% of total billed charges,155.21,90,,,percent of total billed charges,90% of total billed charges,163.83,95,,,percent of total billed charges,95% of total billed charges,163.83,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.31,86,,,percent of total billed charges,86% of total billed charges,137.96,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.28,97,,,percent of total billed charges,97% of total billed charges,155.21,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.28,97,,,percent of total billed charges,97% of total billed charges,160.38,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.28,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.23,708.98,
95970- VNS evaluation,3435519,CDM,510,RC,95970,HCPCS,Outpatient,,,50.05,25.03,,45.05,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,40.04,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.05,90,,,Percent of total Billed charges,90% of total billed charges,21.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,48.55,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,46.05,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,45.05,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,35.04,70,,,percent of total billed charges,70% of total billed charges,45.05,90,,,percent of total billed charges,90% of total billed charges,47.55,95,,,percent of total billed charges,95% of total billed charges,47.55,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,43.04,86,,,percent of total billed charges,86% of total billed charges,40.04,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,48.55,97,,,percent of total billed charges,97% of total billed charges,45.05,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.55,97,,,percent of total billed charges,97% of total billed charges,46.55,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.55,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.34,566.05,
95972 - PF Electronic Analysis Neurostimulator Complex Program by Physician/Health Professional,4331193,CDM,960,RC,95972,HCPCS,Outpatient,,,76.88,38.44,,69.19,90,,,percent of total billed charges,90% of total Billed charges,94.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.2,155,,,Fee Schedule,155% of CMS OPPS Rate,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,58.2,145,,,Fee Schedule,145% of CMS OPPS Rate,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.47,145,,,Fee Schedule,145% of CMS OPPS Rate,58.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,181.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.14,181.89,
95976 - (NPB Global) Electronic analysis of implanted neurostimulator pulse generator/transmitter (e,3635241,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53.00,,95.4,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.8,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.4,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,102.82,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,97.52,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.2,70,,,percent of total billed charges,70% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.16,86,,,percent of total billed charges,86% of total billed charges,84.8,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,102.82,97,,,percent of total billed charges,97% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.82,97,,,percent of total billed charges,97% of total billed charges,98.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.82,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"95976 - (PB Tech) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg,",3635242,CDM,510,RC,95976,HCPCS,Outpatient,,,102.87,51.44,,92.58,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,82.3,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.58,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,99.78,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,94.64,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,92.58,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,72.01,70,,,percent of total billed charges,70% of total billed charges,92.58,90,,,percent of total billed charges,90% of total billed charges,97.73,95,,,percent of total billed charges,95% of total billed charges,97.73,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,88.47,86,,,percent of total billed charges,86% of total billed charges,82.3,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,99.78,97,,,percent of total billed charges,97% of total billed charges,92.58,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.78,97,,,percent of total billed charges,97% of total billed charges,95.67,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.78,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53.00,,95.4,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.8,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.4,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,102.82,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,97.52,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.2,70,,,percent of total billed charges,70% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.16,86,,,percent of total billed charges,86% of total billed charges,84.8,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,102.82,97,,,percent of total billed charges,97% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.82,97,,,percent of total billed charges,97% of total billed charges,98.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.82,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,510,RC,95976,HCPCS,Outpatient,,,106,53.00,,95.4,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.8,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.4,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,102.82,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,97.52,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,74.2,70,,,percent of total billed charges,70% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.16,86,,,percent of total billed charges,86% of total billed charges,84.8,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,102.82,97,,,percent of total billed charges,97% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.82,97,,,percent of total billed charges,97% of total billed charges,98.58,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.82,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,510,RC,95977,HCPCS,Outpatient,,,139.77,69.89,,125.79,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,111.82,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.79,90,,,Percent of total Billed charges,90% of total billed charges,47.37,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.58,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,128.59,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.79,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,97.84,70,,,percent of total billed charges,70% of total billed charges,125.79,90,,,percent of total billed charges,90% of total billed charges,132.78,95,,,percent of total billed charges,95% of total billed charges,132.78,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,120.2,86,,,percent of total billed charges,86% of total billed charges,111.82,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.58,97,,,percent of total billed charges,97% of total billed charges,125.79,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.58,97,,,percent of total billed charges,97% of total billed charges,129.99,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.58,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.06,486.58,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,510,RC,95977,HCPCS,Outpatient,,,139.77,69.89,,125.79,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,111.82,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.79,90,,,Percent of total Billed charges,90% of total billed charges,47.37,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.58,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,128.59,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.79,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,97.84,70,,,percent of total billed charges,70% of total billed charges,125.79,90,,,percent of total billed charges,90% of total billed charges,132.78,95,,,percent of total billed charges,95% of total billed charges,132.78,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,120.2,86,,,percent of total billed charges,86% of total billed charges,111.82,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.58,97,,,percent of total billed charges,97% of total billed charges,125.79,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.58,97,,,percent of total billed charges,97% of total billed charges,129.99,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.58,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.06,486.58,
95992 - Epley Maneuver,3575063,CDM,510,RC,95992,HCPCS,Outpatient,,,112.12,56.06,,100.91,90,,,percent of total billed charges,90% of total Billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,89.7,80,,,Percent of total Billed charges,80% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,108.76,97,,,Percent of total billed charges,97% of total billed charges,35.1,100,,,Fee Schedule,100% of CMS OPPS Rate,103.15,92,,,Percent of total billed charges,92% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,143.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,161.82,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,100.91,90,,,percent of total billed charges,90% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,78.48,70,,,percent of total billed charges,70% of total billed charges,100.91,90,,,percent of total billed charges,90% of total billed charges,106.51,95,,,percent of total billed charges,95% of total billed charges,106.51,95,,,percent of total billed charges,95% of total billed charges,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,96.42,86,,,percent of total billed charges,86% of total billed charges,89.7,80,,,percent of total billed charges,80% of total billed charges,42.15,111,,,Fee Schedule,111% of CMS OPPS Rate,108.76,97,,,percent of total billed charges,97% of total billed charges,100.91,90,,,percent of total billed charges,90% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.76,97,,,percent of total billed charges,97% of total billed charges,104.27,93,,,percent of total billed charges,93% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.76,97,,,percent of total billed charges,97% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.29,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,30,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30,174.41,
96105- Asses aphasia/interp/rpt/per hr,3435448,CDM,510,RC,96105,HCPCS,Outpatient,,,254.2,127.10,,228.78,90,,,percent of total billed charges,90% of total Billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,203.36,80,,,Percent of total Billed charges,80% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.78,90,,,Percent of total Billed charges,90% of total billed charges,33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,246.57,97,,,Percent of total billed charges,97% of total billed charges,93.72,100,,,Fee Schedule,100% of CMS OPPS Rate,233.86,92,,,Percent of total billed charges,92% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,382.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,94.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,431.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,228.78,90,,,percent of total billed charges,90% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,177.94,70,,,percent of total billed charges,70% of total billed charges,228.78,90,,,percent of total billed charges,90% of total billed charges,241.49,95,,,percent of total billed charges,95% of total billed charges,241.49,95,,,percent of total billed charges,95% of total billed charges,94.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,218.61,86,,,percent of total billed charges,86% of total billed charges,203.36,80,,,percent of total billed charges,80% of total billed charges,112.01,111,,,Fee Schedule,111% of CMS OPPS Rate,246.57,97,,,percent of total billed charges,97% of total billed charges,228.78,90,,,percent of total billed charges,90% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.57,97,,,percent of total billed charges,97% of total billed charges,236.41,93,,,percent of total billed charges,93% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.57,97,,,percent of total billed charges,97% of total billed charges,94.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30,465.52,
96110- Developmental screen/score/documen,3435449,CDM,920,RC,96110,HCPCS,Outpatient,,,26.83,13.42,,24.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,21.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.15,90,,,Percent of total Billed charges,90% of total billed charges,7.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,26.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,24.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,17.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,21.1,78.65,,,percent of total billed charges,78.65% of total billed charges,23.97,89.33,,,percent of total billed charges,89.33% of total billed charges,24.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.78,70,,,percent of total billed charges,70% of total billed charges,24.15,90,,,percent of total billed charges,90% of total billed charges,25.49,95,,,percent of total billed charges,95% of total billed charges,25.49,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,86,,,percent of total billed charges,86% of total billed charges,21.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,26.03,97,,,percent of total billed charges,97% of total billed charges,24.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.03,97,,,percent of total billed charges,97% of total billed charges,24.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,26.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.99,26.03,
96110- Developmental Screening,3437848,CDM,983,RC,96110,HCPCS,Outpatient,,,26.83,13.42,,24.15,90,,,percent of total billed charges,90% of total Billed charges,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,13.72,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.72,145,,,Fee Schedule,145% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.23,145,,,Fee Schedule,145% of CMS OPPS Rate,13.72,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.99,27.23,
96116- Neurobehavioral status exam/hr,3435451,CDM,510,RC,96116,HCPCS,Outpatient,,,245.86,122.93,,221.27,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,196.69,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,238.48,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,226.19,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,221.27,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,172.1,70,,,percent of total billed charges,70% of total billed charges,221.27,90,,,percent of total billed charges,90% of total billed charges,233.57,95,,,percent of total billed charges,95% of total billed charges,233.57,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,211.44,86,,,percent of total billed charges,86% of total billed charges,196.69,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,238.48,97,,,percent of total billed charges,97% of total billed charges,221.27,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.48,97,,,percent of total billed charges,97% of total billed charges,228.65,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.48,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,172.1,1365.32,
96116- Neuropsychological Assessment,3437849,CDM,983,RC,96116,HCPCS,Outpatient,,,245.86,122.93,,221.27,90,,,percent of total billed charges,90% of total Billed charges,171.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.54,155,,,Fee Schedule,155% of CMS OPPS Rate,78.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,114.54,145,,,Fee Schedule,145% of CMS OPPS Rate,78.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.57,145,,,Fee Schedule,145% of CMS OPPS Rate,114.54,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.67,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151.67,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.55,248.57,
96125- Stand cognitive perf test/prof I&R,3435455,CDM,510,RC,96125,HCPCS,Outpatient,,,266.64,133.32,,239.98,90,,,percent of total billed charges,90% of total Billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,213.31,80,,,Percent of total Billed charges,80% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,258.64,97,,,Percent of total billed charges,97% of total billed charges,97.49,100,,,Fee Schedule,100% of CMS OPPS Rate,245.31,92,,,Percent of total billed charges,92% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,396.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,448.32,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,239.98,90,,,percent of total billed charges,90% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,186.65,70,,,percent of total billed charges,70% of total billed charges,239.98,90,,,percent of total billed charges,90% of total billed charges,253.31,95,,,percent of total billed charges,95% of total billed charges,253.31,95,,,percent of total billed charges,95% of total billed charges,97.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,229.31,86,,,percent of total billed charges,86% of total billed charges,213.31,80,,,percent of total billed charges,80% of total billed charges,117.4,111,,,Fee Schedule,111% of CMS OPPS Rate,258.64,97,,,percent of total billed charges,97% of total billed charges,239.98,90,,,percent of total billed charges,90% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.64,97,,,percent of total billed charges,97% of total billed charges,247.98,93,,,percent of total billed charges,93% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,258.64,97,,,percent of total billed charges,97% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,83.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,83.1,483.21,
96125- Standardized Cognitive Performance Testing Per Hr,3435456,CDM,510,RC,96125,HCPCS,Outpatient,,,266.64,133.32,,239.98,90,,,percent of total billed charges,90% of total Billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,213.31,80,,,Percent of total Billed charges,80% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,258.64,97,,,Percent of total billed charges,97% of total billed charges,97.49,100,,,Fee Schedule,100% of CMS OPPS Rate,245.31,92,,,Percent of total billed charges,92% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,396.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,483.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,448.32,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,239.98,90,,,percent of total billed charges,90% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,186.65,70,,,percent of total billed charges,70% of total billed charges,239.98,90,,,percent of total billed charges,90% of total billed charges,253.31,95,,,percent of total billed charges,95% of total billed charges,253.31,95,,,percent of total billed charges,95% of total billed charges,97.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,229.31,86,,,percent of total billed charges,86% of total billed charges,213.31,80,,,percent of total billed charges,80% of total billed charges,117.4,111,,,Fee Schedule,111% of CMS OPPS Rate,258.64,97,,,percent of total billed charges,97% of total billed charges,239.98,90,,,percent of total billed charges,90% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.64,97,,,percent of total billed charges,97% of total billed charges,247.98,93,,,percent of total billed charges,93% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,258.64,97,,,percent of total billed charges,97% of total billed charges,97.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,83.1,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,83.1,483.21,
"96127- Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactiv",3566798,CDM,510,RC,96127,HCPCS,Outpatient,,,11.38,5.69,,10.24,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,9.1,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.24,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,11.04,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,10.47,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10.24,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,7.97,70,,,percent of total billed charges,70% of total billed charges,10.24,90,,,percent of total billed charges,90% of total billed charges,10.81,95,,,percent of total billed charges,95% of total billed charges,10.81,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9.79,86,,,percent of total billed charges,86% of total billed charges,9.1,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11.04,97,,,percent of total billed charges,97% of total billed charges,10.24,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.04,97,,,percent of total billed charges,97% of total billed charges,10.58,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,11.04,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,165.55,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,180.73,90.37,,162.66,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,144.58,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.31,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,166.27,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,162.66,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,126.51,70,,,percent of total billed charges,70% of total billed charges,162.66,90,,,percent of total billed charges,90% of total billed charges,171.69,95,,,percent of total billed charges,95% of total billed charges,171.69,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,155.43,86,,,percent of total billed charges,86% of total billed charges,144.58,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,175.31,97,,,percent of total billed charges,97% of total billed charges,162.66,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.31,97,,,percent of total billed charges,97% of total billed charges,168.08,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,175.31,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,369.77,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,121.18,60.59,,109.06,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,96.94,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.54,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,111.49,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,109.06,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,84.83,70,,,percent of total billed charges,70% of total billed charges,109.06,90,,,percent of total billed charges,90% of total billed charges,115.12,95,,,percent of total billed charges,95% of total billed charges,115.12,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,104.21,86,,,percent of total billed charges,86% of total billed charges,96.94,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,117.54,97,,,percent of total billed charges,97% of total billed charges,109.06,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.54,97,,,percent of total billed charges,97% of total billed charges,112.7,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.54,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,369.77,
96159 - Health Coach Add 15 Mins,3635250,CDM,983,RC,96159,HCPCS,Outpatient,,,40.62,20.31,,36.56,90,,,percent of total billed charges,90% of total Billed charges,41.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.14,155,,,Fee Schedule,155% of CMS OPPS Rate,19.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,31.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,31.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,22.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,28.14,145,,,Fee Schedule,145% of CMS OPPS Rate,19.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.45,145,,,Fee Schedule,145% of CMS OPPS Rate,28.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,19.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.66,60.45,
CT RAD Hydration Initial,3348347,CDM,940,RC,96360,HCPCS,Outpatient,,,326.9,163.45,,294.21,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,261.52,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.21,90,,,Percent of total Billed charges,90% of total billed charges,34.79,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,317.09,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,300.75,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,294.21,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,228.83,70,,,percent of total billed charges,70% of total billed charges,294.21,90,,,percent of total billed charges,90% of total billed charges,310.56,95,,,percent of total billed charges,95% of total billed charges,310.56,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,281.13,86,,,percent of total billed charges,86% of total billed charges,261.52,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,317.09,97,,,percent of total billed charges,97% of total billed charges,294.21,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.09,97,,,percent of total billed charges,97% of total billed charges,304.02,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.09,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.63,1007.05,
CT RAD Hydration Add?l Hours,3348349,CDM,940,RC,96361,HCPCS,Outpatient,,,38.16,19.08,,34.34,90,,,percent of total billed charges,90% of total Billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,30.53,80,,,Percent of total Billed charges,80% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.34,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,37.02,97,,,Percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,35.11,92,,,Percent of total billed charges,92% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.34,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.71,70,,,percent of total billed charges,70% of total billed charges,34.34,90,,,percent of total billed charges,90% of total billed charges,36.25,95,,,percent of total billed charges,95% of total billed charges,36.25,95,,,percent of total billed charges,95% of total billed charges,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.82,86,,,percent of total billed charges,86% of total billed charges,30.53,80,,,percent of total billed charges,80% of total billed charges,39.39,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37.02,97,,,percent of total billed charges,97% of total billed charges,34.34,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.02,97,,,percent of total billed charges,97% of total billed charges,35.49,93,,,percent of total billed charges,93% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.02,97,,,percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,206.55,
96369 - SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP,3442011,CDM,940,RC,96369,HCPCS,Outpatient,,,326.9,163.45,,294.21,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,261.52,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.21,90,,,Percent of total Billed charges,90% of total billed charges,93.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,317.09,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,300.75,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,294.21,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,228.83,70,,,percent of total billed charges,70% of total billed charges,294.21,90,,,percent of total billed charges,90% of total billed charges,310.56,95,,,percent of total billed charges,95% of total billed charges,310.56,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,281.13,86,,,percent of total billed charges,86% of total billed charges,261.52,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,317.09,97,,,percent of total billed charges,97% of total billed charges,294.21,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.09,97,,,percent of total billed charges,97% of total billed charges,304.02,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.09,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.27,1007.05,
96370 - SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR,3442012,CDM,940,RC,96370,HCPCS,Outpatient,,,38.16,19.08,,34.34,90,,,percent of total billed charges,90% of total Billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,30.53,80,,,Percent of total Billed charges,80% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.34,90,,,Percent of total Billed charges,90% of total billed charges,9.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,37.02,97,,,Percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,35.11,92,,,Percent of total billed charges,92% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.34,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,26.71,70,,,percent of total billed charges,70% of total billed charges,34.34,90,,,percent of total billed charges,90% of total billed charges,36.25,95,,,percent of total billed charges,95% of total billed charges,36.25,95,,,percent of total billed charges,95% of total billed charges,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.82,86,,,percent of total billed charges,86% of total billed charges,30.53,80,,,percent of total billed charges,80% of total billed charges,39.39,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37.02,97,,,percent of total billed charges,97% of total billed charges,34.34,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.02,97,,,percent of total billed charges,97% of total billed charges,35.49,93,,,percent of total billed charges,93% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.02,97,,,percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.93,206.55,
96371 - SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE,3442013,CDM,940,RC,96371,HCPCS,Outpatient,,,129.74,64.87,,116.77,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,103.79,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.77,90,,,Percent of total Billed charges,90% of total billed charges,48.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,125.85,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,119.36,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,116.77,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,90.82,70,,,percent of total billed charges,70% of total billed charges,116.77,90,,,percent of total billed charges,90% of total billed charges,123.25,95,,,percent of total billed charges,95% of total billed charges,123.25,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,111.58,86,,,percent of total billed charges,86% of total billed charges,103.79,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,125.85,97,,,percent of total billed charges,97% of total billed charges,116.77,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.85,97,,,percent of total billed charges,97% of total billed charges,120.66,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.85,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.94,328.92,
96372 - IM/SQ injectin,3918946,CDM,510,RC,96372,HCPCS,Outpatient,,,27.69,13.85,,24.92,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,22.15,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.92,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,26.86,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,25.47,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,24.92,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,19.38,70,,,percent of total billed charges,70% of total billed charges,24.92,90,,,percent of total billed charges,90% of total billed charges,26.31,95,,,percent of total billed charges,95% of total billed charges,26.31,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.81,86,,,percent of total billed charges,86% of total billed charges,22.15,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,26.86,97,,,percent of total billed charges,97% of total billed charges,24.92,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.86,97,,,percent of total billed charges,97% of total billed charges,25.75,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,26.86,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,328.92,
96373-PF THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL,4321511,CDM,981,RC,96373,HCPCS,Outpatient,,,33.36,16.68,,30.02,90,,,percent of total billed charges,90% of total Billed charges,33.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,24.19,155,,,Fee Schedule,155% of CMS OPPS Rate,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,25.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,25.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,145,,,Fee Schedule,145% of CMS OPPS Rate,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.37,145,,,Fee Schedule,145% of CMS OPPS Rate,24.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.8,48.37,
96374-PF THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG,4321569,CDM,981,RC,96374,HCPCS,Outpatient,,,68.2,34.10,,61.38,90,,,percent of total billed charges,90% of total Billed charges,69.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,48.53,155,,,Fee Schedule,155% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.53,145,,,Fee Schedule,145% of CMS OPPS Rate,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.09,145,,,Fee Schedule,145% of CMS OPPS Rate,48.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.02,100.09,
96401-PF CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO,4321567,CDM,981,RC,96401,HCPCS,Outpatient,,,129.58,64.79,,116.62,90,,,percent of total billed charges,90% of total Billed charges,133.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.53,90,,,Percent of total Billed charges,90% of total billed charges,50.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.93,155,,,Fee Schedule,155% of CMS OPPS Rate,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.93,145,,,Fee Schedule,145% of CMS OPPS Rate,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.14,145,,,Fee Schedule,145% of CMS OPPS Rate,93.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.23,193.14,
96402-PF CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO,4321566,CDM,981,RC,96402,HCPCS,Outpatient,,,61.22,30.61,,55.1,90,,,percent of total billed charges,90% of total Billed charges,60.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,44.38,155,,,Fee Schedule,155% of CMS OPPS Rate,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.38,145,,,Fee Schedule,145% of CMS OPPS Rate,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.26,145,,,Fee Schedule,145% of CMS OPPS Rate,44.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,49.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.61,88.26,
Chemotherapy SQ or IM Hormonal Anti-Neoplastic 96402,3427863,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,72.45,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.45,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.09,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,74.06,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,56.35,70,,,percent of total billed charges,70% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.23,86,,,percent of total billed charges,86% of total billed charges,64.4,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.09,97,,,percent of total billed charges,97% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.09,97,,,percent of total billed charges,97% of total billed charges,74.87,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.09,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,328.92,
96409-PF CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG,4321565,CDM,981,RC,96409,HCPCS,Outpatient,,,179.36,89.68,,161.42,90,,,percent of total billed charges,90% of total Billed charges,184.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.86,90,,,Percent of total Billed charges,90% of total billed charges,92.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.04,155,,,Fee Schedule,155% of CMS OPPS Rate,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.04,145,,,Fee Schedule,145% of CMS OPPS Rate,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.44,145,,,Fee Schedule,145% of CMS OPPS Rate,130.04,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.68,267.44,
96411-PF CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG,4321564,CDM,981,RC,96411,HCPCS,Outpatient,,,99.18,49.59,,89.26,90,,,percent of total billed charges,90% of total Billed charges,101.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.89,155,,,Fee Schedule,155% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.89,145,,,Fee Schedule,145% of CMS OPPS Rate,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.19,145,,,Fee Schedule,145% of CMS OPPS Rate,71.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,94.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49.58,147.19,
96413-PF CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG,4321563,CDM,981,RC,96413,HCPCS,Outpatient,,,231.9,115.95,,208.71,90,,,percent of total billed charges,90% of total Billed charges,238.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.07,90,,,Percent of total Billed charges,90% of total billed charges,124.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,168.11,155,,,Fee Schedule,155% of CMS OPPS Rate,115.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.11,145,,,Fee Schedule,145% of CMS OPPS Rate,115.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,346,145,,,Fee Schedule,145% of CMS OPPS Rate,168.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,115.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,115.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,213.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.94,346,
96415-PF CHEMOTHERAPY ADMN IV INFUSION TQ EA HR,4321562,CDM,981,RC,96415,HCPCS,Outpatient,,,51.32,25.66,,46.19,90,,,percent of total billed charges,90% of total Billed charges,52.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.27,90,,,Percent of total Billed charges,90% of total billed charges,28.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.19,155,,,Fee Schedule,155% of CMS OPPS Rate,25.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.19,145,,,Fee Schedule,145% of CMS OPPS Rate,25.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.91,145,,,Fee Schedule,145% of CMS OPPS Rate,37.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,46.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.65,75.91,
96567- Photodynam tx/pre/malig skin lesio,3437853,CDM,983,RC,96567,HCPCS,Outpatient,,,339.06,169.53,,305.15,90,,,percent of total billed charges,90% of total Billed charges,250.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.09,155,,,Fee Schedule,155% of CMS OPPS Rate,122.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.09,145,,,Fee Schedule,145% of CMS OPPS Rate,122.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,362.95,145,,,Fee Schedule,145% of CMS OPPS Rate,178.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,214.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,108.95,362.95,
96570- Photodynamic endoscop tx/frst 30mi,3437854,CDM,983,RC,96570,HCPCS,Outpatient,,,136.42,68.21,,122.78,90,,,percent of total billed charges,90% of total Billed charges,106.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.81,155,,,Fee Schedule,155% of CMS OPPS Rate,55.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,72.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,79.81,145,,,Fee Schedule,145% of CMS OPPS Rate,55.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.18,145,,,Fee Schedule,145% of CMS OPPS Rate,79.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,55.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,98.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.07,154.18,
96571- Photodynamic endoscop tx/add 15 mi,3437855,CDM,983,RC,96571,HCPCS,Outpatient,,,67.66,33.83,,60.89,90,,,percent of total billed charges,90% of total Billed charges,50.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.84,155,,,Fee Schedule,155% of CMS OPPS Rate,24.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.84,145,,,Fee Schedule,145% of CMS OPPS Rate,24.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.73,145,,,Fee Schedule,145% of CMS OPPS Rate,35.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,44.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.48,72.73,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,125.14,62.57,,112.63,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,100.11,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.63,90,,,Percent of total Billed charges,90% of total billed charges,64.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.39,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,115.13,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,87.6,70,,,percent of total billed charges,70% of total billed charges,112.63,90,,,percent of total billed charges,90% of total billed charges,118.88,95,,,percent of total billed charges,95% of total billed charges,118.88,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.62,86,,,percent of total billed charges,86% of total billed charges,100.11,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.39,97,,,percent of total billed charges,97% of total billed charges,112.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.39,97,,,percent of total billed charges,97% of total billed charges,116.38,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.39,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.68,880.35,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,141.87,70.94,,127.68,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,113.5,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.68,90,,,Percent of total Billed charges,90% of total billed charges,65.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,137.61,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,130.52,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,127.68,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,99.31,70,,,percent of total billed charges,70% of total billed charges,127.68,90,,,percent of total billed charges,90% of total billed charges,134.78,95,,,percent of total billed charges,95% of total billed charges,134.78,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.01,86,,,percent of total billed charges,86% of total billed charges,113.5,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,137.61,97,,,percent of total billed charges,97% of total billed charges,127.68,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.61,97,,,percent of total billed charges,97% of total billed charges,131.94,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.61,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.1,880.35,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,11.04,90,,,percent of total billed charges,90% of total Billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,9.82,80,,,Percent of total Billed charges,80% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.9,97,,,Percent of total billed charges,97% of total billed charges,5.91,100,,,Fee Schedule,100% of CMS OPPS Rate,11.29,92,,,Percent of total billed charges,92% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.28,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,11.04,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,8.59,70,,,percent of total billed charges,70% of total billed charges,11.04,90,,,percent of total billed charges,90% of total billed charges,11.66,95,,,percent of total billed charges,95% of total billed charges,11.66,95,,,percent of total billed charges,95% of total billed charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10.55,86,,,percent of total billed charges,86% of total billed charges,9.82,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,11.9,97,,,percent of total billed charges,97% of total billed charges,11.04,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.9,97,,,percent of total billed charges,97% of total billed charges,11.41,93,,,percent of total billed charges,93% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.9,97,,,percent of total billed charges,97% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.06,29.41,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,24.19,12.10,,21.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,19.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,21.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,22.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,15.45,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,19.03,78.65,,,percent of total billed charges,78.65% of total billed charges,21.61,89.33,,,percent of total billed charges,89.33% of total billed charges,21.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.93,70,,,percent of total billed charges,70% of total billed charges,21.77,90,,,percent of total billed charges,90% of total billed charges,22.98,95,,,percent of total billed charges,95% of total billed charges,22.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,86,,,percent of total billed charges,86% of total billed charges,19.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,23.46,97,,,percent of total billed charges,97% of total billed charges,21.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.46,97,,,percent of total billed charges,97% of total billed charges,22.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,23.46,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,11.58,90,,,percent of total billed charges,90% of total Billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10.3,80,,,Percent of total Billed charges,80% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.48,97,,,Percent of total billed charges,97% of total billed charges,6.2,100,,,Fee Schedule,100% of CMS OPPS Rate,11.84,92,,,Percent of total billed charges,92% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,11.58,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.01,70,,,percent of total billed charges,70% of total billed charges,11.58,90,,,percent of total billed charges,90% of total billed charges,12.23,95,,,percent of total billed charges,95% of total billed charges,12.23,95,,,percent of total billed charges,95% of total billed charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.07,86,,,percent of total billed charges,86% of total billed charges,10.3,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,12.48,97,,,percent of total billed charges,97% of total billed charges,11.58,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.48,97,,,percent of total billed charges,97% of total billed charges,11.97,93,,,percent of total billed charges,93% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12.48,97,,,percent of total billed charges,97% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.31,30.89,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,24.73,90,,,percent of total billed charges,90% of total Billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,21.98,80,,,Percent of total Billed charges,80% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.66,97,,,Percent of total billed charges,97% of total billed charges,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,25.28,92,,,Percent of total billed charges,92% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,62.64,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,24.73,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,19.24,70,,,percent of total billed charges,70% of total billed charges,24.73,90,,,percent of total billed charges,90% of total billed charges,26.11,95,,,percent of total billed charges,95% of total billed charges,26.11,95,,,percent of total billed charges,95% of total billed charges,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.63,86,,,percent of total billed charges,86% of total billed charges,21.98,80,,,percent of total billed charges,80% of total billed charges,15.43,111,,,Fee Schedule,111% of CMS OPPS Rate,26.66,97,,,percent of total billed charges,97% of total billed charges,24.73,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.66,97,,,percent of total billed charges,97% of total billed charges,25.56,93,,,percent of total billed charges,93% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.66,97,,,percent of total billed charges,97% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.61,67.51,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,51.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,45.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,51.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,52.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,40.11,70,,,percent of total billed charges,70% of total billed charges,51.57,90,,,percent of total billed charges,90% of total billed charges,54.44,95,,,percent of total billed charges,95% of total billed charges,54.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.28,86,,,percent of total billed charges,86% of total billed charges,45.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,55.58,97,,,percent of total billed charges,97% of total billed charges,51.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.58,97,,,percent of total billed charges,97% of total billed charges,53.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.11,55.58,
97597 - PF Debridement Open Wound 20 sq cm/<,4311874,CDM,960,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,107.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.85,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.85,145,,,Fee Schedule,145% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.48,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,120.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.26,155.48,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.94,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,70,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.39,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,50.51,70,,,percent of total billed charges,70% of total billed charges,64.94,90,,,percent of total billed charges,90% of total billed charges,68.55,95,,,percent of total billed charges,95% of total billed charges,68.55,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.06,86,,,percent of total billed charges,86% of total billed charges,57.73,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70,97,,,percent of total billed charges,97% of total billed charges,64.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,97,,,percent of total billed charges,97% of total billed charges,67.11,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,880.34,
97597-PF DEBRIDEMENT OPEN WOUND 20 SQ CM/<,4321561,CDM,981,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,107.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.85,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.85,145,,,Fee Schedule,145% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.48,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,120.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.26,155.48,
Selective Debridement <20 sq centimeters,845982,CDM,420,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,57.73,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.94,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,70,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,66.39,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,50.51,70,,,percent of total billed charges,70% of total billed charges,64.94,90,,,percent of total billed charges,90% of total billed charges,68.55,95,,,percent of total billed charges,95% of total billed charges,68.55,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.06,86,,,percent of total billed charges,86% of total billed charges,57.73,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70,97,,,percent of total billed charges,97% of total billed charges,64.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,97,,,percent of total billed charges,97% of total billed charges,67.11,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,880.34,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,45.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,40.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.39,90,,,Percent of total Billed charges,90% of total billed charges,12.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,48.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,46.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.3,70,,,percent of total billed charges,70% of total billed charges,45.39,90,,,percent of total billed charges,90% of total billed charges,47.91,95,,,percent of total billed charges,95% of total billed charges,47.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,86,,,percent of total billed charges,86% of total billed charges,40.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.92,97,,,percent of total billed charges,97% of total billed charges,45.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.92,97,,,percent of total billed charges,97% of total billed charges,46.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,48.92,
"97598 - PF Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement",3715337,CDM,960,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,45.39,90,,,percent of total billed charges,90% of total Billed charges,67.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.48,155,,,Fee Schedule,155% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.48,145,,,Fee Schedule,145% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.35,145,,,Fee Schedule,145% of CMS OPPS Rate,35.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.46,98.35,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,38.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.81,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.22,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,70,,,percent of total billed charges,70% of total billed charges,43.81,90,,,percent of total billed charges,90% of total billed charges,46.25,95,,,percent of total billed charges,95% of total billed charges,46.25,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.86,86,,,percent of total billed charges,86% of total billed charges,38.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.22,97,,,percent of total billed charges,97% of total billed charges,43.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.22,97,,,percent of total billed charges,97% of total billed charges,45.27,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.22,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,880.35,
Debridement Non-Selective,3428412,CDM,761,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,38.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.81,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.22,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,44.79,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,34.08,70,,,percent of total billed charges,70% of total billed charges,43.81,90,,,percent of total billed charges,90% of total billed charges,46.25,95,,,percent of total billed charges,95% of total billed charges,46.25,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.86,86,,,percent of total billed charges,86% of total billed charges,38.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,47.22,97,,,percent of total billed charges,97% of total billed charges,43.81,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.22,97,,,percent of total billed charges,97% of total billed charges,45.27,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.22,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,880.35,
97605 Neg press wound tx,3428369,CDM,983,RC,97605,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,64.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.83,155,,,Fee Schedule,155% of CMS OPPS Rate,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,27.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.83,145,,,Fee Schedule,145% of CMS OPPS Rate,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.9,145,,,Fee Schedule,145% of CMS OPPS Rate,34.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,68.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.95,92.9,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,42.67,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.74,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,49.07,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,48.01,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,37.34,70,,,percent of total billed charges,70% of total billed charges,48.01,90,,,percent of total billed charges,90% of total billed charges,50.67,95,,,percent of total billed charges,95% of total billed charges,50.67,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45.87,86,,,percent of total billed charges,86% of total billed charges,42.67,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.74,97,,,percent of total billed charges,97% of total billed charges,48.01,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.74,97,,,percent of total billed charges,97% of total billed charges,49.61,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.74,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.34,1818.76,
97802- PF Medical Nurtition Assmt&Intrvnt Indv F2F ea 15min,4349185,CDM,960,RC,97802,HCPCS,Outpatient,,,58.72,29.36,,52.85,90,,,percent of total billed charges,90% of total Billed charges,65.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.4,155,,,Fee Schedule,155% of CMS OPPS Rate,30.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.4,145,,,Fee Schedule,145% of CMS OPPS Rate,30.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,95,145,,,Fee Schedule,145% of CMS OPPS Rate,44.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.03,95,
99151-Moderate Sedation Initial,3432113,CDM,370,RC,99151,HCPCS,Outpatient,,,170.44,85.22,,153.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,136.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,153.4,90,,,Percent of total Billed charges,90% of total billed charges,20.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,165.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,156.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,119.31,70,,,percent of total billed charges,70% of total billed charges,153.4,90,,,percent of total billed charges,90% of total billed charges,161.92,95,,,percent of total billed charges,95% of total billed charges,161.92,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.58,86,,,percent of total billed charges,86% of total billed charges,136.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,165.33,97,,,percent of total billed charges,97% of total billed charges,153.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,165.33,97,,,percent of total billed charges,97% of total billed charges,158.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,165.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.02,165.33,
99151-PF Mod Sed Same Phys/QHP <5Yrs,4321559,CDM,981,RC,99151,HCPCS,Outpatient,,,47.82,23.91,,43.04,90,,,percent of total billed charges,90% of total Billed charges,71.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.66,155,,,Fee Schedule,155% of CMS OPPS Rate,23.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,27.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.66,145,,,Fee Schedule,145% of CMS OPPS Rate,23.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.99,145,,,Fee Schedule,145% of CMS OPPS Rate,34.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.02,103.99,
99152-Moderate Sedation Initial,3432114,CDM,963,RC,99152,HCPCS,Outpatient,,,287.26,143.63,,258.53,90,,,percent of total billed charges,90% of total Billed charges,59.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,18.14,155,,,Fee Schedule,155% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,18.14,145,,,Fee Schedule,145% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.61,145,,,Fee Schedule,145% of CMS OPPS Rate,18.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,54.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,258.53,
"99152-PF Moderate Sedation, Initial 15 Minute",4321558,CDM,981,RC,99152,HCPCS,Outpatient,,,25.04,12.52,,22.54,90,,,percent of total billed charges,90% of total Billed charges,37.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,18.14,155,,,Fee Schedule,155% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,18.14,145,,,Fee Schedule,145% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.45,145,,,Fee Schedule,145% of CMS OPPS Rate,18.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,54.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,54.45,
"99153-PF Moderate Sedation, Each Add 15 Min",4321557,CDM,981,RC,99153,HCPCS,Outpatient,,,19.78,9.89,,17.8,90,,,percent of total billed charges,90% of total Billed charges,19.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.34,155,,,Fee Schedule,155% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,145,,,Fee Schedule,145% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.45,145,,,Fee Schedule,145% of CMS OPPS Rate,14.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,11.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,28.45,
99155-PF MOD SED OTHER PHYS/QHP INITIAL 15 MINS <5 YRS,4321512,CDM,981,RC,99155,HCPCS,Outpatient,,,165.74,82.87,,149.17,90,,,percent of total billed charges,90% of total Billed charges,166.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.16,155,,,Fee Schedule,155% of CMS OPPS Rate,82.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.16,145,,,Fee Schedule,145% of CMS OPPS Rate,82.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.89,145,,,Fee Schedule,145% of CMS OPPS Rate,120.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,82.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.18,241.89,
99156-PF MOD SED OTHER PHYS/QHP INITIAL 15 MINS 5/> YRS,4321513,CDM,981,RC,99156,HCPCS,Outpatient,,,151.16,75.58,,136.04,90,,,percent of total billed charges,90% of total Billed charges,152.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.59,155,,,Fee Schedule,155% of CMS OPPS Rate,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,89.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,109.59,145,,,Fee Schedule,145% of CMS OPPS Rate,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.41,145,,,Fee Schedule,145% of CMS OPPS Rate,109.59,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.1,220.41,
99157-PF MOD SED OTHER PHYS/QHP EACH ADDL 15 MINS,4321514,CDM,981,RC,99157,HCPCS,Outpatient,,,121.56,60.78,,109.4,90,,,percent of total billed charges,90% of total Billed charges,122.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.12,155,,,Fee Schedule,155% of CMS OPPS Rate,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.12,145,,,Fee Schedule,145% of CMS OPPS Rate,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.25,145,,,Fee Schedule,145% of CMS OPPS Rate,88.12,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,177.25,
99170- Anogen exam/child/suspect trauma,3437884,CDM,983,RC,99170,HCPCS,Outpatient,,,404.54,202.27,,364.09,90,,,percent of total billed charges,90% of total Billed charges,235.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.5,155,,,Fee Schedule,155% of CMS OPPS Rate,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,93.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.5,145,,,Fee Schedule,145% of CMS OPPS Rate,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.05,145,,,Fee Schedule,145% of CMS OPPS Rate,120.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,230.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.34,364.09,
99175- Ipecac/sim admin for emesis w/obs,3437887,CDM,983,RC,99175,HCPCS,Outpatient,,,67.45,33.73,,60.71,90,,,percent of total billed charges,90% of total Billed charges,51.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.22,155,,,Fee Schedule,155% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,32.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,32.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.22,145,,,Fee Schedule,145% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.98,145,,,Fee Schedule,145% of CMS OPPS Rate,38.22,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,38.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15.98,74.98,
99183- MD/NPP/sv/hyperbaric O2 tx/ea ses,3437888,CDM,983,RC,99183,HCPCS,Outpatient,,,216.6,108.30,,194.94,90,,,percent of total billed charges,90% of total Billed charges,211.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.38,155,,,Fee Schedule,155% of CMS OPPS Rate,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.38,145,,,Fee Schedule,145% of CMS OPPS Rate,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.86,145,,,Fee Schedule,145% of CMS OPPS Rate,152.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,357.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.41,357.52,
99184- Initiate hyperthermia for critically ill nenoate,3437889,CDM,983,RC,99184,HCPCS,Outpatient,,,570.68,285.34,,513.61,90,,,percent of total billed charges,90% of total Billed charges,424.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.43,155,,,Fee Schedule,155% of CMS OPPS Rate,209.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,363.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,334.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,334.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,242.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,304.43,145,,,Fee Schedule,145% of CMS OPPS Rate,209.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,615.6,145,,,Fee Schedule,145% of CMS OPPS Rate,304.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,209.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,255.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,209.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.5,615.6,
99195-PF PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE,4321515,CDM,981,RC,99195,HCPCS,Outpatient,,,170.68,85.34,,153.61,90,,,percent of total billed charges,90% of total Billed charges,175.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,123.74,155,,,Fee Schedule,155% of CMS OPPS Rate,85.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.74,145,,,Fee Schedule,145% of CMS OPPS Rate,85.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.52,145,,,Fee Schedule,145% of CMS OPPS Rate,123.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,85.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,85.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.67,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151.67,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10,254.52,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,86.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,76.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.12,70,,,percent of total billed charges,70% of total billed charges,86.3,90,,,percent of total billed charges,90% of total billed charges,91.1,95,,,percent of total billed charges,95% of total billed charges,91.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.47,86,,,percent of total billed charges,86% of total billed charges,76.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.01,97,,,percent of total billed charges,97% of total billed charges,86.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.01,97,,,percent of total billed charges,97% of total billed charges,89.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.01,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.12,93.01,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,149.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,133.26,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,149.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.57,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,153.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,116.6,70,,,percent of total billed charges,70% of total billed charges,149.91,90,,,percent of total billed charges,90% of total billed charges,158.24,95,,,percent of total billed charges,95% of total billed charges,158.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.25,86,,,percent of total billed charges,86% of total billed charges,133.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,161.57,97,,,percent of total billed charges,97% of total billed charges,149.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.57,97,,,percent of total billed charges,97% of total billed charges,154.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.57,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.6,161.57,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,243.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,216.26,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,262.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,248.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,189.22,70,,,percent of total billed charges,70% of total billed charges,243.29,90,,,percent of total billed charges,90% of total billed charges,256.8,95,,,percent of total billed charges,95% of total billed charges,256.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.48,86,,,percent of total billed charges,86% of total billed charges,216.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,262.21,97,,,percent of total billed charges,97% of total billed charges,243.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,262.21,97,,,percent of total billed charges,97% of total billed charges,251.4,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.22,262.21,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,330.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,293.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,330.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,356.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,338.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,257.21,70,,,percent of total billed charges,70% of total billed charges,330.7,90,,,percent of total billed charges,90% of total billed charges,349.07,95,,,percent of total billed charges,95% of total billed charges,349.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316,86,,,percent of total billed charges,86% of total billed charges,293.95,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,356.42,97,,,percent of total billed charges,97% of total billed charges,330.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,356.42,97,,,percent of total billed charges,97% of total billed charges,341.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.21,356.42,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,15.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,14.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.09,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.33,70,,,percent of total billed charges,70% of total billed charges,15.86,90,,,percent of total billed charges,90% of total billed charges,16.74,95,,,percent of total billed charges,95% of total billed charges,16.74,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.15,86,,,percent of total billed charges,86% of total billed charges,14.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.09,97,,,percent of total billed charges,97% of total billed charges,15.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.09,97,,,percent of total billed charges,97% of total billed charges,16.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.09,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.33,17.09,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,64.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,57.21,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,65.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.06,70,,,percent of total billed charges,70% of total billed charges,64.36,90,,,percent of total billed charges,90% of total billed charges,67.93,95,,,percent of total billed charges,95% of total billed charges,67.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.5,86,,,percent of total billed charges,86% of total billed charges,57.21,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.36,97,,,percent of total billed charges,97% of total billed charges,64.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.36,97,,,percent of total billed charges,97% of total billed charges,66.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.06,69.36,
"99212-PF Outpatient Visit, Estab. Level II",4331996,CDM,981,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,64.36,90,,,percent of total billed charges,90% of total Billed charges,88.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.06,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.02,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,128.02,
"99212-PF Outpatient Visit, Estab. Level II W/Mod",4331997,CDM,981,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,64.36,90,,,percent of total billed charges,90% of total Billed charges,88.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.06,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.02,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,128.02,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,119.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,106.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,119.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,122.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.11,70,,,percent of total billed charges,70% of total billed charges,119.71,90,,,percent of total billed charges,90% of total billed charges,126.36,95,,,percent of total billed charges,95% of total billed charges,126.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.39,86,,,percent of total billed charges,86% of total billed charges,106.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,129.02,97,,,percent of total billed charges,97% of total billed charges,119.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.02,97,,,percent of total billed charges,97% of total billed charges,123.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.11,129.02,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,156.73,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,176.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,190.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,180.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.14,70,,,percent of total billed charges,70% of total billed charges,176.32,90,,,percent of total billed charges,90% of total billed charges,186.11,95,,,percent of total billed charges,95% of total billed charges,186.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.48,86,,,percent of total billed charges,86% of total billed charges,156.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,190.03,97,,,percent of total billed charges,97% of total billed charges,176.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,190.03,97,,,percent of total billed charges,97% of total billed charges,182.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.14,190.03,
99214-PRO FEE ESTABLISHED PATIENT LEVEL 4 (30-39 min),3435840,CDM,983,RC,99214,HCPCS,Outpatient,,,254.68,127.34,,229.21,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,314.87,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,261.65,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,232.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,261.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,282,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,267.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,203.5,70,,,percent of total billed charges,70% of total billed charges,261.65,90,,,percent of total billed charges,90% of total billed charges,276.18,95,,,percent of total billed charges,95% of total billed charges,276.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.02,86,,,percent of total billed charges,86% of total billed charges,232.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,282,97,,,percent of total billed charges,97% of total billed charges,261.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,282,97,,,percent of total billed charges,97% of total billed charges,270.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.5,282,
99221- Initial Hospital IP/OBS Care SF/Low MDM (40 min),3437912,CDM,983,RC,99221,HCPCS,Outpatient,,,261.44,130.72,,235.3,90,,,percent of total billed charges,90% of total Billed charges,180.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.76,155,,,Fee Schedule,155% of CMS OPPS Rate,81.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.76,145,,,Fee Schedule,145% of CMS OPPS Rate,81.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.29,145,,,Fee Schedule,145% of CMS OPPS Rate,118.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,148,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,148,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.5,261.29,
99222- Initial Hospital IP/OBS Care Mod MDM (55 min),3437914,CDM,983,RC,99222,HCPCS,Outpatient,,,349.73,174.87,,314.76,90,,,percent of total billed charges,90% of total Billed charges,259.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.04,90,,,Percent of total Billed charges,90% of total billed charges,29.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,184.96,155,,,Fee Schedule,155% of CMS OPPS Rate,127.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,151.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,184.96,145,,,Fee Schedule,145% of CMS OPPS Rate,127.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.65,145,,,Fee Schedule,145% of CMS OPPS Rate,184.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.5,375.65,
99223-Initial Hospital IP/OBS Care High MDM (75 min),3437916,CDM,983,RC,99223,HCPCS,Outpatient,,,511.97,255.99,,460.77,90,,,percent of total billed charges,90% of total Billed charges,362.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,169.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,246.04,155,,,Fee Schedule,155% of CMS OPPS Rate,169.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,169.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,300.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,300.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,339.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,219.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,246.04,145,,,Fee Schedule,145% of CMS OPPS Rate,169.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.18,145,,,Fee Schedule,145% of CMS OPPS Rate,246.04,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,169.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,169.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,296,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,296,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42,525.18,
99231- Sbsq Hospital IP/OBS Care SF/Low MDM (25 min),3437923,CDM,983,RC,99231,HCPCS,Outpatient,,,100.54,50.27,,90.49,90,,,percent of total billed charges,90% of total Billed charges,86.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.56,90,,,Percent of total Billed charges,90% of total billed charges,17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.99,155,,,Fee Schedule,155% of CMS OPPS Rate,48.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.99,145,,,Fee Schedule,145% of CMS OPPS Rate,48.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.82,145,,,Fee Schedule,145% of CMS OPPS Rate,70.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17,125.82,
99232- Sbsq Hospital IP/OBS Care Mod MDM (35 min),3437925,CDM,983,RC,99232,HCPCS,Outpatient,,,183.94,91.97,,165.55,90,,,percent of total billed charges,90% of total Billed charges,146.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.16,90,,,Percent of total Billed charges,90% of total billed charges,17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,112.2,155,,,Fee Schedule,155% of CMS OPPS Rate,77.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.2,145,,,Fee Schedule,145% of CMS OPPS Rate,77.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.5,145,,,Fee Schedule,145% of CMS OPPS Rate,112.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,77.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,105,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,105,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17,212.5,
99233- Sbsq Hospital IP/OBS Care High MDM (50 min),3437927,CDM,983,RC,99233,HCPCS,Outpatient,,,264.24,132.12,,237.82,90,,,percent of total billed charges,90% of total Billed charges,215.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.42,90,,,Percent of total Billed charges,90% of total billed charges,17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,168.84,155,,,Fee Schedule,155% of CMS OPPS Rate,116.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.84,145,,,Fee Schedule,145% of CMS OPPS Rate,116.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.91,145,,,Fee Schedule,145% of CMS OPPS Rate,168.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,116.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,151,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17,312.91,
99234- Hospital IP/OBS Care Same Date SF/Low MDM (45 min),3437930,CDM,983,RC,99234,HCPCS,Outpatient,,,338.03,169.02,,304.23,90,,,percent of total billed charges,90% of total Billed charges,224.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,140.74,155,,,Fee Schedule,155% of CMS OPPS Rate,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,140.74,145,,,Fee Schedule,145% of CMS OPPS Rate,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.03,145,,,Fee Schedule,145% of CMS OPPS Rate,140.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,197,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.18,325.03,
99234-PF HOSPITAL IP/OBS CARE SAME DATE SF/LOW MDM 45 MIN,4321516,CDM,981,RC,99234,HCPCS,Outpatient,,,194.12,97.06,,174.71,90,,,percent of total billed charges,90% of total Billed charges,224.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,140.74,155,,,Fee Schedule,155% of CMS OPPS Rate,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,199.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,199.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,140.74,145,,,Fee Schedule,145% of CMS OPPS Rate,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.03,145,,,Fee Schedule,145% of CMS OPPS Rate,140.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,197,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.18,325.03,
99235- Hospital IP/OBS Care Same Date Mod MDM (70 min),3437932,CDM,983,RC,99235,HCPCS,Outpatient,,,427.28,213.64,,384.55,90,,,percent of total billed charges,90% of total Billed charges,316.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,225.9,155,,,Fee Schedule,155% of CMS OPPS Rate,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,251.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,251.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,169.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,182.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,225.9,145,,,Fee Schedule,145% of CMS OPPS Rate,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.87,145,,,Fee Schedule,145% of CMS OPPS Rate,225.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.29,458.87,
99235-PF HOSPITAL IP/OBS CARE SAME DATE MOD MDM 70 MIN,4321517,CDM,981,RC,99235,HCPCS,Outpatient,,,311.6,155.80,,280.44,90,,,percent of total billed charges,90% of total Billed charges,316.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,225.9,155,,,Fee Schedule,155% of CMS OPPS Rate,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,251.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,251.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,169.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,182.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,225.9,145,,,Fee Schedule,145% of CMS OPPS Rate,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.87,145,,,Fee Schedule,145% of CMS OPPS Rate,225.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.29,458.87,
99236- Hospital IP/OBS Care Same Date High MDM (85 min),3437934,CDM,983,RC,99236,HCPCS,Outpatient,,,547.82,273.91,,493.04,90,,,percent of total billed charges,90% of total Billed charges,410.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.28,155,,,Fee Schedule,155% of CMS OPPS Rate,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,323.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,323.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,218.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,235.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.28,145,,,Fee Schedule,145% of CMS OPPS Rate,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.98,145,,,Fee Schedule,145% of CMS OPPS Rate,296.28,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,247.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,322,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111.46,594.98,
99236-PF HOSPITAL IP/OBS CARE SAME DATE HIGH MDM 85 MIN,4321520,CDM,981,RC,99236,HCPCS,Outpatient,,,408.68,204.34,,367.81,90,,,percent of total billed charges,90% of total Billed charges,410.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.28,155,,,Fee Schedule,155% of CMS OPPS Rate,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,323.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,323.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,218.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,408.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,235.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.28,145,,,Fee Schedule,145% of CMS OPPS Rate,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.98,145,,,Fee Schedule,145% of CMS OPPS Rate,296.28,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,247.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,322,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,111.46,594.98,
99238- Hospital IP/OBS Discharge Day Mgmt 30 Min/Less than,3437936,CDM,983,RC,99238,HCPCS,Outpatient,,,183.79,91.90,,165.41,90,,,percent of total billed charges,90% of total Billed charges,147.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.51,155,,,Fee Schedule,155% of CMS OPPS Rate,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.51,145,,,Fee Schedule,145% of CMS OPPS Rate,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.7,145,,,Fee Schedule,145% of CMS OPPS Rate,113.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17,213.7,
99238-PF HOSPITAL IP/OBS DISCHARGE DAY MGMT 30 MIN/<,4321521,CDM,981,RC,99238,HCPCS,Outpatient,,,156.56,78.28,,140.9,90,,,percent of total billed charges,90% of total Billed charges,147.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.51,155,,,Fee Schedule,155% of CMS OPPS Rate,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.51,145,,,Fee Schedule,145% of CMS OPPS Rate,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.7,145,,,Fee Schedule,145% of CMS OPPS Rate,113.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17,213.7,
99239- Hospital IP/OBS Discharge Day Mgmt > 30 Min,3437938,CDM,983,RC,99239,HCPCS,Outpatient,,,268.61,134.31,,241.75,90,,,percent of total billed charges,90% of total Billed charges,212.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.43,155,,,Fee Schedule,155% of CMS OPPS Rate,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.43,145,,,Fee Schedule,145% of CMS OPPS Rate,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.89,145,,,Fee Schedule,145% of CMS OPPS Rate,161.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,106.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,155,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,155,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.26,307.89,
99239-PF HOSPITAL IP/OBS DISCHARGE DAY MGMT > 30 MIN,4321522,CDM,981,RC,99239,HCPCS,Outpatient,,,222.66,111.33,,200.39,90,,,percent of total billed charges,90% of total Billed charges,212.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.43,155,,,Fee Schedule,155% of CMS OPPS Rate,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.43,145,,,Fee Schedule,145% of CMS OPPS Rate,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.89,145,,,Fee Schedule,145% of CMS OPPS Rate,161.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,106.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,155,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,155,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.26,307.89,
99242- Office Consult Level 2,3437940,CDM,983,RC,99242,HCPCS,Outpatient,,,275.24,137.62,,247.72,90,,,percent of total billed charges,90% of total Billed charges,138.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.83,90,,,Percent of total Billed charges,90% of total billed charges,55.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,78.97,155,,,Fee Schedule,155% of CMS OPPS Rate,54.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,78.97,145,,,Fee Schedule,145% of CMS OPPS Rate,54.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.17,145,,,Fee Schedule,145% of CMS OPPS Rate,78.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,129,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.46,247.72,
99243- Office Consult New/Est PT Low MDM Level 3 (30 min),3437941,CDM,983,RC,99243,HCPCS,Outpatient,,,585.55,292.78,,527,90,,,percent of total billed charges,90% of total Billed charges,201.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.4,90,,,Percent of total Billed charges,90% of total billed charges,76.93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.28,155,,,Fee Schedule,155% of CMS OPPS Rate,86.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,144.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,144.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,97.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,125.28,145,,,Fee Schedule,145% of CMS OPPS Rate,86.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.68,145,,,Fee Schedule,145% of CMS OPPS Rate,125.28,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,86.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,86.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,176,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.93,527,
99244- Office Consult New/Est PT Mod MDM Level 4 (40 min),3437942,CDM,983,RC,99244,HCPCS,Outpatient,,,603.67,301.84,,543.3,90,,,percent of total billed charges,90% of total Billed charges,304.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.93,90,,,Percent of total Billed charges,90% of total billed charges,120.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,190.92,155,,,Fee Schedule,155% of CMS OPPS Rate,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,190.92,145,,,Fee Schedule,145% of CMS OPPS Rate,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.87,145,,,Fee Schedule,145% of CMS OPPS Rate,190.92,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,260,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,260,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.56,543.3,
99245- Office Consult New/Est PT High MDM Level 5 (55 min),3437943,CDM,983,RC,99245,HCPCS,Outpatient,,,848.33,424.17,,763.5,90,,,percent of total billed charges,90% of total Billed charges,388.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,151.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.26,155,,,Fee Schedule,155% of CMS OPPS Rate,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,270.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,288.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,288.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,259.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.26,145,,,Fee Schedule,145% of CMS OPPS Rate,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.08,145,,,Fee Schedule,145% of CMS OPPS Rate,256.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,318,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.44,763.5,
99252- Initl IP/OBS Consult New/Est Pt SF MDM (35 min),3437946,CDM,983,RC,99252,HCPCS,Outpatient,,,202.11,101.06,,181.9,90,,,percent of total billed charges,90% of total Billed charges,142.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.89,155,,,Fee Schedule,155% of CMS OPPS Rate,70.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,75.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.89,145,,,Fee Schedule,145% of CMS OPPS Rate,70.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.15,145,,,Fee Schedule,145% of CMS OPPS Rate,101.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,70.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,107,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30,206.15,
99253- Initl IP/OBV Consult New/Est Pt Low MDM (45 min),3437947,CDM,510,RC,99253,HCPCS,Outpatient,,,425.49,212.75,,382.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,340.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,382.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,412.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,391.45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,382.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,297.84,70,,,percent of total billed charges,70% of total billed charges,382.94,90,,,percent of total billed charges,90% of total billed charges,404.22,95,,,percent of total billed charges,95% of total billed charges,404.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.92,86,,,percent of total billed charges,86% of total billed charges,340.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,412.73,97,,,percent of total billed charges,97% of total billed charges,382.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,412.73,97,,,percent of total billed charges,97% of total billed charges,395.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.84,412.73,
99254- Initl IP/OBV Consult New/Est Pt Mod MDM (60 min),3437948,CDM,510,RC,99254,HCPCS,Outpatient,,,612.98,306.49,,551.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,490.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,551.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,594.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,563.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,429.09,70,,,percent of total billed charges,70% of total billed charges,551.68,90,,,percent of total billed charges,90% of total billed charges,582.33,95,,,percent of total billed charges,95% of total billed charges,582.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.16,86,,,percent of total billed charges,86% of total billed charges,490.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,594.59,97,,,percent of total billed charges,97% of total billed charges,551.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,594.59,97,,,percent of total billed charges,97% of total billed charges,570.07,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.09,594.59,
99255- Initl IP/OBS Consult New/Est Pt High MDM (80 min),3437949,CDM,983,RC,99255,HCPCS,Outpatient,,,760.57,380.29,,684.51,90,,,percent of total billed charges,90% of total Billed charges,377.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,264.19,155,,,Fee Schedule,155% of CMS OPPS Rate,182.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,204.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,274.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,224.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,264.19,145,,,Fee Schedule,145% of CMS OPPS Rate,182.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.74,145,,,Fee Schedule,145% of CMS OPPS Rate,264.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,182.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,284,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,284,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,684.51,
99281- Emergency dept visit,3437950,CDM,983,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,21.49,90,,,percent of total billed charges,90% of total Billed charges,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.3,155,,,Fee Schedule,155% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,17.3,145,,,Fee Schedule,145% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,17.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.93,49.13,
99281-PF Emergency Room Brief,4321556,CDM,981,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,21.49,90,,,percent of total billed charges,90% of total Billed charges,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.3,155,,,Fee Schedule,155% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,17.3,145,,,Fee Schedule,145% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,17.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.93,49.13,
99281-PF Emergency Room Brief W/Mod,4321554,CDM,981,RC,99281,HCPCS,Outpatient,,,23.88,11.94,,21.49,90,,,percent of total billed charges,90% of total Billed charges,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.3,155,,,Fee Schedule,155% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,17.3,145,,,Fee Schedule,145% of CMS OPPS Rate,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,17.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.93,49.13,
99282- Emergency dept visit,3437951,CDM,983,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,75.47,90,,,percent of total billed charges,90% of total Billed charges,84.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.08,90,,,Percent of total Billed charges,90% of total billed charges,26.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.78,155,,,Fee Schedule,155% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.78,145,,,Fee Schedule,145% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.5,145,,,Fee Schedule,145% of CMS OPPS Rate,60.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.85,122.5,
99282-PF Emer Room Routine,4321555,CDM,981,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,75.47,90,,,percent of total billed charges,90% of total Billed charges,84.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.08,90,,,Percent of total Billed charges,90% of total billed charges,26.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.78,155,,,Fee Schedule,155% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.78,145,,,Fee Schedule,145% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.5,145,,,Fee Schedule,145% of CMS OPPS Rate,60.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.85,122.5,
99282-PF Emer Room Routine W/Mod,4321553,CDM,981,RC,99282,HCPCS,Outpatient,,,83.86,41.93,,75.47,90,,,percent of total billed charges,90% of total Billed charges,84.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.08,90,,,Percent of total Billed charges,90% of total billed charges,26.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.78,155,,,Fee Schedule,155% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.78,145,,,Fee Schedule,145% of CMS OPPS Rate,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.5,145,,,Fee Schedule,145% of CMS OPPS Rate,60.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.85,122.5,
99283- Emergency dept visit,3437952,CDM,983,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,129.85,90,,,percent of total billed charges,90% of total Billed charges,144.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.6,155,,,Fee Schedule,155% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.6,145,,,Fee Schedule,145% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.92,145,,,Fee Schedule,145% of CMS OPPS Rate,104.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,91.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,209.92,
99283-PF Emer Room Moderate,4321551,CDM,981,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,129.85,90,,,percent of total billed charges,90% of total Billed charges,144.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.6,155,,,Fee Schedule,155% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.6,145,,,Fee Schedule,145% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.92,145,,,Fee Schedule,145% of CMS OPPS Rate,104.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,91.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,209.92,
99283-PF Emer Room Moderate W/Mod,4321550,CDM,981,RC,99283,HCPCS,Outpatient,,,144.28,72.14,,129.85,90,,,percent of total billed charges,90% of total Billed charges,144.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.6,155,,,Fee Schedule,155% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.6,145,,,Fee Schedule,145% of CMS OPPS Rate,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.92,145,,,Fee Schedule,145% of CMS OPPS Rate,104.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,91.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,209.92,
99284- Emergency dept visit,3437953,CDM,983,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,217.89,90,,,percent of total billed charges,90% of total Billed charges,243.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.39,90,,,Percent of total Billed charges,90% of total billed charges,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,175.51,155,,,Fee Schedule,155% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.51,145,,,Fee Schedule,145% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.08,145,,,Fee Schedule,145% of CMS OPPS Rate,175.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,353.08,
99284-PF Emer Room Intermediate,4321548,CDM,981,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,217.89,90,,,percent of total billed charges,90% of total Billed charges,243.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.39,90,,,Percent of total Billed charges,90% of total billed charges,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,175.51,155,,,Fee Schedule,155% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.51,145,,,Fee Schedule,145% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.08,145,,,Fee Schedule,145% of CMS OPPS Rate,175.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,353.08,
99284-PF EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY-MOD 25,4321547,CDM,981,RC,99284,HCPCS,Outpatient,,,242.1,121.05,,217.89,90,,,percent of total billed charges,90% of total Billed charges,243.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.39,90,,,Percent of total Billed charges,90% of total billed charges,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,175.51,155,,,Fee Schedule,155% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.51,145,,,Fee Schedule,145% of CMS OPPS Rate,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.08,145,,,Fee Schedule,145% of CMS OPPS Rate,175.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,353.08,
99285- Emergency dept visit,3437954,CDM,983,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,317.86,90,,,percent of total billed charges,90% of total Billed charges,354.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.06,155,,,Fee Schedule,155% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.06,145,,,Fee Schedule,145% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.3,145,,,Fee Schedule,145% of CMS OPPS Rate,256.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,514.3,
99285-PF Emer Room Extended/Comple W/Mod,4321545,CDM,981,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,317.86,90,,,percent of total billed charges,90% of total Billed charges,354.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.06,155,,,Fee Schedule,155% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.06,145,,,Fee Schedule,145% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.3,145,,,Fee Schedule,145% of CMS OPPS Rate,256.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,514.3,
99285-PF Emer Room Extended/Complex,4321546,CDM,981,RC,99285,HCPCS,Outpatient,,,353.18,176.59,,317.86,90,,,percent of total billed charges,90% of total Billed charges,354.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.06,155,,,Fee Schedule,155% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.06,145,,,Fee Schedule,145% of CMS OPPS Rate,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.3,145,,,Fee Schedule,145% of CMS OPPS Rate,256.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,203.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,514.3,
99288-PF PHYS/QHP DIRECTION EMERGENCY MEDICAL SYSTEMS,4321523,CDM,981,RC,99288,HCPCS,Outpatient,,,237,118.50,,213.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,213.3,
99291- Critical care first hour,3437957,CDM,983,RC,99291,HCPCS,Outpatient,,,571.46,285.73,,514.31,90,,,percent of total billed charges,90% of total Billed charges,480.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.77,90,,,Percent of total Billed charges,90% of total billed charges,151.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.96,155,,,Fee Schedule,155% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,250.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.96,145,,,Fee Schedule,145% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.33,145,,,Fee Schedule,145% of CMS OPPS Rate,305.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,279.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,393,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,393,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.63,696.33,
99291-PF Emer Room Critical Care,4321544,CDM,981,RC,99291,HCPCS,Outpatient,,,422.04,211.02,,379.84,90,,,percent of total billed charges,90% of total Billed charges,480.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.77,90,,,Percent of total Billed charges,90% of total billed charges,151.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.96,155,,,Fee Schedule,155% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,250.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.96,145,,,Fee Schedule,145% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.33,145,,,Fee Schedule,145% of CMS OPPS Rate,305.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,279.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,393,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,393,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.63,696.33,
99291-PF Emer Room Critical Care - MOD 25,4369281,CDM,981,RC,99291,HCPCS,Outpatient,,,422.04,211.02,,379.84,90,,,percent of total billed charges,90% of total Billed charges,480.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.77,90,,,Percent of total Billed charges,90% of total billed charges,151.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.96,155,,,Fee Schedule,155% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,250.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.96,145,,,Fee Schedule,145% of CMS OPPS Rate,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.33,145,,,Fee Schedule,145% of CMS OPPS Rate,305.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,279.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,211.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,393,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,393,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.63,696.33,
99292- Critical care addl 30 min,3437958,CDM,983,RC,99292,HCPCS,Outpatient,,,287.08,143.54,,258.37,90,,,percent of total billed charges,90% of total Billed charges,225.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.82,155,,,Fee Schedule,155% of CMS OPPS Rate,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.82,145,,,Fee Schedule,145% of CMS OPPS Rate,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.7,145,,,Fee Schedule,145% of CMS OPPS Rate,153.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,177.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.4,326.7,
99292-PF Emer Room Critical Care Add 30Min,4321542,CDM,981,RC,99292,HCPCS,Outpatient,,,212.16,106.08,,190.94,90,,,percent of total billed charges,90% of total Billed charges,225.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.82,155,,,Fee Schedule,155% of CMS OPPS Rate,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.82,145,,,Fee Schedule,145% of CMS OPPS Rate,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.7,145,,,Fee Schedule,145% of CMS OPPS Rate,153.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,177.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.4,326.7,
99304PF Initial Nursing Facility Care Per Day Low Level Must,4275109,CDM,960,RC,99304,HCPCS,Outpatient,,,165.34,82.67,,148.81,90,,,percent of total billed charges,90% of total Billed charges,163.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.09,155,,,Fee Schedule,155% of CMS OPPS Rate,77.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.09,145,,,Fee Schedule,145% of CMS OPPS Rate,77.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.29,145,,,Fee Schedule,145% of CMS OPPS Rate,113.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,77.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,136,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,136,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.75,237.29,
99305PF Initial Nursing Facility Care Per Day Moderate Level,4275110,CDM,960,RC,99305,HCPCS,Outpatient,,,273.82,136.91,,246.44,90,,,percent of total billed charges,90% of total Billed charges,252.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,187.28,155,,,Fee Schedule,155% of CMS OPPS Rate,129.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,187.28,145,,,Fee Schedule,145% of CMS OPPS Rate,129.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.14,145,,,Fee Schedule,145% of CMS OPPS Rate,187.28,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,129.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,191,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.15,366.14,
99306PF Initial Nursing Facility Care Per Day High Level Mus,4275111,CDM,960,RC,99306,HCPCS,Outpatient,,,374.01,187.01,,336.61,90,,,percent of total billed charges,90% of total Billed charges,335.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,255.81,155,,,Fee Schedule,155% of CMS OPPS Rate,176.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,246.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,246.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,255.81,145,,,Fee Schedule,145% of CMS OPPS Rate,176.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.95,145,,,Fee Schedule,145% of CMS OPPS Rate,255.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,155.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,243.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.92,485.95,
99307- Sbsq Nursing Facility Care/Day E/M Stable 10 Min,3437960,CDM,983,RC,99307,HCPCS,Outpatient,,,111,55.50,,99.9,90,,,percent of total billed charges,90% of total Billed charges,79.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.04,155,,,Fee Schedule,155% of CMS OPPS Rate,37.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.04,145,,,Fee Schedule,145% of CMS OPPS Rate,37.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.55,145,,,Fee Schedule,145% of CMS OPPS Rate,55.04,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,64.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.29,115.55,
99308- Sbsq nf care low mdm 20,3437961,CDM,983,RC,99308,HCPCS,Outpatient,,,148.23,74.12,,133.41,90,,,percent of total billed charges,90% of total Billed charges,137.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.89,155,,,Fee Schedule,155% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,72.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,103.89,145,,,Fee Schedule,145% of CMS OPPS Rate,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.36,145,,,Fee Schedule,145% of CMS OPPS Rate,103.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,99.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.65,199.36,
99309- Nursing fac care subseq,3437962,CDM,983,RC,99309,HCPCS,Outpatient,,,230.27,115.14,,207.24,90,,,percent of total billed charges,90% of total Billed charges,189.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.71,155,,,Fee Schedule,155% of CMS OPPS Rate,102.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,94.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.71,145,,,Fee Schedule,145% of CMS OPPS Rate,102.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.25,145,,,Fee Schedule,145% of CMS OPPS Rate,148.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,102.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,102.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,131,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.27,274.25,
99310- Sbsq Nurs Facil Care/Day Unstabl/New Prob 35 Min,3437964,CDM,983,RC,99310,HCPCS,Outpatient,,,339.88,169.94,,305.89,90,,,percent of total billed charges,90% of total Billed charges,275.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,214.47,155,,,Fee Schedule,155% of CMS OPPS Rate,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,196.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,196.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,139.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,214.47,145,,,Fee Schedule,145% of CMS OPPS Rate,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.78,145,,,Fee Schedule,145% of CMS OPPS Rate,214.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,195,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,195,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.31,399.78,
99315- Nursing fac discharge day,3437965,CDM,983,RC,99315,HCPCS,Outpatient,,,184.59,92.30,,166.13,90,,,percent of total billed charges,90% of total Billed charges,148.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,114.14,155,,,Fee Schedule,155% of CMS OPPS Rate,78.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,114.14,145,,,Fee Schedule,145% of CMS OPPS Rate,78.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.77,145,,,Fee Schedule,145% of CMS OPPS Rate,114.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,94.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.58,214.77,
99316- Nursing fac discharge day,3437966,CDM,983,RC,99316,HCPCS,Outpatient,,,264.36,132.18,,237.92,90,,,percent of total billed charges,90% of total Billed charges,226.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,184.74,155,,,Fee Schedule,155% of CMS OPPS Rate,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,184.74,145,,,Fee Schedule,145% of CMS OPPS Rate,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.89,145,,,Fee Schedule,145% of CMS OPPS Rate,184.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,122.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.94,328.89,
99366- Team Conference Face-to-Face Nonphysician,3438016,CDM,983,RC,99366,HCPCS,Outpatient,,,114.35,57.18,,102.92,90,,,percent of total billed charges,90% of total Billed charges,80.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.29,155,,,Fee Schedule,155% of CMS OPPS Rate,38.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.31,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.29,145,,,Fee Schedule,145% of CMS OPPS Rate,38.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.31,145,,,Fee Schedule,145% of CMS OPPS Rate,56.29,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.31,117.31,
99367- Team conf w/o pat by phys,3438017,CDM,983,RC,99367,HCPCS,Outpatient,,,152.92,76.46,,137.63,90,,,percent of total billed charges,90% of total Billed charges,107.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.57,155,,,Fee Schedule,155% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.88,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.57,145,,,Fee Schedule,145% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,145,,,Fee Schedule,145% of CMS OPPS Rate,76.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.88,155.69,
99368- Team conf w/o pat by hc pro,3438019,CDM,983,RC,99368,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,70.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.69,155,,,Fee Schedule,155% of CMS OPPS Rate,34.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,56.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,56.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.69,145,,,Fee Schedule,145% of CMS OPPS Rate,34.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.08,145,,,Fee Schedule,145% of CMS OPPS Rate,49.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.92,102.08,
99401 COVID-19 Vaccine Education,3894898,CDM,983,RC,99401,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,60.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.09,145,,,Fee Schedule,145% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.26,145,,,Fee Schedule,145% of CMS OPPS Rate,34.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.51,89.75,
99401- Prevent Med Counsel+/Risk Factor Redj Spx 15 Min,3438044,CDM,983,RC,99401,HCPCS,Outpatient,,,97.06,48.53,,87.35,90,,,percent of total billed charges,90% of total Billed charges,60.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.12,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.09,145,,,Fee Schedule,145% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.26,145,,,Fee Schedule,145% of CMS OPPS Rate,34.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.51,87.35,
99402- Prevent Med Counsel+/Risk Factor Redj Spx 30 Min,3438046,CDM,983,RC,99402,HCPCS,Outpatient,,,172.85,86.43,,155.57,90,,,percent of total billed charges,90% of total Billed charges,108.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.93,155,,,Fee Schedule,155% of CMS OPPS Rate,46.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.86,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.93,145,,,Fee Schedule,145% of CMS OPPS Rate,46.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.82,145,,,Fee Schedule,145% of CMS OPPS Rate,67.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,89.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.85,157.82,
99403- Prevent Med Counsel+/Risk Factor Redj Spx 45 Min,3438049,CDM,983,RC,99403,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,155.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.04,155,,,Fee Schedule,155% of CMS OPPS Rate,70.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.2,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,102.04,145,,,Fee Schedule,145% of CMS OPPS Rate,70.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.95,145,,,Fee Schedule,145% of CMS OPPS Rate,102.04,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,70.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,111.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,125.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.37,224.95,
99404- Prevent Med Counsel+/Risk Factor Redj Spx 60 Min,3438051,CDM,983,RC,99404,HCPCS,Outpatient,,,307.16,153.58,,276.44,90,,,percent of total billed charges,90% of total Billed charges,203.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.39,155,,,Fee Schedule,155% of CMS OPPS Rate,93.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,135.39,145,,,Fee Schedule,145% of CMS OPPS Rate,93.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.68,145,,,Fee Schedule,145% of CMS OPPS Rate,135.39,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,93.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,162,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92.15,294.68,
99406 Tobacco Counseling (as part of MWV),3428377,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,21.5,90,,,percent of total billed charges,90% of total Billed charges,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,155,,,Fee Schedule,155% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.83,145,,,Fee Schedule,145% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.25,145,,,Fee Schedule,145% of CMS OPPS Rate,16.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.61,38.25,
99406- Tobacco Use Cessation Intermediate 3-10 Minutes,3438055,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,21.5,90,,,percent of total billed charges,90% of total Billed charges,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,155,,,Fee Schedule,155% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.83,145,,,Fee Schedule,145% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.25,145,,,Fee Schedule,145% of CMS OPPS Rate,16.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.61,38.25,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,510,RC,99406,HCPCS,Outpatient,,,39.3,19.65,,35.37,90,,,percent of total billed charges,90% of total Billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,31.44,80,,,Percent of total Billed charges,80% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,38.12,97,,,Percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.16,92,,,Percent of total billed charges,92% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,144.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.37,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,27.51,70,,,percent of total billed charges,70% of total billed charges,35.37,90,,,percent of total billed charges,90% of total billed charges,37.34,95,,,percent of total billed charges,95% of total billed charges,37.34,95,,,percent of total billed charges,95% of total billed charges,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33.8,86,,,percent of total billed charges,86% of total billed charges,31.44,80,,,percent of total billed charges,80% of total billed charges,28.24,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,38.12,97,,,percent of total billed charges,97% of total billed charges,35.37,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.12,97,,,percent of total billed charges,97% of total billed charges,36.55,93,,,percent of total billed charges,93% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.12,97,,,percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.9,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.9,144.68,
99406-PF TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,4321526,CDM,981,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,21.5,90,,,percent of total billed charges,90% of total Billed charges,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,155,,,Fee Schedule,155% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.83,145,,,Fee Schedule,145% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.25,145,,,Fee Schedule,145% of CMS OPPS Rate,16.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.61,38.25,
99407- Behav chng smoking > 10 min,3438056,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,59.6,90,,,percent of total billed charges,90% of total Billed charges,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,155,,,Fee Schedule,155% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.5,145,,,Fee Schedule,145% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.47,145,,,Fee Schedule,145% of CMS OPPS Rate,35.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,75.47,
99407- Tobacco Use Cessation Intensive >10 Minutes,3438057,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,59.6,90,,,percent of total billed charges,90% of total Billed charges,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,155,,,Fee Schedule,155% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.5,145,,,Fee Schedule,145% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.47,145,,,Fee Schedule,145% of CMS OPPS Rate,35.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,75.47,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,73.32,36.66,,65.99,90,,,percent of total billed charges,90% of total Billed charges,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,155,,,Fee Schedule,155% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.5,145,,,Fee Schedule,145% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.47,145,,,Fee Schedule,145% of CMS OPPS Rate,35.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,75.47,
99407-PF TOBACCO USE CESSATION INTENSIVE >10 MINUTES,4321527,CDM,981,RC,99407,HCPCS,Outpatient,,,48.98,24.49,,44.08,90,,,percent of total billed charges,90% of total Billed charges,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,155,,,Fee Schedule,155% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.5,145,,,Fee Schedule,145% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.47,145,,,Fee Schedule,145% of CMS OPPS Rate,35.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,75.47,
"99408- Alcohol and/or Substance Abuse Screening, 15-30 Mins",3438058,CDM,983,RC,99408,HCPCS,Outpatient,,,74.47,37.24,,67.02,90,,,percent of total billed charges,90% of total Billed charges,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.98,155,,,Fee Schedule,155% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.34,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,36.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.98,145,,,Fee Schedule,145% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.24,145,,,Fee Schedule,145% of CMS OPPS Rate,44.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.34,95.24,
"99409- Alcohol and/or Substance Abuse Screening, 30+ Mins",3438061,CDM,983,RC,99409,HCPCS,Outpatient,,,180.84,90.42,,162.76,90,,,percent of total billed charges,90% of total Billed charges,129.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.97,155,,,Fee Schedule,155% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.25,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.97,145,,,Fee Schedule,145% of CMS OPPS Rate,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.21,145,,,Fee Schedule,145% of CMS OPPS Rate,89.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,100,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.25,187.21,
99417 Office Outpt visit Prolonged each add 15 mins,3572783,CDM,983,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,54.45,90,,,percent of total billed charges,90% of total Billed charges,60.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,155,,,Fee Schedule,155% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,145,,,Fee Schedule,145% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.83,145,,,Fee Schedule,145% of CMS OPPS Rate,42.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,87.83,
99417-PF PROLONGED OUTPATIENT E/M SERVICE EACH 15 MINUTES,4321528,CDM,981,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,54.45,90,,,percent of total billed charges,90% of total Billed charges,60.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,155,,,Fee Schedule,155% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,145,,,Fee Schedule,145% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.83,145,,,Fee Schedule,145% of CMS OPPS Rate,42.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,87.83,
99418 - PROLONGED INPATIENT/OBSERVATION EM SVC EA 15 MIN,4199264,CDM,960,RC,99418,HCPCS,Outpatient,,,63.59,31.80,,57.23,90,,,percent of total billed charges,90% of total Billed charges,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.38,155,,,Fee Schedule,155% of CMS OPPS Rate,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.38,145,,,Fee Schedule,145% of CMS OPPS Rate,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.38,145,,,Fee Schedule,145% of CMS OPPS Rate,55.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,76.38,
99441- Phone e/m phys/qhp 5-10 min,3438071,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,63.51,90,,,percent of total billed charges,90% of total Billed charges,86.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,155,,,Fee Schedule,155% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.17,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.57,145,,,Fee Schedule,145% of CMS OPPS Rate,49.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.69,125.57,
99441- Telephone Est 5 to 10 minutes,3438072,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,63.51,90,,,percent of total billed charges,90% of total Billed charges,86.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,155,,,Fee Schedule,155% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.17,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.57,145,,,Fee Schedule,145% of CMS OPPS Rate,49.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.69,125.57,
99442- Phone e/m phys/qhp 11-20 min,3438073,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,118.87,90,,,percent of total billed charges,90% of total Billed charges,150.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.23,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,39.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.37,218.23,
99442- Telephone Est 11 to 20 minutes,3438074,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,118.87,90,,,percent of total billed charges,90% of total Billed charges,150.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.23,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,39.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.37,218.23,
99443- Phone e/m phys/qhp 21-30 min,3438075,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,216.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.45,155,,,Fee Schedule,155% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,136.45,145,,,Fee Schedule,145% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.62,145,,,Fee Schedule,145% of CMS OPPS Rate,136.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.77,313.62,
99443- Telephone Est 21 to 30 minutes,3438076,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,216.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.45,155,,,Fee Schedule,155% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,136.45,145,,,Fee Schedule,145% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.62,145,,,Fee Schedule,145% of CMS OPPS Rate,136.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.77,313.62,
"99446- Interprofessional Phone/Internet Consult, 5-10 minutes",3438080,CDM,983,RC,99446,HCPCS,Outpatient,,,48.45,24.23,,43.61,90,,,percent of total billed charges,90% of total Billed charges,35.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.59,155,,,Fee Schedule,155% of CMS OPPS Rate,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.54,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,25.59,145,,,Fee Schedule,145% of CMS OPPS Rate,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.01,145,,,Fee Schedule,145% of CMS OPPS Rate,25.59,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.54,52.01,
"99447- Interprofessional Phone/Internet Consult, 11-20 minutes",3438082,CDM,983,RC,99447,HCPCS,Outpatient,,,95.05,47.53,,85.55,90,,,percent of total billed charges,90% of total Billed charges,70.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.18,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.52,102.18,
"99448- Interprofessional Phone/Internet Consult, 21-30 minutes",3438084,CDM,983,RC,99448,HCPCS,Outpatient,,,142.08,71.04,,127.87,90,,,percent of total billed charges,90% of total Billed charges,106.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.82,155,,,Fee Schedule,155% of CMS OPPS Rate,52.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.82,145,,,Fee Schedule,145% of CMS OPPS Rate,52.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.28,145,,,Fee Schedule,145% of CMS OPPS Rate,76.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,154.28,
"99449- Interprofessional Phone/Internet Consult, >=31 minutes",3438086,CDM,983,RC,99449,HCPCS,Outpatient,,,189.93,94.97,,170.94,90,,,percent of total billed charges,90% of total Billed charges,141.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.4,155,,,Fee Schedule,155% of CMS OPPS Rate,69.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.98,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,79.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.4,145,,,Fee Schedule,145% of CMS OPPS Rate,69.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.94,145,,,Fee Schedule,145% of CMS OPPS Rate,101.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,78.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.98,204.94,
99451- NTRPROF PH1/NTRNET/EHR 5/>,3514700,CDM,510,RC,99451,HCPCS,Outpatient,,,93.63,46.82,,84.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,74.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,84.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,86.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.54,70,,,percent of total billed charges,70% of total billed charges,84.27,90,,,percent of total billed charges,90% of total billed charges,88.95,95,,,percent of total billed charges,95% of total billed charges,88.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.52,86,,,percent of total billed charges,86% of total billed charges,74.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,90.82,97,,,percent of total billed charges,97% of total billed charges,84.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.82,97,,,percent of total billed charges,97% of total billed charges,87.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,90.82,
NTRPROF PH1/NTRNET/EHR 5/>,3527886,CDM,960,RC,99451,HCPCS,Outpatient,,,93.63,46.82,,84.27,90,,,percent of total billed charges,90% of total Billed charges,69.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.98,155,,,Fee Schedule,155% of CMS OPPS Rate,34.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.98,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.02,145,,,Fee Schedule,145% of CMS OPPS Rate,49.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.09,101.02,
99452- NTRPROF PH1/NTRNET/EHR RFRL,3514701,CDM,510,RC,99452,HCPCS,Outpatient,,,95.82,47.91,,86.24,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,76.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,92.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.07,70,,,percent of total billed charges,70% of total billed charges,86.24,90,,,percent of total billed charges,90% of total billed charges,91.03,95,,,percent of total billed charges,95% of total billed charges,91.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.41,86,,,percent of total billed charges,86% of total billed charges,76.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,92.95,97,,,percent of total billed charges,97% of total billed charges,86.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,92.95,97,,,percent of total billed charges,97% of total billed charges,89.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.07,92.95,
NTRPROF PH1/NTRNET/EHR RFRL,3527887,CDM,960,RC,99452,HCPCS,Outpatient,,,95.82,47.91,,86.24,90,,,percent of total billed charges,90% of total Billed charges,68.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.02,155,,,Fee Schedule,155% of CMS OPPS Rate,32.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.75,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,47.02,145,,,Fee Schedule,145% of CMS OPPS Rate,32.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.27,145,,,Fee Schedule,145% of CMS OPPS Rate,47.02,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.75,99.27,
99460- 1st Hosp/Birthing Center Care Per Day Nml Nb,3438093,CDM,983,RC,99460,HCPCS,Outpatient,,,245.98,122.99,,221.38,90,,,percent of total billed charges,90% of total Billed charges,183.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.38,155,,,Fee Schedule,155% of CMS OPPS Rate,90.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.38,145,,,Fee Schedule,145% of CMS OPPS Rate,90.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.51,145,,,Fee Schedule,145% of CMS OPPS Rate,131.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,90.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,90.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,88.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.63,265.51,
99461- 1st Care Pr Day Nml Nb Xcpt Hosp/Birthing Center,3438095,CDM,983,RC,99461,HCPCS,Outpatient,,,232.48,116.24,,209.23,90,,,percent of total billed charges,90% of total Billed charges,147.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.57,155,,,Fee Schedule,155% of CMS OPPS Rate,60.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,94.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,94.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.57,145,,,Fee Schedule,145% of CMS OPPS Rate,60.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.31,145,,,Fee Schedule,145% of CMS OPPS Rate,87.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,139,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,139,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.58,214.31,
99462- Subq Hospital Care Per Day E/M Normal Newborn,3438098,CDM,983,RC,99462,HCPCS,Outpatient,,,109.51,54.76,,98.56,90,,,percent of total billed charges,90% of total Billed charges,81.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.1,155,,,Fee Schedule,155% of CMS OPPS Rate,40.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,45.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,58.1,145,,,Fee Schedule,145% of CMS OPPS Rate,40.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.8,145,,,Fee Schedule,145% of CMS OPPS Rate,58.1,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,47.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.92,117.8,
99463- Same day nb discharge,3438099,CDM,983,RC,99463,HCPCS,Outpatient,,,281.89,140.95,,253.7,90,,,percent of total billed charges,90% of total Billed charges,212.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.11,155,,,Fee Schedule,155% of CMS OPPS Rate,106.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,118.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.11,145,,,Fee Schedule,145% of CMS OPPS Rate,106.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.81,145,,,Fee Schedule,145% of CMS OPPS Rate,154.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,122,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,122,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.98,307.81,
99464- Attn At Delivery+ 1 Stabilization of Newborn,3438101,CDM,983,RC,99464,HCPCS,Outpatient,,,193.28,96.64,,173.95,90,,,percent of total billed charges,90% of total Billed charges,143.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.15,155,,,Fee Schedule,155% of CMS OPPS Rate,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,111.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,111.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,103.15,145,,,Fee Schedule,145% of CMS OPPS Rate,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.54,145,,,Fee Schedule,145% of CMS OPPS Rate,103.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,174.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.5,208.54,
99465- Delivery/Birthing Room Resuscitation,3438102,CDM,983,RC,99465,HCPCS,Outpatient,,,376.98,188.49,,339.28,90,,,percent of total billed charges,90% of total Billed charges,280.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.58,155,,,Fee Schedule,155% of CMS OPPS Rate,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.58,145,,,Fee Schedule,145% of CMS OPPS Rate,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.12,145,,,Fee Schedule,145% of CMS OPPS Rate,200.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.98,406.12,
99465-PF DELIVERY/BIRTHING ROOM RESUSCITATION,4321529,CDM,981,RC,99465,HCPCS,Outpatient,,,276.66,138.33,,248.99,90,,,percent of total billed charges,90% of total Billed charges,280.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.58,155,,,Fee Schedule,155% of CMS OPPS Rate,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,200.58,145,,,Fee Schedule,145% of CMS OPPS Rate,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.12,145,,,Fee Schedule,145% of CMS OPPS Rate,200.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.98,406.12,
99466- Critical Care Interfacility Transport 30-74 Min,3438104,CDM,983,RC,99466,HCPCS,Outpatient,,,615.08,307.54,,553.57,90,,,percent of total billed charges,90% of total Billed charges,457.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.16,155,,,Fee Schedule,155% of CMS OPPS Rate,226.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,226.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,356.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,356.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,238.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,320.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,257.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,328.16,145,,,Fee Schedule,145% of CMS OPPS Rate,226.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,663.52,145,,,Fee Schedule,145% of CMS OPPS Rate,328.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,226.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,279.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,226.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,402,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,402,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,226.32,663.52,
99467- Critical Care Interfacility Transport Ea 30 Min,3438106,CDM,983,RC,99467,HCPCS,Outpatient,,,309.89,154.95,,278.9,90,,,percent of total billed charges,90% of total Billed charges,231.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.3,155,,,Fee Schedule,155% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.3,145,,,Fee Schedule,145% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.25,145,,,Fee Schedule,145% of CMS OPPS Rate,166.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,179.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.69,335.25,
99468- 1st Inpatient Critical Care Pr Day Age 28 Days/Less than,3438108,CDM,983,RC,99468,HCPCS,Outpatient,,,2372.52,1186.26,,2135.27,90,,,percent of total billed charges,90% of total Billed charges,1766.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,874.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,548.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1267.74,155,,,Fee Schedule,155% of CMS OPPS Rate,874.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1110,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,874.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1248.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1248.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1373.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1373.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,939.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,874.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1748.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1235.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,992.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1267.74,145,,,Fee Schedule,145% of CMS OPPS Rate,874.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2561.34,145,,,Fee Schedule,145% of CMS OPPS Rate,1267.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,874.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1005.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,874.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1368,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,548.82,2561.34,
99469- Neonate crit care subsq,3438110,CDM,983,RC,99469,HCPCS,Outpatient,,,1027.79,513.90,,925.01,90,,,percent of total billed charges,90% of total Billed charges,764.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,239.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,548.74,155,,,Fee Schedule,155% of CMS OPPS Rate,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,378.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,540.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,594.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,594.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,398.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,535.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,429.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,548.74,145,,,Fee Schedule,145% of CMS OPPS Rate,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1109.13,145,,,Fee Schedule,145% of CMS OPPS Rate,548.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,595.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,239.59,1109.13,
99469- Subq I/P Critical Care Pr Day Age 28 Days/Less than,3438111,CDM,983,RC,99469,HCPCS,Outpatient,,,1027.79,513.90,,925.01,90,,,percent of total billed charges,90% of total Billed charges,764.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,239.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,548.74,155,,,Fee Schedule,155% of CMS OPPS Rate,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,378.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,540.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,594.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,594.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,398.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,535.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,429.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,548.74,145,,,Fee Schedule,145% of CMS OPPS Rate,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1109.13,145,,,Fee Schedule,145% of CMS OPPS Rate,548.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,378.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,595.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,239.59,1109.13,
99471- Initial Ped Critical Care 29 Days Thru 24 Months,3438112,CDM,983,RC,99471,HCPCS,Outpatient,,,2053.37,1026.69,,1848.03,90,,,percent of total billed charges,90% of total Billed charges,1528.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,756.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,480.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1096.65,155,,,Fee Schedule,155% of CMS OPPS Rate,756.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1080.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1080.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1188.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1188.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,854.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,756.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1512.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1069.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,859.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1096.65,145,,,Fee Schedule,145% of CMS OPPS Rate,756.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.24,145,,,Fee Schedule,145% of CMS OPPS Rate,1096.65,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,756.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,932.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,756.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1162,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,480.03,2216.24,
99472- Subsq Ped Critical Care 29 Days Thru 24 Mo,3438115,CDM,983,RC,99472,HCPCS,Outpatient,,,1047.03,523.52,,942.33,90,,,percent of total billed charges,90% of total Billed charges,777.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,240.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,556.68,155,,,Fee Schedule,155% of CMS OPPS Rate,383.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,485.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,383.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,546.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,600.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,600.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,412.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,767.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,540.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,435.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,556.68,145,,,Fee Schedule,145% of CMS OPPS Rate,383.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1127.58,145,,,Fee Schedule,145% of CMS OPPS Rate,556.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,383.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,457.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,383.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,587.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,240.22,1127.58,
99475- Initial Ped Critical Care 2 Thru 5 Years,3438116,CDM,983,RC,99475,HCPCS,Outpatient,,,1475.37,737.69,,1327.83,90,,,percent of total billed charges,90% of total Billed charges,1100.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,545.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,331.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,791.31,155,,,Fee Schedule,155% of CMS OPPS Rate,545.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,676.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,545.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,760.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,836.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,836.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,575.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1091.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,604.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,791.31,145,,,Fee Schedule,145% of CMS OPPS Rate,545.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,1595.74,145,,,Fee Schedule,145% of CMS OPPS Rate,791.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,545.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,577.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,545.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,831,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,831,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,331.12,1595.74,
99476- Subsequent Ped Critical Care 2 Thru 5 Years,3438119,CDM,983,RC,99476,HCPCS,Outpatient,,,884.78,442.39,,796.3,90,,,percent of total billed charges,90% of total Billed charges,661.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,328.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,198.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,477.02,155,,,Fee Schedule,155% of CMS OPPS Rate,328.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,328.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,470.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,517.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,517.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,349.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,657.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,465.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,477.02,145,,,Fee Schedule,145% of CMS OPPS Rate,328.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,959.44,145,,,Fee Schedule,145% of CMS OPPS Rate,477.02,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,328.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,341.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,328.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,508,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,508,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,198.82,959.44,
99477- Init day hosp neonate care,3438120,CDM,983,RC,99477,HCPCS,Outpatient,,,897.54,448.77,,807.79,90,,,percent of total billed charges,90% of total Billed charges,668.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,251.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,480.31,155,,,Fee Schedule,155% of CMS OPPS Rate,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,474.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,521.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,521.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,356.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,469.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,480.31,145,,,Fee Schedule,145% of CMS OPPS Rate,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.69,145,,,Fee Schedule,145% of CMS OPPS Rate,480.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,522.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,251.98,969.69,
99477- Initial Hosp Neonate 28 D/Less than Not Critically Ill,3438121,CDM,983,RC,99477,HCPCS,Outpatient,,,897.54,448.77,,807.79,90,,,percent of total billed charges,90% of total Billed charges,668.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,251.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,480.31,155,,,Fee Schedule,155% of CMS OPPS Rate,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,331.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,474.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,521.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,521.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,356.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,662.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,469.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,480.31,145,,,Fee Schedule,145% of CMS OPPS Rate,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.69,145,,,Fee Schedule,145% of CMS OPPS Rate,480.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,522.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,522.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,251.98,969.69,
99478- Ic lbw inf < 1500 gm subsq,3438122,CDM,983,RC,99478,HCPCS,Outpatient,,,354.57,177.29,,319.11,90,,,percent of total billed charges,90% of total Billed charges,263.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.2,155,,,Fee Schedule,155% of CMS OPPS Rate,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.2,145,,,Fee Schedule,145% of CMS OPPS Rate,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,382.52,145,,,Fee Schedule,145% of CMS OPPS Rate,189.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85.83,382.52,
99478- Subsequent Intensive Care Infant Less than 1500 Grams,3438123,CDM,983,RC,99478,HCPCS,Outpatient,,,354.57,177.29,,319.11,90,,,percent of total billed charges,90% of total Billed charges,263.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.2,155,,,Fee Schedule,155% of CMS OPPS Rate,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.2,145,,,Fee Schedule,145% of CMS OPPS Rate,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,382.52,145,,,Fee Schedule,145% of CMS OPPS Rate,189.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85.83,382.52,
99479- Ic lbw inf 1500-2500 g subsq,3438124,CDM,983,RC,99479,HCPCS,Outpatient,,,323.34,161.67,,291.01,90,,,percent of total billed charges,90% of total Billed charges,240.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,172.49,155,,,Fee Schedule,155% of CMS OPPS Rate,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,169.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,172.49,145,,,Fee Schedule,145% of CMS OPPS Rate,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.8,145,,,Fee Schedule,145% of CMS OPPS Rate,172.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,194,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,194,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.17,348.8,
99479- Subsequent Intensive Care Infant 1500-2500 Grams,3438125,CDM,983,RC,99479,HCPCS,Outpatient,,,323.34,161.67,,291.01,90,,,percent of total billed charges,90% of total Billed charges,240.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,172.49,155,,,Fee Schedule,155% of CMS OPPS Rate,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,169.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,172.49,145,,,Fee Schedule,145% of CMS OPPS Rate,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.8,145,,,Fee Schedule,145% of CMS OPPS Rate,172.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,177.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,194,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,194,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.17,348.8,
99480- Ic inf pbw 2501-5000 g subsq,3438126,CDM,983,RC,99480,HCPCS,Outpatient,,,309.89,154.95,,278.9,90,,,percent of total billed charges,90% of total Billed charges,231.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,166.3,155,,,Fee Schedule,155% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.3,145,,,Fee Schedule,145% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.25,145,,,Fee Schedule,145% of CMS OPPS Rate,166.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,176,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.04,335.25,
99480- Subsequent Intensive Care Infant 2501-5000 Grams,3438127,CDM,983,RC,99480,HCPCS,Outpatient,,,309.89,154.95,,278.9,90,,,percent of total billed charges,90% of total Billed charges,231.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.04,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,166.3,155,,,Fee Schedule,155% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.3,145,,,Fee Schedule,145% of CMS OPPS Rate,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.25,145,,,Fee Schedule,145% of CMS OPPS Rate,166.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,176,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.04,335.25,
99487- Cmplx chron care w/o pt vsit,3438132,CDM,983,RC,99487,HCPCS,Outpatient,,,181.62,90.81,,163.46,90,,,percent of total billed charges,90% of total Billed charges,213.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.09,155,,,Fee Schedule,155% of CMS OPPS Rate,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,128.09,145,,,Fee Schedule,145% of CMS OPPS Rate,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.91,145,,,Fee Schedule,145% of CMS OPPS Rate,128.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.37,309.91,
99497 Advanced Directives Counseling (as part of MWV),3428378,CDM,983,RC,99497,HCPCS,Outpatient,,,200.41,100.21,,180.37,90,,,percent of total billed charges,90% of total Billed charges,155.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.55,155,,,Fee Schedule,155% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,60.12,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,106.55,145,,,Fee Schedule,145% of CMS OPPS Rate,73.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.27,145,,,Fee Schedule,145% of CMS OPPS Rate,106.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,73.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.12,225.27,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,190.09,95.05,,171.08,90,,,percent of total billed charges,90% of total Billed charges,140.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.78,155,,,Fee Schedule,155% of CMS OPPS Rate,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,79.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.78,145,,,Fee Schedule,145% of CMS OPPS Rate,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.41,145,,,Fee Schedule,145% of CMS OPPS Rate,100.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.03,204.41,
99499- Unlisted e&m service,3438138,CDM,983,RC,99499,HCPCS,Outpatient,,,59.84,29.92,,53.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.95,53.86,
0236T-Add on code: Transluminal Peripheral Atherectomy Abd. Aorta,4271209,CDM,481,RC,0236T,HCPCS,Outpatient,,,11283.7,5641.85,,10155.33,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9026.96,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10155.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10945.19,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,10381,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10155.33,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7898.59,70,,,percent of total billed charges,70% of total billed charges,10155.33,90,,,percent of total billed charges,90% of total billed charges,10719.52,95,,,percent of total billed charges,95% of total billed charges,10719.52,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9703.98,86,,,percent of total billed charges,86% of total billed charges,9026.96,80,,,percent of total billed charges,80% of total billed charges,10244.12,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10945.19,97,,,percent of total billed charges,97% of total billed charges,10155.33,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10945.19,97,,,percent of total billed charges,97% of total billed charges,10493.84,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10945.19,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7898.59,51750.98,
0236T-PF Add on code: Transluminal Peripheral Atherectomy Abd. Aorta,4271210,CDM,960,RC,0236T,HCPCS,Outpatient,,,11283.7,5641.85,,10155.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1693.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1904.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1904.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1728.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1728.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3385.11,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.6,10155.33,
0238T-Iliac Atherectomy,4271211,CDM,481,RC,0238T,HCPCS,Outpatient,,,19250.66,9625.33,,17325.59,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15400.53,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,17325.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18673.14,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,17710.61,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,17325.59,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,13475.46,70,,,percent of total billed charges,70% of total billed charges,17325.59,90,,,percent of total billed charges,90% of total billed charges,18288.13,95,,,percent of total billed charges,95% of total billed charges,18288.13,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,16555.57,86,,,percent of total billed charges,86% of total billed charges,15400.53,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,18673.14,97,,,percent of total billed charges,97% of total billed charges,17325.59,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18673.14,97,,,percent of total billed charges,97% of total billed charges,17903.11,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18673.14,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
0238T-PF Iliac Atherectomy,4271212,CDM,960,RC,0238T,HCPCS,Outpatient,,,19250.66,9625.33,,17325.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1168.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1314.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1314.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1192.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1192.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,5775.2,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,729.49,17325.59,
0338T-PF Renal Denervation Unilateral,4317233,CDM,960,RC,0338T,HCPCS,Outpatient,,,2000,1000.00,,1800,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1469.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1652.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1652.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,450,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,450,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,600,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450,1800,
0338T-Renal Denervation Unilateral,4317232,CDM,481,RC,0338T,HCPCS,Outpatient,,,2000,1000.00,,1800,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1800,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1940,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1840,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1800,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1400,70,,,percent of total billed charges,70% of total billed charges,1800,90,,,percent of total billed charges,90% of total billed charges,1900,95,,,percent of total billed charges,95% of total billed charges,1900,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1720,86,,,percent of total billed charges,86% of total billed charges,1600,80,,,percent of total billed charges,80% of total billed charges,5121.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1940,97,,,percent of total billed charges,97% of total billed charges,1800,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1940,97,,,percent of total billed charges,97% of total billed charges,1860,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1940,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1400,25425.73,
Renal Denervation Unilateral,,,481,RC,0338T,HCPCS,Outpatient,,,2000,1000.00,,1800,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1600,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1800,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1940,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1840,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1800,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1400,70,,,percent of total billed charges,70% of total billed charges,1800,90,,,percent of total billed charges,90% of total billed charges,1900,95,,,percent of total billed charges,95% of total billed charges,1900,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1720,86,,,percent of total billed charges,86% of total billed charges,1600,80,,,percent of total billed charges,80% of total billed charges,5121.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1940,97,,,percent of total billed charges,97% of total billed charges,1800,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1940,97,,,percent of total billed charges,97% of total billed charges,1860,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1940,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1400,25425.73,
0339T-PF Renal Denervation Bilateral,4317236,CDM,960,RC,0339T,HCPCS,Outpatient,,,3000,1500.00,,2700,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1771.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,1992.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1992.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,543,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,543,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,900,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543,2700,
0339T-Renal Denervation Bilateral,4317235,CDM,481,RC,0339T,HCPCS,Outpatient,,,3000,1500.00,,2700,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2400,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2700,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2910,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2760,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2700,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2100,70,,,percent of total billed charges,70% of total billed charges,2700,90,,,percent of total billed charges,90% of total billed charges,2850,95,,,percent of total billed charges,95% of total billed charges,2850,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2580,86,,,percent of total billed charges,86% of total billed charges,2400,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2910,97,,,percent of total billed charges,97% of total billed charges,2700,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2910,97,,,percent of total billed charges,97% of total billed charges,2790,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2910,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2100,25425.73,
Renal Denervation Bilateral,,,481,RC,0339T,HCPCS,Outpatient,,,3000,1500.00,,2700,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2400,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2700,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2910,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2760,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2700,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2100,70,,,percent of total billed charges,70% of total billed charges,2700,90,,,percent of total billed charges,90% of total billed charges,2850,95,,,percent of total billed charges,95% of total billed charges,2850,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2580,86,,,percent of total billed charges,86% of total billed charges,2400,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2910,97,,,percent of total billed charges,97% of total billed charges,2700,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2910,97,,,percent of total billed charges,97% of total billed charges,2790,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2910,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2100,25425.73,
0421T - Waterjet Prostate Abltj Cmpl,4189302,CDM,960,RC,0421T,HCPCS,Outpatient,,,474.88,237.44,,427.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.46,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.46,427.39,
0505T-Endovenous Fem/Pop arterial revasc with stent graft placement and closure,4271241,CDM,481,RC,0505T,HCPCS,Outpatient,,,20087,10043.50,,18078.3,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,16069.6,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18078.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19484.39,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,18480.04,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18078.3,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,14060.9,70,,,percent of total billed charges,70% of total billed charges,18078.3,90,,,percent of total billed charges,90% of total billed charges,19082.65,95,,,percent of total billed charges,95% of total billed charges,19082.65,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17274.82,86,,,percent of total billed charges,86% of total billed charges,16069.6,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,19484.39,97,,,percent of total billed charges,97% of total billed charges,18078.3,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,19484.39,97,,,percent of total billed charges,97% of total billed charges,18680.91,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19484.39,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
0505T-PF Endovenous Fem/Pop arterial revasc with stent graft placement and closure,4271242,CDM,960,RC,0505T,HCPCS,Outpatient,,,20087,10043.50,,18078.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15144.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,15144.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6026.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10915.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6026.1,18078.3,
0619T- PF Optilume/cystourethroscopy for BPH,4339431,CDM,960,RC,0619T,HCPCS,Outpatient,,,314.08,157.04,,282.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.22,282.67,
0795T-PF Transcatheter insert dual chamber leadless pacemaker,4361315,CDM,960,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,649.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.49,649.48,
0795T-Transcatheter insert dual chamber leadless pacemaker,4361245,CDM,481,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,649.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,577.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,649.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,663.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,505.15,70,,,percent of total billed charges,70% of total billed charges,649.48,90,,,percent of total billed charges,90% of total billed charges,685.56,95,,,percent of total billed charges,95% of total billed charges,685.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.61,86,,,percent of total billed charges,86% of total billed charges,577.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,649.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,671.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.15,699.99,
Transcatheter insert dual chamber leadless pacemaker,,,481,RC,0795T,HCPCS,Outpatient,,,721.64,360.82,,649.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,577.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,649.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,663.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,505.15,70,,,percent of total billed charges,70% of total billed charges,649.48,90,,,percent of total billed charges,90% of total billed charges,685.56,95,,,percent of total billed charges,95% of total billed charges,685.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.61,86,,,percent of total billed charges,86% of total billed charges,577.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,649.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,671.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.15,699.99,
0796T-PF Upgrade Dual Chamber Leadless (RA only),4361329,CDM,960,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.18,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.18,840.53,
0796T-Upgrade Dual Chamber Leadless (RA only),4361287,CDM,481,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,747.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,840.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,859.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,653.74,70,,,percent of total billed charges,70% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.17,86,,,percent of total billed charges,86% of total billed charges,747.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,868.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.74,905.9,
Upgrade Dual Chamber Leadless (RA only),,,481,RC,0796T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,747.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,840.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,859.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,653.74,70,,,percent of total billed charges,70% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.17,86,,,percent of total billed charges,86% of total billed charges,747.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,868.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.74,905.9,
0797T-PF Upgrade Dual Chamber Leadless (RV only),4361331,CDM,960,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.18,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.18,840.53,
0797T-Upgrade Dual Chamber Leadless (RV only),4361288,CDM,481,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,747.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,840.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,859.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,653.74,70,,,percent of total billed charges,70% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.17,86,,,percent of total billed charges,86% of total billed charges,747.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,868.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.74,15601.71,
Upgrade Dual Chamber Leadless (RV only),,,481,RC,0797T,HCPCS,Outpatient,,,933.92,466.96,,840.53,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,747.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,840.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,859.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,653.74,70,,,percent of total billed charges,70% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,887.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,803.17,86,,,percent of total billed charges,86% of total billed charges,747.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,840.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,868.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,905.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,653.74,15601.71,
0798T-PF Transcatheter remove dual chamber leadless pacemaker,4361317,CDM,960,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,1513.06,
0798T-Transcatheter remove dual chamber leadless pacemaker,4361256,CDM,481,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,1630.74,
Transcatheter remove dual chamber leadless pacemaker,,,481,RC,0798T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,1630.74,
0799T-PF Transcatheter remove dual chamber leadless pacemaker (RA),4361319,CDM,960,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,1513.06,
0799T-Transcatheter remove dual chamber leadless pacemaker (RA),4361257,CDM,481,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,1630.74,
Transcatheter remove dual chamber leadless pacemaker (RA),,,481,RC,0799T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,1630.74,
0800T-PF Transcatheter remove dual chamber leadless pacemaker (RV),4361321,CDM,960,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,504.35,1513.06,
0800T-Transcatheter remove dual chamber leadless pacemaker (RV),4361258,CDM,481,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,2705.67,
Transcatheter remove dual chamber leadless pacemaker (RV),,,481,RC,0800T,HCPCS,Outpatient,,,1681.18,840.59,,1513.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1513.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1546.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1176.83,70,,,percent of total billed charges,70% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,1597.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1445.81,86,,,percent of total billed charges,86% of total billed charges,1344.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1513.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,1563.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1630.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1176.83,2705.67,
0801T-PF Transcatheter remove/replace dual chamber leadless pacemaker,4361323,CDM,960,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,621.97,
0801T-Transcatheter remove/replace dual chamber leadless pacemaker,4361275,CDM,481,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,670.35,
Transcatheter remove/replace dual chamber leadless pacemaker,,,481,RC,0801T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,670.35,
0802T-PF Transcatheter remove/replace dual chamber leadless pacemaker (RA),4361325,CDM,960,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,621.97,
0802T-Transcatheter remove/replace dual chamber leadless pacemaker (RA),4361285,CDM,481,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,670.35,
Transcatheter remove/replace dual chamber leadless pacemaker (RA),,,481,RC,0802T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,670.35,
0803T-PF Transcatheter remove/replace dual chamber leadless pacemaker (RV),4361327,CDM,960,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.32,621.97,
0803T-Transcatheter remove/replace dual chamber leadless pacemaker (RV),4361286,CDM,481,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,15601.71,
Transcatheter remove/replace dual chamber leadless pacemaker (RV),,,481,RC,0803T,HCPCS,Outpatient,,,691.08,345.54,,621.97,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,552.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,635.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,483.76,70,,,percent of total billed charges,70% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,656.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,594.33,86,,,percent of total billed charges,86% of total billed charges,552.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,621.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,642.7,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,483.76,15601.71,
0804T-In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,4361289,CDM,481,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,46.87,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,41.66,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.52,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,47.91,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,46.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,36.46,70,,,percent of total billed charges,70% of total billed charges,46.87,90,,,percent of total billed charges,90% of total billed charges,49.48,95,,,percent of total billed charges,95% of total billed charges,49.48,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.79,86,,,percent of total billed charges,86% of total billed charges,41.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.52,97,,,percent of total billed charges,97% of total billed charges,46.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.52,97,,,percent of total billed charges,97% of total billed charges,48.43,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.52,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
0804T-PF In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,4361333,CDM,960,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,46.87,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.62,46.87,
In-person programming rvw/rprt by prvdr; leadless pacer dual chamber,,,481,RC,0804T,HCPCS,Outpatient,,,52.08,26.04,,46.87,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,41.66,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.52,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,47.91,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,46.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,36.46,70,,,percent of total billed charges,70% of total billed charges,46.87,90,,,percent of total billed charges,90% of total billed charges,49.48,95,,,percent of total billed charges,95% of total billed charges,49.48,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.79,86,,,percent of total billed charges,86% of total billed charges,41.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.52,97,,,percent of total billed charges,97% of total billed charges,46.87,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.52,97,,,percent of total billed charges,97% of total billed charges,48.43,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.52,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
3015F-CERV CANCER SCREEN DOCD Profee,3565240,CDM,983,RC,3015F,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
C9604-PCI IN/VIA SVG/IMA DES CIRC,3352895,CDM,481,RC,C9604,HCPCS,Outpatient,,,1165.18,582.59,,1048.66,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,932.14,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1048.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1130.22,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.97,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1048.66,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,815.63,70,,,percent of total billed charges,70% of total billed charges,1048.66,90,,,percent of total billed charges,90% of total billed charges,1106.92,95,,,percent of total billed charges,95% of total billed charges,1106.92,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1002.05,86,,,percent of total billed charges,86% of total billed charges,932.14,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1130.22,97,,,percent of total billed charges,97% of total billed charges,1048.66,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.22,97,,,percent of total billed charges,97% of total billed charges,1083.62,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1130.22,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,815.63,51750.98,
C9605-ADDL PCI IN/VIA SVG/IMA DES LAD,3352952,CDM,481,RC,C9605,HCPCS,Outpatient,,,1236.51,618.26,,1112.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,989.21,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1112.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1199.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1137.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,865.56,70,,,percent of total billed charges,70% of total billed charges,1112.86,90,,,percent of total billed charges,90% of total billed charges,1174.68,95,,,percent of total billed charges,95% of total billed charges,1174.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1063.4,86,,,percent of total billed charges,86% of total billed charges,989.21,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1199.41,97,,,percent of total billed charges,97% of total billed charges,1112.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1199.41,97,,,percent of total billed charges,97% of total billed charges,1149.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,865.56,1199.41,
C9606-PCI AMI TOTAL/SUN DES RCA,3353315,CDM,481,RC,C9606,HCPCS,Outpatient,,,1307.84,653.92,,1177.06,90,,,percent of total billed charges,90% of total Billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1046.27,80,,,Percent of total Billed charges,80% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1177.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1268.6,97,,,Percent of total billed charges,97% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1203.21,92,,,Percent of total billed charges,92% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1177.06,90,,,percent of total billed charges,90% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.49,70,,,percent of total billed charges,70% of total billed charges,1177.06,90,,,percent of total billed charges,90% of total billed charges,1242.45,95,,,percent of total billed charges,95% of total billed charges,1242.45,95,,,percent of total billed charges,95% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1124.74,86,,,percent of total billed charges,86% of total billed charges,1046.27,80,,,percent of total billed charges,80% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1268.6,97,,,percent of total billed charges,97% of total billed charges,1177.06,90,,,percent of total billed charges,90% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1268.6,97,,,percent of total billed charges,97% of total billed charges,1216.29,93,,,percent of total billed charges,93% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1268.6,97,,,percent of total billed charges,97% of total billed charges,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,915.49,1307.84,
C9772-PF Shockwave Tibial/Peroneal Arteries,4271214,CDM,960,RC,C9772,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,9230.4,
C9772-Shockwave Tibial/Peroneal Arteries,4271213,CDM,481,RC,C9772,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8204.8,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9230.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9435.52,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9230.4,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7179.2,70,,,percent of total billed charges,70% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8820.16,86,,,percent of total billed charges,86% of total billed charges,8204.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9948.32,97,,,percent of total billed charges,97% of total billed charges,9538.08,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7179.2,51750.98,
C9773-PF Shockwave with stent Tibial/Peroneal Arteries,4271216,CDM,960,RC,C9773,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,9230.4,
C9773-Shockwave with stent Tibial/Peroneal Arteries,4271215,CDM,481,RC,C9773,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8204.8,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9230.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9435.52,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7179.2,70,,,percent of total billed charges,70% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8820.16,86,,,percent of total billed charges,86% of total billed charges,8204.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9948.32,97,,,percent of total billed charges,97% of total billed charges,9538.08,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7179.2,83742.97,
C9774-PF Shockwave with atherectomy Tibial/Peroneal Arteries,4271218,CDM,960,RC,C9774,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,9230.4,
C9774-Shockwave with atherectomy Tibial/Peroneal Arteries,4271217,CDM,481,RC,C9774,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8204.8,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9230.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9435.52,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7179.2,70,,,percent of total billed charges,70% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8820.16,86,,,percent of total billed charges,86% of total billed charges,8204.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9948.32,97,,,percent of total billed charges,97% of total billed charges,9538.08,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7179.2,83742.97,
C9775-PF Shockwave with stent with atherectomy Tibial/Peroneal Arteries,4271220,CDM,960,RC,C9775,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.8,9230.4,
C9775-Shockwave with stent with atherectomy Tibial/Peroneal Arteries,4271219,CDM,481,RC,C9775,HCPCS,Outpatient,,,10256,5128.00,,9230.4,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8204.8,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9230.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9435.52,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7179.2,70,,,percent of total billed charges,70% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,9743.2,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8820.16,86,,,percent of total billed charges,86% of total billed charges,8204.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,9230.4,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9948.32,97,,,percent of total billed charges,97% of total billed charges,9538.08,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9948.32,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7179.2,83742.97,
C9779 - PF ESD Endoscopic Submucosal Dissection,4347164,CDM,960,RC,C9779,HCPCS,Outpatient,,,667.21,333.61,,600.49,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.16,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.16,600.49,
G0102 Prostate Cancer Screening; Digital Rectal Exam,3555130,CDM,510,RC,G0102,HCPCS,Outpatient,,,56.36,28.18,,50.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,45.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,51.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.45,70,,,percent of total billed charges,70% of total billed charges,50.72,90,,,percent of total billed charges,90% of total billed charges,53.54,95,,,percent of total billed charges,95% of total billed charges,53.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.47,86,,,percent of total billed charges,86% of total billed charges,45.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,54.67,97,,,percent of total billed charges,97% of total billed charges,50.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.67,97,,,percent of total billed charges,97% of total billed charges,52.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.45,54.67,
G0104 - Colorectal cancer screening; flexible sigmoidoscopy,3899095,CDM,983,RC,G0104,HCPCS,Outpatient,,,462.14,231.07,,415.93,90,,,percent of total billed charges,90% of total Billed charges,227.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.69,155,,,Fee Schedule,155% of CMS OPPS Rate,53.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.64,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.69,145,,,Fee Schedule,145% of CMS OPPS Rate,53.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.66,145,,,Fee Schedule,145% of CMS OPPS Rate,77.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,110.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,229.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53.58,415.93,
G0105 - PF Colorectal Scrn; Hi Risk Ind,4311873,CDM,960,RC,G0105,HCPCS,Outpatient,,,425.49,212.75,,382.94,90,,,percent of total billed charges,90% of total Billed charges,506.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.83,155,,,Fee Schedule,155% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.65,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,215.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,259.83,145,,,Fee Schedule,145% of CMS OPPS Rate,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.18,145,,,Fee Schedule,145% of CMS OPPS Rate,259.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,328.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,650.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127.65,734.18,
G0121 - PF Colon Ca Scrn Not Hi Rsk Ind,4311872,CDM,960,RC,G0121,HCPCS,Outpatient,,,426.51,213.26,,383.86,90,,,percent of total billed charges,90% of total Billed charges,507.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.45,155,,,Fee Schedule,155% of CMS OPPS Rate,179.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,282.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,282.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,359.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,260.45,145,,,Fee Schedule,145% of CMS OPPS Rate,179.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,735.41,145,,,Fee Schedule,145% of CMS OPPS Rate,260.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,179.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,179.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,650.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127.95,735.41,
G0124 - Screen C/V Thin Layer by MD,3899096,CDM,983,RC,G0124,HCPCS,Outpatient,,,55.05,27.53,,49.55,90,,,percent of total billed charges,90% of total Billed charges,41.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.71,155,,,Fee Schedule,155% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,24.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,30.71,145,,,Fee Schedule,145% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.71,145,,,Fee Schedule,145% of CMS OPPS Rate,30.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,49.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.52,60.71,
G0168-PF WOUND CLOSURE BY ADHESIVE,4321532,CDM,981,RC,G0168,HCPCS,Outpatient,,,30.24,15.12,,27.22,90,,,percent of total billed charges,90% of total Billed charges,45.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.91,155,,,Fee Schedule,155% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,28.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,28.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.07,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,23.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,21.91,145,,,Fee Schedule,145% of CMS OPPS Rate,15.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,145,,,Fee Schedule,145% of CMS OPPS Rate,21.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,148.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.07,148.82,
G0180- Home Health Certification,3438154,CDM,983,RC,G0180,HCPCS,Outpatient,,,104.39,52.20,,93.95,90,,,percent of total billed charges,90% of total Billed charges,98.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,155,,,Fee Schedule,155% of CMS OPPS Rate,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,145,,,Fee Schedule,145% of CMS OPPS Rate,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.26,145,,,Fee Schedule,145% of CMS OPPS Rate,70.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,86.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.75,143.26,
"G0180- Home health certification, physician",3435920,CDM,960,RC,G0180,HCPCS,Outpatient,,,104.39,52.20,,93.95,90,,,percent of total billed charges,90% of total Billed charges,98.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,155,,,Fee Schedule,155% of CMS OPPS Rate,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.91,145,,,Fee Schedule,145% of CMS OPPS Rate,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.26,145,,,Fee Schedule,145% of CMS OPPS Rate,70.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,86.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.75,143.26,
"G0250- Phys Revw,Intrp/Mngmt Home Inr",3435922,CDM,960,RC,G0250,HCPCS,Outpatient,,,21.62,10.81,,19.46,90,,,percent of total billed charges,90% of total Billed charges,16.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,155,,,Fee Schedule,155% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.19,145,,,Fee Schedule,145% of CMS OPPS Rate,12.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.49,24.19,
G0269 - PF Placement of occlusive device in vein or art,4197110,CDM,960,RC,G0269,HCPCS,Outpatient,,,2982.25,1491.13,,2684.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,894.68,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,894.68,2684.03,
G0269 - Placement of occlusive device in vein or art,4197109,CDM,481,RC,G0269,HCPCS,Outpatient,,,2982.25,1491.13,,2684.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2385.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2684.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2892.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2743.67,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2684.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2087.58,70,,,percent of total billed charges,70% of total billed charges,2684.03,90,,,percent of total billed charges,90% of total billed charges,2833.14,95,,,percent of total billed charges,95% of total billed charges,2833.14,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2564.74,86,,,percent of total billed charges,86% of total billed charges,2385.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2892.78,97,,,percent of total billed charges,97% of total billed charges,2684.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2892.78,97,,,percent of total billed charges,97% of total billed charges,2773.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2892.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2087.58,2892.78,
"G0278 - Iliac Art Angio, Cardiac Cath",4201240,CDM,983,RC,G0278,HCPCS,Outpatient,,,30.17,15.09,,27.15,90,,,percent of total billed charges,90% of total Billed charges,27.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.81,155,,,Fee Schedule,155% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,21.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,21.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,18.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,19.81,145,,,Fee Schedule,145% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.43,145,,,Fee Schedule,145% of CMS OPPS Rate,19.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.05,40.43,
"G0289- Arthroscopy,Knee,Remove Fb",3435317,CDM,510,RC,G0289,HCPCS,Outpatient,,,226.6,113.30,,203.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,181.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,219.8,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,208.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,158.62,70,,,percent of total billed charges,70% of total billed charges,203.94,90,,,percent of total billed charges,90% of total billed charges,215.27,95,,,percent of total billed charges,95% of total billed charges,215.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.88,86,,,percent of total billed charges,86% of total billed charges,181.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,219.8,97,,,percent of total billed charges,97% of total billed charges,203.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,219.8,97,,,percent of total billed charges,97% of total billed charges,210.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.8,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.62,219.8,
G0296 - Counseling Visit to discuss need for LDCT for Lung Cancer Screening,3571392,CDM,770,RC,G0296,HCPCS,Outpatient,,,53.36,26.68,,48.02,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,42.69,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.76,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.09,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,48.02,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,37.35,70,,,percent of total billed charges,70% of total billed charges,48.02,90,,,percent of total billed charges,90% of total billed charges,50.69,95,,,percent of total billed charges,95% of total billed charges,50.69,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45.89,86,,,percent of total billed charges,86% of total billed charges,42.69,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.76,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.35,369.77,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,250,125.00,,225,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,200,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,225,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,242.5,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,230,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,175,70,,,percent of total billed charges,70% of total billed charges,225,90,,,percent of total billed charges,90% of total billed charges,237.5,95,,,percent of total billed charges,95% of total billed charges,237.5,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215,86,,,percent of total billed charges,86% of total billed charges,200,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,242.5,97,,,percent of total billed charges,97% of total billed charges,225,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.5,97,,,percent of total billed charges,97% of total billed charges,232.5,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.5,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,708.98,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,109.83,54.92,,98.85,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,87.86,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,106.54,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,101.04,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,98.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,76.88,70,,,percent of total billed charges,70% of total billed charges,98.85,90,,,percent of total billed charges,90% of total billed charges,104.34,95,,,percent of total billed charges,95% of total billed charges,104.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,94.45,86,,,percent of total billed charges,86% of total billed charges,87.86,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,106.54,97,,,percent of total billed charges,97% of total billed charges,98.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.54,97,,,percent of total billed charges,97% of total billed charges,102.14,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106.54,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.88,1365.32,
G0443 Face-to-face behavioral counseling for alcohol misuse 15 minutes,3555131,CDM,510,RC,G0443,HCPCS,Outpatient,,,67.95,33.98,,61.16,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,54.36,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.91,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,62.51,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.16,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,47.57,70,,,percent of total billed charges,70% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.44,86,,,percent of total billed charges,86% of total billed charges,54.36,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,65.91,97,,,percent of total billed charges,97% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.91,97,,,percent of total billed charges,97% of total billed charges,63.19,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.91,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.57,369.77,
G0444 Depression Screening (as part of MWV),3428460,CDM,510,RC,G0444,HCPCS,Outpatient,,,45.32,22.66,,40.79,90,,,percent of total billed charges,90% of total Billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,36.26,80,,,Percent of total Billed charges,80% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.96,97,,,Percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,41.69,92,,,Percent of total billed charges,92% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,144.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,40.79,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,31.72,70,,,percent of total billed charges,70% of total billed charges,40.79,90,,,percent of total billed charges,90% of total billed charges,43.05,95,,,percent of total billed charges,95% of total billed charges,43.05,95,,,percent of total billed charges,95% of total billed charges,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.98,86,,,percent of total billed charges,86% of total billed charges,36.26,80,,,percent of total billed charges,80% of total billed charges,28.24,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.96,97,,,percent of total billed charges,97% of total billed charges,40.79,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.96,97,,,percent of total billed charges,97% of total billed charges,42.15,93,,,percent of total billed charges,93% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.96,97,,,percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.9,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.9,144.68,
"G0445 High-intensity behavioral counseling to prevent STIs, performed semi-annually, 30 minutes",3555132,CDM,510,RC,G0445,HCPCS,Outpatient,,,70.32,35.16,,63.29,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,56.26,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.21,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,64.69,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.29,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,49.22,70,,,percent of total billed charges,70% of total billed charges,63.29,90,,,percent of total billed charges,90% of total billed charges,66.8,95,,,percent of total billed charges,95% of total billed charges,66.8,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.48,86,,,percent of total billed charges,86% of total billed charges,56.26,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.21,97,,,percent of total billed charges,97% of total billed charges,63.29,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.21,97,,,percent of total billed charges,97% of total billed charges,65.4,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,68.21,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.22,369.77,
G0446- Intensive Behavioral Therapy for Cardiovasc Risk,3435926,CDM,510,RC,G0446,HCPCS,Outpatient,,,67.95,33.98,,61.16,90,,,percent of total billed charges,90% of total Billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,54.36,80,,,Percent of total Billed charges,80% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.91,97,,,Percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,62.51,92,,,Percent of total billed charges,92% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,144.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.16,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,47.57,70,,,percent of total billed charges,70% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.44,86,,,percent of total billed charges,86% of total billed charges,54.36,80,,,percent of total billed charges,80% of total billed charges,28.24,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,65.91,97,,,percent of total billed charges,97% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.91,97,,,percent of total billed charges,97% of total billed charges,63.19,93,,,percent of total billed charges,93% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.91,97,,,percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.9,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.9,144.68,
G0447- Behavior Counsel Obesity 15M,3435927,CDM,510,RC,G0447,HCPCS,Outpatient,,,67.95,33.98,,61.16,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,54.36,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.91,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,62.51,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.16,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,47.57,70,,,percent of total billed charges,70% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,64.55,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.44,86,,,percent of total billed charges,86% of total billed charges,54.36,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,65.91,97,,,percent of total billed charges,97% of total billed charges,61.16,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.91,97,,,percent of total billed charges,97% of total billed charges,63.19,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.91,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.57,369.77,
G0500-PF MOD SEDAT ENDO SERVICE >5YRS,4321533,CDM,981,RC,G0500,HCPCS,Outpatient,,,10.82,5.41,,9.74,90,,,percent of total billed charges,90% of total Billed charges,16.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,155,,,Fee Schedule,155% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,8.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,8.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3.25,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,7.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,145,,,Fee Schedule,145% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.53,145,,,Fee Schedule,145% of CMS OPPS Rate,7.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.25,61.09,
G2211 Visit complexity inherent to evaluation and management associated with medical care services t,3623805,CDM,983,RC,G2211,HCPCS,Outpatient,,,33.14,16.57,,29.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.94,29.83,
G2213-PF NITIAT MED ASSIST TX IN ER,4321534,CDM,981,RC,G2213,HCPCS,Outpatient,,,125.98,62.99,,113.38,90,,,percent of total billed charges,90% of total Billed charges,130.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.32,155,,,Fee Schedule,155% of CMS OPPS Rate,62.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.79,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.32,145,,,Fee Schedule,145% of CMS OPPS Rate,62.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.56,145,,,Fee Schedule,145% of CMS OPPS Rate,91.32,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.79,188.56,
S2083 - PF Adjustment Gastric Band,4311871,CDM,960,RC,S2083,HCPCS,Outpatient,,,519.99,260.00,,467.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60,467.99,
S2900 Robotic Surgery,4311870,CDM,960,RC,S2900,HCPCS,Outpatient,,,3561.6,1780.80,,3205.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.48,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1068.48,3205.44,
S2900- Surgical techniques requiring use of robotic surgical system (list separately in addition to,3566799,CDM,510,RC,S2900,HCPCS,Outpatient,,,1,0.50,,0.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.7,70,,,percent of total billed charges,70% of total billed charges,0.9,90,,,percent of total billed charges,90% of total billed charges,0.95,95,,,percent of total billed charges,95% of total billed charges,0.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.86,86,,,percent of total billed charges,86% of total billed charges,0.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.97,97,,,percent of total billed charges,97% of total billed charges,0.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.97,97,,,percent of total billed charges,97% of total billed charges,0.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.7,0.97,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,983,RC,10005,HCPCS,Outpatient,,,195.76,97.88,,176.18,90,,,percent of total billed charges,90% of total Billed charges,203.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.18,155,,,Fee Schedule,155% of CMS OPPS Rate,316.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,316.18,
Read,4345736,CDM,972,RC,10005,HCPCS,Outpatient,,,145.6,72.80,,131.04,90,,,percent of total billed charges,90% of total Billed charges,203.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.18,155,,,Fee Schedule,155% of CMS OPPS Rate,316.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,316.18,
Read,4345738,CDM,972,RC,10005,HCPCS,Outpatient,,,145.6,72.80,,131.04,90,,,percent of total billed charges,90% of total Billed charges,203.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.82,155,,,Fee Schedule,155% of CMS OPPS Rate,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.18,155,,,Fee Schedule,155% of CMS OPPS Rate,316.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.78,316.18,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,960,RC,10006,HCPCS,Outpatient,,,156.74,78.37,,141.07,90,,,percent of total billed charges,90% of total Billed charges,108.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,76.34,155,,,Fee Schedule,155% of CMS OPPS Rate,49.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.34,155,,,Fee Schedule,155% of CMS OPPS Rate,49.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.69,155,,,Fee Schedule,155% of CMS OPPS Rate,167.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,167.69,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,960,RC,10007,HCPCS,Outpatient,,,183.1,91.55,,164.79,90,,,percent of total billed charges,90% of total Billed charges,270.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,135.7,155,,,Fee Schedule,155% of CMS OPPS Rate,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,135.7,155,,,Fee Schedule,155% of CMS OPPS Rate,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,419.51,155,,,Fee Schedule,155% of CMS OPPS Rate,419.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,87.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.74,419.51,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,960,RC,10008,HCPCS,Outpatient,,,107.17,53.59,,96.45,90,,,percent of total billed charges,90% of total Billed charges,160.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,70.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.42,155,,,Fee Schedule,155% of CMS OPPS Rate,248.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,248.42,
10021- Fine needle asp w/o image guide,3431472,CDM,960,RC,10021,HCPCS,Outpatient,,,111.98,55.99,,100.78,90,,,percent of total billed charges,90% of total Billed charges,150.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,65.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.18,155,,,Fee Schedule,155% of CMS OPPS Rate,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.2,155,,,Fee Schedule,155% of CMS OPPS Rate,233.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.31,289.68,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,960,RC,10035,HCPCS,Outpatient,,,223.36,111.68,,201.02,90,,,percent of total billed charges,90% of total Billed charges,306.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.25,155,,,Fee Schedule,155% of CMS OPPS Rate,83.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,95.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.25,155,,,Fee Schedule,155% of CMS OPPS Rate,83.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.46,155,,,Fee Schedule,155% of CMS OPPS Rate,475.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.26,560.92,
10040- Acne surgery,3431474,CDM,960,RC,10040,HCPCS,Outpatient,,,287.12,143.56,,258.41,90,,,percent of total billed charges,90% of total Billed charges,158.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,78.38,155,,,Fee Schedule,155% of CMS OPPS Rate,50.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,59.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,78.38,155,,,Fee Schedule,155% of CMS OPPS Rate,50.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.72,155,,,Fee Schedule,155% of CMS OPPS Rate,245.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,258.41,
10060- Abscess/simple/single/I  & D,3431475,CDM,960,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,215.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.73,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.66,155,,,Fee Schedule,155% of CMS OPPS Rate,334.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,334.66,
10060-PF I & D Abscess Simple/SinglE,4345252,CDM,983,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,215.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.73,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.36,155,,,Fee Schedule,155% of CMS OPPS Rate,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.66,155,,,Fee Schedule,155% of CMS OPPS Rate,334.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,334.66,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,378.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.66,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.85,155,,,Fee Schedule,155% of CMS OPPS Rate,586.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.5,586.85,
"10061- Incision and Drainage, Complex",3428467,CDM,960,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,378.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.66,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.85,155,,,Fee Schedule,155% of CMS OPPS Rate,586.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.5,586.85,
10061-PF I & D Abscess Complicated/Multiple,4345253,CDM,983,RC,10061,HCPCS,Outpatient,,,366.63,183.32,,329.97,90,,,percent of total billed charges,90% of total Billed charges,378.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.66,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,267.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,350.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,315.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,271.5,155,,,Fee Schedule,155% of CMS OPPS Rate,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.85,155,,,Fee Schedule,155% of CMS OPPS Rate,586.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,175.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.5,586.85,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,960,RC,10080,HCPCS,Outpatient,,,208.5,104.25,,187.65,90,,,percent of total billed charges,90% of total Billed charges,307.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.95,155,,,Fee Schedule,155% of CMS OPPS Rate,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.95,155,,,Fee Schedule,155% of CMS OPPS Rate,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.12,155,,,Fee Schedule,155% of CMS OPPS Rate,477.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36,477.12,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,960,RC,10081,HCPCS,Outpatient,,,347.49,173.75,,312.74,90,,,percent of total billed charges,90% of total Billed charges,494.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,258.14,155,,,Fee Schedule,155% of CMS OPPS Rate,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,256.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,256.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,302.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,198.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,258.14,155,,,Fee Schedule,155% of CMS OPPS Rate,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,766.51,155,,,Fee Schedule,155% of CMS OPPS Rate,766.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,166.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,524.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.5,766.51,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,960,RC,10120,HCPCS,Outpatient,,,207.49,103.75,,186.74,90,,,percent of total billed charges,90% of total Billed charges,239.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,175.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,108.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,154.43,155,,,Fee Schedule,155% of CMS OPPS Rate,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.16,155,,,Fee Schedule,155% of CMS OPPS Rate,371.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,276.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,371.16,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,960,RC,10121,HCPCS,Outpatient,,,369.64,184.82,,332.68,90,,,percent of total billed charges,90% of total Billed charges,429.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.33,155,,,Fee Schedule,155% of CMS OPPS Rate,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,277.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,277.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,327.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,214.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.33,155,,,Fee Schedule,155% of CMS OPPS Rate,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.42,155,,,Fee Schedule,155% of CMS OPPS Rate,666.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,539.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,666.42,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,983,RC,10140,HCPCS,Outpatient,,,235.62,117.81,,212.06,90,,,percent of total billed charges,90% of total Billed charges,273.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.62,155,,,Fee Schedule,155% of CMS OPPS Rate,423.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,319.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,319.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,423.62,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,960,RC,10160,HCPCS,Outpatient,,,191.33,95.67,,172.2,90,,,percent of total billed charges,90% of total Billed charges,214,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.91,155,,,Fee Schedule,155% of CMS OPPS Rate,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.7,155,,,Fee Schedule,155% of CMS OPPS Rate,331.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,92.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,255.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24,331.7,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,983,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,424.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.29,155,,,Fee Schedule,155% of CMS OPPS Rate,658.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,483.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.41,658.29,
10180- Postop wound infection/complex/I&D,3431479,CDM,960,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,424.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.29,155,,,Fee Schedule,155% of CMS OPPS Rate,658.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,483.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.41,658.29,
10180-PF I & D Complex PO Wound Infection,4345254,CDM,983,RC,10180,HCPCS,Outpatient,,,361.23,180.62,,325.11,90,,,percent of total billed charges,90% of total Billed charges,424.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,265.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,312.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269,155,,,Fee Schedule,155% of CMS OPPS Rate,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.29,155,,,Fee Schedule,155% of CMS OPPS Rate,658.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,206.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,483.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.41,658.29,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,960,RC,11000,HCPCS,Outpatient,,,56.46,28.23,,50.81,90,,,percent of total billed charges,90% of total Billed charges,81.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.26,90,,,Percent of total Billed charges,90% of total billed charges,29.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,41.4,155,,,Fee Schedule,155% of CMS OPPS Rate,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,41.4,155,,,Fee Schedule,155% of CMS OPPS Rate,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.5,155,,,Fee Schedule,155% of CMS OPPS Rate,126.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,126.5,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,983,RC,11001,HCPCS,Outpatient,,,30.19,15.10,,27.17,90,,,percent of total billed charges,90% of total Billed charges,40.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.92,155,,,Fee Schedule,155% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,21.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,21.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,16.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,22.92,155,,,Fee Schedule,155% of CMS OPPS Rate,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.29,155,,,Fee Schedule,155% of CMS OPPS Rate,62.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.9,62.29,
11004- Debride skn/sq/musc/ext genit/peri,3431480,CDM,960,RC,11004,HCPCS,Outpatient,,,1530.74,765.37,,1377.67,90,,,percent of total billed charges,90% of total Billed charges,1144.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,437.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,881.8,155,,,Fee Schedule,155% of CMS OPPS Rate,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,568.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,869.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,869.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,899.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,899.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,464.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1061.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,743.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,881.8,155,,,Fee Schedule,155% of CMS OPPS Rate,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1773.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1773.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,602.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,568.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1182.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.26,1773.98,
11005- Debride skn/sq/musc/abd wall,3431481,CDM,960,RC,11005,HCPCS,Outpatient,,,2101.66,1050.83,,1891.49,90,,,percent of total billed charges,90% of total Billed charges,1570.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,780.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,594.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1209.28,155,,,Fee Schedule,155% of CMS OPPS Rate,780.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1052.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,780.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1183.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1183.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1232.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1232.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,630.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,780.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1560.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1454.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1059.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1209.28,155,,,Fee Schedule,155% of CMS OPPS Rate,780.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2434.23,155,,,Fee Schedule,155% of CMS OPPS Rate,2434.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,780.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,822.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,780.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1598.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1598.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,594.74,2434.23,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,960,RC,11011,HCPCS,Outpatient,,,610.39,305.20,,549.35,90,,,percent of total billed charges,90% of total Billed charges,771.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,453.64,155,,,Fee Schedule,155% of CMS OPPS Rate,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,452.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,461.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,461.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,240.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,585.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,544.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,376.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,453.64,155,,,Fee Schedule,155% of CMS OPPS Rate,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1195.7,155,,,Fee Schedule,155% of CMS OPPS Rate,1195.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,268,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,474.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,292.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1054,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,240.82,1195.7,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,960,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,110.02,90,,,percent of total billed charges,90% of total Billed charges,179.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.92,155,,,Fee Schedule,155% of CMS OPPS Rate,277.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,277.92,
11042-PF Dbrdmt Subcutaneous Tissue 20 Sq Cm/<,4345255,CDM,983,RC,11042,HCPCS,Outpatient,,,122.24,61.12,,110.02,90,,,percent of total billed charges,90% of total Billed charges,179.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.93,155,,,Fee Schedule,155% of CMS OPPS Rate,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.92,155,,,Fee Schedule,155% of CMS OPPS Rate,277.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,277.92,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,960,RC,11043,HCPCS,Outpatient,,,313,156.50,,281.7,90,,,percent of total billed charges,90% of total Billed charges,374.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,188.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.43,155,,,Fee Schedule,155% of CMS OPPS Rate,580.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,381.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,580.43,
11043-PF Dbdmt Muscle & Fascia 20 Sq Cm/<,4345256,CDM,983,RC,11043,HCPCS,Outpatient,,,313,156.50,,281.7,90,,,percent of total billed charges,90% of total Billed charges,374.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,188.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,233.91,155,,,Fee Schedule,155% of CMS OPPS Rate,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.43,155,,,Fee Schedule,155% of CMS OPPS Rate,580.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,381.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,580.43,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,960,RC,11044,HCPCS,Outpatient,,,462.97,231.49,,416.67,90,,,percent of total billed charges,90% of total Billed charges,523.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,412.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.32,155,,,Fee Schedule,155% of CMS OPPS Rate,811.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,811.32,
11044-PF Dbrdmt Bone Muscle & Fascia 20 Sq Cm/<,4345257,CDM,983,RC,11044,HCPCS,Outpatient,,,462.7,231.35,,416.43,90,,,percent of total billed charges,90% of total Billed charges,523.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,349.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,412.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,278.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.29,155,,,Fee Schedule,155% of CMS OPPS Rate,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,811.32,155,,,Fee Schedule,155% of CMS OPPS Rate,811.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,811.32,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,960,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,47.05,90,,,percent of total billed charges,90% of total Billed charges,64.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.39,155,,,Fee Schedule,155% of CMS OPPS Rate,100.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.45,100.39,
11045-PF Debrdmt Subcutaneous Tissue Ea Addl 20 Sq Cm,4345258,CDM,983,RC,11045,HCPCS,Outpatient,,,52.28,26.14,,47.05,90,,,percent of total billed charges,90% of total Billed charges,64.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.26,155,,,Fee Schedule,155% of CMS OPPS Rate,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.39,155,,,Fee Schedule,155% of CMS OPPS Rate,100.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.45,100.39,
11046 Deb Mus Fasica Add On,3550404,CDM,960,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,102.25,90,,,percent of total billed charges,90% of total Billed charges,126.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.8,155,,,Fee Schedule,155% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.8,155,,,Fee Schedule,155% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.62,155,,,Fee Schedule,155% of CMS OPPS Rate,196.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.43,196.62,
11046-PF Dbrdmt Muscle & Fascia Ea Addl 20 Sq Cm,4345259,CDM,983,RC,11046,HCPCS,Outpatient,,,113.61,56.81,,102.25,90,,,percent of total billed charges,90% of total Billed charges,126.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.8,155,,,Fee Schedule,155% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.8,155,,,Fee Schedule,155% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.62,155,,,Fee Schedule,155% of CMS OPPS Rate,196.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.43,196.62,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,960,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,180.92,90,,,percent of total billed charges,90% of total Billed charges,215.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,150.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,150.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.54,155,,,Fee Schedule,155% of CMS OPPS Rate,334.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53,334.54,
11047-PF Dbrdmt Bone Each Additional 20 Sq Cm,4345260,CDM,983,RC,11047,HCPCS,Outpatient,,,201.02,100.51,,180.92,90,,,percent of total billed charges,90% of total Billed charges,215.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,150.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,128.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,150.33,155,,,Fee Schedule,155% of CMS OPPS Rate,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.54,155,,,Fee Schedule,155% of CMS OPPS Rate,334.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53,334.54,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,960,RC,11055,HCPCS,Outpatient,,,31.86,15.93,,28.67,90,,,percent of total billed charges,90% of total Billed charges,47.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,24.65,155,,,Fee Schedule,155% of CMS OPPS Rate,15.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,18.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,24.65,155,,,Fee Schedule,155% of CMS OPPS Rate,15.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,74.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,15.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,99.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15.9,99.28,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,960,RC,11056,HCPCS,Outpatient,,,44.99,22.50,,40.49,90,,,percent of total billed charges,90% of total Billed charges,66.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.88,155,,,Fee Schedule,155% of CMS OPPS Rate,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,27.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.88,155,,,Fee Schedule,155% of CMS OPPS Rate,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.62,155,,,Fee Schedule,155% of CMS OPPS Rate,103.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,118.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.86,118.32,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,960,RC,11057,HCPCS,Outpatient,,,58.72,29.36,,52.85,90,,,percent of total billed charges,90% of total Billed charges,86.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,43.57,155,,,Fee Schedule,155% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,43.57,155,,,Fee Schedule,155% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.59,155,,,Fee Schedule,155% of CMS OPPS Rate,134.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,140.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.11,140.08,
11102 Shave Biopsy,3428674,CDM,960,RC,11102,HCPCS,Outpatient,,,75.62,37.81,,68.06,90,,,percent of total billed charges,90% of total Billed charges,112.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.66,90,,,Percent of total Billed charges,90% of total billed charges,32.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,56.93,155,,,Fee Schedule,155% of CMS OPPS Rate,36.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,44.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.93,155,,,Fee Schedule,155% of CMS OPPS Rate,36.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.14,155,,,Fee Schedule,155% of CMS OPPS Rate,174.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.23,174.14,
11103 Additional Shave Biopsy,3428675,CDM,960,RC,11103,HCPCS,Outpatient,,,43.84,21.92,,39.46,90,,,percent of total billed charges,90% of total Billed charges,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.65,90,,,Percent of total Billed charges,90% of total billed charges,18.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.55,155,,,Fee Schedule,155% of CMS OPPS Rate,21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,32.55,155,,,Fee Schedule,155% of CMS OPPS Rate,21,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.5,155,,,Fee Schedule,155% of CMS OPPS Rate,100.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100.5,
11104 Punch Biopsy with Suture,3428676,CDM,960,RC,11104,HCPCS,Outpatient,,,94.4,47.20,,84.96,90,,,percent of total billed charges,90% of total Billed charges,140.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.34,90,,,Percent of total Billed charges,90% of total billed charges,40.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.02,155,,,Fee Schedule,155% of CMS OPPS Rate,45.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,71.02,155,,,Fee Schedule,155% of CMS OPPS Rate,45.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.34,155,,,Fee Schedule,155% of CMS OPPS Rate,217.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.43,217.34,
11105 Add'l Punch Biospy with suture,3428677,CDM,960,RC,11105,HCPCS,Outpatient,,,51.75,25.88,,46.58,90,,,percent of total billed charges,90% of total Billed charges,76.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.01,90,,,Percent of total Billed charges,90% of total billed charges,22.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.91,155,,,Fee Schedule,155% of CMS OPPS Rate,25.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.91,155,,,Fee Schedule,155% of CMS OPPS Rate,25.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.12,155,,,Fee Schedule,155% of CMS OPPS Rate,119.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,119.12,
11106 Wedge Biopsy with Suture,3428678,CDM,960,RC,11106,HCPCS,Outpatient,,,114.46,57.23,,103.01,90,,,percent of total billed charges,90% of total Billed charges,169.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.82,90,,,Percent of total Billed charges,90% of total billed charges,49.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,85.42,155,,,Fee Schedule,155% of CMS OPPS Rate,55.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,64.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,85.42,155,,,Fee Schedule,155% of CMS OPPS Rate,55.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.83,155,,,Fee Schedule,155% of CMS OPPS Rate,262.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,161.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.21,262.83,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,960,RC,11107,HCPCS,Outpatient,,,61.9,30.95,,55.71,90,,,percent of total billed charges,90% of total Billed charges,91.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.67,90,,,Percent of total Billed charges,90% of total billed charges,26.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.56,155,,,Fee Schedule,155% of CMS OPPS Rate,30.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,35.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.56,155,,,Fee Schedule,155% of CMS OPPS Rate,30.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.51,155,,,Fee Schedule,155% of CMS OPPS Rate,142.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,30.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,142.51,
11200- Remove skin tags </= 15,3431493,CDM,960,RC,11200,HCPCS,Outpatient,,,149.01,74.51,,134.11,90,,,percent of total billed charges,90% of total Billed charges,156.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.15,155,,,Fee Schedule,155% of CMS OPPS Rate,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.15,155,,,Fee Schedule,155% of CMS OPPS Rate,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.91,155,,,Fee Schedule,155% of CMS OPPS Rate,241.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,172.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31,241.91,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,960,RC,11201,HCPCS,Outpatient,,,32.48,16.24,,29.23,90,,,percent of total billed charges,90% of total Billed charges,34.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.11,155,,,Fee Schedule,155% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,18.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,25.11,155,,,Fee Schedule,155% of CMS OPPS Rate,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.89,155,,,Fee Schedule,155% of CMS OPPS Rate,52.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,38.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.27,52.89,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,960,RC,11300,HCPCS,Outpatient,,,68.48,34.24,,61.63,90,,,percent of total billed charges,90% of total Billed charges,101.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.52,155,,,Fee Schedule,155% of CMS OPPS Rate,33.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,38.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,51.52,155,,,Fee Schedule,155% of CMS OPPS Rate,33.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.67,155,,,Fee Schedule,155% of CMS OPPS Rate,157.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,33.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,137.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25,157.67,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,960,RC,11301,HCPCS,Outpatient,,,102.84,51.42,,92.56,90,,,percent of total billed charges,90% of total Billed charges,152.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.41,155,,,Fee Schedule,155% of CMS OPPS Rate,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.41,155,,,Fee Schedule,155% of CMS OPPS Rate,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.81,155,,,Fee Schedule,155% of CMS OPPS Rate,236.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,185.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,236.81,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,960,RC,11302,HCPCS,Outpatient,,,119.57,59.79,,107.61,90,,,percent of total billed charges,90% of total Billed charges,177.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,90.01,155,,,Fee Schedule,155% of CMS OPPS Rate,58.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,90.01,155,,,Fee Schedule,155% of CMS OPPS Rate,58.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.34,155,,,Fee Schedule,155% of CMS OPPS Rate,275.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,58.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,221.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38,275.34,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,960,RC,11303,HCPCS,Outpatient,,,142.8,71.40,,128.52,90,,,percent of total billed charges,90% of total Billed charges,211.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.03,155,,,Fee Schedule,155% of CMS OPPS Rate,69.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,107.03,155,,,Fee Schedule,155% of CMS OPPS Rate,69.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.37,155,,,Fee Schedule,155% of CMS OPPS Rate,328.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,69.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47,328.37,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,960,RC,11305,HCPCS,Outpatient,,,76.36,38.18,,68.72,90,,,percent of total billed charges,90% of total Billed charges,113.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.51,155,,,Fee Schedule,155% of CMS OPPS Rate,37.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,60.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,60.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,45.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,57.51,155,,,Fee Schedule,155% of CMS OPPS Rate,37.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.86,155,,,Fee Schedule,155% of CMS OPPS Rate,175.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,37.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,62.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,138.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,175.86,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,960,RC,11306,HCPCS,Outpatient,,,98.9,49.45,,89.01,90,,,percent of total billed charges,90% of total Billed charges,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.13,155,,,Fee Schedule,155% of CMS OPPS Rate,48.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,75.13,155,,,Fee Schedule,155% of CMS OPPS Rate,48.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.42,155,,,Fee Schedule,155% of CMS OPPS Rate,228.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,48.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,228.42,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,960,RC,11307,HCPCS,Outpatient,,,126.12,63.06,,113.51,90,,,percent of total billed charges,90% of total Billed charges,187.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,95.39,155,,,Fee Schedule,155% of CMS OPPS Rate,61.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,95.39,155,,,Fee Schedule,155% of CMS OPPS Rate,61.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.87,155,,,Fee Schedule,155% of CMS OPPS Rate,290.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,61.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41,290.87,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,960,RC,11308,HCPCS,Outpatient,,,142.1,71.05,,127.89,90,,,percent of total billed charges,90% of total Billed charges,209.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,106.8,155,,,Fee Schedule,155% of CMS OPPS Rate,68.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,111.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,111.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,106.8,155,,,Fee Schedule,155% of CMS OPPS Rate,68.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.36,155,,,Fee Schedule,155% of CMS OPPS Rate,325.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,68.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,118.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,325.36,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,960,RC,11310,HCPCS,Outpatient,,,91.39,45.70,,82.25,90,,,percent of total billed charges,90% of total Billed charges,136.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,69.44,155,,,Fee Schedule,155% of CMS OPPS Rate,44.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,69.44,155,,,Fee Schedule,155% of CMS OPPS Rate,44.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.09,155,,,Fee Schedule,155% of CMS OPPS Rate,211.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,211.09,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,960,RC,11311,HCPCS,Outpatient,,,125.76,62.88,,113.18,90,,,percent of total billed charges,90% of total Billed charges,186.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.66,155,,,Fee Schedule,155% of CMS OPPS Rate,61.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,71.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,94.66,155,,,Fee Schedule,155% of CMS OPPS Rate,61.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.59,155,,,Fee Schedule,155% of CMS OPPS Rate,289.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,61.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38,289.59,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,960,RC,11312,HCPCS,Outpatient,,,148.68,74.34,,133.81,90,,,percent of total billed charges,90% of total Billed charges,219.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.91,155,,,Fee Schedule,155% of CMS OPPS Rate,73.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.91,155,,,Fee Schedule,155% of CMS OPPS Rate,73.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.99,155,,,Fee Schedule,155% of CMS OPPS Rate,339.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50,339.99,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,960,RC,11313,HCPCS,Outpatient,,,192.84,96.42,,173.56,90,,,percent of total billed charges,90% of total Billed charges,264.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,144.23,155,,,Fee Schedule,155% of CMS OPPS Rate,93.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,144.23,155,,,Fee Schedule,155% of CMS OPPS Rate,93.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.38,155,,,Fee Schedule,155% of CMS OPPS Rate,410.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,93.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,93.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63,410.38,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,960,RC,11400,HCPCS,Outpatient,,,165.13,82.57,,148.62,90,,,percent of total billed charges,90% of total Billed charges,198.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,122.54,155,,,Fee Schedule,155% of CMS OPPS Rate,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,122.54,155,,,Fee Schedule,155% of CMS OPPS Rate,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.21,155,,,Fee Schedule,155% of CMS OPPS Rate,307.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,79.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,307.21,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,960,RC,11401,HCPCS,Outpatient,,,208.37,104.19,,187.53,90,,,percent of total billed charges,90% of total Billed charges,247.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.44,155,,,Fee Schedule,155% of CMS OPPS Rate,100.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,83.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.44,155,,,Fee Schedule,155% of CMS OPPS Rate,100.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.21,155,,,Fee Schedule,155% of CMS OPPS Rate,384.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,100.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,100.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,292.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,292.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.5,384.21,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,960,RC,11402,HCPCS,Outpatient,,,228.94,114.47,,206.05,90,,,percent of total billed charges,90% of total Billed charges,272.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,170.55,155,,,Fee Schedule,155% of CMS OPPS Rate,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,124.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,170.55,155,,,Fee Schedule,155% of CMS OPPS Rate,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,421.79,155,,,Fee Schedule,155% of CMS OPPS Rate,421.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54,421.79,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,960,RC,11403,HCPCS,Outpatient,,,296.93,148.47,,267.24,90,,,percent of total billed charges,90% of total Billed charges,329,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,220.3,155,,,Fee Schedule,155% of CMS OPPS Rate,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,216.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,118.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,220.3,155,,,Fee Schedule,155% of CMS OPPS Rate,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,509.95,155,,,Fee Schedule,155% of CMS OPPS Rate,509.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,173.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,142.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65,509.95,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,960,RC,11404,HCPCS,Outpatient,,,329.05,164.53,,296.15,90,,,percent of total billed charges,90% of total Billed charges,371.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,244.76,155,,,Fee Schedule,155% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,242.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,283.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,244.76,155,,,Fee Schedule,155% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.38,155,,,Fee Schedule,155% of CMS OPPS Rate,575.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,190.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,427.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,80.5,575.38,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,960,RC,11406,HCPCS,Outpatient,,,503.48,251.74,,453.13,90,,,percent of total billed charges,90% of total Billed charges,548.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.55,155,,,Fee Schedule,155% of CMS OPPS Rate,241,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,369.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,369.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,436.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,293.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,373.55,155,,,Fee Schedule,155% of CMS OPPS Rate,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.88,155,,,Fee Schedule,155% of CMS OPPS Rate,849.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,241,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,616.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,849.88,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,145.39,90,,,percent of total billed charges,90% of total Billed charges,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.6,155,,,Fee Schedule,155% of CMS OPPS Rate,305.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,305.6,
Clinic Excision Benign Lesion 0.5- 11420,4351219,CDM,960,RC,11420,HCPCS,Outpatient,,,161.54,80.77,,145.39,90,,,percent of total billed charges,90% of total Billed charges,197.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.59,155,,,Fee Schedule,155% of CMS OPPS Rate,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.6,155,,,Fee Schedule,155% of CMS OPPS Rate,305.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,305.6,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,960,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,194.87,90,,,percent of total billed charges,90% of total Billed charges,255.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.16,155,,,Fee Schedule,155% of CMS OPPS Rate,396.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,310.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,396.16,
Clinic Excision Benign Lesion 0.6-1.0-  11421,4351220,CDM,960,RC,11421,HCPCS,Outpatient,,,216.52,108.26,,194.87,90,,,percent of total billed charges,90% of total Billed charges,255.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,160.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.35,155,,,Fee Schedule,155% of CMS OPPS Rate,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.16,155,,,Fee Schedule,155% of CMS OPPS Rate,396.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,310.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,396.16,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,241.46,90,,,percent of total billed charges,90% of total Billed charges,298.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.97,90,,,Percent of total Billed charges,90% of total billed charges,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.81,155,,,Fee Schedule,155% of CMS OPPS Rate,462.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,462.81,
Clinic Excision Benign Lesion 1.1-2.0 - 11422,4351221,CDM,960,RC,11422,HCPCS,Outpatient,,,268.29,134.15,,241.46,90,,,percent of total billed charges,90% of total Billed charges,298.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.97,90,,,Percent of total Billed charges,90% of total billed charges,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,233.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,148.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,199.98,155,,,Fee Schedule,155% of CMS OPPS Rate,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.81,155,,,Fee Schedule,155% of CMS OPPS Rate,462.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,129.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,462.81,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,960,RC,11423,HCPCS,Outpatient,,,312.19,156.10,,280.97,90,,,percent of total billed charges,90% of total Billed charges,343.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,231.4,155,,,Fee Schedule,155% of CMS OPPS Rate,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,231.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,231.4,155,,,Fee Schedule,155% of CMS OPPS Rate,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.75,155,,,Fee Schedule,155% of CMS OPPS Rate,532.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,400.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36,532.75,
Clinic Excision Benign Lesion 2.1-3.0 - 11423,4351222,CDM,960,RC,11423,HCPCS,Outpatient,,,312.19,156.10,,280.97,90,,,percent of total billed charges,90% of total Billed charges,343.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,231.4,155,,,Fee Schedule,155% of CMS OPPS Rate,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,231.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,231.4,155,,,Fee Schedule,155% of CMS OPPS Rate,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.75,155,,,Fee Schedule,155% of CMS OPPS Rate,532.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,400.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36,532.75,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,960,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,326.3,90,,,percent of total billed charges,90% of total Billed charges,395.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,266.01,155,,,Fee Schedule,155% of CMS OPPS Rate,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,264.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,264.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,266.01,155,,,Fee Schedule,155% of CMS OPPS Rate,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.98,155,,,Fee Schedule,155% of CMS OPPS Rate,612.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,460.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.5,612.98,
Clinic Excision Benign Lesion 3.1-4.0 - 11424,4351223,CDM,960,RC,11424,HCPCS,Outpatient,,,362.56,181.28,,326.3,90,,,percent of total billed charges,90% of total Billed charges,395.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,266.01,155,,,Fee Schedule,155% of CMS OPPS Rate,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,264.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,264.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,343.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,266.01,155,,,Fee Schedule,155% of CMS OPPS Rate,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.98,155,,,Fee Schedule,155% of CMS OPPS Rate,612.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,460.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.5,612.98,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,960,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,487.87,90,,,percent of total billed charges,90% of total Billed charges,584.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,407.11,155,,,Fee Schedule,155% of CMS OPPS Rate,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,262.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,411.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,412.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,412.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,220.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,486.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,407.11,155,,,Fee Schedule,155% of CMS OPPS Rate,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,906.66,155,,,Fee Schedule,155% of CMS OPPS Rate,906.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,329.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,661.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,121,906.66,
Clinic Excision Benign Lesion over 4.0 - 11426,4351224,CDM,960,RC,11426,HCPCS,Outpatient,,,542.08,271.04,,487.87,90,,,percent of total billed charges,90% of total Billed charges,584.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,407.11,155,,,Fee Schedule,155% of CMS OPPS Rate,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,262.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,411.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,412.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,412.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,220.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,525.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,486.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,407.11,155,,,Fee Schedule,155% of CMS OPPS Rate,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,906.66,155,,,Fee Schedule,155% of CMS OPPS Rate,906.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,329.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,262.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,661.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,121,906.66,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,960,RC,11440,HCPCS,Outpatient,,,207.53,103.77,,186.78,90,,,percent of total billed charges,90% of total Billed charges,232.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.18,90,,,Percent of total Billed charges,90% of total billed charges,54.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.25,155,,,Fee Schedule,155% of CMS OPPS Rate,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,82.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,105.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.25,155,,,Fee Schedule,155% of CMS OPPS Rate,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,360.22,155,,,Fee Schedule,155% of CMS OPPS Rate,360.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,123.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.5,360.22,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,960,RC,11441,HCPCS,Outpatient,,,262.35,131.18,,236.12,90,,,percent of total billed charges,90% of total Billed charges,289.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.19,90,,,Percent of total Billed charges,90% of total billed charges,65.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,194.63,155,,,Fee Schedule,155% of CMS OPPS Rate,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,188.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,188.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,139.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,194.63,155,,,Fee Schedule,155% of CMS OPPS Rate,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,449.25,155,,,Fee Schedule,155% of CMS OPPS Rate,449.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,331.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.5,449.25,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,960,RC,11442,HCPCS,Outpatient,,,290.48,145.24,,261.43,90,,,percent of total billed charges,90% of total Billed charges,321.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.85,90,,,Percent of total Billed charges,90% of total billed charges,78.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,215.76,155,,,Fee Schedule,155% of CMS OPPS Rate,139.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,210.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,210.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,116.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,248.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,157.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,215.76,155,,,Fee Schedule,155% of CMS OPPS Rate,139.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,498.7,155,,,Fee Schedule,155% of CMS OPPS Rate,498.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,173.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.5,498.7,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,960,RC,11443,HCPCS,Outpatient,,,356.01,178.01,,320.41,90,,,percent of total billed charges,90% of total Billed charges,387.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.7,90,,,Percent of total Billed charges,90% of total billed charges,89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,264.57,155,,,Fee Schedule,155% of CMS OPPS Rate,170.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,264.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,260.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,260.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,142.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,196.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,264.57,155,,,Fee Schedule,155% of CMS OPPS Rate,170.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.72,155,,,Fee Schedule,155% of CMS OPPS Rate,600.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,170.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,446.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,446.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89,600.72,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,960,RC,11444,HCPCS,Outpatient,,,451.24,225.62,,406.12,90,,,percent of total billed charges,90% of total Billed charges,488.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,336.38,155,,,Fee Schedule,155% of CMS OPPS Rate,217.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,338.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,338.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,335.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,335.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,181.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,256.6,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,336.38,155,,,Fee Schedule,155% of CMS OPPS Rate,217.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,756.94,155,,,Fee Schedule,155% of CMS OPPS Rate,756.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,217.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,117,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,217.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,562.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,562.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117,756.94,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,960,RC,11446,HCPCS,Outpatient,,,638.48,319.24,,574.63,90,,,percent of total billed charges,90% of total Billed charges,678.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,305.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,474.22,155,,,Fee Schedule,155% of CMS OPPS Rate,305.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,305.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,482.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,481.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,481.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,260.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,611.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,567.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,369.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,474.22,155,,,Fee Schedule,155% of CMS OPPS Rate,305.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1051.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1051.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,305.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,364.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,305.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,784.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,784.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,118.5,1051.15,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,960,RC,11450,HCPCS,Outpatient,,,530.15,265.08,,477.14,90,,,percent of total billed charges,90% of total Billed charges,668.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,183.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,394.04,155,,,Fee Schedule,155% of CMS OPPS Rate,254.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,383.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,381.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,381.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,449.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,305.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,394.04,155,,,Fee Schedule,155% of CMS OPPS Rate,254.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1036.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1036.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,254.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,255.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,254.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,740.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,740.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,183.24,1036.05,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,960,RC,11451,HCPCS,Outpatient,,,673.08,336.54,,605.77,90,,,percent of total billed charges,90% of total Billed charges,828.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,323.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,252.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,502.08,155,,,Fee Schedule,155% of CMS OPPS Rate,323.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,490.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,490.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,490.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,490.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,261.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,578.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,393.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,502.08,155,,,Fee Schedule,155% of CMS OPPS Rate,323.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,1284.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1284.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,323.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,338.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,323.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,933.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,933.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,252.67,1284.72,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,960,RC,11462,HCPCS,Outpatient,,,503.35,251.68,,453.02,90,,,percent of total billed charges,90% of total Billed charges,640.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,173.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,371.98,155,,,Fee Schedule,155% of CMS OPPS Rate,239.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,239.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,365.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,365.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,361.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,361.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,479.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,426.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,371.98,155,,,Fee Schedule,155% of CMS OPPS Rate,239.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.73,155,,,Fee Schedule,155% of CMS OPPS Rate,992.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,239.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,239.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,722.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,722.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,173.95,992.73,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,960,RC,11463,HCPCS,Outpatient,,,674.75,337.38,,607.28,90,,,percent of total billed charges,90% of total Billed charges,838.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,325.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,257.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,504.35,155,,,Fee Schedule,155% of CMS OPPS Rate,325.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,439.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,325.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,494.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,494,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,494,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,262.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,650.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,582.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,396.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,504.35,155,,,Fee Schedule,155% of CMS OPPS Rate,325.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1299.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1299.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,325.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,355.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,325.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,946.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,257.76,1299.6,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,960,RC,11470,HCPCS,Outpatient,,,580.73,290.37,,522.66,90,,,percent of total billed charges,90% of total Billed charges,714.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,212.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,432.87,155,,,Fee Schedule,155% of CMS OPPS Rate,279.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,279.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,422.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,420.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,420.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,225.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,558.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,496.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,432.87,155,,,Fee Schedule,155% of CMS OPPS Rate,279.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.38,155,,,Fee Schedule,155% of CMS OPPS Rate,1107.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,279.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,279.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,812.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,212.98,1107.38,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,960,RC,11471,HCPCS,Outpatient,,,712.09,356.05,,640.88,90,,,percent of total billed charges,90% of total Billed charges,865.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,278.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,528.75,155,,,Fee Schedule,155% of CMS OPPS Rate,341.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,522.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,521.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,521.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,682.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,615.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,413.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,528.75,155,,,Fee Schedule,155% of CMS OPPS Rate,341.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,1340.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1340.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,341.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,341.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,998.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.14,1340.84,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,960,RC,11600,HCPCS,Outpatient,,,243.02,121.51,,218.72,90,,,percent of total billed charges,90% of total Billed charges,302.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,181.1,155,,,Fee Schedule,155% of CMS OPPS Rate,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,180.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,181.1,155,,,Fee Schedule,155% of CMS OPPS Rate,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.34,155,,,Fee Schedule,155% of CMS OPPS Rate,469.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,158.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,80,469.34,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,960,RC,11601,HCPCS,Outpatient,,,294.28,147.14,,264.85,90,,,percent of total billed charges,90% of total Billed charges,357.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.76,155,,,Fee Schedule,155% of CMS OPPS Rate,141.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,283.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,257.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,163.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.76,155,,,Fee Schedule,155% of CMS OPPS Rate,141.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.49,155,,,Fee Schedule,155% of CMS OPPS Rate,553.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,452.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,452.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99,553.49,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,960,RC,11602,HCPCS,Outpatient,,,318.93,159.47,,287.04,90,,,percent of total billed charges,90% of total Billed charges,383.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,238.39,155,,,Fee Schedule,155% of CMS OPPS Rate,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,175.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,238.39,155,,,Fee Schedule,155% of CMS OPPS Rate,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.36,155,,,Fee Schedule,155% of CMS OPPS Rate,594.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,214.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,493,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,493,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81,594.36,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,960,RC,11603,HCPCS,Outpatient,,,383.4,191.70,,345.06,90,,,percent of total billed charges,90% of total Billed charges,448.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,287.48,155,,,Fee Schedule,155% of CMS OPPS Rate,185.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,288.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,285.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,285.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,157.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,337.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.48,155,,,Fee Schedule,155% of CMS OPPS Rate,185.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.11,155,,,Fee Schedule,155% of CMS OPPS Rate,695.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,563.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85.5,695.11,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,960,RC,11604,HCPCS,Outpatient,,,424.06,212.03,,381.65,90,,,percent of total billed charges,90% of total Billed charges,498.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,125.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,317.75,155,,,Fee Schedule,155% of CMS OPPS Rate,205,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,317.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,317.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,410,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,374.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,240.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,317.75,155,,,Fee Schedule,155% of CMS OPPS Rate,205,100,,,Fee Schedule,100% of CMS OPPS Rate ,773.05,155,,,Fee Schedule,155% of CMS OPPS Rate,773.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,205,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,625.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.5,773.05,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,960,RC,11606,HCPCS,Outpatient,,,642.59,321.30,,578.33,90,,,percent of total billed charges,90% of total Billed charges,737.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,308.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,246,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,478.76,155,,,Fee Schedule,155% of CMS OPPS Rate,308.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,308.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,476.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,476.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,480.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,480.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,257.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,566.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,376.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,478.76,155,,,Fee Schedule,155% of CMS OPPS Rate,308.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,1143.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1143.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,308.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,246,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,308.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,896.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,896.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,246,1143.5,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,960,RC,11620,HCPCS,Outpatient,,,245.22,122.61,,220.7,90,,,percent of total billed charges,90% of total Billed charges,304.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,182.08,155,,,Fee Schedule,155% of CMS OPPS Rate,117.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,179.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,179.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,212.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,135.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,182.08,155,,,Fee Schedule,155% of CMS OPPS Rate,117.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,471.31,155,,,Fee Schedule,155% of CMS OPPS Rate,471.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,117.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,117.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,381.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.5,471.31,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,960,RC,11621,HCPCS,Outpatient,,,295.91,147.96,,266.32,90,,,percent of total billed charges,90% of total Billed charges,358.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,221.39,155,,,Fee Schedule,155% of CMS OPPS Rate,142.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,259.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,221.39,155,,,Fee Schedule,155% of CMS OPPS Rate,142.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.11,155,,,Fee Schedule,155% of CMS OPPS Rate,556.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,142.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,142.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.5,556.11,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,960,RC,11622,HCPCS,Outpatient,,,335.96,167.98,,302.36,90,,,percent of total billed charges,90% of total Billed charges,399.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.23,155,,,Fee Schedule,155% of CMS OPPS Rate,161.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,249.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,249.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,294.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.23,155,,,Fee Schedule,155% of CMS OPPS Rate,161.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.68,155,,,Fee Schedule,155% of CMS OPPS Rate,618.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,511.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,511.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112,618.68,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,960,RC,11623,HCPCS,Outpatient,,,416.86,208.43,,375.17,90,,,percent of total billed charges,90% of total Billed charges,482.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,312.36,155,,,Fee Schedule,155% of CMS OPPS Rate,201.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,201.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,312.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,312.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,403.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,368.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,235.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,312.36,155,,,Fee Schedule,155% of CMS OPPS Rate,201.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.69,155,,,Fee Schedule,155% of CMS OPPS Rate,747.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,201.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,262.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,201.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,601.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.5,747.69,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,960,RC,11624,HCPCS,Outpatient,,,477.13,238.57,,429.42,90,,,percent of total billed charges,90% of total Billed charges,550.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,229.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.41,155,,,Fee Schedule,155% of CMS OPPS Rate,229.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,356.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,356.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,356.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,420.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,356.41,155,,,Fee Schedule,155% of CMS OPPS Rate,229.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,853.79,155,,,Fee Schedule,155% of CMS OPPS Rate,853.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,229.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,229.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,677.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,677.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,189,853.79,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,960,RC,11626,HCPCS,Outpatient,,,589.34,294.67,,530.41,90,,,percent of total billed charges,90% of total Billed charges,675.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,284.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,240,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,441.07,155,,,Fee Schedule,155% of CMS OPPS Rate,284.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,439.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,442.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,442.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,569.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,522.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,348.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,441.07,155,,,Fee Schedule,155% of CMS OPPS Rate,284.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1046.92,155,,,Fee Schedule,155% of CMS OPPS Rate,1046.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,284.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,346.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,284.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,819.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,819.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,236.51,1046.92,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,960,RC,11640,HCPCS,Outpatient,,,250.84,125.42,,225.76,90,,,percent of total billed charges,90% of total Billed charges,311.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,186.39,155,,,Fee Schedule,155% of CMS OPPS Rate,120.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,183.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,183.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,137.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,186.39,155,,,Fee Schedule,155% of CMS OPPS Rate,120.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.28,155,,,Fee Schedule,155% of CMS OPPS Rate,482.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,120.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,168.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,120.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,395.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,482.28,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,960,RC,11641,HCPCS,Outpatient,,,308.46,154.23,,277.61,90,,,percent of total billed charges,90% of total Billed charges,371.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.41,155,,,Fee Schedule,155% of CMS OPPS Rate,148.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,231.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,228.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,228.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,270.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,171.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.41,155,,,Fee Schedule,155% of CMS OPPS Rate,148.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,575.48,155,,,Fee Schedule,155% of CMS OPPS Rate,575.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,148.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,208.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,473.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,575.48,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,960,RC,11642,HCPCS,Outpatient,,,362.33,181.17,,326.1,90,,,percent of total billed charges,90% of total Billed charges,426.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,135,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,269.34,155,,,Fee Schedule,155% of CMS OPPS Rate,173.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,173.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,317.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,202.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,269.34,155,,,Fee Schedule,155% of CMS OPPS Rate,173.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.46,155,,,Fee Schedule,155% of CMS OPPS Rate,661.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,173.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,135,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,232.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,173.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,541.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,541.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135,661.46,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,960,RC,11643,HCPCS,Outpatient,,,454.1,227.05,,408.69,90,,,percent of total billed charges,90% of total Billed charges,518.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,218.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,338.99,155,,,Fee Schedule,155% of CMS OPPS Rate,218.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,339.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,339.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,185.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,437.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,257.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,338.99,155,,,Fee Schedule,155% of CMS OPPS Rate,218.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,803.18,155,,,Fee Schedule,155% of CMS OPPS Rate,803.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,218.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,218.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,642.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,642.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,185.03,803.18,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,960,RC,11644,HCPCS,Outpatient,,,565.09,282.55,,508.58,90,,,percent of total billed charges,90% of total Billed charges,643.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,221,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,422.34,155,,,Fee Schedule,155% of CMS OPPS Rate,272.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,423.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,423.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,228.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,272.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,544.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,500.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,325.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,422.34,155,,,Fee Schedule,155% of CMS OPPS Rate,272.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,996.98,155,,,Fee Schedule,155% of CMS OPPS Rate,996.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,272.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,272.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,793.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,793.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221,996.98,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,960,RC,11646,HCPCS,Outpatient,,,787.05,393.53,,708.35,90,,,percent of total billed charges,90% of total Billed charges,867.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,380.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,256,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,589.14,155,,,Fee Schedule,155% of CMS OPPS Rate,380.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,587.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,590.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,590.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,317.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,380.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,760.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,697.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,459.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,589.14,155,,,Fee Schedule,155% of CMS OPPS Rate,380.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.49,155,,,Fee Schedule,155% of CMS OPPS Rate,1344.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,380.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,256,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,380.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1042.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1042.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,256,1344.49,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,983,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,43.52,90,,,percent of total billed charges,90% of total Billed charges,65.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.11,155,,,Fee Schedule,155% of CMS OPPS Rate,101.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,101.11,
11721- Debride/nails/any method/6 or more,3431551,CDM,960,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,43.52,90,,,percent of total billed charges,90% of total Billed charges,65.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.11,155,,,Fee Schedule,155% of CMS OPPS Rate,101.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,101.11,
11721-PF Dbrdmt Nail Any Method 6/>,4345261,CDM,983,RC,11721,HCPCS,Outpatient,,,48.36,24.18,,43.52,90,,,percent of total billed charges,90% of total Billed charges,65.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.44,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.11,155,,,Fee Schedule,155% of CMS OPPS Rate,101.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,101.11,
11730- Avulsion/nail plate/simple/single,3431552,CDM,960,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,97.86,90,,,percent of total billed charges,90% of total Billed charges,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.95,90,,,Percent of total Billed charges,90% of total billed charges,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,249.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.75,249.16,
11730-PF Nail avulsion; single,4345262,CDM,983,RC,11730,HCPCS,Outpatient,,,108.73,54.37,,97.86,90,,,percent of total billed charges,90% of total Billed charges,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.95,90,,,Percent of total Billed charges,90% of total billed charges,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,81.67,155,,,Fee Schedule,155% of CMS OPPS Rate,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,249.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.75,249.16,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,960,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,31.08,90,,,percent of total billed charges,90% of total Billed charges,49.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,19.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.32,155,,,Fee Schedule,155% of CMS OPPS Rate,76.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,87.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.21,87.72,
11732-PF Nail avulsion; each additional,4345263,CDM,983,RC,11732,HCPCS,Outpatient,,,34.53,17.27,,31.08,90,,,percent of total billed charges,90% of total Billed charges,49.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,26.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.3,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,19.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,26.68,155,,,Fee Schedule,155% of CMS OPPS Rate,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.32,155,,,Fee Schedule,155% of CMS OPPS Rate,76.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,87.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.21,87.72,
11750- Excise/nail/matrix/perm removal,3431555,CDM,960,RC,11750,HCPCS,Outpatient,,,258.92,129.46,,233.03,90,,,percent of total billed charges,90% of total Billed charges,246.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.23,155,,,Fee Schedule,155% of CMS OPPS Rate,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.23,155,,,Fee Schedule,155% of CMS OPPS Rate,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,382.52,155,,,Fee Schedule,155% of CMS OPPS Rate,382.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,194.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,438.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,96.28,438.6,
11900- Intralesional injection/</=7,3431563,CDM,960,RC,11900,HCPCS,Outpatient,,,60.21,30.11,,54.19,90,,,percent of total billed charges,90% of total Billed charges,82.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.29,155,,,Fee Schedule,155% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,33.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,45.29,155,,,Fee Schedule,155% of CMS OPPS Rate,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.47,155,,,Fee Schedule,155% of CMS OPPS Rate,127.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,110.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.93,127.47,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,960,RC,11901,HCPCS,Outpatient,,,91.05,45.53,,81.95,90,,,percent of total billed charges,90% of total Billed charges,111.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.56,155,,,Fee Schedule,155% of CMS OPPS Rate,44.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.56,155,,,Fee Schedule,155% of CMS OPPS Rate,44.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.47,155,,,Fee Schedule,155% of CMS OPPS Rate,172.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.79,172.47,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,135.38,67.69,,121.84,90,,,percent of total billed charges,90% of total Billed charges,127.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.28,155,,,Fee Schedule,155% of CMS OPPS Rate,198.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,198.28,
11950- Subq inj/fill material/1cc or <,3431566,CDM,960,RC,11950,HCPCS,Outpatient,,,106.02,53.01,,95.42,90,,,percent of total billed charges,90% of total Billed charges,127.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.28,155,,,Fee Schedule,155% of CMS OPPS Rate,198.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,198.28,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,960,RC,11951,HCPCS,Outpatient,,,148.44,74.22,,133.6,90,,,percent of total billed charges,90% of total Billed charges,174.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.46,155,,,Fee Schedule,155% of CMS OPPS Rate,71.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.46,155,,,Fee Schedule,155% of CMS OPPS Rate,71.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.88,155,,,Fee Schedule,155% of CMS OPPS Rate,270.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,110.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,199.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.05,270.88,
11980- Hormone pellet implant/subq,3431570,CDM,960,RC,11980,HCPCS,Outpatient,,,132.8,66.40,,119.52,90,,,percent of total billed charges,90% of total Billed charges,144.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.69,155,,,Fee Schedule,155% of CMS OPPS Rate,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,66.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.69,155,,,Fee Schedule,155% of CMS OPPS Rate,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.36,155,,,Fee Schedule,155% of CMS OPPS Rate,223.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,208.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.93,223.36,
11981- Insert/drug delivery implant,3431571,CDM,960,RC,11981,HCPCS,Outpatient,,,165.86,82.93,,149.27,90,,,percent of total billed charges,90% of total Billed charges,159.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,82.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.66,155,,,Fee Schedule,155% of CMS OPPS Rate,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.88,155,,,Fee Schedule,155% of CMS OPPS Rate,247.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.36,264.52,
11982- Remove/drug delivery implant,3431572,CDM,960,RC,11982,HCPCS,Outpatient,,,156.69,78.35,,141.02,90,,,percent of total billed charges,90% of total Billed charges,183.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,114.56,155,,,Fee Schedule,155% of CMS OPPS Rate,73.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,114.56,155,,,Fee Schedule,155% of CMS OPPS Rate,73.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.41,155,,,Fee Schedule,155% of CMS OPPS Rate,284.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,289,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73.91,289,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,983,RC,12001,HCPCS,Outpatient,,,93.47,46.74,,84.12,90,,,percent of total billed charges,90% of total Billed charges,134.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.4,90,,,Percent of total Billed charges,90% of total billed charges,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.32,155,,,Fee Schedule,155% of CMS OPPS Rate,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.68,155,,,Fee Schedule,155% of CMS OPPS Rate,208.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,208.68,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,960,RC,12002,HCPCS,Outpatient,,,123.43,61.72,,111.09,90,,,percent of total billed charges,90% of total Billed charges,167.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.35,90,,,Percent of total Billed charges,90% of total billed charges,35.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.12,155,,,Fee Schedule,155% of CMS OPPS Rate,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.12,155,,,Fee Schedule,155% of CMS OPPS Rate,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.9,155,,,Fee Schedule,155% of CMS OPPS Rate,259.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.5,259.9,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,960,RC,12004,HCPCS,Outpatient,,,154.93,77.47,,139.44,90,,,percent of total billed charges,90% of total Billed charges,200.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,114.36,155,,,Fee Schedule,155% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,114.36,155,,,Fee Schedule,155% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.19,155,,,Fee Schedule,155% of CMS OPPS Rate,310.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,176.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,244.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,310.19,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,960,RC,12005,HCPCS,Outpatient,,,201.29,100.65,,181.16,90,,,percent of total billed charges,90% of total Billed charges,267.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.3,155,,,Fee Schedule,155% of CMS OPPS Rate,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,153.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,153.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.3,155,,,Fee Schedule,155% of CMS OPPS Rate,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,414.41,155,,,Fee Schedule,155% of CMS OPPS Rate,414.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,318.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,414.41,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,960,RC,12006,HCPCS,Outpatient,,,245.31,122.66,,220.78,90,,,percent of total billed charges,90% of total Billed charges,318.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,183.68,155,,,Fee Schedule,155% of CMS OPPS Rate,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,158.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.68,155,,,Fee Schedule,155% of CMS OPPS Rate,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.4,155,,,Fee Schedule,155% of CMS OPPS Rate,494.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,494.4,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,960,RC,12007,HCPCS,Outpatient,,,304.05,152.03,,273.65,90,,,percent of total billed charges,90% of total Billed charges,373.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,227.49,155,,,Fee Schedule,155% of CMS OPPS Rate,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,227.49,155,,,Fee Schedule,155% of CMS OPPS Rate,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,579.19,155,,,Fee Schedule,155% of CMS OPPS Rate,579.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,310.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,146.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,448.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,579.19,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,960,RC,12011,HCPCS,Outpatient,,,116.45,58.23,,104.81,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,252.36,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,960,RC,12013,HCPCS,Outpatient,,,123.04,61.52,,110.74,90,,,percent of total billed charges,90% of total Billed charges,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,92.89,155,,,Fee Schedule,155% of CMS OPPS Rate,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,94.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,94.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,92.89,155,,,Fee Schedule,155% of CMS OPPS Rate,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,267.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,176.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,267.17,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,204.72,102.36,,184.25,90,,,percent of total billed charges,90% of total Billed charges,214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.8,155,,,Fee Schedule,155% of CMS OPPS Rate,332.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,332.8,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,960,RC,12015,HCPCS,Outpatient,,,200.19,100.10,,180.17,90,,,percent of total billed charges,90% of total Billed charges,262.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.14,155,,,Fee Schedule,155% of CMS OPPS Rate,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,149.14,155,,,Fee Schedule,155% of CMS OPPS Rate,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,407.42,155,,,Fee Schedule,155% of CMS OPPS Rate,407.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,252.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,323.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.5,407.42,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,960,RC,12016,HCPCS,Outpatient,,,271.32,135.66,,244.19,90,,,percent of total billed charges,90% of total Billed charges,344.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202.23,155,,,Fee Schedule,155% of CMS OPPS Rate,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,206.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,206.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,175.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202.23,155,,,Fee Schedule,155% of CMS OPPS Rate,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.02,155,,,Fee Schedule,155% of CMS OPPS Rate,534.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,288.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,534.02,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,960,RC,12018,HCPCS,Outpatient,,,369.73,184.87,,332.76,90,,,percent of total billed charges,90% of total Billed charges,356.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,275.62,155,,,Fee Schedule,155% of CMS OPPS Rate,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,264.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,279.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,279.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,329.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,239.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.62,155,,,Fee Schedule,155% of CMS OPPS Rate,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.79,155,,,Fee Schedule,155% of CMS OPPS Rate,552.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,177.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,346.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,552.79,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,960,RC,12020,HCPCS,Outpatient,,,378,189.00,,340.2,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,723.74,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,483.59,241.80,,435.23,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,723.74,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,960,RC,12020,HCPCS,Outpatient,,,378,189.00,,340.2,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,723.74,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,960,RC,12021,HCPCS,Outpatient,,,282.55,141.28,,254.3,90,,,percent of total billed charges,90% of total Billed charges,305.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,118,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,210.46,155,,,Fee Schedule,155% of CMS OPPS Rate,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,207.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,207.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,210.46,155,,,Fee Schedule,155% of CMS OPPS Rate,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.49,155,,,Fee Schedule,155% of CMS OPPS Rate,473.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,327.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.81,473.49,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,960,RC,12031,HCPCS,Outpatient,,,299,149.50,,269.1,90,,,percent of total billed charges,90% of total Billed charges,391.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,223.76,155,,,Fee Schedule,155% of CMS OPPS Rate,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,223.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,223.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,263.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,223.76,155,,,Fee Schedule,155% of CMS OPPS Rate,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.12,155,,,Fee Schedule,155% of CMS OPPS Rate,607.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,144.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,495.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,607.12,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,960,RC,12032,HCPCS,Outpatient,,,374.71,187.36,,337.24,90,,,percent of total billed charges,90% of total Billed charges,463.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,279.48,155,,,Fee Schedule,155% of CMS OPPS Rate,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,278.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,278.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,328.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,279.48,155,,,Fee Schedule,155% of CMS OPPS Rate,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.18,155,,,Fee Schedule,155% of CMS OPPS Rate,719.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,180.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33,719.18,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,960,RC,12034,HCPCS,Outpatient,,,409.54,204.77,,368.59,90,,,percent of total billed charges,90% of total Billed charges,513.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.91,155,,,Fee Schedule,155% of CMS OPPS Rate,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,305.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,305.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,360.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.91,155,,,Fee Schedule,155% of CMS OPPS Rate,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,796.05,155,,,Fee Schedule,155% of CMS OPPS Rate,796.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,618.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.5,796.05,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,960,RC,12035,HCPCS,Outpatient,,,487.35,243.68,,438.62,90,,,percent of total billed charges,90% of total Billed charges,605.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,361.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,362.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,362.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,192.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,427.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,286.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,363.71,155,,,Fee Schedule,155% of CMS OPPS Rate,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.2,155,,,Fee Schedule,155% of CMS OPPS Rate,938.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,234.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,938.2,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,960,RC,12037,HCPCS,Outpatient,,,671.36,335.68,,604.22,90,,,percent of total billed charges,90% of total Billed charges,788.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,502.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,263.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,409.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,498.26,155,,,Fee Schedule,155% of CMS OPPS Rate,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1222.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1222.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,321.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,916.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1222.64,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,960,RC,12041,HCPCS,Outpatient,,,288.91,144.46,,260.02,90,,,percent of total billed charges,90% of total Billed charges,387.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,215.67,155,,,Fee Schedule,155% of CMS OPPS Rate,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,217.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,217.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,256.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,215.67,155,,,Fee Schedule,155% of CMS OPPS Rate,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.17,155,,,Fee Schedule,155% of CMS OPPS Rate,601.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,221.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,518.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.5,601.17,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,960,RC,12042,HCPCS,Outpatient,,,388.17,194.09,,349.35,90,,,percent of total billed charges,90% of total Billed charges,479.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,293.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,289.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,373.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,341.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,214.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,289.12,155,,,Fee Schedule,155% of CMS OPPS Rate,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.84,155,,,Fee Schedule,155% of CMS OPPS Rate,742.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,257.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,186.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,582.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.5,742.84,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,960,RC,12044,HCPCS,Outpatient,,,429.43,214.72,,386.49,90,,,percent of total billed charges,90% of total Billed charges,565.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,319.67,155,,,Fee Schedule,155% of CMS OPPS Rate,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,320.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,320.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,320.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,172.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,377.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,246.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.67,155,,,Fee Schedule,155% of CMS OPPS Rate,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,876,155,,,Fee Schedule,155% of CMS OPPS Rate,876,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,707.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.5,876,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,960,RC,12045,HCPCS,Outpatient,,,550.35,275.18,,495.32,90,,,percent of total billed charges,90% of total Billed charges,653.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,411.8,155,,,Fee Schedule,155% of CMS OPPS Rate,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,265.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,402.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,402.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,531.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,475.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,314.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,411.8,155,,,Fee Schedule,155% of CMS OPPS Rate,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1013.68,155,,,Fee Schedule,155% of CMS OPPS Rate,1013.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,265.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,741.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1013.68,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,960,RC,12046,HCPCS,Outpatient,,,651.05,325.53,,585.95,90,,,percent of total billed charges,90% of total Billed charges,794.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,483.32,155,,,Fee Schedule,155% of CMS OPPS Rate,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,420.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,476.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,476.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,249.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,623.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,562.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,394.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,483.32,155,,,Fee Schedule,155% of CMS OPPS Rate,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1231.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1231.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,460.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,311.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,876.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1231.35,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,960,RC,12047,HCPCS,Outpatient,,,724.43,362.22,,651.99,90,,,percent of total billed charges,90% of total Billed charges,877.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,539.62,155,,,Fee Schedule,155% of CMS OPPS Rate,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,469.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,527.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,527.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,533.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,533.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,296.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,696.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,629.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,444.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,539.62,155,,,Fee Schedule,155% of CMS OPPS Rate,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1360.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,481.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,348.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,962.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1360.4,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,960,RC,12051,HCPCS,Outpatient,,,336.44,168.22,,302.8,90,,,percent of total billed charges,90% of total Billed charges,429.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,251.19,155,,,Fee Schedule,155% of CMS OPPS Rate,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,252.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,252.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,185.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,251.19,155,,,Fee Schedule,155% of CMS OPPS Rate,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.42,155,,,Fee Schedule,155% of CMS OPPS Rate,665.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,162.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,539.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,665.42,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,960,RC,12052,HCPCS,Outpatient,,,396.16,198.08,,356.54,90,,,percent of total billed charges,90% of total Billed charges,489.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.42,155,,,Fee Schedule,155% of CMS OPPS Rate,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,299.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,295.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,295.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,164.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,348.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,219.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.42,155,,,Fee Schedule,155% of CMS OPPS Rate,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,758.48,155,,,Fee Schedule,155% of CMS OPPS Rate,758.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,269.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,616.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,616.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,758.48,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,960,RC,12053,HCPCS,Outpatient,,,428.81,214.41,,385.93,90,,,percent of total billed charges,90% of total Billed charges,551.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,321.14,155,,,Fee Schedule,155% of CMS OPPS Rate,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,320.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,320.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,414.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,378.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,242.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,321.14,155,,,Fee Schedule,155% of CMS OPPS Rate,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.22,155,,,Fee Schedule,155% of CMS OPPS Rate,854.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,207.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,686.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,854.22,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,960,RC,12054,HCPCS,Outpatient,,,444.86,222.43,,400.37,90,,,percent of total billed charges,90% of total Billed charges,581.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,332.66,155,,,Fee Schedule,155% of CMS OPPS Rate,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,214.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,333.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,333.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,178.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,393.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,260.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,332.66,155,,,Fee Schedule,155% of CMS OPPS Rate,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,901.54,155,,,Fee Schedule,155% of CMS OPPS Rate,901.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,307.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,214.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,731.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,731.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.5,901.54,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,960,RC,12055,HCPCS,Outpatient,,,611.13,305.57,,550.02,90,,,percent of total billed charges,90% of total Billed charges,773.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,454.4,155,,,Fee Schedule,155% of CMS OPPS Rate,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,451.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,451.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,453.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,453.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,244.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,586.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,359.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,454.4,155,,,Fee Schedule,155% of CMS OPPS Rate,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1198.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1198.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,293.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,884,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,884,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1198.48,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,960,RC,12056,HCPCS,Outpatient,,,772.15,386.08,,694.94,90,,,percent of total billed charges,90% of total Billed charges,925.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,577.34,155,,,Fee Schedule,155% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,514.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,578.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,578.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,575.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,575.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,273.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,744.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,678.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,450.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,577.34,155,,,Fee Schedule,155% of CMS OPPS Rate,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1434.63,155,,,Fee Schedule,155% of CMS OPPS Rate,1434.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,514.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,372.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1080.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1434.63,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,960,RC,12057,HCPCS,Outpatient,,,846.26,423.13,,761.63,90,,,percent of total billed charges,90% of total Billed charges,994.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,631.8,155,,,Fee Schedule,155% of CMS OPPS Rate,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,568.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,407.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,639.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,639.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,638.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,638.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,314.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,815.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,753.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,501.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,631.8,155,,,Fee Schedule,155% of CMS OPPS Rate,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1541.43,155,,,Fee Schedule,155% of CMS OPPS Rate,1541.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,407.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1249.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1249.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92,1541.43,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,960,RC,13101,HCPCS,Outpatient,,,487.66,243.83,,438.89,90,,,percent of total billed charges,90% of total Billed charges,611.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,366.03,155,,,Fee Schedule,155% of CMS OPPS Rate,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,372.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,372.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,366.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,366.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,203.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,472.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,432.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,271.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,366.03,155,,,Fee Schedule,155% of CMS OPPS Rate,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,947.65,155,,,Fee Schedule,155% of CMS OPPS Rate,947.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,357.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,236.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,794.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,794.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,947.65,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,983,RC,13102,HCPCS,Outpatient,,,145.88,72.94,,131.29,90,,,percent of total billed charges,90% of total Billed charges,182.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,108.93,155,,,Fee Schedule,155% of CMS OPPS Rate,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,86.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,108.93,155,,,Fee Schedule,155% of CMS OPPS Rate,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.64,155,,,Fee Schedule,155% of CMS OPPS Rate,282.64,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,219.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.7,282.64,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,960,RC,13120,HCPCS,Outpatient,,,457.5,228.75,,411.75,90,,,percent of total billed charges,90% of total Billed charges,558,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,343.51,155,,,Fee Schedule,155% of CMS OPPS Rate,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,221.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,348.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,348.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,342.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,342.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,404.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,255.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,343.51,155,,,Fee Schedule,155% of CMS OPPS Rate,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,864.9,155,,,Fee Schedule,155% of CMS OPPS Rate,864.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,294.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,221.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,649.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60,864.9,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,960,RC,13121,HCPCS,Outpatient,,,513.25,256.63,,461.93,90,,,percent of total billed charges,90% of total Billed charges,649.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,259.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,383.01,155,,,Fee Schedule,155% of CMS OPPS Rate,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,390.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,387.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,387.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,219.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,494.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,288.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,383.01,155,,,Fee Schedule,155% of CMS OPPS Rate,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.07,155,,,Fee Schedule,155% of CMS OPPS Rate,1006.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,394.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,247.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,888.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,888.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,219.93,1006.07,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,960,RC,13122,HCPCS,Outpatient,,,167.59,83.80,,150.83,90,,,percent of total billed charges,90% of total Billed charges,202.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.94,155,,,Fee Schedule,155% of CMS OPPS Rate,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,125.94,155,,,Fee Schedule,155% of CMS OPPS Rate,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.51,155,,,Fee Schedule,155% of CMS OPPS Rate,314.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.84,314.51,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,960,RC,13131,HCPCS,Outpatient,,,482.19,241.10,,433.97,90,,,percent of total billed charges,90% of total Billed charges,599.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,360.24,155,,,Fee Schedule,155% of CMS OPPS Rate,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,366.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,366.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,364.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,364.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,201.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,273.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,360.24,155,,,Fee Schedule,155% of CMS OPPS Rate,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,929.71,155,,,Fee Schedule,155% of CMS OPPS Rate,929.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,325.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,232.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,718.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,718.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71,929.71,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,960,RC,13132,HCPCS,Outpatient,,,602.31,301.16,,542.08,90,,,percent of total billed charges,90% of total Billed charges,739.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,452.06,155,,,Fee Schedule,155% of CMS OPPS Rate,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,408.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,291.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,459.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,459.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,456.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,456.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,318.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,538.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,339.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,452.06,155,,,Fee Schedule,155% of CMS OPPS Rate,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1145.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,519.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,291.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,1171.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1171.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,177,1171.64,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,960,RC,13151,HCPCS,Outpatient,,,554.7,277.35,,499.23,90,,,percent of total billed charges,90% of total Billed charges,670.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,416.08,155,,,Fee Schedule,155% of CMS OPPS Rate,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,268.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,421.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,421.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,419.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,419.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,231.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,536.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,495.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,315.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,416.08,155,,,Fee Schedule,155% of CMS OPPS Rate,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1039.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,402.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,268.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,814.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,814.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,177,1039.88,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,960,RC,13152,HCPCS,Outpatient,,,669.92,334.96,,602.93,90,,,percent of total billed charges,90% of total Billed charges,797.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,351,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,502.12,155,,,Fee Schedule,155% of CMS OPPS Rate,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,323.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,507.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,505.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,505.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,502.12,155,,,Fee Schedule,155% of CMS OPPS Rate,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1235.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1235.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,351,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,517.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,323.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1130.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298.96,1235.97,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,960,RC,13160,HCPCS,Outpatient,,,1612.56,806.28,,1451.3,90,,,percent of total billed charges,90% of total Billed charges,1560.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1065.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1197.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1197.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1203.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,642.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1554.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1419.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,950.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1205.08,155,,,Fee Schedule,155% of CMS OPPS Rate,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2419.19,155,,,Fee Schedule,155% of CMS OPPS Rate,2419.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,770.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,777.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1650.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,244,2419.19,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,960,RC,14001,HCPCS,Outpatient,,,1314.46,657.23,,1183.01,90,,,percent of total billed charges,90% of total Billed charges,1404.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,631.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,264,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,978.17,155,,,Fee Schedule,155% of CMS OPPS Rate,631.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,861.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,631.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,968.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,968.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,963.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,963.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,527.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1262.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1136.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,754.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,978.17,155,,,Fee Schedule,155% of CMS OPPS Rate,631.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2176.84,155,,,Fee Schedule,155% of CMS OPPS Rate,2176.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,631.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,264,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,743.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,631.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1620.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1620.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,264,2176.84,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,960,RC,14020,HCPCS,Outpatient,,,1124.34,562.17,,1011.91,90,,,percent of total billed charges,90% of total Billed charges,1201.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,539.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,835.98,155,,,Fee Schedule,155% of CMS OPPS Rate,539.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,743.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,539.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,836.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,836.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,820.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,820.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,456.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1078.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,967.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,612.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,835.98,155,,,Fee Schedule,155% of CMS OPPS Rate,539.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1862.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1862.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,539.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,150,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,629.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,539.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1408.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1408.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,150,1862.98,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,960,RC,14021,HCPCS,Outpatient,,,1410.33,705.17,,1269.3,90,,,percent of total billed charges,90% of total Billed charges,1499.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,678.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,226.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1051.38,155,,,Fee Schedule,155% of CMS OPPS Rate,678.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,678.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1057.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1057.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1042.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1042.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,577.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1230.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,783.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1051.38,155,,,Fee Schedule,155% of CMS OPPS Rate,678.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,2323.98,155,,,Fee Schedule,155% of CMS OPPS Rate,2323.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,678.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,832.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,678.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,1768.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1768.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,226.5,2323.98,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,960,RC,14040,HCPCS,Outpatient,,,1239.78,619.89,,1115.8,90,,,percent of total billed charges,90% of total Billed charges,1314.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,596.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,924.17,155,,,Fee Schedule,155% of CMS OPPS Rate,596.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,825.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,596.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,929.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,915.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,915.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,507.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,596.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1192.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1079.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,681.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,924.17,155,,,Fee Schedule,155% of CMS OPPS Rate,596.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,2037.15,155,,,Fee Schedule,155% of CMS OPPS Rate,2037.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,596.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,692.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,596.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1553.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1553.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,177.5,2037.15,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,960,RC,14041,HCPCS,Outpatient,,,1514.25,757.13,,1362.83,90,,,percent of total billed charges,90% of total Billed charges,1601.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,728.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,277.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1129.8,155,,,Fee Schedule,155% of CMS OPPS Rate,728.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1012.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,728.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1139,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1139,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1123.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1123.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,628.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1457.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1326.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,834.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1129.8,155,,,Fee Schedule,155% of CMS OPPS Rate,728.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,2481.92,155,,,Fee Schedule,155% of CMS OPPS Rate,2481.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,728.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,912.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,728.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1920.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,277.5,2481.92,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,960,RC,14060,HCPCS,Outpatient,,,1514.25,757.13,,1362.83,90,,,percent of total billed charges,90% of total Billed charges,1363.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,635.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.79,155,,,Fee Schedule,155% of CMS OPPS Rate,635.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,989.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,989.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,974.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,974.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,540.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,635.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1270.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1150.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,722.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.79,155,,,Fee Schedule,155% of CMS OPPS Rate,635.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2114.17,155,,,Fee Schedule,155% of CMS OPPS Rate,2114.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,635.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,749.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,635.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1583.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1583.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,244,2114.17,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,960,RC,15040,HCPCS,Outpatient,,,255.71,127.86,,230.14,90,,,percent of total billed charges,90% of total Billed charges,371.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.82,155,,,Fee Schedule,155% of CMS OPPS Rate,121.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,156.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,188.82,155,,,Fee Schedule,155% of CMS OPPS Rate,121.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,576.12,155,,,Fee Schedule,155% of CMS OPPS Rate,576.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,121.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,245.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,121.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.52,576.12,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,960,RC,15101,HCPCS,Outpatient,,,226.37,113.19,,203.73,90,,,percent of total billed charges,90% of total Billed charges,289.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,168.93,155,,,Fee Schedule,155% of CMS OPPS Rate,108.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,139.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.93,155,,,Fee Schedule,155% of CMS OPPS Rate,108.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,448.45,155,,,Fee Schedule,155% of CMS OPPS Rate,448.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,366.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.56,448.45,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,960,RC,15110,HCPCS,Outpatient,,,1459.07,729.54,,1313.16,90,,,percent of total billed charges,90% of total Billed charges,1514.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,700.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,491.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1085.43,155,,,Fee Schedule,155% of CMS OPPS Rate,700.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,700.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1039.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1051.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1051.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,551.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1240.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,842.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1085.43,155,,,Fee Schedule,155% of CMS OPPS Rate,700.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2347.17,155,,,Fee Schedule,155% of CMS OPPS Rate,2347.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,700.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,788.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,700.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1717.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1717.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,491.98,2347.17,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,960,RC,15111,HCPCS,Outpatient,,,212.17,106.09,,190.95,90,,,percent of total billed charges,90% of total Billed charges,216.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,159.22,155,,,Fee Schedule,155% of CMS OPPS Rate,102.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,83.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,205.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,159.22,155,,,Fee Schedule,155% of CMS OPPS Rate,102.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.96,155,,,Fee Schedule,155% of CMS OPPS Rate,334.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,102.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,102.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.36,334.96,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,960,RC,15115,HCPCS,Outpatient,,,1415.57,707.79,,1274.01,90,,,percent of total billed charges,90% of total Billed charges,1460.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,675.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,484.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1046.81,155,,,Fee Schedule,155% of CMS OPPS Rate,675.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,912.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,675.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1025.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1025.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1032.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1032.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,555.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1350.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1218.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,795.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1046.81,155,,,Fee Schedule,155% of CMS OPPS Rate,675.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2264.21,155,,,Fee Schedule,155% of CMS OPPS Rate,2264.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,675.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,484.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,739.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,675.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1765.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1765.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,484.69,2264.21,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,983,RC,15120,HCPCS,Outpatient,,,1392.29,696.15,,1253.06,90,,,percent of total billed charges,90% of total Billed charges,1483.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,669.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,438.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1038.11,155,,,Fee Schedule,155% of CMS OPPS Rate,669.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,924.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,669.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1039.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1038.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1038.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,558.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,669.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1339.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1224.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,808.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1038.11,155,,,Fee Schedule,155% of CMS OPPS Rate,669.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2299.58,155,,,Fee Schedule,155% of CMS OPPS Rate,2299.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,669.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,796.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,669.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1946.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1946.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,438.5,2299.58,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,960,RC,15200,HCPCS,Outpatient,,,1353.32,676.66,,1217.99,90,,,percent of total billed charges,90% of total Billed charges,1452.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,649.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,349,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1006.85,155,,,Fee Schedule,155% of CMS OPPS Rate,649.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,893.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,649.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1005.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1005.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,997.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,997.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,540.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1299.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1176.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,771.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1006.85,155,,,Fee Schedule,155% of CMS OPPS Rate,649.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2250.85,155,,,Fee Schedule,155% of CMS OPPS Rate,2250.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,649.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,349,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,800.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,649.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1675.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1675.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,349,2250.85,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,960,RC,15220,HCPCS,Outpatient,,,1213.83,606.92,,1092.45,90,,,percent of total billed charges,90% of total Billed charges,1309.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,582.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,903,155,,,Fee Schedule,155% of CMS OPPS Rate,582.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,809.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,582.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,910.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,910.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,897.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,897.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,494.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1165.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1058.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,677.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,903,155,,,Fee Schedule,155% of CMS OPPS Rate,582.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2030.04,155,,,Fee Schedule,155% of CMS OPPS Rate,2030.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,582.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,363,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,754.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,582.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1559.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1559.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,363,2030.04,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,960,RC,15221,HCPCS,Outpatient,,,140.94,70.47,,126.85,90,,,percent of total billed charges,90% of total Billed charges,192.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,105.15,155,,,Fee Schedule,155% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,105.15,155,,,Fee Schedule,155% of CMS OPPS Rate,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.27,155,,,Fee Schedule,155% of CMS OPPS Rate,298.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,274.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.51,298.27,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,960,RC,15240,HCPCS,Outpatient,,,1578.13,789.07,,1420.32,90,,,percent of total billed charges,90% of total Billed charges,1638.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,757.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,376.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1174.28,155,,,Fee Schedule,155% of CMS OPPS Rate,757.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1053.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,757.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1184.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1163.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1163.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,644.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1373.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,870.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1174.28,155,,,Fee Schedule,155% of CMS OPPS Rate,757.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2539.29,155,,,Fee Schedule,155% of CMS OPPS Rate,2539.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,757.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,918.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,757.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1895.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1895.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,376.5,2539.29,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,960,RC,15241,HCPCS,Outpatient,,,218.23,109.12,,196.41,90,,,percent of total billed charges,90% of total Billed charges,269.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.8,155,,,Fee Schedule,155% of CMS OPPS Rate,103.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,160.8,155,,,Fee Schedule,155% of CMS OPPS Rate,103.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,418,155,,,Fee Schedule,155% of CMS OPPS Rate,418,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,103.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,375.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.4,418,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,960,RC,15260,HCPCS,Outpatient,,,1673.85,836.93,,1506.47,90,,,percent of total billed charges,90% of total Billed charges,1749.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,805.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,388.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1248.42,155,,,Fee Schedule,155% of CMS OPPS Rate,805.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,805.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1259.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1259.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1238.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1238.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,690.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1610.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1461.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,912.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1248.42,155,,,Fee Schedule,155% of CMS OPPS Rate,805.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2711.45,155,,,Fee Schedule,155% of CMS OPPS Rate,2711.45,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,805.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,388.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,997.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,805.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2051.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2051.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,388.5,2711.45,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,960,RC,15261,HCPCS,Outpatient,,,272.7,136.35,,245.43,90,,,percent of total billed charges,90% of total Billed charges,328.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,126.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,204.58,155,,,Fee Schedule,155% of CMS OPPS Rate,131.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,207.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,207.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,159.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,204.58,155,,,Fee Schedule,155% of CMS OPPS Rate,131.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,509.33,155,,,Fee Schedule,155% of CMS OPPS Rate,509.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,437.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.45,509.33,
15271-PF App Skn Sub Grft T/A/L Area/100 Sq Cm/<1st 25,4345264,CDM,983,RC,15271,HCPCS,Outpatient,,,171.15,85.58,,154.04,90,,,percent of total billed charges,90% of total Billed charges,229.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.29,155,,,Fee Schedule,155% of CMS OPPS Rate,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.29,155,,,Fee Schedule,155% of CMS OPPS Rate,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.34,155,,,Fee Schedule,155% of CMS OPPS Rate,355.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,128.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.13,355.34,
15272-PF App Skn Sub Grft T/A/L Area/100 Sq Cm Ea Adl 25sqc,4345265,CDM,983,RC,15272,HCPCS,Outpatient,,,34.73,17.37,,31.26,90,,,percent of total billed charges,90% of total Billed charges,41.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.4,155,,,Fee Schedule,155% of CMS OPPS Rate,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,27.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,22.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,25.4,155,,,Fee Schedule,155% of CMS OPPS Rate,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.71,155,,,Fee Schedule,155% of CMS OPPS Rate,63.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,24.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.69,63.71,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,960,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,361.36,90,,,percent of total billed charges,90% of total Billed charges,500.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,301.58,155,,,Fee Schedule,155% of CMS OPPS Rate,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,310.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,310.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,177.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,366.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,301.58,155,,,Fee Schedule,155% of CMS OPPS Rate,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.93,155,,,Fee Schedule,155% of CMS OPPS Rate,775.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,265.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.74,775.93,
15273-PF App Skn Subgrft T/A/L Area 100 Sq Cm 1st 100 Sq Cm,4345266,CDM,983,RC,15273,HCPCS,Outpatient,,,401.51,200.76,,361.36,90,,,percent of total billed charges,90% of total Billed charges,500.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,164.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,301.58,155,,,Fee Schedule,155% of CMS OPPS Rate,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,303.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,310.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,310.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,177.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,366.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,301.58,155,,,Fee Schedule,155% of CMS OPPS Rate,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.93,155,,,Fee Schedule,155% of CMS OPPS Rate,775.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,265.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.74,775.93,
15274-PF App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,4345267,CDM,983,RC,15274,HCPCS,Outpatient,,,92.2,46.10,,82.98,90,,,percent of total billed charges,90% of total Billed charges,125.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,69.8,155,,,Fee Schedule,155% of CMS OPPS Rate,45.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,69.8,155,,,Fee Schedule,155% of CMS OPPS Rate,45.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.68,155,,,Fee Schedule,155% of CMS OPPS Rate,194.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,62.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.78,194.68,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,960,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,170.54,90,,,percent of total billed charges,90% of total Billed charges,243.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.91,155,,,Fee Schedule,155% of CMS OPPS Rate,377.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.44,377.91,
15275-PF Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,4345268,CDM,983,RC,15275,HCPCS,Outpatient,,,189.49,94.75,,170.54,90,,,percent of total billed charges,90% of total Billed charges,243.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.91,155,,,Fee Schedule,155% of CMS OPPS Rate,377.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.44,377.91,
15276-PF Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,4345269,CDM,983,RC,15276,HCPCS,Outpatient,,,51.37,25.69,,46.23,90,,,percent of total billed charges,90% of total Billed charges,57.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.6,155,,,Fee Schedule,155% of CMS OPPS Rate,24.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.6,155,,,Fee Schedule,155% of CMS OPPS Rate,24.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.49,155,,,Fee Schedule,155% of CMS OPPS Rate,88.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,24.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.68,88.49,
15760- Composite graft/pri close/don area,3431628,CDM,960,RC,15760,HCPCS,Outpatient,,,1394.05,697.03,,1254.65,90,,,percent of total billed charges,90% of total Billed charges,1478.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,673.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,298.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1043.8,155,,,Fee Schedule,155% of CMS OPPS Rate,673.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,930.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,673.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1046.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1035.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1035.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,568.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1346.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1221.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,782.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1043.8,155,,,Fee Schedule,155% of CMS OPPS Rate,673.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2291.43,155,,,Fee Schedule,155% of CMS OPPS Rate,2291.43,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,673.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,669.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,673.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1740.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1740.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,298.5,2291.43,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,960,RC,15788,HCPCS,Outpatient,,,419.21,209.61,,377.29,90,,,percent of total billed charges,90% of total Billed charges,560.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,200.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.15,155,,,Fee Schedule,155% of CMS OPPS Rate,200.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,325.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,325.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,197.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,401.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,384.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,236.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,311.15,155,,,Fee Schedule,155% of CMS OPPS Rate,200.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,868.06,155,,,Fee Schedule,155% of CMS OPPS Rate,868.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,200.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,431.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,200.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,919.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,919.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197.49,919.36,
"15789 - Chemical peel, facial; dermal",3715293,CDM,960,RC,15789,HCPCS,Outpatient,,,805.26,402.63,,724.73,90,,,percent of total billed charges,90% of total Billed charges,881.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,386.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.11,155,,,Fee Schedule,155% of CMS OPPS Rate,386.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,539.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,386.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,607.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,592.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,592.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,340.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,773.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,699.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,599.11,155,,,Fee Schedule,155% of CMS OPPS Rate,386.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.96,155,,,Fee Schedule,155% of CMS OPPS Rate,1366.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,386.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,542.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,386.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,1108.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1108.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,340.68,1366.96,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,960,RC,15792,HCPCS,Outpatient,,,406.23,203.12,,365.61,90,,,percent of total billed charges,90% of total Billed charges,499.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.24,155,,,Fee Schedule,155% of CMS OPPS Rate,193.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,306.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,193.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,326.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,326.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,387.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,385.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,235.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,300.24,155,,,Fee Schedule,155% of CMS OPPS Rate,193.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,774.3,155,,,Fee Schedule,155% of CMS OPPS Rate,774.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,193.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,414.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,193.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,864.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,864.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193.7,864.96,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,960,RC,15793,HCPCS,Outpatient,,,699.07,349.54,,629.16,90,,,percent of total billed charges,90% of total Billed charges,774.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.03,155,,,Fee Schedule,155% of CMS OPPS Rate,333.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,333.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,524.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,510.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,510.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,295.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,601.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,382.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,517.03,155,,,Fee Schedule,155% of CMS OPPS Rate,333.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1201.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1201.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,333.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,472.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,333.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,983.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,295.98,1201.08,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,960,RC,15820,HCPCS,Outpatient,,,1002.38,501.19,,902.14,90,,,percent of total billed charges,90% of total Billed charges,1022.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.79,155,,,Fee Schedule,155% of CMS OPPS Rate,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,481.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,731.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,731.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,418.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,963.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,863.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,519.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,746.79,155,,,Fee Schedule,155% of CMS OPPS Rate,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1585.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1585.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,556.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,481.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1151.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,418.38,1585.05,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,960,RC,15851,HCPCS,Outpatient,,,131.14,65.57,,118.03,90,,,percent of total billed charges,90% of total Billed charges,163.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.82,155,,,Fee Schedule,155% of CMS OPPS Rate,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.82,155,,,Fee Schedule,155% of CMS OPPS Rate,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,253.27,155,,,Fee Schedule,155% of CMS OPPS Rate,253.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,191.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.03,253.27,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,960,RC,16020,HCPCS,Outpatient,,,111.26,55.63,,100.13,90,,,percent of total billed charges,90% of total Billed charges,132.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.31,155,,,Fee Schedule,155% of CMS OPPS Rate,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.24,155,,,Fee Schedule,155% of CMS OPPS Rate,205.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,205.24,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,960,RC,16025,HCPCS,Outpatient,,,226.01,113.01,,203.41,90,,,percent of total billed charges,90% of total Billed charges,258.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,166.7,155,,,Fee Schedule,155% of CMS OPPS Rate,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.7,155,,,Fee Schedule,155% of CMS OPPS Rate,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,400.26,155,,,Fee Schedule,155% of CMS OPPS Rate,400.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,300.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.82,400.26,
17000- Destruct premalig lesion/1st les,3431633,CDM,960,RC,17000,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,114.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.55,90,,,Percent of total Billed charges,90% of total billed charges,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,79.39,155,,,Fee Schedule,155% of CMS OPPS Rate,51.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,79.39,155,,,Fee Schedule,155% of CMS OPPS Rate,51.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.89,155,,,Fee Schedule,155% of CMS OPPS Rate,176.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,160.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,176.89,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,960,RC,17003,HCPCS,Outpatient,,,3.96,1.98,,3.56,90,,,percent of total billed charges,90% of total Billed charges,5.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2.99,155,,,Fee Schedule,155% of CMS OPPS Rate,1.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.13,155,,,Fee Schedule,155% of CMS OPPS Rate,9.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,13.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1.93,14.13,
17004- Destroy premal lesions 15/>,3428770,CDM,960,RC,17004,HCPCS,Outpatient,,,194.55,97.28,,175.1,90,,,percent of total billed charges,90% of total Billed charges,251.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,116.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,146.96,155,,,Fee Schedule,155% of CMS OPPS Rate,94.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,103.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,146.96,155,,,Fee Schedule,155% of CMS OPPS Rate,94.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.69,155,,,Fee Schedule,155% of CMS OPPS Rate,389.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,94.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,342.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94.81,389.69,
17110- Destruct benign lesion 1-14,3431075,CDM,983,RC,17110,HCPCS,Outpatient,,,132.86,66.43,,119.57,90,,,percent of total billed charges,90% of total Billed charges,167.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.41,90,,,Percent of total Billed charges,90% of total billed charges,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.98,155,,,Fee Schedule,155% of CMS OPPS Rate,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,96.98,155,,,Fee Schedule,155% of CMS OPPS Rate,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.87,155,,,Fee Schedule,155% of CMS OPPS Rate,258.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,216.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,258.87,
17111- Destruct lesion 15 or more,3431076,CDM,983,RC,17111,HCPCS,Outpatient,,,162.75,81.38,,146.48,90,,,percent of total billed charges,90% of total Billed charges,200.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.92,155,,,Fee Schedule,155% of CMS OPPS Rate,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.92,155,,,Fee Schedule,155% of CMS OPPS Rate,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.47,155,,,Fee Schedule,155% of CMS OPPS Rate,310.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.37,310.47,
17250- Chemical cautery of granulated tissue,3431077,CDM,983,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,67.53,90,,,percent of total billed charges,90% of total Billed charges,110.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.82,155,,,Fee Schedule,155% of CMS OPPS Rate,171.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,153,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.82,171.82,
17250-PF Chemical Cauterization if Granulation Tissue,4345270,CDM,983,RC,17250,HCPCS,Outpatient,,,75.03,37.52,,67.53,90,,,percent of total billed charges,90% of total Billed charges,110.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.52,155,,,Fee Schedule,155% of CMS OPPS Rate,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.82,155,,,Fee Schedule,155% of CMS OPPS Rate,171.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,153,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.82,171.82,
17260- Destruction of skin lesions,3431078,CDM,983,RC,17260,HCPCS,Outpatient,,,139.33,69.67,,125.4,90,,,percent of total billed charges,90% of total Billed charges,160.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.05,155,,,Fee Schedule,155% of CMS OPPS Rate,67.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,102.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,102.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.05,155,,,Fee Schedule,155% of CMS OPPS Rate,67.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.22,155,,,Fee Schedule,155% of CMS OPPS Rate,249.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,67.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51.44,249.22,
17261- Destruction of skin lesions,3431079,CDM,983,RC,17261,HCPCS,Outpatient,,,172.72,86.36,,155.45,90,,,percent of total billed charges,90% of total Billed charges,219.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.61,155,,,Fee Schedule,155% of CMS OPPS Rate,82.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,127.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,127.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,92.39,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.61,155,,,Fee Schedule,155% of CMS OPPS Rate,82.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,340.49,155,,,Fee Schedule,155% of CMS OPPS Rate,340.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,284.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.76,340.49,
17262- Destruction of skin lesions,3431080,CDM,983,RC,17262,HCPCS,Outpatient,,,219.23,109.62,,197.31,90,,,percent of total billed charges,90% of total Billed charges,273.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.97,155,,,Fee Schedule,155% of CMS OPPS Rate,105.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,211.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,163.97,155,,,Fee Schedule,155% of CMS OPPS Rate,105.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.4,155,,,Fee Schedule,155% of CMS OPPS Rate,423.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,105.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,105.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,345.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85,423.4,
17263- Destruction of skin lesions,3431081,CDM,983,RC,17263,HCPCS,Outpatient,,,242.85,121.43,,218.57,90,,,percent of total billed charges,90% of total Billed charges,298.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,181.1,155,,,Fee Schedule,155% of CMS OPPS Rate,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,181.1,155,,,Fee Schedule,155% of CMS OPPS Rate,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.29,155,,,Fee Schedule,155% of CMS OPPS Rate,462.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,169.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,380.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99,462.29,
17264- Destruction of skin lesions,3431082,CDM,983,RC,17264,HCPCS,Outpatient,,,259.89,129.95,,233.9,90,,,percent of total billed charges,90% of total Billed charges,318.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,110.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,193.25,155,,,Fee Schedule,155% of CMS OPPS Rate,124.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,197.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,195.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,195.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,143.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,193.25,155,,,Fee Schedule,155% of CMS OPPS Rate,124.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.17,155,,,Fee Schedule,155% of CMS OPPS Rate,494.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,124.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,190.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,124.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,408.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,109.83,494.17,
17266- Destruction of skin lesions,3431083,CDM,983,RC,17266,HCPCS,Outpatient,,,305.13,152.57,,274.62,90,,,percent of total billed charges,90% of total Billed charges,368.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.42,155,,,Fee Schedule,155% of CMS OPPS Rate,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,170.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.42,155,,,Fee Schedule,155% of CMS OPPS Rate,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,571.78,155,,,Fee Schedule,155% of CMS OPPS Rate,571.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,235.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,463.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.61,571.78,
17270- Destruction of skin lesions,3431084,CDM,983,RC,17270,HCPCS,Outpatient,,,189.76,94.88,,170.78,90,,,percent of total billed charges,90% of total Billed charges,230.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,141.98,155,,,Fee Schedule,155% of CMS OPPS Rate,91.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,140.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,140.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.98,155,,,Fee Schedule,155% of CMS OPPS Rate,91.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.09,155,,,Fee Schedule,155% of CMS OPPS Rate,357.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.1,357.09,
17271- Destruction of skin lesions,3431085,CDM,983,RC,17271,HCPCS,Outpatient,,,208.48,104.24,,187.63,90,,,percent of total billed charges,90% of total Billed charges,255.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,156.33,155,,,Fee Schedule,155% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,156.33,155,,,Fee Schedule,155% of CMS OPPS Rate,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.58,155,,,Fee Schedule,155% of CMS OPPS Rate,396.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,100.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,327.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.5,396.58,
17272- Destruction of skin lesions,3431086,CDM,983,RC,17272,HCPCS,Outpatient,,,240.85,120.43,,216.77,90,,,percent of total billed charges,90% of total Billed charges,293.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,179.6,155,,,Fee Schedule,155% of CMS OPPS Rate,115.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,183.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,181.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,181.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,231.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,179.6,155,,,Fee Schedule,155% of CMS OPPS Rate,115.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.65,155,,,Fee Schedule,155% of CMS OPPS Rate,454.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,115.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,163.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,115.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,373.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.1,454.65,
17273- Destruction of skin lesions,3431087,CDM,983,RC,17273,HCPCS,Outpatient,,,272.65,136.33,,245.39,90,,,percent of total billed charges,90% of total Billed charges,327.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.53,155,,,Fee Schedule,155% of CMS OPPS Rate,131.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,207.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,205.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,205.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,151.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.53,155,,,Fee Schedule,155% of CMS OPPS Rate,131.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,508.23,155,,,Fee Schedule,155% of CMS OPPS Rate,508.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,193.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,416.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.5,508.23,
17274- Destruction of skin lesions,3431088,CDM,983,RC,17274,HCPCS,Outpatient,,,333.31,166.66,,299.98,90,,,percent of total billed charges,90% of total Billed charges,391.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,249.67,155,,,Fee Schedule,155% of CMS OPPS Rate,161.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,252.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,252.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,141.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,322.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,186.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,249.67,155,,,Fee Schedule,155% of CMS OPPS Rate,161.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.07,155,,,Fee Schedule,155% of CMS OPPS Rate,607.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,490.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,141.46,607.07,
17276- Destruction of skin lesions,3431089,CDM,983,RC,17276,HCPCS,Outpatient,,,403.39,201.70,,363.05,90,,,percent of total billed charges,90% of total Billed charges,464.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,175.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,301.94,155,,,Fee Schedule,155% of CMS OPPS Rate,194.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,305.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,303.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,303.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,168.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,389.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,358.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,223.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,301.94,155,,,Fee Schedule,155% of CMS OPPS Rate,194.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.76,155,,,Fee Schedule,155% of CMS OPPS Rate,719.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,570.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,570.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,168.77,719.76,
17280- Destruction of skin lesions,3431090,CDM,983,RC,17280,HCPCS,Outpatient,,,172.12,86.06,,154.91,90,,,percent of total billed charges,90% of total Billed charges,212.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,127.16,155,,,Fee Schedule,155% of CMS OPPS Rate,82.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,126.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,126.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,92.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.16,155,,,Fee Schedule,155% of CMS OPPS Rate,82.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.99,155,,,Fee Schedule,155% of CMS OPPS Rate,328.99,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,279.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.76,328.99,
17281- Destruction of skin lesions,3431091,CDM,983,RC,17281,HCPCS,Outpatient,,,235,117.50,,211.5,90,,,percent of total billed charges,90% of total Billed charges,282.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,175.62,155,,,Fee Schedule,155% of CMS OPPS Rate,113.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,175.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,175.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,175.62,155,,,Fee Schedule,155% of CMS OPPS Rate,113.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,437.67,155,,,Fee Schedule,155% of CMS OPPS Rate,437.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,157.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93,437.67,
17282- Destruction of skin lesions,3431092,CDM,983,RC,17282,HCPCS,Outpatient,,,271.36,135.68,,244.22,90,,,percent of total billed charges,90% of total Billed charges,324.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203,155,,,Fee Schedule,155% of CMS OPPS Rate,130.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,204.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,204.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,241.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,151.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203,155,,,Fee Schedule,155% of CMS OPPS Rate,130.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.02,155,,,Fee Schedule,155% of CMS OPPS Rate,503.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,130.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,192.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,410.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.14,503.02,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,960,RC,17283,HCPCS,Outpatient,,,340.43,170.22,,306.39,90,,,percent of total billed charges,90% of total Billed charges,392.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,253.19,155,,,Fee Schedule,155% of CMS OPPS Rate,163.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,257.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,257.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,303.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,190.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,253.19,155,,,Fee Schedule,155% of CMS OPPS Rate,163.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,608.22,155,,,Fee Schedule,155% of CMS OPPS Rate,608.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,163.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,163.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,495.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143.97,608.22,
17284- Destruction of skin lesions,3431093,CDM,983,RC,17284,HCPCS,Outpatient,,,396.61,198.31,,356.95,90,,,percent of total billed charges,90% of total Billed charges,453.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.84,155,,,Fee Schedule,155% of CMS OPPS Rate,191.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,302.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,300.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,300.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,168.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,383.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,354.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,221.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.84,155,,,Fee Schedule,155% of CMS OPPS Rate,191.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,703.05,155,,,Fee Schedule,155% of CMS OPPS Rate,703.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,280.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,573.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,573.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,168.06,703.05,
17286- Destruction of skin lesions,3431094,CDM,983,RC,17286,HCPCS,Outpatient,,,539.99,270.00,,485.99,90,,,percent of total billed charges,90% of total Billed charges,596.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,259.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,401.85,155,,,Fee Schedule,155% of CMS OPPS Rate,259.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,259.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,409.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,409.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,225.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,518.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,482.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,305.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,401.85,155,,,Fee Schedule,155% of CMS OPPS Rate,259.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.75,155,,,Fee Schedule,155% of CMS OPPS Rate,924.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,259.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,390.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,259.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,731,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,731,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,225.11,924.75,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,960,RC,17999,HCPCS,Outpatient,,,340,170.00,,306,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102,306,
19000- Drainage Of Breast Lesion,3431635,CDM,960,RC,19000,HCPCS,Outpatient,,,112.81,56.41,,101.53,90,,,percent of total billed charges,90% of total Billed charges,138.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.5,90,,,Percent of total Billed charges,90% of total billed charges,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,65.43,155,,,Fee Schedule,155% of CMS OPPS Rate,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,65.43,155,,,Fee Schedule,155% of CMS OPPS Rate,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,215.39,155,,,Fee Schedule,155% of CMS OPPS Rate,215.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.72,231.5,
19001- Punc asp breast cyst ea additional,3428771,CDM,960,RC,19001,HCPCS,Outpatient,,,56,28.00,,50.4,90,,,percent of total billed charges,90% of total Billed charges,46.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.5,155,,,Fee Schedule,155% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,25.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,31.5,155,,,Fee Schedule,155% of CMS OPPS Rate,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.95,155,,,Fee Schedule,155% of CMS OPPS Rate,71.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.34,71.95,
19020-,3428772,CDM,960,RC,19020,HCPCS,Outpatient,,,813.04,406.52,,731.74,90,,,percent of total billed charges,90% of total Billed charges,754.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,472.66,155,,,Fee Schedule,155% of CMS OPPS Rate,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,246.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,545.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,371.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,472.66,155,,,Fee Schedule,155% of CMS OPPS Rate,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1170.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1170.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,388.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,304.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,915.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,915.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,73,1170.2,
19081- Bx breast 1st lesion w/o US,3428775,CDM,960,RC,19081,HCPCS,Outpatient,,,1264.59,632.30,,1138.13,90,,,percent of total billed charges,90% of total Billed charges,636.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,321.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,249.16,155,,,Fee Schedule,155% of CMS OPPS Rate,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,986.22,155,,,Fee Schedule,155% of CMS OPPS Rate,986.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,705.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,160.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.3,1138.13,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,960,RC,19082,HCPCS,Outpatient,,,217.96,108.98,,196.16,90,,,percent of total billed charges,90% of total Billed charges,299.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.74,155,,,Fee Schedule,155% of CMS OPPS Rate,81.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,125.74,155,,,Fee Schedule,155% of CMS OPPS Rate,81.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.57,155,,,Fee Schedule,155% of CMS OPPS Rate,463.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,564.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,564.58,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,960,RC,19083,HCPCS,Outpatient,,,409,204.50,,368.1,90,,,percent of total billed charges,90% of total Billed charges,559.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,301.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,285.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,234.02,155,,,Fee Schedule,155% of CMS OPPS Rate,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,867.97,155,,,Fee Schedule,155% of CMS OPPS Rate,867.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,699.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,150.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.89,867.97,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,960,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,182.07,90,,,percent of total billed charges,90% of total Billed charges,278.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.45,155,,,Fee Schedule,155% of CMS OPPS Rate,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,119.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,119.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.45,155,,,Fee Schedule,155% of CMS OPPS Rate,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.02,155,,,Fee Schedule,155% of CMS OPPS Rate,432.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,556.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,556.53,
"19084 Biopsy, breast, with placement of breast localization device(s) ProFee",3621150,CDM,960,RC,19084,HCPCS,Outpatient,,,202.3,101.15,,182.07,90,,,percent of total billed charges,90% of total Billed charges,278.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.45,155,,,Fee Schedule,155% of CMS OPPS Rate,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,119.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,119.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,140.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,88.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.45,155,,,Fee Schedule,155% of CMS OPPS Rate,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.02,155,,,Fee Schedule,155% of CMS OPPS Rate,432.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,556.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,556.53,
19100- Bx breast percut w/o image,3428778,CDM,960,RC,19100,HCPCS,Outpatient,,,188.95,94.48,,170.06,90,,,percent of total billed charges,90% of total Billed charges,217.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.09,90,,,Percent of total Billed charges,90% of total billed charges,61.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,108.33,155,,,Fee Schedule,155% of CMS OPPS Rate,69.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,108.33,155,,,Fee Schedule,155% of CMS OPPS Rate,69.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.65,155,,,Fee Schedule,155% of CMS OPPS Rate,337.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,69.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.23,337.65,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,960,RC,19110,HCPCS,Outpatient,,,921.54,460.77,,829.39,90,,,percent of total billed charges,90% of total Billed charges,816.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,344.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,198,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,534.47,155,,,Fee Schedule,155% of CMS OPPS Rate,344.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,521.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,520.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,520.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,275.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,689.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,614.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,424.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,534.47,155,,,Fee Schedule,155% of CMS OPPS Rate,344.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1265.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1265.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,344.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,198,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,510.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,344.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,957.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,957.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,198,1265.79,
19120- Removal of breast lesion,3428780,CDM,960,RC,19120,HCPCS,Outpatient,,,1349.16,674.58,,1214.24,90,,,percent of total billed charges,90% of total Billed charges,920.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1132.19,90,,,Percent of total Billed charges,90% of total billed charges,173,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,640.69,155,,,Fee Schedule,155% of CMS OPPS Rate,413.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,625.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,625.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,631.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,631.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,745.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,523.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,640.69,155,,,Fee Schedule,155% of CMS OPPS Rate,413.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1427.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1427.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,413.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,442.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,413.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,973.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,973.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,173,1427.05,
"19303- Mastectomy, simple, complete",3569390,CDM,960,RC,19303,HCPCS,Outpatient,,,2571.8,1285.90,,2314.62,90,,,percent of total billed charges,90% of total Billed charges,1924.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,957.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1484.08,155,,,Fee Schedule,155% of CMS OPPS Rate,957.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1289.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,957.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1450.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1450.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1483.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1483.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,812.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1914.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1750.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1251.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1484.08,155,,,Fee Schedule,155% of CMS OPPS Rate,957.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2983.07,155,,,Fee Schedule,155% of CMS OPPS Rate,2983.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,957.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1005.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,957.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,2032.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2032.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,812.83,2983.07,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,960,RC,21011,HCPCS,Outpatient,,,518.64,259.32,,466.78,90,,,percent of total billed charges,90% of total Billed charges,601.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,248.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,385.64,155,,,Fee Schedule,155% of CMS OPPS Rate,248.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,248.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,411.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,376.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,376.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,248.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,497.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,444.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,385.64,155,,,Fee Schedule,155% of CMS OPPS Rate,248.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,932.79,155,,,Fee Schedule,155% of CMS OPPS Rate,932.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,248.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,248.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,657.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,189.16,932.79,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,960,RC,21012,HCPCS,Outpatient,,,688.11,344.06,,619.3,90,,,percent of total billed charges,90% of total Billed charges,662.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,330.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,259.78,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,512.66,155,,,Fee Schedule,155% of CMS OPPS Rate,330.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,481.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,541.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,541.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,503.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,503.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,340.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,661.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,594.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,399.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,512.66,155,,,Fee Schedule,155% of CMS OPPS Rate,330.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1026.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1026.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,330.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,332.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,330.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,692.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,259.78,1026.41,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,960,RC,21013,HCPCS,Outpatient,,,811.54,405.77,,730.39,90,,,percent of total billed charges,90% of total Billed charges,904.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,391.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,305.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,606.45,155,,,Fee Schedule,155% of CMS OPPS Rate,391.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,391.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,642.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,596.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,596.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,399.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,391.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,782.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,703.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,462.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,606.45,155,,,Fee Schedule,155% of CMS OPPS Rate,391.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1402.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1402.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,391.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,478.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,391.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1015.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1015.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,305.52,1402.52,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,960,RC,21552,HCPCS,Outpatient,,,938.8,469.40,,844.92,90,,,percent of total billed charges,90% of total Billed charges,887.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,686.39,155,,,Fee Schedule,155% of CMS OPPS Rate,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,442.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,678.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,678.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,359.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,885.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,800.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,556.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,686.39,155,,,Fee Schedule,155% of CMS OPPS Rate,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1376.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1376.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,445.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,442.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,909.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,348.4,1376.29,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,983,RC,24065,HCPCS,Outpatient,,,325.87,162.94,,293.28,90,,,percent of total billed charges,90% of total Billed charges,402.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,155.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,241.58,155,,,Fee Schedule,155% of CMS OPPS Rate,155.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,262.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,240.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,240.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,284.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,241.58,155,,,Fee Schedule,155% of CMS OPPS Rate,155.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.28,155,,,Fee Schedule,155% of CMS OPPS Rate,624.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,155.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,155.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,510,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,510,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,624.28,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,652.9,326.45,,587.61,90,,,percent of total billed charges,90% of total Billed charges,804.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,311.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1247.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,943.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1247.05,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,852.37,426.19,,767.13,90,,,percent of total billed charges,90% of total Billed charges,842.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,333.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,374.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,1305.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1305.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,989.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,989.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,1305.16,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,512.44,256.22,,461.2,90,,,percent of total billed charges,90% of total Billed charges,514.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,229.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.82,155,,,Fee Schedule,155% of CMS OPPS Rate,797.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,663,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,663,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,797.82,
27337- Exc SQ tumor/thigh/knee area 3cm/>,3435004,CDM,960,RC,27337,HCPCS,Outpatient,,,1108.71,554.36,,997.84,90,,,percent of total billed charges,90% of total Billed charges,830.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.42,155,,,Fee Schedule,155% of CMS OPPS Rate,413.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,413.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,674.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,635.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,635.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,422.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,827.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,749.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,520.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,641.42,155,,,Fee Schedule,155% of CMS OPPS Rate,413.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1287.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1287.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,413.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,415.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,413.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,850,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,850,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,413.82,1287.62,
"27596 - (PF) Amputation, thigh, through femur, any level; re-amputation",3634896,CDM,960,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,1716.4,90,,,percent of total billed charges,90% of total Billed charges,1426.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,709.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1099.52,155,,,Fee Schedule,155% of CMS OPPS Rate,709.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1057.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,709.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1189.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1189.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1101.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1101.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,699.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1299.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,921.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1099.52,155,,,Fee Schedule,155% of CMS OPPS Rate,709.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2211.09,155,,,Fee Schedule,155% of CMS OPPS Rate,2211.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,709.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,864.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,709.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1497.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,699.47,2211.09,
"27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s)",3621977,CDM,960,RC,27602,HCPCS,Outpatient,,,1285.76,642.88,,1157.18,90,,,percent of total billed charges,90% of total Billed charges,960.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,476.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,275,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,738.89,155,,,Fee Schedule,155% of CMS OPPS Rate,476.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,694.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,476.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,781.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,781.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,749.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,749.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,495.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,953.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,883.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,629.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,738.89,155,,,Fee Schedule,155% of CMS OPPS Rate,476.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1488.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1488.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,476.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,275,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,575.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,476.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1034.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1034.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,275,1488.28,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,960,RC,27613,HCPCS,Outpatient,,,411.56,205.78,,370.4,90,,,percent of total billed charges,90% of total Billed charges,393.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,239.54,155,,,Fee Schedule,155% of CMS OPPS Rate,154.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,236.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,236.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,177.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,239.54,155,,,Fee Schedule,155% of CMS OPPS Rate,154.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,609.2,155,,,Fee Schedule,155% of CMS OPPS Rate,609.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,154.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,154.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,505.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,609.2,
28122- Part exc/tarsal/metatarsal,3435162,CDM,960,RC,28122,HCPCS,Outpatient,,,1489.07,744.54,,1340.16,90,,,percent of total billed charges,90% of total Billed charges,982.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,262.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,655,155,,,Fee Schedule,155% of CMS OPPS Rate,422.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,702.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,702.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,652.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,652.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,484.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,770.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,483.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,655,155,,,Fee Schedule,155% of CMS OPPS Rate,422.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1522.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1522.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,675.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1306.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1306.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,262.5,1522.89,
28190- Remove foreign body/foot/subq,3435165,CDM,960,RC,28190,HCPCS,Outpatient,,,339.68,169.84,,305.71,90,,,percent of total billed charges,90% of total Billed charges,353.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.35,155,,,Fee Schedule,155% of CMS OPPS Rate,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,126.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,198.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,198.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,253.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.35,155,,,Fee Schedule,155% of CMS OPPS Rate,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,548.05,155,,,Fee Schedule,155% of CMS OPPS Rate,548.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,126.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.5,548.05,
"28810 Amputation, metatarsal, with toe, single",3621667,CDM,960,RC,28810,HCPCS,Outpatient,,,1109.8,554.90,,998.82,90,,,percent of total billed charges,90% of total Billed charges,829.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,411.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,229.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,638.43,155,,,Fee Schedule,155% of CMS OPPS Rate,411.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,411.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,688.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,688.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,648.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,648.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,428.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,823.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,764.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,509.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,638.43,155,,,Fee Schedule,155% of CMS OPPS Rate,411.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1285.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1285.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,411.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,525.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,411.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,896.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,896.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,229.5,1285.28,
29260-PF Strapng Elbow/Wrist,4345271,CDM,983,RC,29260,HCPCS,Outpatient,,,38.22,19.11,,34.4,90,,,percent of total billed charges,90% of total Billed charges,47.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.47,155,,,Fee Schedule,155% of CMS OPPS Rate,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,21.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,29.47,155,,,Fee Schedule,155% of CMS OPPS Rate,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.66,155,,,Fee Schedule,155% of CMS OPPS Rate,73.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,102,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.01,102,
29280-PF Strapng Hand/Finger,4345272,CDM,983,RC,29280,HCPCS,Outpatient,,,41.28,20.64,,37.15,90,,,percent of total billed charges,90% of total Billed charges,47.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.36,155,,,Fee Schedule,155% of CMS OPPS Rate,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,31.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,31.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,24.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,30.36,155,,,Fee Schedule,155% of CMS OPPS Rate,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.09,155,,,Fee Schedule,155% of CMS OPPS Rate,74.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,99.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.59,99.28,
29405-PF App. Short Leg Cast Below Knee-Toe,4345273,CDM,983,RC,29405,HCPCS,Outpatient,,,117.83,58.92,,106.05,90,,,percent of total billed charges,90% of total Billed charges,130.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.9,90,,,Percent of total Billed charges,90% of total billed charges,50.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.03,155,,,Fee Schedule,155% of CMS OPPS Rate,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,87.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,66.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.03,155,,,Fee Schedule,155% of CMS OPPS Rate,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.54,155,,,Fee Schedule,155% of CMS OPPS Rate,202.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,175.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.5,202.54,
29425-PF App. Short Leg Cast Walking/Ambulatory,4345274,CDM,983,RC,29425,HCPCS,Outpatient,,,108.46,54.23,,97.61,90,,,percent of total billed charges,90% of total Billed charges,122.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.15,90,,,Percent of total Billed charges,90% of total billed charges,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,80.74,155,,,Fee Schedule,155% of CMS OPPS Rate,52.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.74,155,,,Fee Schedule,155% of CMS OPPS Rate,52.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,155,,,Fee Schedule,155% of CMS OPPS Rate,189.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,52.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,187,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,187,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.09,189.91,
29445-PF App. Rigid Total Contact Leg Cast,4345275,CDM,983,RC,29445,HCPCS,Outpatient,,,200.11,100.06,,180.1,90,,,percent of total billed charges,90% of total Billed charges,218.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.58,155,,,Fee Schedule,155% of CMS OPPS Rate,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,118.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.58,155,,,Fee Schedule,155% of CMS OPPS Rate,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.28,155,,,Fee Schedule,155% of CMS OPPS Rate,339.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,278.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,95.86,339.28,
29540-PF Strapping Ankle & or Foot,4345276,CDM,983,RC,29540,HCPCS,Outpatient,,,35.23,17.62,,31.71,90,,,percent of total billed charges,90% of total Billed charges,44.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.2,155,,,Fee Schedule,155% of CMS OPPS Rate,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,27.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,27.2,155,,,Fee Schedule,155% of CMS OPPS Rate,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.63,155,,,Fee Schedule,155% of CMS OPPS Rate,68.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,65.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.55,68.63,
29580 Application of Unna Boot,4135334,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,48.81,90,,,percent of total billed charges,90% of total Billed charges,80.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.82,155,,,Fee Schedule,155% of CMS OPPS Rate,124.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.3,124.82,
29580-PF Application of Paste Boot,4345278,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,48.81,90,,,percent of total billed charges,90% of total Billed charges,80.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.82,155,,,Fee Schedule,155% of CMS OPPS Rate,124.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.3,124.82,
29580-PF Application of Paste Boot - Bilateral,4345277,CDM,983,RC,29580,HCPCS,Outpatient,,,54.23,27.12,,48.81,90,,,percent of total billed charges,90% of total Billed charges,80.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.77,155,,,Fee Schedule,155% of CMS OPPS Rate,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.82,155,,,Fee Schedule,155% of CMS OPPS Rate,124.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.3,124.82,
29581-PF Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,4345280,CDM,983,RC,29581,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,79.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.3,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.3,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.98,155,,,Fee Schedule,155% of CMS OPPS Rate,122.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,183.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.95,183.6,
29581-PF Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bilateral,4345279,CDM,983,RC,29581,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,79.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.3,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,40.3,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.98,155,,,Fee Schedule,155% of CMS OPPS Rate,122.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,183.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.95,183.6,
29584-PF Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4345281,CDM,983,RC,29584,HCPCS,Outpatient,,,31.21,15.61,,28.09,90,,,percent of total billed charges,90% of total Billed charges,46.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.01,155,,,Fee Schedule,155% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,16.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,24.01,155,,,Fee Schedule,155% of CMS OPPS Rate,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.39,155,,,Fee Schedule,155% of CMS OPPS Rate,72.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.49,72.39,
31231- Nasal endoscopy dx,3431300,CDM,960,RC,31231,HCPCS,Outpatient,,,1000.27,500.14,,900.24,90,,,percent of total billed charges,90% of total Billed charges,238.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,98.89,155,,,Fee Schedule,155% of CMS OPPS Rate,63.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,72.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,98.89,155,,,Fee Schedule,155% of CMS OPPS Rate,63.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.31,155,,,Fee Schedule,155% of CMS OPPS Rate,370.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,386.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.54,900.24,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,638.37,319.19,,574.53,90,,,percent of total billed charges,90% of total Billed charges,658.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,197,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,435.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1020.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,574.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197,1020.6,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,983,RC,31575,HCPCS,Outpatient,,,285.02,142.51,,256.52,90,,,percent of total billed charges,90% of total Billed charges,185.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.44,90,,,Percent of total Billed charges,90% of total billed charges,69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.59,155,,,Fee Schedule,155% of CMS OPPS Rate,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,115.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.59,155,,,Fee Schedule,155% of CMS OPPS Rate,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.11,155,,,Fee Schedule,155% of CMS OPPS Rate,288.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,128.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.85,288.11,
"31600 - (PF) Tracheostomy, planned (separate procedure);",3634897,CDM,960,RC,31600,HCPCS,Outpatient,,,817.75,408.88,,735.98,90,,,percent of total billed charges,90% of total Billed charges,612.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,248,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,472.73,155,,,Fee Schedule,155% of CMS OPPS Rate,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,448.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,448.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,476.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,476.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,318,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,609.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,562.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,391.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,472.73,155,,,Fee Schedule,155% of CMS OPPS Rate,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,949.34,155,,,Fee Schedule,155% of CMS OPPS Rate,949.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,248,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,436.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,304.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,821.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,821.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,248,949.34,
33238 - (PF) Removal of permanent transvenous electrode(s) by thoracotomy,3634898,CDM,960,RC,33238,HCPCS,Outpatient,,,2521.79,1260.90,,2269.61,90,,,percent of total billed charges,90% of total Billed charges,1885.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,937.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,863.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1453.26,155,,,Fee Schedule,155% of CMS OPPS Rate,937.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1388.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,937.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1561.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1561.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1452.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1452.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,754,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,937.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1875.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1713.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1220.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1453.26,155,,,Fee Schedule,155% of CMS OPPS Rate,937.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,2923.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2923.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,937.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,937.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,1933.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1933.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,754,2923.1,
33340 - PF - Percutaneous transcatheter closure of the left atrial appendage with endocardial implan,3640908,CDM,960,RC,33340,HCPCS,Outpatient,,,2110.39,1055.20,,1899.35,90,,,percent of total billed charges,90% of total Billed charges,1571.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.41,155,,,Fee Schedule,155% of CMS OPPS Rate,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1172.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1318.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1318.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1237.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1237.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,709.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1556.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1459.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1050.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1206.41,155,,,Fee Schedule,155% of CMS OPPS Rate,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,2436.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2436.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,901.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,778.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.42,2436.46,
"33418 Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when",3623384,CDM,960,RC,33418,HCPCS,Outpatient,,,4824.81,2412.41,,4342.33,90,,,percent of total billed charges,90% of total Billed charges,3596.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1782.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2763.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1782.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2666.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1782.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2998.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2998.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2817.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2817.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1494.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1782.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3565.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3325.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2393.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2763.12,155,,,Fee Schedule,155% of CMS OPPS Rate,1782.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5575.29,155,,,Fee Schedule,155% of CMS OPPS Rate,5575.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1782.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2079.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1782.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1494.19,5575.29,
33426- TMVR w/prosthetic ring,3430652,CDM,960,RC,33426,HCPCS,Outpatient,,,4948.42,2474.21,,4453.58,90,,,percent of total billed charges,90% of total Billed charges,4783.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2377.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3685.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2377.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3527.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2377.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3967.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3967.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3742.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3742.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1924.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4755.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4416.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,3212.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3685.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2377.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,7414.98,155,,,Fee Schedule,155% of CMS OPPS Rate,7414.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2377.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2627.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2377.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,4984.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4984.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,7414.98,
33735 - (PF) Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation),3634899,CDM,960,RC,33735,HCPCS,Outpatient,,,3466.59,1733.30,,3119.93,90,,,percent of total billed charges,90% of total Billed charges,2596.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1292.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,899,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2003.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1292.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1914.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1292.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2153.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2153.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2016.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2016.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1052.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1292.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2585.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2379.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1715.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2003.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1292.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,4024.08,155,,,Fee Schedule,155% of CMS OPPS Rate,4024.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1292.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,899,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2135.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1292.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,2681.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2681.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,899,4024.08,
34703 Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni,3623200,CDM,960,RC,34703,HCPCS,Outpatient,,,3726.28,1863.14,,3353.65,90,,,percent of total billed charges,90% of total Billed charges,2782.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2038.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2292.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2292.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2184.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1240.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2577.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1903.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2141.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,4313.5,155,,,Fee Schedule,155% of CMS OPPS Rate,4313.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1571.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1381.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1150.5,4313.5,
"35305 Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial",3622973,CDM,960,RC,35305,HCPCS,Outpatient,,,3328.55,1664.28,,2995.7,90,,,percent of total billed charges,90% of total Billed charges,2482.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1230.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.51,155,,,Fee Schedule,155% of CMS OPPS Rate,1230.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1820.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1230.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2047.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2047.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1952.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1952.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1003.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1230.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2461.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2304.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1711.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1907.51,155,,,Fee Schedule,155% of CMS OPPS Rate,1230.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3847.55,155,,,Fee Schedule,155% of CMS OPPS Rate,3847.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1230.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1180.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1230.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2672.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2672.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1003.68,3847.55,
"35351 - (PF) Thromboendarterectomy, including patch graft, if performed; iliac",3634901,CDM,960,RC,35351,HCPCS,Outpatient,,,3494.35,1747.18,,3144.92,90,,,percent of total billed charges,90% of total Billed charges,2604.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1290.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,957,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2000.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1290.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1290.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2145.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2044.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2044.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1042.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1290.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2580.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2412.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1791.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2000.24,155,,,Fee Schedule,155% of CMS OPPS Rate,1290.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,4036.94,155,,,Fee Schedule,155% of CMS OPPS Rate,4036.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1290.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,957,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1485.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1290.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,2771,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2771,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,957,4036.94,
35531 Bypass graft with vein aortoceliac or aortomesenteri,3623346,CDM,960,RC,35531,HCPCS,Outpatient,,,5325.01,2662.51,,4792.51,90,,,percent of total billed charges,90% of total Billed charges,3974.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1972.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3056.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1972.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2895.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1972.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3256.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3256.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3128.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3128.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1653.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1972.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3944.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3691.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2774.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3056.83,155,,,Fee Schedule,155% of CMS OPPS Rate,1972.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,6160.52,155,,,Fee Schedule,155% of CMS OPPS Rate,6160.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1972.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1939.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1972.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4364.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4364.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6160.52,
"35570 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial",3623374,CDM,960,RC,35570,HCPCS,Outpatient,,,4017,2008.50,,3615.3,90,,,percent of total billed charges,90% of total Billed charges,2997.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1487.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2305.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1487.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2187.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1487.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2460.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2460.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2359.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2359.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1205.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1487.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2974.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2783.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2088.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2305.02,155,,,Fee Schedule,155% of CMS OPPS Rate,1487.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,4646.34,155,,,Fee Schedule,155% of CMS OPPS Rate,4646.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1487.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1677.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1487.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2853.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2853.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1205.1,4646.34,
"35646 - (PF) Bypass graft, with other than vein; aortobifemoral",3634902,CDM,960,RC,35646,HCPCS,Outpatient,,,4635.95,2317.98,,4172.36,90,,,percent of total billed charges,90% of total Billed charges,3458.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1715.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2659.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1715.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2550.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1715.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2868.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2868.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2735.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2735.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1401.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1715.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3431.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3227.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2397.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2659.1,155,,,Fee Schedule,155% of CMS OPPS Rate,1715.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,5361.17,155,,,Fee Schedule,155% of CMS OPPS Rate,5361.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1715.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2107.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1715.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,3701.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3701.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5361.17,
"35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal artery",3622963,CDM,960,RC,35671,HCPCS,Outpatient,,,3068.12,1534.06,,2761.31,90,,,percent of total billed charges,90% of total Billed charges,2288.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1134.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1758.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1134.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1669.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1134.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1877.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1877.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,911.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1134.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2268.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2100.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1549.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1758.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1134.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,3546.63,155,,,Fee Schedule,155% of CMS OPPS Rate,3546.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1134.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1347.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1134.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2414.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2414.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,911.13,3546.63,
"35697 - (PF) Bypass graft, with other than vein; aortofemoral",3634903,CDM,960,RC,35697,HCPCS,Outpatient,,,400.79,200.40,,360.71,90,,,percent of total billed charges,90% of total Billed charges,299.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.28,155,,,Fee Schedule,155% of CMS OPPS Rate,148.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,246.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,237.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,237.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,297.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,209.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.28,155,,,Fee Schedule,155% of CMS OPPS Rate,148.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,463.88,155,,,Fee Schedule,155% of CMS OPPS Rate,463.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,148.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,320.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.23,463.88,
"35701 Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)",3621969,CDM,960,RC,35701,HCPCS,Outpatient,,,1155.4,577.70,,1039.86,90,,,percent of total billed charges,90% of total Billed charges,868.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,433.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,672.37,155,,,Fee Schedule,155% of CMS OPPS Rate,433.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,433.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,727.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,727.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,671.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,671.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,458.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,867.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,792.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,538.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,672.37,155,,,Fee Schedule,155% of CMS OPPS Rate,433.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1345.79,155,,,Fee Schedule,155% of CMS OPPS Rate,1345.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,433.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,494.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,433.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1192.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1192.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,301,1345.79,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,960,RC,36010,HCPCS,Outpatient,,,291.78,145.89,,262.6,90,,,percent of total billed charges,90% of total Billed charges,399.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,166.87,155,,,Fee Schedule,155% of CMS OPPS Rate,107.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,142.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,166.87,155,,,Fee Schedule,155% of CMS OPPS Rate,107.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.13,155,,,Fee Schedule,155% of CMS OPPS Rate,619.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,176.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1001.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1001.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.19,1001.64,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,960,RC,36012,HCPCS,Outpatient,,,463.26,231.63,,416.93,90,,,percent of total billed charges,90% of total Billed charges,634.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,265.19,155,,,Fee Schedule,155% of CMS OPPS Rate,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,265.19,155,,,Fee Schedule,155% of CMS OPPS Rate,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.24,155,,,Fee Schedule,155% of CMS OPPS Rate,983.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,234.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,171.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1712.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1712.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.5,1712.92,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,960,RC,36248,HCPCS,Outpatient,,,127.2,63.60,,114.48,90,,,percent of total billed charges,90% of total Billed charges,159.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.67,155,,,Fee Schedule,155% of CMS OPPS Rate,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.67,155,,,Fee Schedule,155% of CMS OPPS Rate,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.74,155,,,Fee Schedule,155% of CMS OPPS Rate,246.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,297.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.35,297.16,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,18.53,9.27,,16.68,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,10.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.59,155,,,Fee Schedule,155% of CMS OPPS Rate,39.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.43,39.59,
36465-PF NJX Noncmpnd Sclerosant Single Incmptnt Vein,4345282,CDM,983,RC,36465,HCPCS,Outpatient,,,246.39,123.20,,221.75,90,,,percent of total billed charges,90% of total Billed charges,365.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.86,155,,,Fee Schedule,155% of CMS OPPS Rate,118.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,223.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,159.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,183.86,155,,,Fee Schedule,155% of CMS OPPS Rate,118.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.77,155,,,Fee Schedule,155% of CMS OPPS Rate,565.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,118.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1679.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,118.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.95,1679.25,
36466-PF NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,4345283,CDM,983,RC,36466,HCPCS,Outpatient,,,314.31,157.16,,282.88,90,,,percent of total billed charges,90% of total Billed charges,467.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.24,155,,,Fee Schedule,155% of CMS OPPS Rate,153.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,256.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,241.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,241.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,306.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,284.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,199.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,237.24,155,,,Fee Schedule,155% of CMS OPPS Rate,153.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.42,155,,,Fee Schedule,155% of CMS OPPS Rate,724.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1755.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.71,1755.97,
36468-PF Tx of symptomatic spider veins sclerotherapy,4345284,CDM,983,RC,36468,HCPCS,Outpatient,,,213.27,106.64,,191.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,104.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.98,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.98,191.94,
36470-PF Injection Sclerosant Single Incmptnt Vein,4345285,CDM,983,RC,36470,HCPCS,Outpatient,,,79.1,39.55,,71.19,90,,,percent of total billed charges,90% of total Billed charges,118.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.64,155,,,Fee Schedule,155% of CMS OPPS Rate,39.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,49.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.64,155,,,Fee Schedule,155% of CMS OPPS Rate,39.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.24,155,,,Fee Schedule,155% of CMS OPPS Rate,183.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,147.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,287.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.35,287.64,
36471-PF Injection Sclerosant Multiple Incmptnt Veins,4345286,CDM,983,RC,36471,HCPCS,Outpatient,,,157.62,78.81,,141.86,90,,,percent of total billed charges,90% of total Billed charges,233.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.94,155,,,Fee Schedule,155% of CMS OPPS Rate,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,100.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.94,155,,,Fee Schedule,155% of CMS OPPS Rate,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,362.25,155,,,Fee Schedule,155% of CMS OPPS Rate,362.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.09,362.25,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,960,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,518.45,90,,,percent of total billed charges,90% of total Billed charges,853.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,253.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1322.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1322.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2037.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,3529.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3529.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,253.22,3529.2,
36475 Endovenous rf 1st vein,3428319,CDM,983,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,518.45,90,,,percent of total billed charges,90% of total Billed charges,853.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,253.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1322.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1322.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2037.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,3529.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3529.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,253.22,3529.2,
36475-PF Radiofrequency ablation vein,4345287,CDM,983,RC,36475,HCPCS,Outpatient,,,576.05,288.03,,518.45,90,,,percent of total billed charges,90% of total Billed charges,853.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,253.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,554.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,517.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,429.88,155,,,Fee Schedule,155% of CMS OPPS Rate,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1322.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1322.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2037.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,277.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,3529.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3529.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,253.22,3529.2,
36478-PF Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,4345288,CDM,983,RC,36478,HCPCS,Outpatient,,,574.1,287.05,,516.69,90,,,percent of total billed charges,90% of total Billed charges,850.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,428.36,155,,,Fee Schedule,155% of CMS OPPS Rate,276.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,412.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,463.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,463.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,436.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,436.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,255.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,514.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,364.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,428.36,155,,,Fee Schedule,155% of CMS OPPS Rate,276.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1428.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2675.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2675.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,255.66,2675.12,
36482-PF Endoven Ablti Ther Chem Adhesive 1st Vein,4345289,CDM,983,RC,36482,HCPCS,Outpatient,,,371.83,185.92,,334.65,90,,,percent of total billed charges,90% of total Billed charges,550.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.24,155,,,Fee Schedule,155% of CMS OPPS Rate,178.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,298.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,282.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,282.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,356.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,333.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,237.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,276.24,155,,,Fee Schedule,155% of CMS OPPS Rate,178.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,852.58,155,,,Fee Schedule,155% of CMS OPPS Rate,852.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,178.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2236.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,178.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.32,2236.31,
36483-PF Endoven Ablti Ther Chem Adhesive Sbsq Vein,4345290,CDM,983,RC,36483,HCPCS,Outpatient,,,184.5,92.25,,166.05,90,,,percent of total billed charges,90% of total Billed charges,223.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.75,155,,,Fee Schedule,155% of CMS OPPS Rate,88.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,121.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.75,155,,,Fee Schedule,155% of CMS OPPS Rate,88.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.96,155,,,Fee Schedule,155% of CMS OPPS Rate,345.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,88.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,156.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.24,345.96,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,960,RC,36561,HCPCS,Outpatient,,,880,440.00,,792,90,,,percent of total billed charges,90% of total Billed charges,1206.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,497.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,559.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,516.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,273.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,652.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,609.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,411.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,505.75,155,,,Fee Schedule,155% of CMS OPPS Rate,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,1869.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1869.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1468.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,326.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,2303.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2303.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,273.41,2303.16,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,960,RC,36571,HCPCS,Outpatient,,,829.3,414.65,,746.37,90,,,percent of total billed charges,90% of total Billed charges,1136.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.56,155,,,Fee Schedule,155% of CMS OPPS Rate,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,461.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,519.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,519.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,478.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,478.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,249.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,614.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,564.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,389.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,476.56,155,,,Fee Schedule,155% of CMS OPPS Rate,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,1761.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1761.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4188.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,2491.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2491.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,249.82,4188.55,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,960,RC,36575,HCPCS,Outpatient,,,89.43,44.72,,80.49,90,,,percent of total billed charges,90% of total Billed charges,122.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.69,155,,,Fee Schedule,155% of CMS OPPS Rate,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.69,155,,,Fee Schedule,155% of CMS OPPS Rate,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.3,155,,,Fee Schedule,155% of CMS OPPS Rate,189.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,165.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,314.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.93,314.16,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,960,RC,36582,HCPCS,Outpatient,,,760.91,380.46,,684.82,90,,,percent of total billed charges,90% of total Billed charges,1042.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,274.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,437.21,155,,,Fee Schedule,155% of CMS OPPS Rate,282.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,429.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,482.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,482.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,445.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,445.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,234.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,564.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,525.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,356.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,437.21,155,,,Fee Schedule,155% of CMS OPPS Rate,282.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1616.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1616.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,282.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2760.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,282.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,2147.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2147.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,234.48,2760.05,
36589- Rmv tunnel cent ven access cath,3430724,CDM,960,RC,36589,HCPCS,Outpatient,,,358.34,179.17,,322.51,90,,,percent of total billed charges,90% of total Billed charges,295.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.51,155,,,Fee Schedule,155% of CMS OPPS Rate,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,208.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,208.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,110,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,246.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,206.51,155,,,Fee Schedule,155% of CMS OPPS Rate,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.7,155,,,Fee Schedule,155% of CMS OPPS Rate,457.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,172.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,334.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,110,457.7,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,960,RC,36590,HCPCS,Outpatient,,,500.7,250.35,,450.63,90,,,percent of total billed charges,90% of total Billed charges,406.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,291.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,343.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.62,155,,,Fee Schedule,155% of CMS OPPS Rate,630.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,366.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,586.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,586.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,153.8,630.62,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,960,RC,36595,HCPCS,Outpatient,,,477.14,238.57,,429.43,90,,,percent of total billed charges,90% of total Billed charges,654.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,176.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,274.3,155,,,Fee Schedule,155% of CMS OPPS Rate,176.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,302.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,280.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,280.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,146.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,330.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,274.3,155,,,Fee Schedule,155% of CMS OPPS Rate,176.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1013.87,155,,,Fee Schedule,155% of CMS OPPS Rate,1013.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,176.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,828.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1077.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1077.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146.2,1077.8,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,960,RC,36901,HCPCS,Outpatient,,,447.25,223.63,,402.53,90,,,percent of total billed charges,90% of total Billed charges,613.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,166.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,119.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,257.36,155,,,Fee Schedule,155% of CMS OPPS Rate,166.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,263.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,263.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,310.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,257.36,155,,,Fee Schedule,155% of CMS OPPS Rate,166.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.6,155,,,Fee Schedule,155% of CMS OPPS Rate,950.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,166.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,604.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,166.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.24,950.6,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,960,RC,36902,HCPCS,Outpatient,,,635.55,317.78,,572,90,,,percent of total billed charges,90% of total Billed charges,871.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,235.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,365.52,155,,,Fee Schedule,155% of CMS OPPS Rate,235.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,399.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,372.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,372.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,190.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,471.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,439.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,365.52,155,,,Fee Schedule,155% of CMS OPPS Rate,235.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1350.62,155,,,Fee Schedule,155% of CMS OPPS Rate,1350.62,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,235.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1280.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,235.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.66,1350.62,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,960,RC,36903,HCPCS,Outpatient,,,840.93,420.47,,756.84,90,,,percent of total billed charges,90% of total Billed charges,1151.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,482.1,155,,,Fee Schedule,155% of CMS OPPS Rate,311.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,528.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,528.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,495.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,495.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,260.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,585.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,396.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,482.1,155,,,Fee Schedule,155% of CMS OPPS Rate,311.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1785.54,155,,,Fee Schedule,155% of CMS OPPS Rate,1785.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,311.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5830.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,311.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.21,5830.57,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,974.65,487.33,,877.19,90,,,percent of total billed charges,90% of total Billed charges,1337.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,280.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,617.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,299.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,681.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,2073.57,155,,,Fee Schedule,155% of CMS OPPS Rate,2073.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1869.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.06,2073.57,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,960,RC,36905,HCPCS,Outpatient,,,1175.34,587.67,,1057.81,90,,,percent of total billed charges,90% of total Billed charges,1610.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,435.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,351.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,674.68,155,,,Fee Schedule,155% of CMS OPPS Rate,435.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,435.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,740.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,691.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,691.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,375.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,815.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,542.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,674.68,155,,,Fee Schedule,155% of CMS OPPS Rate,435.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2496.46,155,,,Fee Schedule,155% of CMS OPPS Rate,2496.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,435.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2391.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,435.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.53,2496.46,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,1353.17,676.59,,1217.85,90,,,percent of total billed charges,90% of total Billed charges,1856.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,410.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,438.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,631.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2877.3,155,,,Fee Schedule,155% of CMS OPPS Rate,2877.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7079.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.24,7079.03,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,960,RC,36908,HCPCS,Outpatient,,,552.63,276.32,,497.37,90,,,percent of total billed charges,90% of total Billed charges,757.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,153.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,317.02,155,,,Fee Schedule,155% of CMS OPPS Rate,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,204.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,325.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,325.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,164.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,409.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,384.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,262.01,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,317.02,155,,,Fee Schedule,155% of CMS OPPS Rate,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1173.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2805.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,204.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,2805.13,
"37217 - PF - Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery",3640915,CDM,960,RC,37217,HCPCS,Outpatient,,,2922.56,1461.28,,2630.3,90,,,percent of total billed charges,90% of total Billed charges,2185.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1683.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1603.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1086.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1803.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1803.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1712.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1712.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,935.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2172.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2020.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1485.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1683.75,155,,,Fee Schedule,155% of CMS OPPS Rate,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,3387.15,155,,,Fee Schedule,155% of CMS OPPS Rate,3387.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1264.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1086.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,935.54,3387.15,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,960,RC,37222,HCPCS,Outpatient,,,504.09,252.05,,453.68,90,,,percent of total billed charges,90% of total Billed charges,689.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.96,155,,,Fee Schedule,155% of CMS OPPS Rate,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,311.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,163.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,257.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,287.96,155,,,Fee Schedule,155% of CMS OPPS Rate,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1069.3,155,,,Fee Schedule,155% of CMS OPPS Rate,1069.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,867.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1830.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1830.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,163.43,1830.56,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,983,RC,37226,HCPCS,Outpatient,,,1101.81,550.91,,991.63,90,,,percent of total billed charges,90% of total Billed charges,1621.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,870.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,828.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,437.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,977.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,713.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,805.55,155,,,Fee Schedule,155% of CMS OPPS Rate,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,2513.36,155,,,Fee Schedule,155% of CMS OPPS Rate,2513.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8046.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,519.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18020.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,18020.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,437.53,18020.68,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,975,RC,37231,HCPCS,Outpatient,,,1543.81,771.91,,1389.43,90,,,percent of total billed charges,90% of total Billed charges,2272.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,728.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1128.73,155,,,Fee Schedule,155% of CMS OPPS Rate,728.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,728.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1267.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1267.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1200.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1200.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,655.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,728.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1456.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1417.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1022.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1128.73,155,,,Fee Schedule,155% of CMS OPPS Rate,728.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3521.63,155,,,Fee Schedule,155% of CMS OPPS Rate,3521.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,728.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12011.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,728.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,26908.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,26908.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,655.77,26908.96,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,960,RC,37238,HCPCS,Outpatient,,,820.98,410.49,,738.88,90,,,percent of total billed charges,90% of total Billed charges,1124.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,303.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,267.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,470.75,155,,,Fee Schedule,155% of CMS OPPS Rate,303.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,453.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,303.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,510.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,510.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,481.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,481.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,276.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,607.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,568.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,399.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,470.75,155,,,Fee Schedule,155% of CMS OPPS Rate,303.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1743.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1743.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,303.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4266.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,303.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.48,4266.27,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,960,RC,37239,HCPCS,Outpatient,,,405.33,202.67,,364.8,90,,,percent of total billed charges,90% of total Billed charges,554.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,231.6,155,,,Fee Schedule,155% of CMS OPPS Rate,149.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,241.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,241.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,122.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,284.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,204.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,231.6,155,,,Fee Schedule,155% of CMS OPPS Rate,149.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.86,155,,,Fee Schedule,155% of CMS OPPS Rate,859.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2120.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.5,2120.05,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,960,RC,37241,HCPCS,Outpatient,,,1142.52,571.26,,1028.27,90,,,percent of total billed charges,90% of total Billed charges,1566.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,366.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,424.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,730.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,730.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,685.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,685.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,382.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,848.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,808.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,552.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,657.37,155,,,Fee Schedule,155% of CMS OPPS Rate,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,2428.28,155,,,Fee Schedule,155% of CMS OPPS Rate,2428.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4728.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,424.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.22,4728.31,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,960,RC,37246,HCPCS,Outpatient,,,930.15,465.08,,837.14,90,,,percent of total billed charges,90% of total Billed charges,1275.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,291.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,535.48,155,,,Fee Schedule,155% of CMS OPPS Rate,345.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,517.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,581.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,547.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,547.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,312.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,345.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,690.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,646.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,448.24,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,535.48,155,,,Fee Schedule,155% of CMS OPPS Rate,345.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.21,155,,,Fee Schedule,155% of CMS OPPS Rate,1977.21,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,345.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2254.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,345.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.76,2254.22,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,960,RC,37247,HCPCS,Outpatient,,,460.22,230.11,,414.2,90,,,percent of total billed charges,90% of total Billed charges,632.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144.67,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,254.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,172.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,220.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,267.17,155,,,Fee Schedule,155% of CMS OPPS Rate,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.51,155,,,Fee Schedule,155% of CMS OPPS Rate,980.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,914.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,172.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,980.51,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,960,RC,37248,HCPCS,Outpatient,,,788.33,394.17,,709.5,90,,,percent of total billed charges,90% of total Billed charges,1079.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,250.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,452.07,155,,,Fee Schedule,155% of CMS OPPS Rate,291.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,441.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,291.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,496.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,496.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,464.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,464.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,268.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,291.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,583.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,548.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,368.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,452.07,155,,,Fee Schedule,155% of CMS OPPS Rate,291.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1673.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1673.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,291.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1565.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,291.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.89,1673.98,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,960,RC,37252,HCPCS,Outpatient,,,238.67,119.34,,214.8,90,,,percent of total billed charges,90% of total Billed charges,327.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.14,155,,,Fee Schedule,155% of CMS OPPS Rate,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,143.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,143.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,169.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,122.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.14,155,,,Fee Schedule,155% of CMS OPPS Rate,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,508.07,155,,,Fee Schedule,155% of CMS OPPS Rate,508.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.56,1459.47,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,960,RC,37253,HCPCS,Outpatient,,,188.51,94.26,,169.66,90,,,percent of total billed charges,90% of total Billed charges,230.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.18,155,,,Fee Schedule,155% of CMS OPPS Rate,70.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,109.18,155,,,Fee Schedule,155% of CMS OPPS Rate,70.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.03,155,,,Fee Schedule,155% of CMS OPPS Rate,358.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,70.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.24,358.03,
37609- Ligation/biopsy/temporal artery,3430918,CDM,960,RC,37609,HCPCS,Outpatient,,,537.61,268.81,,483.85,90,,,percent of total billed charges,90% of total Billed charges,503.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,311.83,155,,,Fee Schedule,155% of CMS OPPS Rate,201.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,201.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,312.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,312.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,402.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,368.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,253.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,311.83,155,,,Fee Schedule,155% of CMS OPPS Rate,201.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,780.72,155,,,Fee Schedule,155% of CMS OPPS Rate,780.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,201.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,124,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,409.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,201.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,631.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124,780.72,
"37722 - (PF) Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral",3634911,CDM,960,RC,37722,HCPCS,Outpatient,,,1258.4,629.20,,1132.56,90,,,percent of total billed charges,90% of total Billed charges,938.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,465.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,720.83,155,,,Fee Schedule,155% of CMS OPPS Rate,465.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,699.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,787.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,787.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,739.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,739.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,387.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,930.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,872.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,635.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,720.83,155,,,Fee Schedule,155% of CMS OPPS Rate,465.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1454.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1454.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,465.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,520.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,465.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1025.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1025.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,387.7,1454.29,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,960,RC,37765,HCPCS,Outpatient,,,724.9,362.45,,652.41,90,,,percent of total billed charges,90% of total Billed charges,688,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,269.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,356.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,417.46,155,,,Fee Schedule,155% of CMS OPPS Rate,269.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,402.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,269.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,453.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,453.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,424.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,424.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,307.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,538.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,500.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,356.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,417.46,155,,,Fee Schedule,155% of CMS OPPS Rate,269.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1066.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,269.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,668.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,269.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1354.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1354.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,269.33,1354.56,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,983,RC,38505,HCPCS,Outpatient,,,198.72,99.36,,178.85,90,,,percent of total billed charges,90% of total Billed charges,251.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,390,155,,,Fee Schedule,155% of CMS OPPS Rate,390,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,243.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.95,390,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,960,RC,38505,HCPCS,Outpatient,,,222.57,111.29,,200.31,90,,,percent of total billed charges,90% of total Billed charges,251.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.05,155,,,Fee Schedule,155% of CMS OPPS Rate,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,390,155,,,Fee Schedule,155% of CMS OPPS Rate,390,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,243.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.95,390,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,960,RC,38525,HCPCS,Outpatient,,,1172.13,586.07,,1054.92,90,,,percent of total billed charges,90% of total Billed charges,878.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,156,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,677.92,155,,,Fee Schedule,155% of CMS OPPS Rate,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,548.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,437.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,616.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,616.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,671.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,671.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,353.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,874.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,791.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,559.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,677.92,155,,,Fee Schedule,155% of CMS OPPS Rate,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.09,155,,,Fee Schedule,155% of CMS OPPS Rate,1361.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,156,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,426.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,437.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,876.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,156,1361.09,
38570- Laparoscopy/surg/retroper lymph bx,3431456,CDM,960,RC,38570,HCPCS,Outpatient,,,1360.33,680.17,,1224.3,90,,,percent of total billed charges,90% of total Billed charges,1019.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,507.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,486.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,786.73,155,,,Fee Schedule,155% of CMS OPPS Rate,507.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,507.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,781.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,781.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,404.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,507.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1015.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,922.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,623.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,786.73,155,,,Fee Schedule,155% of CMS OPPS Rate,507.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1579.59,155,,,Fee Schedule,155% of CMS OPPS Rate,1579.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,507.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,561.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,507.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1076.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,404.67,1579.59,
38792- Lymphangiography/sentinel node,3431465,CDM,960,RC,38792,HCPCS,Outpatient,,,87.88,43.94,,79.09,90,,,percent of total billed charges,90% of total Billed charges,109.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.85,155,,,Fee Schedule,155% of CMS OPPS Rate,32.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.85,155,,,Fee Schedule,155% of CMS OPPS Rate,32.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.65,155,,,Fee Schedule,155% of CMS OPPS Rate,169.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,32.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,80.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.05,169.65,
38900- Intraop map/sentinel node/inj dye,3431466,CDM,960,RC,38900,HCPCS,Outpatient,,,373.61,186.81,,336.25,90,,,percent of total billed charges,90% of total Billed charges,278.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.15,155,,,Fee Schedule,155% of CMS OPPS Rate,138.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,190.19,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,214.15,155,,,Fee Schedule,155% of CMS OPPS Rate,138.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,431.89,155,,,Fee Schedule,155% of CMS OPPS Rate,431.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,138.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,274.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.41,431.89,
"39010 - PF - Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transtho",3640921,CDM,960,RC,39010,HCPCS,Outpatient,,,2104.86,1052.43,,1894.37,90,,,percent of total billed charges,90% of total Billed charges,1573.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,637,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1214.07,155,,,Fee Schedule,155% of CMS OPPS Rate,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1162.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,783.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1308,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1308,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1220.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,635.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1566.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1440.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1032.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1214.07,155,,,Fee Schedule,155% of CMS OPPS Rate,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,2439.44,155,,,Fee Schedule,155% of CMS OPPS Rate,2439.44,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,973.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,783.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1625.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1625.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,635.91,2439.44,
"43233- Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30",3621459,CDM,983,RC,43233,HCPCS,Outpatient,,,603.37,301.69,,543.03,90,,,percent of total billed charges,90% of total Billed charges,449.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,345.6,155,,,Fee Schedule,155% of CMS OPPS Rate,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,312.01,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,350.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,350.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,445.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,413.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,274.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,345.6,155,,,Fee Schedule,155% of CMS OPPS Rate,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.27,155,,,Fee Schedule,155% of CMS OPPS Rate,697.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,260.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,222.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.26,697.27,
43239- EGD w/biopsy/single/multiple,3431169,CDM,983,RC,43239,HCPCS,Outpatient,,,358.69,179.35,,322.82,90,,,percent of total billed charges,90% of total Billed charges,492.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.14,155,,,Fee Schedule,155% of CMS OPPS Rate,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,247.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,159.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,207.14,155,,,Fee Schedule,155% of CMS OPPS Rate,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,763.11,155,,,Fee Schedule,155% of CMS OPPS Rate,763.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,374.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,133.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,670.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,670.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,123.2,763.11,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,983,RC,43251,HCPCS,Outpatient,,,510.29,255.15,,459.26,90,,,percent of total billed charges,90% of total Billed charges,666.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,189.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,294.21,155,,,Fee Schedule,155% of CMS OPPS Rate,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,189.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,266.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,159.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,379.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,226.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,294.21,155,,,Fee Schedule,155% of CMS OPPS Rate,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1032.53,155,,,Fee Schedule,155% of CMS OPPS Rate,1032.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,189.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,446.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,446.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,159.28,1032.53,
"43279 - (PF) Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when",3634912,CDM,960,RC,43279,HCPCS,Outpatient,,,3475.34,1737.67,,3127.81,90,,,percent of total billed charges,90% of total Billed charges,2598.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,710.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2002.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1979.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1291.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2226.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2022.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2022.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1043.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2583.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2387.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1730.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2002.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,4027.95,155,,,Fee Schedule,155% of CMS OPPS Rate,4027.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1253.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1291.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2639.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2639.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,710.08,4027.95,
"43280-Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)",3622755,CDM,983,RC,43280,HCPCS,Outpatient,,,2914.67,1457.34,,2623.2,90,,,percent of total billed charges,90% of total Billed charges,2180.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,925.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1680.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1659.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1084.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1866.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1866.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1691.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1691.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,874.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2168.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1995.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1442.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1680.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3379.11,155,,,Fee Schedule,155% of CMS OPPS Rate,3379.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,925.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1190.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1084.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2199.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2199.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,874.24,3379.11,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,983,RC,43450,HCPCS,Outpatient,,,204.29,102.15,,183.86,90,,,percent of total billed charges,90% of total Billed charges,254.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,154.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,87.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,119.63,155,,,Fee Schedule,155% of CMS OPPS Rate,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.71,155,,,Fee Schedule,155% of CMS OPPS Rate,394.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,153.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59,394.71,
"43499 - PF Unlisted procedure, esophagus",3641211,CDM,960,RC,43499,HCPCS,Outpatient,,,531.87,265.94,,478.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.56,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.56,478.68,
"43633- Gastrectomy, partial, distal; with Roux-en-Y reconstruction",3623575,CDM,983,RC,43633,HCPCS,Outpatient,,,5205.31,2602.66,,4684.78,90,,,percent of total billed charges,90% of total Billed charges,3894.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3002.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2869.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1937.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3227.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3227.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3026.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3026.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1553.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3874.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3571.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2595.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3002.78,155,,,Fee Schedule,155% of CMS OPPS Rate,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,6036.71,155,,,Fee Schedule,155% of CMS OPPS Rate,6036.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1754.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1937.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,3906.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3906.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6036.71,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,960,RC,43762,HCPCS,Outpatient,,,567.08,283.54,,510.37,90,,,percent of total billed charges,90% of total Billed charges,250.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,57.3,155,,,Fee Schedule,155% of CMS OPPS Rate,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.81,155,,,Fee Schedule,155% of CMS OPPS Rate,387.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,236.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.1,510.37,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,983,RC,43999,HCPCS,Outpatient,,,519.99,260.00,,467.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156,467.99,
"44125- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3622968,CDM,983,RC,44125,HCPCS,Outpatient,,,3166.96,1583.48,,2850.26,90,,,percent of total billed charges,90% of total Billed charges,2365.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,623.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1821.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1809.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1175.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2035.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2035.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1840.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1840.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,953.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2350.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2172.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1550.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1821.41,155,,,Fee Schedule,155% of CMS OPPS Rate,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,3667.28,155,,,Fee Schedule,155% of CMS OPPS Rate,3667.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1104.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1175.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,2400.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2400.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,623.5,3667.28,
"44130- Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separ",3622980,CDM,983,RC,44130,HCPCS,Outpatient,,,3543.12,1771.56,,3188.81,90,,,percent of total billed charges,90% of total Billed charges,2650.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1318.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,645.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2043.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2017.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1318.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2269.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2269.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2052.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2052.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1061.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1318.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2636.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2422.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1734.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2043.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,4108.71,155,,,Fee Schedule,155% of CMS OPPS Rate,4108.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1318.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1182.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1318.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2668.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2668.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,645.5,4108.71,
"44145- Colectomy, partial; with coloproctostomy (low pelvic anastomosis",3623381,CDM,983,RC,44145,HCPCS,Outpatient,,,4423.53,2211.77,,3981.18,90,,,percent of total billed charges,90% of total Billed charges,3309.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,794,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2456.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2763.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2763.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2575.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1338.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3292.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3039.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2149.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,5129.77,155,,,Fee Schedule,155% of CMS OPPS Rate,5129.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,794,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1568.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1646.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3378.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3378.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,794,5129.77,
"44147 - (PF) Colectomy, partial; abdominal and transanal approach",3634913,CDM,960,RC,44147,HCPCS,Outpatient,,,5200.83,2600.42,,4680.75,90,,,percent of total billed charges,90% of total Billed charges,3888.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1933.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,630,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2996.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1933.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2883.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1933.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3242.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3031.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3031.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1569.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1933.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3866.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3577.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2556.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2996.27,155,,,Fee Schedule,155% of CMS OPPS Rate,1933.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6027.58,155,,,Fee Schedule,155% of CMS OPPS Rate,6027.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1933.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,630,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1546.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1933.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,3956.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3956.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,630,6027.58,
"44150 - (PF) Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy",3634914,CDM,960,RC,44150,HCPCS,Outpatient,,,4946.61,2473.31,,4451.95,90,,,percent of total billed charges,90% of total Billed charges,3699.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,923.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2851.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2768.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1839.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3113.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3113.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2883.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2883.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1511.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3679.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3402.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2397.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2851.64,155,,,Fee Schedule,155% of CMS OPPS Rate,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,5734.78,155,,,Fee Schedule,155% of CMS OPPS Rate,5734.78,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,923.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1707.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1839.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3798.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3798.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,923.5,5734.78,
"44157 - (PF) Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop",3635060,CDM,960,RC,44157,HCPCS,Outpatient,,,5901.29,2950.65,,5311.16,90,,,percent of total billed charges,90% of total Billed charges,4409.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2190,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3394.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2190,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3267.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3675.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3675.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3425.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3425.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1743.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4380,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4041.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2922.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3394.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2190,100,,,Fee Schedule,100% of CMS OPPS Rate ,6834.09,155,,,Fee Schedule,155% of CMS OPPS Rate,6834.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,2190,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2012.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2190,100,,,Fee Schedule,100% of CMS OPPS Rate ,4422.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4422.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6834.09,
"44188 - (PF) Laparoscopy, surgical, colostomy or skin level cecostomy",3635061,CDM,960,RC,44188,HCPCS,Outpatient,,,3236.21,1618.11,,2912.59,90,,,percent of total billed charges,90% of total Billed charges,2419.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1203.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,665.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1864.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1203.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1868.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1203.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2101.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2101.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1879.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1879.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,990.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1203.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2217.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1547.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1864.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1203.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,3750.89,155,,,Fee Schedule,155% of CMS OPPS Rate,3750.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1203.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1132.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1203.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2485.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2485.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,665.1,3750.89,
"44202 - (PF) Laparoscopy, surgical; enterectomy, resection of small intestine, single resection",3635062,CDM,960,RC,44202,HCPCS,Outpatient,,,3734.9,1867.45,,3361.41,90,,,percent of total billed charges,90% of total Billed charges,2794.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2154.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2062.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1390.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2319.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2319.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2164.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2164.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1120,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2780.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2553.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1829.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2154.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,4331.63,155,,,Fee Schedule,155% of CMS OPPS Rate,4331.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1304.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1390.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2819.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2819.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4331.63,
"44208- Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic",3623578,CDM,960,RC,44208,HCPCS,Outpatient,,,5254.12,2627.06,,4728.71,90,,,percent of total billed charges,90% of total Billed charges,3929.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3028.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3024.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1954.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3402.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3402.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3060.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3060.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1603.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3908.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3611.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2507.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,3028.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,6091.1,155,,,Fee Schedule,155% of CMS OPPS Rate,6091.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1634.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1954.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,4056.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,4056.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,6091.1,
"44300- Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate p",3622392,CDM,960,RC,44300,HCPCS,Outpatient,,,2267.21,1133.61,,2040.49,90,,,percent of total billed charges,90% of total Billed charges,1695.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,843.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,399.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1307.3,155,,,Fee Schedule,155% of CMS OPPS Rate,843.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1293.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,843.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1455,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1455,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1313.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1313.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,680.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,843.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1686.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1549.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1113.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1307.3,155,,,Fee Schedule,155% of CMS OPPS Rate,843.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2628.75,155,,,Fee Schedule,155% of CMS OPPS Rate,2628.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,843.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,782.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,843.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1709.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1709.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,399.5,2628.75,
44340 - (PF) Revision of colostomy; simple (release of superficial scar) (separate proc,3635063,CDM,960,RC,44340,HCPCS,Outpatient,,,1657.43,828.72,,1491.69,90,,,percent of total billed charges,90% of total Billed charges,1242.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,277.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,960.09,155,,,Fee Schedule,155% of CMS OPPS Rate,619.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,952.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,619.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1070.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1070.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,951.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,951.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,504.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1122.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,777.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,960.09,155,,,Fee Schedule,155% of CMS OPPS Rate,619.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1926.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1926.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,619.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,469.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,619.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1258.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1258.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,277.5,1926.11,
"44361 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635065,CDM,960,RC,44361,HCPCS,Outpatient,,,412.28,206.14,,371.05,90,,,percent of total billed charges,90% of total Billed charges,307.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,236.56,155,,,Fee Schedule,155% of CMS OPPS Rate,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,180.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,236.56,155,,,Fee Schedule,155% of CMS OPPS Rate,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,476.86,155,,,Fee Schedule,155% of CMS OPPS Rate,476.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,175.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.14,476.86,
"44373 - (PF) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not includ",3635064,CDM,960,RC,44373,HCPCS,Outpatient,,,500.4,250.20,,450.36,90,,,percent of total billed charges,90% of total Billed charges,374.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,178.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,292.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,292.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,371.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,345.5,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,288.18,155,,,Fee Schedule,155% of CMS OPPS Rate,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,579.84,155,,,Fee Schedule,155% of CMS OPPS Rate,579.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,347.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,419.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,419.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,156.4,579.84,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,960,RC,44380,HCPCS,Outpatient,,,144.77,72.39,,130.29,90,,,percent of total billed charges,90% of total Billed charges,199.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.63,155,,,Fee Schedule,155% of CMS OPPS Rate,54.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,61.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,84.63,155,,,Fee Schedule,155% of CMS OPPS Rate,54.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.02,155,,,Fee Schedule,155% of CMS OPPS Rate,309.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,54.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,138.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49.52,309.02,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,983,RC,44388,HCPCS,Outpatient,,,409.69,204.85,,368.72,90,,,percent of total billed charges,90% of total Billed charges,456.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,236.53,155,,,Fee Schedule,155% of CMS OPPS Rate,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,152.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,213.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,305.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,282.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,188.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,236.53,155,,,Fee Schedule,155% of CMS OPPS Rate,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.82,155,,,Fee Schedule,155% of CMS OPPS Rate,706.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,152.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,694.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,694.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,127.25,706.82,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,960,RC,44394,HCPCS,Outpatient,,,592.29,296.15,,533.06,90,,,percent of total billed charges,90% of total Billed charges,643.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,224.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,340.18,155,,,Fee Schedule,155% of CMS OPPS Rate,219.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,344.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,344.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,183.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,438.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,406.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,265.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,340.18,155,,,Fee Schedule,155% of CMS OPPS Rate,219.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,996.96,155,,,Fee Schedule,155% of CMS OPPS Rate,996.96,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,219.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,441.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,219.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,992.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,183.94,996.96,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,449.96,224.98,,404.96,90,,,percent of total billed charges,90% of total Billed charges,572.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.72,155,,,Fee Schedule,155% of CMS OPPS Rate,886.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,453.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.71,886.72,
"44603- Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury o",3618862,CDM,960,RC,44603,HCPCS,Outpatient,,,4353.35,2176.68,,3918.02,90,,,percent of total billed charges,90% of total Billed charges,3258.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,785.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2513.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2485.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1621.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2795.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2795.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2536.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2536.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1310.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3242.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2992.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2144.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2513.03,155,,,Fee Schedule,155% of CMS OPPS Rate,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,5050.4,155,,,Fee Schedule,155% of CMS OPPS Rate,5050.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,785.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1471.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1621.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,3294.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3294.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,785.16,5050.4,
"44626 - (PF) Closure of enterostomy, large or small intestine; with resection and colorectal anas",3635068,CDM,960,RC,44626,HCPCS,Outpatient,,,4295.18,2147.59,,3865.66,90,,,percent of total billed charges,90% of total Billed charges,3210.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,948.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2472.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2378.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1595.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2675.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2675.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2502.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2502.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1295.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3190.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2952.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2110.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2472.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4975.73,155,,,Fee Schedule,155% of CMS OPPS Rate,4975.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,948.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1520.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1595.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,3270.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3270.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,948.86,4975.73,
44640 - PF - Closure of intestinal cutaneous fistula,3640922,CDM,960,RC,44640,HCPCS,Outpatient,,,3760.05,1880.03,,3384.05,90,,,percent of total billed charges,90% of total Billed charges,2810.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2164,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2145,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1396.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2412.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2412.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2185.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2185.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1132.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2792.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2578.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1838.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2164,155,,,Fee Schedule,155% of CMS OPPS Rate,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4355.55,155,,,Fee Schedule,155% of CMS OPPS Rate,4355.55,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1176.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1396.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2856.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2856.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,4355.55,
44660- Closure of enterovesical fistula; without intestinal or bladder resection,3622986,CDM,960,RC,44660,HCPCS,Outpatient,,,3551.58,1775.79,,3196.42,90,,,percent of total billed charges,90% of total Billed charges,2661.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1326.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,448,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2055.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1326.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1979.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1326.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2226.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2068.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2068.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1075.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1326.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2652.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2440.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1676.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2055.44,155,,,Fee Schedule,155% of CMS OPPS Rate,1326.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,4125.5,155,,,Fee Schedule,155% of CMS OPPS Rate,4125.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1326.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1149.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1326.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,2710.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2710.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,448,4125.5,
"44799- Unlisted procedure, small intestine",3623581,CDM,960,RC,44799,HCPCS,Outpatient,,,2659.33,1329.67,,2393.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.8,2393.4,
44955- Appendectomy w/ other major procedure,3431236,CDM,983,RC,44955,HCPCS,Outpatient,,,224.56,112.28,,202.1,90,,,percent of total billed charges,90% of total Billed charges,168.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.53,155,,,Fee Schedule,155% of CMS OPPS Rate,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,130.53,155,,,Fee Schedule,155% of CMS OPPS Rate,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.41,155,,,Fee Schedule,155% of CMS OPPS Rate,261.41,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.9,261.41,
"44979 - (PF) Unlisted laparoscopy procedure, appendix",3635069,CDM,960,RC,44979,HCPCS,Outpatient,,,1637.88,818.94,,1474.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.36,1474.09,
45100- Biopsy of rectum,3431238,CDM,983,RC,45100,HCPCS,Outpatient,,,784.55,392.28,,706.1,90,,,percent of total billed charges,90% of total Billed charges,588.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,150.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,455.64,155,,,Fee Schedule,155% of CMS OPPS Rate,293.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,293.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,512.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,512.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,447.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,447.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,241.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,587.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,528.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,351.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,455.64,155,,,Fee Schedule,155% of CMS OPPS Rate,293.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,912.9,155,,,Fee Schedule,155% of CMS OPPS Rate,912.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,293.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,378.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,293.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,599.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,150.5,912.9,
"45110 - (PF) Proctectomy; complete, combined abdominoperineal, with colostomy",3635070,CDM,960,RC,45110,HCPCS,Outpatient,,,4830.35,2415.18,,4347.32,90,,,percent of total billed charges,90% of total Billed charges,3612.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1796.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,989,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2784.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1796.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2715.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1796.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3054.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3054.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2820.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2820.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1489.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1796.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3592.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3328.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2285.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2784.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1796.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,5599.47,155,,,Fee Schedule,155% of CMS OPPS Rate,5599.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1796.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,989,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1557.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1796.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,3767.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3767.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,989,5599.47,
"45111 - (PF) Proctectomy; partial resection of rectum, transabdominal approach",3635071,CDM,960,RC,45111,HCPCS,Outpatient,,,2893.57,1446.79,,2604.21,90,,,percent of total billed charges,90% of total Billed charges,2160.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1072.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,627,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1663,155,,,Fee Schedule,155% of CMS OPPS Rate,1072.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1610.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1072.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1811.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1811.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1674.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1674.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,876.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1072.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2145.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1976.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1372.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1663,155,,,Fee Schedule,155% of CMS OPPS Rate,1072.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,3349.5,155,,,Fee Schedule,155% of CMS OPPS Rate,3349.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1072.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,627,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1173.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1072.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,2218.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2218.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,627,3349.5,
"45171 - (PF) Excision of rectal tumor, transanal approach; not including muscularis propria",3635072,CDM,960,RC,45171,HCPCS,Outpatient,,,1611.42,805.71,,1450.28,90,,,percent of total billed charges,90% of total Billed charges,1205.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,599.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,460.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,928.98,155,,,Fee Schedule,155% of CMS OPPS Rate,599.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,599.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1037.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,906.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,906.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,485.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1198.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1069.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,714.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,928.98,155,,,Fee Schedule,155% of CMS OPPS Rate,599.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1868.2,155,,,Fee Schedule,155% of CMS OPPS Rate,1868.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,599.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,460.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,587.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,599.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1201.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1201.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,460.8,1868.2,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,983,RC,45300,HCPCS,Outpatient,,,124.45,62.23,,112.01,90,,,percent of total billed charges,90% of total Billed charges,167.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,90,,,Percent of total Billed charges,90% of total billed charges,24.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.04,155,,,Fee Schedule,155% of CMS OPPS Rate,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.04,155,,,Fee Schedule,155% of CMS OPPS Rate,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.15,155,,,Fee Schedule,155% of CMS OPPS Rate,260.15,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,238,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.37,260.15,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,960,RC,45303,HCPCS,Outpatient,,,221.79,110.90,,199.61,90,,,percent of total billed charges,90% of total Billed charges,305.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,129.47,155,,,Fee Schedule,155% of CMS OPPS Rate,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,152.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,129.47,155,,,Fee Schedule,155% of CMS OPPS Rate,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.25,155,,,Fee Schedule,155% of CMS OPPS Rate,473.25,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1793.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1793.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.31,1793.84,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,960,RC,45305,HCPCS,Outpatient,,,190.27,95.14,,171.24,90,,,percent of total billed charges,90% of total Billed charges,243.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.07,155,,,Fee Schedule,155% of CMS OPPS Rate,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,87.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,110.07,155,,,Fee Schedule,155% of CMS OPPS Rate,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.98,155,,,Fee Schedule,155% of CMS OPPS Rate,376.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,157.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,377.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53,377.4,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,960,RC,45338,HCPCS,Outpatient,,,312.55,156.28,,281.3,90,,,percent of total billed charges,90% of total Billed charges,401.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,180.06,155,,,Fee Schedule,155% of CMS OPPS Rate,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,180.06,155,,,Fee Schedule,155% of CMS OPPS Rate,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,622.26,155,,,Fee Schedule,155% of CMS OPPS Rate,622.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,376.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,620.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,101.39,622.26,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,960,RC,45381,HCPCS,Outpatient,,,522.05,261.03,,469.85,90,,,percent of total billed charges,90% of total Billed charges,619.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,213.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,300.95,155,,,Fee Schedule,155% of CMS OPPS Rate,194.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,304.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,304.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,176.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,388.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,359.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,232.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,300.95,155,,,Fee Schedule,155% of CMS OPPS Rate,194.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,960.07,155,,,Fee Schedule,155% of CMS OPPS Rate,960.07,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,194.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,563.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,194.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,895.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,895.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,176.04,960.07,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,983,RC,45385,HCPCS,Outpatient,,,664.87,332.44,,598.38,90,,,percent of total billed charges,90% of total Billed charges,685.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.08,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,381.86,155,,,Fee Schedule,155% of CMS OPPS Rate,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,246.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,346.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,346.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,387.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,387.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,221.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,492.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,294.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,381.86,155,,,Fee Schedule,155% of CMS OPPS Rate,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1063.01,155,,,Fee Schedule,155% of CMS OPPS Rate,1063.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,246.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1042.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1042.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221.04,1063.01,
45905 - (PF) Dilation of anal sphincter (separate procedure) under anesthesia other than,3635075,CDM,960,RC,45905,HCPCS,Outpatient,,,439.93,219.97,,395.94,90,,,percent of total billed charges,90% of total Billed charges,330.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.6,155,,,Fee Schedule,155% of CMS OPPS Rate,165.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,288.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,288.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,252.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,252.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,331.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,197.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.6,155,,,Fee Schedule,155% of CMS OPPS Rate,165.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,513,155,,,Fee Schedule,155% of CMS OPPS Rate,513,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,165.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,511.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,165.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,338.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44,513,
45910 - (PF) Dilation of rectal stricture (separate procedure) under anesthesia other than,3635076,CDM,960,RC,45910,HCPCS,Outpatient,,,506.13,253.07,,455.52,90,,,percent of total billed charges,90% of total Billed charges,378.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,292.04,155,,,Fee Schedule,155% of CMS OPPS Rate,188.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,328.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,288.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,288.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,155.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,340.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,292.04,155,,,Fee Schedule,155% of CMS OPPS Rate,188.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.03,155,,,Fee Schedule,155% of CMS OPPS Rate,587.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,188.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,890.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,188.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44,890.02,
46020- Placement of seton,3566790,CDM,960,RC,46020,HCPCS,Outpatient,,,305,152.50,,274.5,90,,,percent of total billed charges,90% of total Billed charges,229.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,174.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,177.88,155,,,Fee Schedule,155% of CMS OPPS Rate,114.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,404.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,404.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,350.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,350.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,188.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,305,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,272.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,177.88,155,,,Fee Schedule,155% of CMS OPPS Rate,114.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.63,155,,,Fee Schedule,155% of CMS OPPS Rate,355.63,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,114.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,234.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,114.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,546.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.76,546.72,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,960,RC,46050,HCPCS,Outpatient,,,259.02,129.51,,233.12,90,,,percent of total billed charges,90% of total Billed charges,320.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,75.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.76,155,,,Fee Schedule,155% of CMS OPPS Rate,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,195.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.76,155,,,Fee Schedule,155% of CMS OPPS Rate,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,496.48,155,,,Fee Schedule,155% of CMS OPPS Rate,496.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,387.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75.66,496.48,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,983,RC,46080,HCPCS,Outpatient,,,418.89,209.45,,377,90,,,percent of total billed charges,90% of total Billed charges,434.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,133,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,243.3,155,,,Fee Schedule,155% of CMS OPPS Rate,156.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,243.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,243.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,287.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,199.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,243.3,155,,,Fee Schedule,155% of CMS OPPS Rate,156.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.38,155,,,Fee Schedule,155% of CMS OPPS Rate,673.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,156.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,133,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,156.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,490.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128.54,673.38,
46083-Incise external hemorrhoid,3431258,CDM,983,RC,46083,HCPCS,Outpatient,,,212.94,106.47,,191.65,90,,,percent of total billed charges,90% of total Billed charges,305.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,165.03,155,,,Fee Schedule,155% of CMS OPPS Rate,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,127.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,165.03,155,,,Fee Schedule,155% of CMS OPPS Rate,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.7,155,,,Fee Schedule,155% of CMS OPPS Rate,473.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,220.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,340,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,340,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41,473.7,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,983,RC,46200,HCPCS,Outpatient,,,860.66,430.33,,774.59,90,,,percent of total billed charges,90% of total Billed charges,771.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,497.67,155,,,Fee Schedule,155% of CMS OPPS Rate,321.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,565.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,565.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,483.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,483.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,263,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,642.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,570.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,367.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,497.67,155,,,Fee Schedule,155% of CMS OPPS Rate,321.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1196.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,321.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,182,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,436.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,321.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,862.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,182,1196.29,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,983,RC,46220,HCPCS,Outpatient,,,235.42,117.71,,211.88,90,,,percent of total billed charges,90% of total Billed charges,353.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,182.44,155,,,Fee Schedule,155% of CMS OPPS Rate,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,117.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,177.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,177.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,138.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,182.44,155,,,Fee Schedule,155% of CMS OPPS Rate,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,547.34,155,,,Fee Schedule,155% of CMS OPPS Rate,547.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,189.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,117.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,403.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,403.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,80,547.34,
46221 - PF Ligation of hemorroid(s),3700932,CDM,960,RC,46221,HCPCS,Outpatient,,,721.34,360.67,,649.21,90,,,percent of total billed charges,90% of total Billed charges,455.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.79,90,,,Percent of total Billed charges,90% of total billed charges,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.87,155,,,Fee Schedule,155% of CMS OPPS Rate,705.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,527,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,527,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,705.87,
46221-Ligation of hemorrhoid(s),3431259,CDM,983,RC,46221,HCPCS,Outpatient,,,497.87,248.94,,448.08,90,,,percent of total billed charges,90% of total Billed charges,455.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.79,90,,,Percent of total Billed charges,90% of total billed charges,46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,153.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,368.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,331.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,210.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,285.45,155,,,Fee Schedule,155% of CMS OPPS Rate,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.87,155,,,Fee Schedule,155% of CMS OPPS Rate,705.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,184.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,527,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,527,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46,705.87,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,960,RC,46255,HCPCS,Outpatient,,,835.39,417.70,,751.85,90,,,percent of total billed charges,90% of total Billed charges,850.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,347,100,,,Fee Schedule,100% of CMS OPPS Rate ,1131.52,90,,,Percent of total Billed charges,90% of total billed charges,262.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,537.85,155,,,Fee Schedule,155% of CMS OPPS Rate,347,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,610.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,535.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,535.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,284.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,632.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,424.78,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,537.85,155,,,Fee Schedule,155% of CMS OPPS Rate,347,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1318.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,347,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,448.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,347,100,,,Fee Schedule,100% of CMS OPPS Rate ,987.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,987.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,262.5,1318.82,
46320-Removal of hemorrhoid clot,3431262,CDM,983,RC,46320,HCPCS,Outpatient,,,295.51,147.76,,265.96,90,,,percent of total billed charges,90% of total Billed charges,313.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.47,90,,,Percent of total Billed charges,90% of total billed charges,40,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,170.48,155,,,Fee Schedule,155% of CMS OPPS Rate,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.38,155,,,Fee Schedule,155% of CMS OPPS Rate,485.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,109.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,359.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40,485.38,
46600-Diagnostic anoscopy spx,3430923,CDM,960,RC,46600,HCPCS,Outpatient,,,104.75,52.38,,94.28,90,,,percent of total billed charges,90% of total Billed charges,144.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.74,155,,,Fee Schedule,155% of CMS OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,60.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,60.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.74,155,,,Fee Schedule,155% of CMS OPPS Rate,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.1,155,,,Fee Schedule,155% of CMS OPPS Rate,224.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,224.1,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,983,RC,46606,HCPCS,Outpatient,,,197.54,98.77,,177.79,90,,,percent of total billed charges,90% of total Billed charges,270.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.82,155,,,Fee Schedule,155% of CMS OPPS Rate,73.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,89.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.82,155,,,Fee Schedule,155% of CMS OPPS Rate,73.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,420,155,,,Fee Schedule,155% of CMS OPPS Rate,420,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,432.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,432.48,
46916 - Cryosurgery Anal Les,4327324,CDM,983,RC,46916,HCPCS,Outpatient,,,281.6,140.80,,253.44,90,,,percent of total billed charges,90% of total Billed charges,378.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,208.92,155,,,Fee Schedule,155% of CMS OPPS Rate,134.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,206.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,206.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,150.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,208.92,155,,,Fee Schedule,155% of CMS OPPS Rate,134.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.02,155,,,Fee Schedule,155% of CMS OPPS Rate,587.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,186.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.04,587.02,
"46999 - PF Unlisted procedure, anus",3641212,CDM,960,RC,46999,HCPCS,Outpatient,,,664.83,332.42,,598.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.45,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.45,598.35,
47100-PF WEDGE BIOPSY OF LIVER,3429984,CDM,960,RC,47100,HCPCS,Outpatient,,,2272.42,1136.21,,2045.18,90,,,percent of total billed charges,90% of total Billed charges,1699.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,243.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1309.05,155,,,Fee Schedule,155% of CMS OPPS Rate,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1298.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,844.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1460.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1460.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1306.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1306.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,682.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1689.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1542.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1092.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1309.05,155,,,Fee Schedule,155% of CMS OPPS Rate,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,2633.53,155,,,Fee Schedule,155% of CMS OPPS Rate,2633.53,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,770.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,844.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,1702.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1702.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,243.5,2633.53,
47562- Cholecystectomy/laparoscopy,3431265,CDM,983,RC,47562,HCPCS,Outpatient,,,1778.76,889.38,,1600.88,90,,,percent of total billed charges,90% of total Billed charges,1329.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,589.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1024.16,155,,,Fee Schedule,155% of CMS OPPS Rate,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1011.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,660.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1137.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1137.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1024.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1024.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,531.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1321.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1208.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,866.52,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1024.16,155,,,Fee Schedule,155% of CMS OPPS Rate,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,2060.91,155,,,Fee Schedule,155% of CMS OPPS Rate,2060.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,844.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,660.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1515.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1515.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,531.59,2060.91,
47605- Cholecystectomy; with cholangiography,3622764,CDM,983,RC,47605,HCPCS,Outpatient,,,3045.49,1522.75,,2740.94,90,,,percent of total billed charges,90% of total Billed charges,2278.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,2657.24,90,,,Percent of total Billed charges,90% of total billed charges,522,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1756.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1729.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1133.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1944.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1944.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1757.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1757.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,908.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2266.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2073.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1494.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1756.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,3531.4,155,,,Fee Schedule,155% of CMS OPPS Rate,3531.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,522,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,912.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1133.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,1989.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1989.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,522,3531.4,
"48140 - (PF) Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticoj",3635077,CDM,960,RC,48140,HCPCS,Outpatient,,,4222.05,2111.03,,3799.85,90,,,percent of total billed charges,90% of total Billed charges,3162.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1575.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,830,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2441.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1575.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2402.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1575.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2702.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2448.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2448.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1264.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1575.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3150.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2889.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2085.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2441.58,155,,,Fee Schedule,155% of CMS OPPS Rate,1575.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,4902.4,155,,,Fee Schedule,155% of CMS OPPS Rate,4902.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1575.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,830,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1383.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1575.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,3169.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3169.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,830,4902.4,
"49060 - (PF) Drainage of retroperitoneal abscess, open",3635078,CDM,960,RC,49060,HCPCS,Outpatient,,,2954.19,1477.10,,2658.77,90,,,percent of total billed charges,90% of total Billed charges,2206,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1095.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,266.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1697.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1095.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1636.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1095.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1840.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1840.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1714.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1714.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,886.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1095.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2190.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2022.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1437.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1697.45,155,,,Fee Schedule,155% of CMS OPPS Rate,1095.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,3419.3,155,,,Fee Schedule,155% of CMS OPPS Rate,3419.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1095.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1033.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1095.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2227.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2227.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,266.5,3419.3,
"49084 - (PF) Peritoneal lavage, including imaging guidance, when performed",3635079,CDM,960,RC,49084,HCPCS,Outpatient,,,288.8,144.40,,259.92,90,,,percent of total billed charges,90% of total Billed charges,216.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,167.73,155,,,Fee Schedule,155% of CMS OPPS Rate,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,187.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,187.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,171.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,171.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,201.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,145.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.73,155,,,Fee Schedule,155% of CMS OPPS Rate,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,336.04,155,,,Fee Schedule,155% of CMS OPPS Rate,336.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.62,336.04,
"49255 - (PF) Omentectomy, epiploectomy, resection of omentum (separate proc",3635080,CDM,960,RC,49255,HCPCS,Outpatient,,,2105.96,1052.98,,1895.36,90,,,percent of total billed charges,90% of total Billed charges,1578.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,786.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,333,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1219.62,155,,,Fee Schedule,155% of CMS OPPS Rate,786.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1205.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,786.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1355.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1355.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1212.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1212.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,638.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,786.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1573.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1430.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,996.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1219.62,155,,,Fee Schedule,155% of CMS OPPS Rate,786.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,2447.06,155,,,Fee Schedule,155% of CMS OPPS Rate,2447.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,786.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,333,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,673.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,786.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1595.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1595.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,333,2447.06,
"49321-PF LAPAROSCOPY, BIOPSY",3430016,CDM,960,RC,49321,HCPCS,Outpatient,,,918.78,459.39,,826.9,90,,,percent of total billed charges,90% of total Billed charges,688.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.22,90,,,Percent of total Billed charges,90% of total billed charges,294.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,531.31,155,,,Fee Schedule,155% of CMS OPPS Rate,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,528.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,594.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,531.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,531.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,278.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,627.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,531.31,155,,,Fee Schedule,155% of CMS OPPS Rate,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.82,155,,,Fee Schedule,155% of CMS OPPS Rate,1066.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,701.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,701.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,278.08,1066.82,
"49326 - (PF) Laparoscopy, surgical; with omentopexy (omental tacking procedure)",3635081,CDM,960,RC,49326,HCPCS,Outpatient,,,516.55,258.28,,464.9,90,,,percent of total billed charges,90% of total Billed charges,385,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,295.68,155,,,Fee Schedule,155% of CMS OPPS Rate,190.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,327.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,300.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,300.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,381.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,355.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,262.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,295.68,155,,,Fee Schedule,155% of CMS OPPS Rate,190.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,596.75,155,,,Fee Schedule,155% of CMS OPPS Rate,596.75,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,190.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,660.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,190.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,386.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,386.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131.3,660.41,
"49329-MA AST UNLISTED LAP ABD,PERIT,OMENT",3430021,CDM,960,RC,49329,HCPCS,Outpatient,,,461.21,230.61,,415.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.36,415.09,
"49421- Insertion of tunneled intraperitoneal catheter for dialysis, open",3621513,CDM,960,RC,49421,HCPCS,Outpatient,,,616.62,308.31,,554.96,90,,,percent of total billed charges,90% of total Billed charges,460.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,200,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,354.5,155,,,Fee Schedule,155% of CMS OPPS Rate,228.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,394.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,361.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,361.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,230.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,457.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,426.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,310.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,354.5,155,,,Fee Schedule,155% of CMS OPPS Rate,228.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,713.88,155,,,Fee Schedule,155% of CMS OPPS Rate,713.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,228.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,200,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,391.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,228.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,471.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,471.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,200,713.88,
"49520- Repair recurrent inguinal hernia, any age; reducible",3622240,CDM,960,RC,49520,HCPCS,Outpatient,,,1706.37,853.19,,1535.73,90,,,percent of total billed charges,90% of total Billed charges,1276.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,432,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,984.17,155,,,Fee Schedule,155% of CMS OPPS Rate,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,969.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,634.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1090.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1090.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,981,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,981,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,510.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1269.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1157.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,828.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,984.17,155,,,Fee Schedule,155% of CMS OPPS Rate,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1978.71,155,,,Fee Schedule,155% of CMS OPPS Rate,1978.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,432,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,634.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1275.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,432,1978.71,
"49521 - (PF) Repair recurrent inguinal hernia, any age; incarcerated or strangulated",3635082,CDM,960,RC,49521,HCPCS,Outpatient,,,1931.01,965.51,,1737.91,90,,,percent of total billed charges,90% of total Billed charges,1445.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,510.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1115.74,155,,,Fee Schedule,155% of CMS OPPS Rate,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1101.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,719.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1238.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1238.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1115.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1115.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,578.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1439.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1316.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,945.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1115.74,155,,,Fee Schedule,155% of CMS OPPS Rate,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,2241.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2241.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,701.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,719.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,1547,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1547,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,510.07,2241.24,
"49650 - PF - Laparoscopy, surgical; repair initial inguinal hernia",3640923,CDM,960,RC,49650,HCPCS,Outpatient,,,1154.79,577.40,,1039.31,90,,,percent of total billed charges,90% of total Billed charges,864.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,341.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,667.26,155,,,Fee Schedule,155% of CMS OPPS Rate,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,658.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,430.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,741.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,741.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,661.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,661.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,860.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,780.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,551.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,667.26,155,,,Fee Schedule,155% of CMS OPPS Rate,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1340.32,155,,,Fee Schedule,155% of CMS OPPS Rate,1340.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,502.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,430.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,860.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,341.4,1340.32,
"49999 - PF Unlisted procedure, abdomen, peritoneum and omentum",3641213,CDM,960,RC,49999,HCPCS,Outpatient,,,3723.06,1861.53,,3350.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1116.92,3350.75,
"50080 - Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, l",3572811,CDM,983,RC,50080,HCPCS,Outpatient,,,2266.36,1133.18,,2039.72,90,,,percent of total billed charges,90% of total Billed charges,1530.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,776,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1051.3,155,,,Fee Schedule,155% of CMS OPPS Rate,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1322.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,678.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1487.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1487.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1323.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1323.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,692.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1356.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1562.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1009.08,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1051.3,155,,,Fee Schedule,155% of CMS OPPS Rate,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.24,155,,,Fee Schedule,155% of CMS OPPS Rate,2372.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,776,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1098.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,678.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1734.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1734.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,678.26,2372.24,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,960,RC,50432,HCPCS,Outpatient,,,529.89,264.95,,476.9,90,,,percent of total billed charges,90% of total Billed charges,728.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,353.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,314.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,397.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,371.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,233.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,308.06,155,,,Fee Schedule,155% of CMS OPPS Rate,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,1129.39,155,,,Fee Schedule,155% of CMS OPPS Rate,1129.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,889.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,198.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.29,1129.39,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,688.31,344.16,,619.48,90,,,percent of total billed charges,90% of total Billed charges,946.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,244.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,485.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,305.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.34,155,,,Fee Schedule,155% of CMS OPPS Rate,1467.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.83,1467.34,
51700- Bladder irrigate/lavage/instill,3435948,CDM,983,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,63.86,90,,,percent of total billed charges,90% of total Billed charges,100.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,38.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.29,155,,,Fee Schedule,155% of CMS OPPS Rate,156.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.7,159.8,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,960,RC,51700,HCPCS,Outpatient,,,70.95,35.48,,63.86,90,,,percent of total billed charges,90% of total Billed charges,100.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,38.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.29,155,,,Fee Schedule,155% of CMS OPPS Rate,156.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.7,159.8,
51701- Insert/non-indwelling bladder cath,3435949,CDM,983,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,53.84,90,,,percent of total billed charges,90% of total Billed charges,68.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.51,155,,,Fee Schedule,155% of CMS OPPS Rate,105.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,105.51,
51702- Insert temp indwell blad cath/simp,3435950,CDM,983,RC,51702,HCPCS,Outpatient,,,58.79,29.40,,52.91,90,,,percent of total billed charges,90% of total Billed charges,82.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,38.38,155,,,Fee Schedule,155% of CMS OPPS Rate,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.6,155,,,Fee Schedule,155% of CMS OPPS Rate,128.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,134.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.09,134.64,
51703- Insert temp indwell blad cath/comp,3435951,CDM,983,RC,51703,HCPCS,Outpatient,,,178.12,89.06,,160.31,90,,,percent of total billed charges,90% of total Billed charges,218.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,116.28,155,,,Fee Schedule,155% of CMS OPPS Rate,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.04,155,,,Fee Schedule,155% of CMS OPPS Rate,338.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.88,338.04,
51705- Change Cystostomy (Bladder) Tube,4363185,CDM,983,RC,51705,HCPCS,Outpatient,,,118.91,59.46,,107.02,90,,,percent of total billed charges,90% of total Billed charges,141.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.62,155,,,Fee Schedule,155% of CMS OPPS Rate,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.03,155,,,Fee Schedule,155% of CMS OPPS Rate,219.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,203.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,203.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,219.03,
51720- Bladder instill/anticancer agent,3435955,CDM,983,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,92.4,90,,,percent of total billed charges,90% of total Billed charges,125.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.65,155,,,Fee Schedule,155% of CMS OPPS Rate,194.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.23,212.16,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,960,RC,51720,HCPCS,Outpatient,,,102.67,51.34,,92.4,90,,,percent of total billed charges,90% of total Billed charges,125.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.01,155,,,Fee Schedule,155% of CMS OPPS Rate,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.65,155,,,Fee Schedule,155% of CMS OPPS Rate,194.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,185.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.23,212.16,
Clinic Cystometrogram Simple,3550630,CDM,960,RC,51725,HCPCS,Outpatient,,,497.91,248.96,,448.12,90,,,percent of total billed charges,90% of total Billed charges,274.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.11,155,,,Fee Schedule,155% of CMS OPPS Rate,134.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,358.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,358.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,295.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,295.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,188.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,269.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,211.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.11,155,,,Fee Schedule,155% of CMS OPPS Rate,134.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.32,155,,,Fee Schedule,155% of CMS OPPS Rate,425.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,264.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,357.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,448.12,
Clinic Cystometrogram Complex,3550631,CDM,960,RC,51726,HCPCS,Outpatient,,,651.01,325.51,,585.91,90,,,percent of total billed charges,90% of total Billed charges,389.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,669,90,,,Percent of total Billed charges,90% of total billed charges,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.3,155,,,Fee Schedule,155% of CMS OPPS Rate,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,433.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,487.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,487.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,265.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.3,155,,,Fee Schedule,155% of CMS OPPS Rate,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.17,155,,,Fee Schedule,155% of CMS OPPS Rate,603.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,321.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,514.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,669,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,983,RC,51728,HCPCS,Outpatient,,,214.59,107.30,,193.13,90,,,percent of total billed charges,90% of total Billed charges,429.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,214.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,225.65,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,332.61,155,,,Fee Schedule,155% of CMS OPPS Rate,214.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,214.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,592.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,592.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,484.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,484.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,251.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,429.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,214.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.61,155,,,Fee Schedule,155% of CMS OPPS Rate,214.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.23,155,,,Fee Schedule,155% of CMS OPPS Rate,665.23,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,214.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,285.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,214.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,607.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,193.13,665.23,
51729- Comp cystometrogram/void/uret pres,3435958,CDM,983,RC,51729,HCPCS,Outpatient,,,838.74,419.37,,754.87,90,,,percent of total billed charges,90% of total Billed charges,469.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,247.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,356.83,155,,,Fee Schedule,155% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,562.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,230.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,632.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,632.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,520.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,520.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,271.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,460.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,384.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.83,155,,,Fee Schedule,155% of CMS OPPS Rate,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,727.66,155,,,Fee Schedule,155% of CMS OPPS Rate,727.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,275.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,230.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,665.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,230.21,754.87,
51736 Urine flow measurement,4267409,CDM,983,RC,51736,HCPCS,Outpatient,,,30.25,15.13,,27.23,90,,,percent of total billed charges,90% of total Billed charges,9.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,7.44,155,,,Fee Schedule,155% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,19.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.44,155,,,Fee Schedule,155% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.52,155,,,Fee Schedule,155% of CMS OPPS Rate,14.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.8,61,
Clinic Complex Uroflometry - 51741,4305355,CDM,983,RC,51741,HCPCS,Outpatient,,,17.74,8.87,,15.97,90,,,percent of total billed charges,90% of total Billed charges,9.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.22,90,,,Percent of total Billed charges,90% of total billed charges,24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,7.89,155,,,Fee Schedule,155% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.89,155,,,Fee Schedule,155% of CMS OPPS Rate,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.42,155,,,Fee Schedule,155% of CMS OPPS Rate,15.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.09,111.49,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,983,RC,51784,HCPCS,Outpatient,,,76.93,38.47,,69.24,90,,,percent of total billed charges,90% of total Billed charges,48.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.25,155,,,Fee Schedule,155% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,96.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.25,155,,,Fee Schedule,155% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.69,155,,,Fee Schedule,155% of CMS OPPS Rate,74.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,378.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.03,378.08,
51797- Voiding pressure study/intra-abd,3435962,CDM,983,RC,51797,HCPCS,Outpatient,,,411.58,205.79,,370.42,90,,,percent of total billed charges,90% of total Billed charges,275.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,208.23,155,,,Fee Schedule,155% of CMS OPPS Rate,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,273.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,221.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,221.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.23,155,,,Fee Schedule,155% of CMS OPPS Rate,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.29,155,,,Fee Schedule,155% of CMS OPPS Rate,427.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,427.29,
51798- PVR urine/bladder capacity/US,3435963,CDM,983,RC,51798,HCPCS,Outpatient,,,22.46,11.23,,20.21,90,,,percent of total billed charges,90% of total Billed charges,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,155,,,Fee Schedule,155% of CMS OPPS Rate,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.11,155,,,Fee Schedule,155% of CMS OPPS Rate,29.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,34.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.46,34.68,
51860-PF REPAIR OF BLADDER WOUND,3430085,CDM,960,RC,51860,HCPCS,Outpatient,,,1959.81,979.91,,1763.83,90,,,percent of total billed charges,90% of total Billed charges,1467.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,730.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,416,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1132.57,155,,,Fee Schedule,155% of CMS OPPS Rate,730.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1136.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,730.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1277.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1136.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1136.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,596.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1461.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1341.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,891.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1132.57,155,,,Fee Schedule,155% of CMS OPPS Rate,730.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2274.86,155,,,Fee Schedule,155% of CMS OPPS Rate,2274.86,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,730.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,416,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,791.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,730.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1504.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,416,2274.86,
Clinic Cystoscopy,3550628,CDM,960,RC,52000,HCPCS,Outpatient,,,186.75,93.38,,168.08,90,,,percent of total billed charges,90% of total Billed charges,265.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.15,90,,,Percent of total Billed charges,90% of total billed charges,75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.91,155,,,Fee Schedule,155% of CMS OPPS Rate,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,95.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.91,155,,,Fee Schedule,155% of CMS OPPS Rate,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.37,155,,,Fee Schedule,155% of CMS OPPS Rate,411.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,328.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,75,493.15,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,983,RC,52005,HCPCS,Outpatient,,,324.28,162.14,,291.85,90,,,percent of total billed charges,90% of total Billed charges,416.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.76,90,,,Percent of total Billed charges,90% of total billed charges,116,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,225.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,152.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198,155,,,Fee Schedule,155% of CMS OPPS Rate,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,645.02,155,,,Fee Schedule,155% of CMS OPPS Rate,645.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1087.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,523.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,523.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106.51,1087.01,
52204- Cystourethroscopy with biopsy,3430089,CDM,960,RC,52204,HCPCS,Outpatient,,,324.06,162.03,,291.65,90,,,percent of total billed charges,90% of total Billed charges,460.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,123.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,211.54,155,,,Fee Schedule,155% of CMS OPPS Rate,136.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,215.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,215.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,211.54,155,,,Fee Schedule,155% of CMS OPPS Rate,136.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,713.84,155,,,Fee Schedule,155% of CMS OPPS Rate,713.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,136.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,745.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,693.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,693.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.01,745.63,
Clinic Cysto Calib Dilat Urtl Strix/Stenosis 52281,4301628,CDM,983,RC,52281,HCPCS,Outpatient,,,312.51,156.26,,281.26,90,,,percent of total billed charges,90% of total Billed charges,458.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.05,90,,,Percent of total Billed charges,90% of total billed charges,107.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,259.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,272.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.49,155,,,Fee Schedule,155% of CMS OPPS Rate,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.61,155,,,Fee Schedule,155% of CMS OPPS Rate,710.61,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,614.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.5,761.05,
52287- Cystoscopy chemodenervation,3435976,CDM,983,RC,52287,HCPCS,Outpatient,,,392.66,196.33,,353.39,90,,,percent of total billed charges,90% of total Billed charges,535.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.32,155,,,Fee Schedule,155% of CMS OPPS Rate,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,289.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,289.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,259.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,259.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,330.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,306.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,200.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.32,155,,,Fee Schedule,155% of CMS OPPS Rate,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,830.6,155,,,Fee Schedule,155% of CMS OPPS Rate,830.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,165.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.74,830.6,
Clinic Cystoscopy w/stent removal,3550633,CDM,960,RC,52310,HCPCS,Outpatient,,,349.63,174.82,,314.67,90,,,percent of total billed charges,90% of total Billed charges,450.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.68,90,,,Percent of total Billed charges,90% of total billed charges,129,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,257.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,230.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,120.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,271.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,176.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.24,155,,,Fee Schedule,155% of CMS OPPS Rate,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,697.66,155,,,Fee Schedule,155% of CMS OPPS Rate,697.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,456.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.97,697.66,
"52341- Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electro",3621519,CDM,960,RC,52341,HCPCS,Outpatient,,,739,369.50,,665.1,90,,,percent of total billed charges,90% of total Billed charges,554.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,281.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,428.13,155,,,Fee Schedule,155% of CMS OPPS Rate,276.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,431.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,276.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,485.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,485.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,434.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,434.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,242.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,552.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,512.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,333.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,428.13,155,,,Fee Schedule,155% of CMS OPPS Rate,276.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,858.84,155,,,Fee Schedule,155% of CMS OPPS Rate,858.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,276.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,399.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,276.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,578,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,578,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,242.08,858.84,
"52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, b",3621659,CDM,960,RC,52345,HCPCS,Outpatient,,,1028.58,514.29,,925.72,90,,,percent of total billed charges,90% of total Billed charges,769.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,383.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,384.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,593.73,155,,,Fee Schedule,155% of CMS OPPS Rate,383.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,383.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,674.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,674.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,604.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,604.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,327.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,766.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,712.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,463.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,593.73,155,,,Fee Schedule,155% of CMS OPPS Rate,383.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1193.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1193.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,383.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,533.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,383.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,809.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,809.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,327.79,1193.22,
53200 Biopsy of urethra,3621304,CDM,960,RC,53200,HCPCS,Outpatient,,,370.29,185.15,,333.26,90,,,percent of total billed charges,90% of total Billed charges,292.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,214.66,155,,,Fee Schedule,155% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,242.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,216.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,216.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,113.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,255.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,214.66,155,,,Fee Schedule,155% of CMS OPPS Rate,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.95,155,,,Fee Schedule,155% of CMS OPPS Rate,453.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64,453.95,
"53505 - PF Urethrorrhaphy, suture of urethral wound or injury; penile",3641188,CDM,960,RC,53505,HCPCS,Outpatient,,,1263.34,631.67,,1137.01,90,,,percent of total billed charges,90% of total Billed charges,946.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,471.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,730.75,155,,,Fee Schedule,155% of CMS OPPS Rate,471.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,738.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,471.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,830.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,830.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,733.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,733.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,387.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,942.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,865.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,553.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,730.75,155,,,Fee Schedule,155% of CMS OPPS Rate,471.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1467.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,471.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,323,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,519.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,471.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,964.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,964.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,323,1467.08,
53600-Dilate urethra stricture,3435998,CDM,983,RC,53600,HCPCS,Outpatient,,,149.97,74.99,,134.97,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.76,155,,,Fee Schedule,155% of CMS OPPS Rate,229.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,229.76,
53601 -Dilation Urethral Stricture Passage of Sound/Urethral,4271221,CDM,983,RC,53601,HCPCS,Outpatient,,,123.59,61.80,,111.23,90,,,percent of total billed charges,90% of total Billed charges,132.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,80.68,155,,,Fee Schedule,155% of CMS OPPS Rate,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.68,155,,,Fee Schedule,155% of CMS OPPS Rate,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.2,155,,,Fee Schedule,155% of CMS OPPS Rate,205.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,155.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,205.2,
53605- Dilate urethral stricture/anesth,3435999,CDM,983,RC,53605,HCPCS,Outpatient,,,150.75,75.38,,135.68,90,,,percent of total billed charges,90% of total Billed charges,126.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,98.41,155,,,Fee Schedule,155% of CMS OPPS Rate,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,110.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,98.41,155,,,Fee Schedule,155% of CMS OPPS Rate,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.84,155,,,Fee Schedule,155% of CMS OPPS Rate,195.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,129.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,195.84,
53620- Dilation/urethral strict/male/ini,3436000,CDM,983,RC,53620,HCPCS,Outpatient,,,200.9,100.45,,180.81,90,,,percent of total billed charges,90% of total Billed charges,248.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,132.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,169.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.15,155,,,Fee Schedule,155% of CMS OPPS Rate,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.6,155,,,Fee Schedule,155% of CMS OPPS Rate,384.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,84.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,226.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,384.6,
53621- Dilation/urethral strict/male/subs,3436001,CDM,983,RC,53621,HCPCS,Outpatient,,,166.78,83.39,,150.1,90,,,percent of total billed charges,90% of total Billed charges,224.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,108.86,155,,,Fee Schedule,155% of CMS OPPS Rate,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,108.86,155,,,Fee Schedule,155% of CMS OPPS Rate,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.66,155,,,Fee Schedule,155% of CMS OPPS Rate,348.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,348.66,
53660- Dilation/female urethra/initial,3436002,CDM,983,RC,53660,HCPCS,Outpatient,,,96.38,48.19,,86.74,90,,,percent of total billed charges,90% of total Billed charges,111.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,63.08,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,63.08,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.59,155,,,Fee Schedule,155% of CMS OPPS Rate,172.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,172.59,
53661- Dilation/female urethra/subsequent,3436003,CDM,983,RC,53661,HCPCS,Outpatient,,,94.4,47.20,,84.96,90,,,percent of total billed charges,90% of total Billed charges,109.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.63,155,,,Fee Schedule,155% of CMS OPPS Rate,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,61.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,61.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,47.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.63,155,,,Fee Schedule,155% of CMS OPPS Rate,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.54,155,,,Fee Schedule,155% of CMS OPPS Rate,169.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,133.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,169.54,
54055- Destruct penis les/smp/electrodesi,3431643,CDM,960,RC,54055,HCPCS,Outpatient,,,217.54,108.77,,195.79,90,,,percent of total billed charges,90% of total Billed charges,218.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,142,155,,,Fee Schedule,155% of CMS OPPS Rate,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,136.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,136.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142,155,,,Fee Schedule,155% of CMS OPPS Rate,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.24,155,,,Fee Schedule,155% of CMS OPPS Rate,338.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,278.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,230.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.5,338.24,
54056- Cryosurgery/penis lesion(s),3431644,CDM,960,RC,54056,HCPCS,Outpatient,,,248.84,124.42,,223.96,90,,,percent of total billed charges,90% of total Billed charges,237.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,162.44,155,,,Fee Schedule,155% of CMS OPPS Rate,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,89.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,112.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.44,155,,,Fee Schedule,155% of CMS OPPS Rate,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.2,155,,,Fee Schedule,155% of CMS OPPS Rate,368.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,150.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,284.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28,368.2,
54060- Destruct penis lesion/smp/excision,3431645,CDM,960,RC,54060,HCPCS,Outpatient,,,298.98,149.49,,269.08,90,,,percent of total billed charges,90% of total Billed charges,310.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,195.18,155,,,Fee Schedule,155% of CMS OPPS Rate,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.18,155,,,Fee Schedule,155% of CMS OPPS Rate,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,482.02,155,,,Fee Schedule,155% of CMS OPPS Rate,482.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,270.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,348.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.5,482.02,
54065 - Dstr lesion penis extensive,4241824,CDM,983,RC,54065,HCPCS,Outpatient,,,347.53,173.77,,312.78,90,,,percent of total billed charges,90% of total Billed charges,373.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,135.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,254.08,155,,,Fee Schedule,155% of CMS OPPS Rate,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,272.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,251.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,251.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,186.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,254.08,155,,,Fee Schedule,155% of CMS OPPS Rate,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,578.89,155,,,Fee Schedule,155% of CMS OPPS Rate,578.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,163.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,436.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135.89,578.89,
54100- Biopsy of penis,3431646,CDM,960,RC,54100,HCPCS,Outpatient,,,242.27,121.14,,218.04,90,,,percent of total billed charges,90% of total Billed charges,306.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,179.94,155,,,Fee Schedule,155% of CMS OPPS Rate,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,194.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,181.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,181.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,179.94,155,,,Fee Schedule,155% of CMS OPPS Rate,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.11,155,,,Fee Schedule,155% of CMS OPPS Rate,475.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,196.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,475.11,
54150- Circumcision/clamp/other device,3431648,CDM,960,RC,54150,HCPCS,Outpatient,,,226.78,113.39,,204.1,90,,,percent of total billed charges,90% of total Billed charges,239.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.52,90,,,Percent of total Billed charges,90% of total billed charges,79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.04,155,,,Fee Schedule,155% of CMS OPPS Rate,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,158.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,158.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,151.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,119.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.04,155,,,Fee Schedule,155% of CMS OPPS Rate,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.48,155,,,Fee Schedule,155% of CMS OPPS Rate,370.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,336.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,303.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,303.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.9,376.52,
54160- Circumcise/surg/28 days or <,3431649,CDM,960,RC,54160,HCPCS,Outpatient,,,335.86,167.93,,302.27,90,,,percent of total billed charges,90% of total Billed charges,351.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,219.23,155,,,Fee Schedule,155% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,218.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,218.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,165.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,219.23,155,,,Fee Schedule,155% of CMS OPPS Rate,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,544.31,155,,,Fee Schedule,155% of CMS OPPS Rate,544.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,141.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.79,544.31,
54161- Circumcise/surg/> 28 days of age,3431650,CDM,960,RC,54161,HCPCS,Outpatient,,,454.58,227.29,,409.12,90,,,percent of total billed charges,90% of total Billed charges,384.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.72,90,,,Percent of total Billed charges,90% of total billed charges,128,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,296.73,155,,,Fee Schedule,155% of CMS OPPS Rate,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,191.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,350.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,296.73,155,,,Fee Schedule,155% of CMS OPPS Rate,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.32,155,,,Fee Schedule,155% of CMS OPPS Rate,595.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,191.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,391,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,391,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,128,595.32,
54200- Peyronie disease/injection proc,3431654,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,194.8,90,,,percent of total billed charges,90% of total Billed charges,189.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.33,155,,,Fee Schedule,155% of CMS OPPS Rate,294.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.03,294.33,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,194.8,90,,,percent of total billed charges,90% of total Billed charges,189.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.33,155,,,Fee Schedule,155% of CMS OPPS Rate,294.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.03,294.33,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,960,RC,54200,HCPCS,Outpatient,,,216.44,108.22,,194.8,90,,,percent of total billed charges,90% of total Billed charges,189.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,127.22,155,,,Fee Schedule,155% of CMS OPPS Rate,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.33,155,,,Fee Schedule,155% of CMS OPPS Rate,294.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.03,294.33,
54235- Corpora cavernosa injection,3431656,CDM,960,RC,54235,HCPCS,Outpatient,,,185.91,92.96,,167.32,90,,,percent of total billed charges,90% of total Billed charges,155.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.29,155,,,Fee Schedule,155% of CMS OPPS Rate,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,129.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,81.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.29,155,,,Fee Schedule,155% of CMS OPPS Rate,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.27,155,,,Fee Schedule,155% of CMS OPPS Rate,241.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.64,241.27,
54360 Plastic operation on penis to correct angulation,3622376,CDM,960,RC,54360,HCPCS,Outpatient,,,1881.45,940.73,,1693.31,90,,,percent of total billed charges,90% of total Billed charges,1409.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,702.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,310.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1088.75,155,,,Fee Schedule,155% of CMS OPPS Rate,702.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1031.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,702.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1159.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1159.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1095.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1095.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,574.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,702.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1404.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1292.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,832.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1088.75,155,,,Fee Schedule,155% of CMS OPPS Rate,702.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2185.35,155,,,Fee Schedule,155% of CMS OPPS Rate,2185.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,702.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,766.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,702.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,1434.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1434.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,310.5,2185.35,
"54406 - (PF) Removal of all components of a multi-component, inflatable penile prosthesis without",3635228,CDM,960,RC,54406,HCPCS,Outpatient,,,1907.19,953.60,,1716.47,90,,,percent of total billed charges,90% of total Billed charges,1428.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,711.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1103.32,155,,,Fee Schedule,155% of CMS OPPS Rate,711.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1045.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,711.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1175.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1175.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1110.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1110.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,582.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,711.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1423.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1310.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,844.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1103.32,155,,,Fee Schedule,155% of CMS OPPS Rate,711.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2214.93,155,,,Fee Schedule,155% of CMS OPPS Rate,2214.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,711.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,680.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,711.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1453.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1453.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,582.19,2214.93,
"54408 - PF - Repair of component(s) of a multi-component, inflatable penile prosthesis",3640924,CDM,960,RC,54408,HCPCS,Outpatient,,,2061.67,1030.84,,1855.5,90,,,percent of total billed charges,90% of total Billed charges,1544.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1192.23,155,,,Fee Schedule,155% of CMS OPPS Rate,769.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1130.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,769.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1271.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1271.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1200.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1200.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,630,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1538.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1416.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,913.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1192.23,155,,,Fee Schedule,155% of CMS OPPS Rate,769.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,2393.87,155,,,Fee Schedule,155% of CMS OPPS Rate,2393.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,769.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,717,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,769.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1574.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1574.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,630,2393.87,
"54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or",3621664,CDM,960,RC,54435,HCPCS,Outpatient,,,1071.52,535.76,,964.37,90,,,percent of total billed charges,90% of total Billed charges,804.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,401.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,621.84,155,,,Fee Schedule,155% of CMS OPPS Rate,401.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,593.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,401.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,667.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,667.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,625.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,333,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,737.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,472.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,621.84,155,,,Fee Schedule,155% of CMS OPPS Rate,401.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1246.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1246.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,401.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,130,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,454.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,401.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,824.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,824.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,130,1246.37,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,983,RC,54450,HCPCS,Outpatient,,,119.14,59.57,,107.23,90,,,percent of total billed charges,90% of total Billed charges,122.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.39,155,,,Fee Schedule,155% of CMS OPPS Rate,189.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,137.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.95,189.39,
54512 Excision of extraparenchymal lesion of testis,3622072,CDM,960,RC,54512,HCPCS,Outpatient,,,1399.81,699.91,,1259.83,90,,,percent of total billed charges,90% of total Billed charges,1049.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,522.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,451.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,810.48,155,,,Fee Schedule,155% of CMS OPPS Rate,522.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,770.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,522.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,866.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,866.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,817.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,817.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,431.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,522.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1045.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,964.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,623.27,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,810.48,155,,,Fee Schedule,155% of CMS OPPS Rate,522.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1626.37,155,,,Fee Schedule,155% of CMS OPPS Rate,1626.37,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,522.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,451.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,567.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,522.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1071,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1071,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,431.01,1626.37,
Clinic Puncture Asp of Hydrocele,3550632,CDM,960,RC,55000,HCPCS,Outpatient,,,194.3,97.15,,174.87,90,,,percent of total billed charges,90% of total Billed charges,197.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,126.82,155,,,Fee Schedule,155% of CMS OPPS Rate,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,128.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,128.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,126.82,155,,,Fee Schedule,155% of CMS OPPS Rate,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.94,155,,,Fee Schedule,155% of CMS OPPS Rate,305.94,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,162.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,227.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,305.94,
55100- Drainage of scrotal wall abscess,3430108,CDM,960,RC,55100,HCPCS,Outpatient,,,383.64,191.82,,345.28,90,,,percent of total billed charges,90% of total Billed charges,381.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,267.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,267.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,249.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,293.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,190.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,250.43,155,,,Fee Schedule,155% of CMS OPPS Rate,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,591.65,155,,,Fee Schedule,155% of CMS OPPS Rate,591.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,431.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,591.65,
Clinic Vasectomy,3550629,CDM,960,RC,55250,HCPCS,Outpatient,,,521.56,260.78,,469.4,90,,,percent of total billed charges,90% of total Billed charges,538.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,862.01,90,,,Percent of total Billed charges,90% of total billed charges,148.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,340.47,155,,,Fee Schedule,155% of CMS OPPS Rate,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,364.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,338.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,338.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,182.59,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,439.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,399.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,252.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,340.47,155,,,Fee Schedule,155% of CMS OPPS Rate,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,834.12,155,,,Fee Schedule,155% of CMS OPPS Rate,834.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,605.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,219.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,746.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,148.5,862.01,
55700- Bx/prostate/needle/punch/sng/mul,3431675,CDM,960,RC,55700,HCPCS,Outpatient,,,301.59,150.80,,271.43,90,,,percent of total billed charges,90% of total Billed charges,357.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.04,90,,,Percent of total Billed charges,90% of total billed charges,89.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,209.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,200.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,236.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,153.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.88,155,,,Fee Schedule,155% of CMS OPPS Rate,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.49,155,,,Fee Schedule,155% of CMS OPPS Rate,553.49,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,420.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,420.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,89.5,595.04,
"55725 Prostatotomy, external drainage of prostatic abscess, any approach; complicated",3622080,CDM,960,RC,55725,HCPCS,Outpatient,,,1546.74,773.37,,1392.07,90,,,percent of total billed charges,90% of total Billed charges,1159.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,577.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,387,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,895.87,155,,,Fee Schedule,155% of CMS OPPS Rate,577.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,577.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,954.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,954.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,897.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,897.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,526.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,577.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1155.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1058.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,678.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,895.87,155,,,Fee Schedule,155% of CMS OPPS Rate,577.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1797.4,155,,,Fee Schedule,155% of CMS OPPS Rate,1797.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,577.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,387,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,577.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1177.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1177.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,387,1797.4,
55876- Place interstitdevice/rad tx guide/prostate/sng/mult,3431680,CDM,960,RC,55876,HCPCS,Outpatient,,,116.64,58.32,,104.98,90,,,percent of total billed charges,90% of total Billed charges,214.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.29,155,,,Fee Schedule,155% of CMS OPPS Rate,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,333.08,155,,,Fee Schedule,155% of CMS OPPS Rate,333.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,262.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.99,333.08,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,960,RC,55899,HCPCS,Outpatient,,,2659.33,1329.67,,2393.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,797.8,2393.4,
55899- Unlisted proc/male genital system,3431681,CDM,960,RC,55899,HCPCS,Outpatient,,,3343.24,1671.62,,3008.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.97,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1002.97,3008.92,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,960,RC,56405,HCPCS,Outpatient,,,327.34,163.67,,294.61,90,,,percent of total billed charges,90% of total Billed charges,265.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.29,155,,,Fee Schedule,155% of CMS OPPS Rate,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.42,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.29,155,,,Fee Schedule,155% of CMS OPPS Rate,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.91,155,,,Fee Schedule,155% of CMS OPPS Rate,410.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,220.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.81,410.91,
56420- Bartholin's gland abscess/I & D,3431353,CDM,960,RC,56420,HCPCS,Outpatient,,,256.2,128.10,,230.58,90,,,percent of total billed charges,90% of total Billed charges,285.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,215.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,181.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.25,155,,,Fee Schedule,155% of CMS OPPS Rate,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,442.34,155,,,Fee Schedule,155% of CMS OPPS Rate,442.34,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,241.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.5,442.34,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,960,RC,56501,HCPCS,Outpatient,,,265.32,132.66,,238.79,90,,,percent of total billed charges,90% of total Billed charges,312.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.99,155,,,Fee Schedule,155% of CMS OPPS Rate,128.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,184.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,184.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,140.03,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,198.99,155,,,Fee Schedule,155% of CMS OPPS Rate,128.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.71,155,,,Fee Schedule,155% of CMS OPPS Rate,483.71,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,128.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,261.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63.5,483.71,
56605- BX vulva or perineum/1 lesion,3431357,CDM,960,RC,56605,HCPCS,Outpatient,,,158.21,79.11,,142.39,90,,,percent of total billed charges,90% of total Billed charges,152.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.87,155,,,Fee Schedule,155% of CMS OPPS Rate,59.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,91.87,155,,,Fee Schedule,155% of CMS OPPS Rate,59.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,155,,,Fee Schedule,155% of CMS OPPS Rate,237,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,59.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,165.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.51,237,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,960,RC,56606,HCPCS,Outpatient,,,77.92,38.96,,70.13,90,,,percent of total billed charges,90% of total Billed charges,67.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.93,155,,,Fee Schedule,155% of CMS OPPS Rate,29.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,37.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,45.93,155,,,Fee Schedule,155% of CMS OPPS Rate,29.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.22,155,,,Fee Schedule,155% of CMS OPPS Rate,104.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,74.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.4,104.22,
56625-PF COMPLETE REMOVAL OF VULVA,3430126,CDM,960,RC,56625,HCPCS,Outpatient,,,1749.47,874.74,,1574.52,90,,,percent of total billed charges,90% of total Billed charges,1309.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,651.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,294.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1010.14,155,,,Fee Schedule,155% of CMS OPPS Rate,651.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,651.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,962.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,962.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,970.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,970.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,569.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1303.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1145.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,756.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1010.14,155,,,Fee Schedule,155% of CMS OPPS Rate,651.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,2029.82,155,,,Fee Schedule,155% of CMS OPPS Rate,2029.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,651.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,772.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,651.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,1232.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1232.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,294.5,2029.82,
56630-PF EXTENSIVE VULVA SURG,3430128,CDM,960,RC,56630,HCPCS,Outpatient,,,2526.02,1263.01,,2273.42,90,,,percent of total billed charges,90% of total Billed charges,1893.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1462.92,155,,,Fee Schedule,155% of CMS OPPS Rate,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1245.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,943.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1400.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1400.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1420.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1420.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,822.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1887.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1676.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1116.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1462.92,155,,,Fee Schedule,155% of CMS OPPS Rate,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2935.2,155,,,Fee Schedule,155% of CMS OPPS Rate,2935.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1114.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,943.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1821.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1821.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.5,2935.2,
"56631 - PF Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy",3641189,CDM,960,RC,56631,HCPCS,Outpatient,,,3125.22,1562.61,,2812.7,90,,,percent of total billed charges,90% of total Billed charges,2342.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1809.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1555.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1167.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1749.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1749.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1779.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1051.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2334.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2100.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1402.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1809.55,155,,,Fee Schedule,155% of CMS OPPS Rate,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,3631.09,155,,,Fee Schedule,155% of CMS OPPS Rate,3631.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1545.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1167.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2307.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2307.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.5,3631.09,
57061-MA DESTROY VAG LESIONS,3430142,CDM,960,RC,57061,HCPCS,Outpatient,,,229.09,114.55,,206.18,90,,,percent of total billed charges,90% of total Billed charges,270.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,171.45,155,,,Fee Schedule,155% of CMS OPPS Rate,110.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,110.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,157.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,157.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,186.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,171.45,155,,,Fee Schedule,155% of CMS OPPS Rate,110.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.97,155,,,Fee Schedule,155% of CMS OPPS Rate,418.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,110.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70,418.97,
57100 - Bx vaginal mucosa; simple,3431363,CDM,960,RC,57100,HCPCS,Outpatient,,,137.46,68.73,,123.71,90,,,percent of total billed charges,90% of total Billed charges,165.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,100.5,155,,,Fee Schedule,155% of CMS OPPS Rate,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.5,155,,,Fee Schedule,155% of CMS OPPS Rate,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.95,155,,,Fee Schedule,155% of CMS OPPS Rate,255.95,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.99,255.95,
57135-MA REMOVE VAGINA LESION,3430152,CDM,960,RC,57135,HCPCS,Outpatient,,,489.83,244.92,,440.85,90,,,percent of total billed charges,90% of total Billed charges,423.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,183.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,143,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,284.91,155,,,Fee Schedule,155% of CMS OPPS Rate,183.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,183.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,272.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,272.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,367.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,284.91,155,,,Fee Schedule,155% of CMS OPPS Rate,183.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,656.46,155,,,Fee Schedule,155% of CMS OPPS Rate,656.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,183.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,143,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,212.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,183.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,384.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,143,656.46,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,960,RC,57156,HCPCS,Outpatient,,,388.84,194.42,,349.96,90,,,percent of total billed charges,90% of total Billed charges,362.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,228.19,155,,,Fee Schedule,155% of CMS OPPS Rate,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,224.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,224.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,294.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,162.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.19,155,,,Fee Schedule,155% of CMS OPPS Rate,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,562.06,155,,,Fee Schedule,155% of CMS OPPS Rate,562.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,158.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.4,562.06,
57200- Colporrhapy/vag injury sut/non OB,3431371,CDM,960,RC,57200,HCPCS,Outpatient,,,866.27,433.14,,779.64,90,,,percent of total billed charges,90% of total Billed charges,647.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,321.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,498.67,155,,,Fee Schedule,155% of CMS OPPS Rate,321.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,321.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,474.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,474.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,474,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,474,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,284.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,321.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,559.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,364.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,498.67,155,,,Fee Schedule,155% of CMS OPPS Rate,321.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,1003.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1003.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,321.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,287.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,321.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,604.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,604.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131.5,1003.56,
"57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including cy",3622085,CDM,960,RC,57240,HCPCS,Outpatient,,,1620.01,810.01,,1458.01,90,,,percent of total billed charges,90% of total Billed charges,1214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,263.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,938.57,155,,,Fee Schedule,155% of CMS OPPS Rate,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,605.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1037,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1037,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,920.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,920.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,600.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1211.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1085.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,717.11,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,938.57,155,,,Fee Schedule,155% of CMS OPPS Rate,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1882.8,155,,,Fee Schedule,155% of CMS OPPS Rate,1882.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,605.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1360.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,263.5,1882.8,
"57425-PF LAPAROSCOPY, SURG COLPOPEXY",3430189,CDM,960,RC,57425,HCPCS,Outpatient,,,2587.48,1293.74,,2328.73,90,,,percent of total billed charges,90% of total Billed charges,1937.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,964.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,696.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1495.38,155,,,Fee Schedule,155% of CMS OPPS Rate,964.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1301.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,964.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1464.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1464.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1497.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1497.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,918.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,964.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1929.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1767.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1175.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1495.38,155,,,Fee Schedule,155% of CMS OPPS Rate,964.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,3003.48,155,,,Fee Schedule,155% of CMS OPPS Rate,3003.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,964.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,962.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,964.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1993.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1993.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,696.55,3003.48,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,960,RC,57454,HCPCS,Outpatient,,,312.35,156.18,,281.12,90,,,percent of total billed charges,90% of total Billed charges,298.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.17,90,,,Percent of total Billed charges,90% of total billed charges,105.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,203.9,155,,,Fee Schedule,155% of CMS OPPS Rate,131.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,201.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,201.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,206.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,206.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,164.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,203.9,155,,,Fee Schedule,155% of CMS OPPS Rate,131.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,462.09,155,,,Fee Schedule,155% of CMS OPPS Rate,462.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,131.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,173.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,310.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,105.94,462.09,
57500- Biopsy/cervix/single/multiple,3431393,CDM,983,RC,57500,HCPCS,Outpatient,,,174.04,87.02,,156.64,90,,,percent of total billed charges,90% of total Billed charges,221.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.6,155,,,Fee Schedule,155% of CMS OPPS Rate,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,146.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,89.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,113.6,155,,,Fee Schedule,155% of CMS OPPS Rate,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.69,155,,,Fee Schedule,155% of CMS OPPS Rate,342.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,250.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,66.12,342.69,
57505- Endocervical curettage,3431394,CDM,960,RC,57505,HCPCS,Outpatient,,,280,140.00,,252,90,,,percent of total billed charges,90% of total Billed charges,252.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.42,155,,,Fee Schedule,155% of CMS OPPS Rate,104.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,147.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,147.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,111.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.42,155,,,Fee Schedule,155% of CMS OPPS Rate,104.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,390.89,155,,,Fee Schedule,155% of CMS OPPS Rate,390.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22,390.89,
58100- EMB w/o cervical dilation,3431398,CDM,960,RC,58100,HCPCS,Outpatient,,,170.52,85.26,,153.47,90,,,percent of total billed charges,90% of total Billed charges,162.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.87,90,,,Percent of total Billed charges,90% of total billed charges,51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.87,155,,,Fee Schedule,155% of CMS OPPS Rate,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,80.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.87,155,,,Fee Schedule,155% of CMS OPPS Rate,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.01,155,,,Fee Schedule,155% of CMS OPPS Rate,252.01,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,220.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,51,252.01,
58110- EMB w/colposcopy,3431399,CDM,960,RC,58110,HCPCS,Outpatient,,,94.93,47.47,,85.44,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.97,155,,,Fee Schedule,155% of CMS OPPS Rate,39.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,63.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,63.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,51.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.97,155,,,Fee Schedule,155% of CMS OPPS Rate,39.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.14,155,,,Fee Schedule,155% of CMS OPPS Rate,138.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,97.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.05,138.14,
58300- Insertion/intrauterine device,3431410,CDM,960,RC,58300,HCPCS,Outpatient,,,179.5,89.75,,161.55,90,,,percent of total billed charges,90% of total Billed charges,155.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.82,155,,,Fee Schedule,155% of CMS OPPS Rate,240.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,137.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.25,240.82,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,960,RC,58300,HCPCS,Outpatient,,,179.27,89.64,,161.34,90,,,percent of total billed charges,90% of total Billed charges,155.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,78.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,78.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.31,155,,,Fee Schedule,155% of CMS OPPS Rate,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.82,155,,,Fee Schedule,155% of CMS OPPS Rate,240.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,137.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.25,240.82,
"58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g;",3622389,CDM,960,RC,58543,HCPCS,Outpatient,,,2244.77,1122.39,,2020.29,90,,,percent of total billed charges,90% of total Billed charges,1683.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,838.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,682.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1300.31,155,,,Fee Schedule,155% of CMS OPPS Rate,838.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1120.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,838.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1259.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1259.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1289.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1289.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,894.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,838.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1677.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1521.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1022.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1300.31,155,,,Fee Schedule,155% of CMS OPPS Rate,838.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2608.68,155,,,Fee Schedule,155% of CMS OPPS Rate,2608.68,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,838.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,682.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1032.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,838.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2021.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2021.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,682.63,2608.68,
"58545 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250",3622563,CDM,960,RC,58545,HCPCS,Outpatient,,,2401.35,1200.68,,2161.22,90,,,percent of total billed charges,90% of total Billed charges,1800.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,897.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,670.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1390.97,155,,,Fee Schedule,155% of CMS OPPS Rate,897.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1198.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,897.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1348.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1348.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1382.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1382.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,858.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,897.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1794.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1631,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1100.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1390.97,155,,,Fee Schedule,155% of CMS OPPS Rate,897.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,2790.59,155,,,Fee Schedule,155% of CMS OPPS Rate,2790.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,897.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,670.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,930.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,897.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1843.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1843.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,670.11,2790.59,
"58546 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myo",3622758,CDM,960,RC,58546,HCPCS,Outpatient,,,2978.1,1489.05,,2680.29,90,,,percent of total billed charges,90% of total Billed charges,2232.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1112.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,847.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1724.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1112.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1494.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1112.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1681.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1681.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1728.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1728.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1087.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1112.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2225.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2039.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1375.75,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1724.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1112.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3460.39,155,,,Fee Schedule,155% of CMS OPPS Rate,3460.39,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1112.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,847.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1170.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1112.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2326.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2326.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,847.1,3460.39,
"58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method)",3621643,CDM,960,RC,58560,HCPCS,Outpatient,,,833.68,416.84,,750.31,90,,,percent of total billed charges,90% of total Billed charges,624.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,311.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.03,90,,,Percent of total Billed charges,90% of total billed charges,337.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,482.42,155,,,Fee Schedule,155% of CMS OPPS Rate,311.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,311.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,473.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,488.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,488.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,622.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,576.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,390.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,482.42,155,,,Fee Schedule,155% of CMS OPPS Rate,311.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,968.33,155,,,Fee Schedule,155% of CMS OPPS Rate,968.33,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,311.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,337.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,418.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,311.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,800.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,800.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,311.24,968.33,
"58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g;",3622748,CDM,960,RC,58572,HCPCS,Outpatient,,,2752.62,1376.31,,2477.36,90,,,percent of total billed charges,90% of total Billed charges,2065.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,813.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1597.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1373.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1030.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1544.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1544.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1581.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1581.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1075.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2061.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1866.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1254.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1597.76,155,,,Fee Schedule,155% of CMS OPPS Rate,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,3202.11,155,,,Fee Schedule,155% of CMS OPPS Rate,3202.11,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1357.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1030.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,2382.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2382.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,813.33,3202.11,
"58952 - (PF) Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral",3635229,CDM,960,RC,58952,HCPCS,Outpatient,,,4354.52,2177.26,,3919.07,90,,,percent of total billed charges,90% of total Billed charges,3264.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1627.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2522.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1627.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2401.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1627.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2700.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2700.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2481.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2481.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1477.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3254.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2928.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1966.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2522.61,155,,,Fee Schedule,155% of CMS OPPS Rate,1627.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,5060.66,155,,,Fee Schedule,155% of CMS OPPS Rate,5060.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1627.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1804.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1627.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,3229.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3229.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5060.66,
58958-PF RESECT RECUR GYN MAL W/LYM,3430294,CDM,960,RC,58958,HCPCS,Outpatient,,,4425.47,2212.74,,3982.92,90,,,percent of total billed charges,90% of total Billed charges,3316.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1652.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2561.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1652.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2314.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1652.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2602.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2602.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2662.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2662.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1534.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1652.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3304.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2122.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2561.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1652.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,5140.5,155,,,Fee Schedule,155% of CMS OPPS Rate,5140.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1652.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1474.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1652.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3434.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3434.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,5140.5,
Clinic NST,3428544,CDM,960,RC,59025,HCPCS,Outpatient,,,124.16,62.08,,111.74,90,,,percent of total billed charges,90% of total Billed charges,34.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.07,90,,,Percent of total Billed charges,90% of total billed charges,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.31,155,,,Fee Schedule,155% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.31,155,,,Fee Schedule,155% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.17,155,,,Fee Schedule,155% of CMS OPPS Rate,54.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,95.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.5,111.74,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,394.67,197.34,,355.2,90,,,percent of total billed charges,90% of total Billed charges,376.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,132.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,254.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,200.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,583.36,155,,,Fee Schedule,155% of CMS OPPS Rate,583.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,132.94,583.36,
59899 Unlisted procedure maternity care and delivery Bakri,3623306,CDM,960,RC,59899,HCPCS,Outpatient,,,6648.32,3324.16,,5983.49,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,789.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,789.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1994.5,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,701.59,5983.49,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,983,RC,60300,HCPCS,Outpatient,,,270.06,135.03,,243.05,90,,,percent of total billed charges,90% of total Billed charges,149.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.86,155,,,Fee Schedule,155% of CMS OPPS Rate,47.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.86,155,,,Fee Schedule,155% of CMS OPPS Rate,47.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.26,155,,,Fee Schedule,155% of CMS OPPS Rate,231.26,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,221,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.81,243.05,
"61885 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or ind",3622067,CDM,960,RC,61885,HCPCS,Outpatient,,,1386.02,693.01,,1247.42,90,,,percent of total billed charges,90% of total Billed charges,1048.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,527.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,451.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,816.9,155,,,Fee Schedule,155% of CMS OPPS Rate,527.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,643.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,527.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,724.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,724.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,784.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,784.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,563.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1054.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,925.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,680.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,816.9,155,,,Fee Schedule,155% of CMS OPPS Rate,527.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1624.73,155,,,Fee Schedule,155% of CMS OPPS Rate,1624.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,527.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,451.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,527.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1041.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1041.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,451.75,1624.73,
Clinic Lumbar Puncture,3435540,CDM,960,RC,62270,HCPCS,Outpatient,,,126.32,63.16,,113.69,90,,,percent of total billed charges,90% of total Billed charges,183.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.58,90,,,Percent of total Billed charges,90% of total billed charges,42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,97.88,155,,,Fee Schedule,155% of CMS OPPS Rate,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.32,155,,,Fee Schedule,155% of CMS OPPS Rate,284.32,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,302.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,302.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42,312.58,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,960,RC,64425,HCPCS,Outpatient,,,143.34,71.67,,129.01,90,,,percent of total billed charges,90% of total Billed charges,158.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.66,155,,,Fee Schedule,155% of CMS OPPS Rate,53.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,84.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,84.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.66,155,,,Fee Schedule,155% of CMS OPPS Rate,53.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.35,155,,,Fee Schedule,155% of CMS OPPS Rate,245.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,53.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,273.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,273.36,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,960,RC,64450,HCPCS,Outpatient,,,110.52,55.26,,99.47,90,,,percent of total billed charges,90% of total Billed charges,112.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.7,90,,,Percent of total Billed charges,90% of total billed charges,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,63.22,155,,,Fee Schedule,155% of CMS OPPS Rate,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,49.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,63.22,155,,,Fee Schedule,155% of CMS OPPS Rate,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.58,155,,,Fee Schedule,155% of CMS OPPS Rate,174.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,210.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,210.8,
64561(50) Percutaneous neurostimulator,3623710,CDM,983,RC,64561,HCPCS,Outpatient,,,706.19,353.10,,635.57,90,,,percent of total billed charges,90% of total Billed charges,1002.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,546.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,355.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1554.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1288.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1545.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1545.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,297.41,1554.28,
Clinic PNE,3550634,CDM,960,RC,64561,HCPCS,Outpatient,,,706.19,353.10,,635.57,90,,,percent of total billed charges,90% of total Billed charges,1002.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,378.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,425.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,462.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,332.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,594.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,546.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,355.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,460.99,155,,,Fee Schedule,155% of CMS OPPS Rate,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.28,155,,,Fee Schedule,155% of CMS OPPS Rate,1554.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1288.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,297.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1545.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1545.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,297.41,1554.28,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,960,RC,64595,HCPCS,Outpatient,,,325.61,162.81,,293.05,90,,,percent of total billed charges,90% of total Billed charges,340.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,128.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,189.61,155,,,Fee Schedule,155% of CMS OPPS Rate,122.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,143.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.61,155,,,Fee Schedule,155% of CMS OPPS Rate,122.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.04,155,,,Fee Schedule,155% of CMS OPPS Rate,528.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,122.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,391.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,471.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,471.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,122.33,528.04,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,960,RC,64612,HCPCS,Outpatient,,,238.73,119.37,,214.86,90,,,percent of total billed charges,90% of total Billed charges,243.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.77,155,,,Fee Schedule,155% of CMS OPPS Rate,377.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.84,377.77,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,960,RC,65220,HCPCS,Outpatient,,,83.34,41.67,,75.01,90,,,percent of total billed charges,90% of total Billed charges,97.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.44,90,,,Percent of total Billed charges,90% of total billed charges,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,62.91,155,,,Fee Schedule,155% of CMS OPPS Rate,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.42,155,,,Fee Schedule,155% of CMS OPPS Rate,151.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,897.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.5,897.45,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,960,RC,65222,HCPCS,Outpatient,,,98.83,49.42,,88.95,90,,,percent of total billed charges,90% of total Billed charges,110.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.8,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.42,155,,,Fee Schedule,155% of CMS OPPS Rate,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,53.41,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.42,155,,,Fee Schedule,155% of CMS OPPS Rate,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.85,155,,,Fee Schedule,155% of CMS OPPS Rate,171.85,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,153,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,171.85,
67700- Drainage of eyelid abscess,3431315,CDM,960,RC,67700,HCPCS,Outpatient,,,224.66,112.33,,202.19,90,,,percent of total billed charges,90% of total Billed charges,332.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,515.79,155,,,Fee Schedule,155% of CMS OPPS Rate,515.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,507.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,507.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.81,515.79,
67800- Excision of chalazion/single,3431316,CDM,960,RC,67800,HCPCS,Outpatient,,,199,99.50,,179.1,90,,,percent of total billed charges,90% of total Billed charges,215.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.46,155,,,Fee Schedule,155% of CMS OPPS Rate,334.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.49,334.46,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,960,RC,67801,HCPCS,Outpatient,,,256.56,128.28,,230.9,90,,,percent of total billed charges,90% of total Billed charges,276.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.38,155,,,Fee Schedule,155% of CMS OPPS Rate,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,191.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,191.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,193.38,155,,,Fee Schedule,155% of CMS OPPS Rate,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.09,155,,,Fee Schedule,155% of CMS OPPS Rate,429.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,359,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,124.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,332.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,104.62,429.09,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,983,RC,67805,HCPCS,Outpatient,,,317.85,158.93,,286.07,90,,,percent of total billed charges,90% of total Billed charges,343.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.25,155,,,Fee Schedule,155% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,235.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,235.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,238.25,155,,,Fee Schedule,155% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.38,155,,,Fee Schedule,155% of CMS OPPS Rate,532.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,378.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,412.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,412.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.42,532.38,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,175.2,87.60,,157.68,90,,,percent of total billed charges,90% of total Billed charges,237.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.22,155,,,Fee Schedule,155% of CMS OPPS Rate,368.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.01,422.28,
67820- Revise eyelashes,3431319,CDM,960,RC,67820,HCPCS,Outpatient,,,43.21,21.61,,38.89,90,,,percent of total billed charges,90% of total Billed charges,39.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.7,155,,,Fee Schedule,155% of CMS OPPS Rate,60.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.73,104.16,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,960,RC,67840,HCPCS,Outpatient,,,305.03,152.52,,274.53,90,,,percent of total billed charges,90% of total Billed charges,409.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,267.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.12,155,,,Fee Schedule,155% of CMS OPPS Rate,634.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.6,634.12,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,393,196.50,,353.7,90,,,percent of total billed charges,90% of total Billed charges,409.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,267.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.12,155,,,Fee Schedule,155% of CMS OPPS Rate,634.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.6,634.12,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,960,RC,67850,HCPCS,Outpatient,,,255.86,127.93,,230.27,90,,,percent of total billed charges,90% of total Billed charges,324.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,224.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,135.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,502.57,155,,,Fee Schedule,155% of CMS OPPS Rate,502.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.71,502.57,
67875- Temp eyelid closure/suture,3431322,CDM,960,RC,67875,HCPCS,Outpatient,,,186.79,93.40,,168.11,90,,,percent of total billed charges,90% of total Billed charges,258.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.14,155,,,Fee Schedule,155% of CMS OPPS Rate,401.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.79,454,
67880- Revision of eyelid,3431323,CDM,960,RC,67880,HCPCS,Outpatient,,,712.32,356.16,,641.09,90,,,percent of total billed charges,90% of total Billed charges,778.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,290.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,373.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,587.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,918.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,918.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,290.41,1205.98,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,983,RC,67903,HCPCS,Outpatient,,,1200.32,600.16,,1080.29,90,,,percent of total billed charges,90% of total Billed charges,1015.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,449.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,696.11,155,,,Fee Schedule,155% of CMS OPPS Rate,449.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,740.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,449.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,832.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,832.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,695.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,695.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,380.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,449.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,820.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,498.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,696.11,155,,,Fee Schedule,155% of CMS OPPS Rate,449.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1573.36,155,,,Fee Schedule,155% of CMS OPPS Rate,1573.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,449.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,630.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,449.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,1208.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1208.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,380.87,1573.36,
67904 - PF Repair of blepharoptosis; (tarso) levator resecti,3641193,CDM,960,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,1041.41,90,,,percent of total billed charges,90% of total Billed charges,1250.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1029.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,470.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,614.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1938.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,756.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1485.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,470.57,1938.29,
67909- Revise eyelid defect,3431327,CDM,960,RC,67909,HCPCS,Outpatient,,,846.9,423.45,,762.21,90,,,percent of total billed charges,90% of total Billed charges,923.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,452.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1431.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1431.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,559.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1082.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1082.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,345.97,1431.67,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,960,RC,67935,HCPCS,Outpatient,,,857.79,428.90,,772.01,90,,,percent of total billed charges,90% of total Billed charges,976.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.87,155,,,Fee Schedule,155% of CMS OPPS Rate,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,414.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,763.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,641.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,641.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,348.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,828.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,756.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,464.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,641.87,155,,,Fee Schedule,155% of CMS OPPS Rate,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1513,155,,,Fee Schedule,155% of CMS OPPS Rate,1513,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,801.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1207,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1207,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,348.29,1513,
67938- Removal of embedded FB/eyelid,3431333,CDM,960,RC,67938,HCPCS,Outpatient,,,226.2,113.10,,203.58,90,,,percent of total billed charges,90% of total Billed charges,335.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.93,155,,,Fee Schedule,155% of CMS OPPS Rate,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,169.93,155,,,Fee Schedule,155% of CMS OPPS Rate,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.54,155,,,Fee Schedule,155% of CMS OPPS Rate,520.54,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,811.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,464.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.77,811.31,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,960,RC,67961,HCPCS,Outpatient,,,879.65,439.83,,791.69,90,,,percent of total billed charges,90% of total Billed charges,970.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,784.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,358.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,466.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1504.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,542.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1158.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,358.5,1504.88,
68720 -OCC Dacryocystorhinostomy,3548682,CDM,983,RC,68720,HCPCS,Outpatient,,,2028.62,1014.31,,1825.76,90,,,percent of total billed charges,90% of total Billed charges,1520.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,757.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,757.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1199.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,757.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1349.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1349.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1120.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1120.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,595.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,757.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1515.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1322.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,800.12,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1174.42,155,,,Fee Schedule,155% of CMS OPPS Rate,757.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2356.81,155,,,Fee Schedule,155% of CMS OPPS Rate,2356.81,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,757.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,760.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,757.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,1556.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1556.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,595.54,2356.81,
68761- Close lacrimal punctum/plug/each,3431340,CDM,960,RC,68761,HCPCS,Outpatient,,,224.95,112.48,,202.46,90,,,percent of total billed charges,90% of total Billed charges,245.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.48,155,,,Fee Schedule,155% of CMS OPPS Rate,380.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,204.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.71,380.48,
68801- Dilation of lacrimal punctum,3431341,CDM,960,RC,68801,HCPCS,Outpatient,,,151.9,75.95,,136.71,90,,,percent of total billed charges,90% of total Billed charges,160.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.52,155,,,Fee Schedule,155% of CMS OPPS Rate,249.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,136.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,244.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.54,249.52,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,960,RC,68811,HCPCS,Outpatient,,,262.12,131.06,,235.91,90,,,percent of total billed charges,90% of total Billed charges,251.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,232.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,232.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,137.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,195.1,155,,,Fee Schedule,155% of CMS OPPS Rate,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.1,155,,,Fee Schedule,155% of CMS OPPS Rate,389.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,125.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,425,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,425,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,125.87,425,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,960,RC,68815,HCPCS,Outpatient,,,429.19,214.60,,386.27,90,,,percent of total billed charges,90% of total Billed charges,555.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,373.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.92,155,,,Fee Schedule,155% of CMS OPPS Rate,860.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,723.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,874.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,874.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,174.94,874.48,
68840- Probe lacrimal canaliculi,3431343,CDM,960,RC,68840,HCPCS,Outpatient,,,225.17,112.59,,202.65,90,,,percent of total billed charges,90% of total Billed charges,231.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.18,155,,,Fee Schedule,155% of CMS OPPS Rate,359.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.92,359.18,
69100- Biopsy external ear,3430622,CDM,960,RC,69100,HCPCS,Outpatient,,,93.28,46.64,,83.95,90,,,percent of total billed charges,90% of total Billed charges,136.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.87,155,,,Fee Schedule,155% of CMS OPPS Rate,45.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,54.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.87,155,,,Fee Schedule,155% of CMS OPPS Rate,45.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.22,155,,,Fee Schedule,155% of CMS OPPS Rate,211.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,45.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,199.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41.32,211.22,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,960,RC,73206,HCPCS,Outpatient,,,225.46,112.73,,202.91,90,,,percent of total billed charges,90% of total Billed charges,399.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.76,155,,,Fee Schedule,155% of CMS OPPS Rate,196.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,664.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,664.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,445.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,445.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,296.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,225.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,291.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,275.76,140,,,Fee Schedule,140% of CMS OPPS Rate,196.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.76,140,,,Fee Schedule,140% of CMS OPPS Rate,559.5,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,196.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,346.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.31,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,680.31,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,196.97,680.31,
"74740 - PF - Hysterosalpingography, radiological supervision and interpretation",3640903,CDM,960,RC,74740,HCPCS,Outpatient,,,48.24,24.12,,43.42,90,,,percent of total billed charges,90% of total Billed charges,96.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,155,,,Fee Schedule,155% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,174.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,121.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,121.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.54,140,,,Fee Schedule,140% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.54,140,,,Fee Schedule,140% of CMS OPPS Rate,135.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,146.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.42,174.41,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,960,RC,75557,HCPCS,Outpatient,,,291.73,145.87,,262.56,90,,,percent of total billed charges,90% of total Billed charges,323.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,343.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,221.1,155,,,Fee Schedule,155% of CMS OPPS Rate,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,575.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,647.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,647.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,438.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,438.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,315.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,291.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.1,140,,,Fee Schedule,140% of CMS OPPS Rate,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.1,140,,,Fee Schedule,140% of CMS OPPS Rate,452.38,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,692.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,157.93,692.76,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,960,RC,75559,HCPCS,Outpatient,,,363.05,181.53,,326.75,90,,,percent of total billed charges,90% of total Billed charges,454.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,221.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,310.46,155,,,Fee Schedule,155% of CMS OPPS Rate,221.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,799.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,221.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,899.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,899.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,605.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,605.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,381.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,443.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,363.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.46,140,,,Fee Schedule,140% of CMS OPPS Rate,221.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.46,140,,,Fee Schedule,140% of CMS OPPS Rate,636.69,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,221.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,683.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,221.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,964.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,964.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,221.76,964.75,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,960,RC,75561,HCPCS,Outpatient,,,322.95,161.48,,290.66,90,,,percent of total billed charges,90% of total Billed charges,463.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,486.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,316.58,155,,,Fee Schedule,155% of CMS OPPS Rate,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,226.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,849.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,849.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,570.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,570.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,419.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,452.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,316.58,140,,,Fee Schedule,140% of CMS OPPS Rate,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,316.58,140,,,Fee Schedule,140% of CMS OPPS Rate,648.21,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,657.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,226.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,922.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,922.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,226.13,922.8,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,960,RC,75565,HCPCS,Outpatient,,,31.23,15.62,,28.11,90,,,percent of total billed charges,90% of total Billed charges,62.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,155,,,Fee Schedule,155% of CMS OPPS Rate,31.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,140,,,Fee Schedule,140% of CMS OPPS Rate,31.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.65,140,,,Fee Schedule,140% of CMS OPPS Rate,87.37,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,143.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.11,143.53,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,960,RC,75572,HCPCS,Outpatient,,,218.84,109.42,,196.96,90,,,percent of total billed charges,90% of total Billed charges,270.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,236.36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,187.63,155,,,Fee Schedule,155% of CMS OPPS Rate,134.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,134.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,503.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,503.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,225.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,268.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,218.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.63,140,,,Fee Schedule,140% of CMS OPPS Rate,134.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.63,140,,,Fee Schedule,140% of CMS OPPS Rate,379.08,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,134.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,134.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,565.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,134.02,565.61,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,960,RC,75574,HCPCS,Outpatient,,,298.21,149.11,,268.39,90,,,percent of total billed charges,90% of total Billed charges,391.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,299.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,268.81,155,,,Fee Schedule,155% of CMS OPPS Rate,192.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,728.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,728.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,491.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,491.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,302.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,298.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,323.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,268.81,140,,,Fee Schedule,140% of CMS OPPS Rate,192.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.81,140,,,Fee Schedule,140% of CMS OPPS Rate,548.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,192.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,859.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,192.01,859.88,
"75625(26)- Aortography, abdominal, by serialography, radiological supervision and interpretation",3621145,CDM,960,RC,75625,HCPCS,Outpatient,,,169.79,84.90,,152.81,90,,,percent of total billed charges,90% of total Billed charges,106.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.63,155,,,Fee Schedule,155% of CMS OPPS Rate,52.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,281.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,281.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.63,140,,,Fee Schedule,140% of CMS OPPS Rate,52.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.63,140,,,Fee Schedule,140% of CMS OPPS Rate,149.44,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,524.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,296.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,296.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39,524.85,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,960,RC,75630,HCPCS,Outpatient,,,191.18,95.59,,172.06,90,,,percent of total billed charges,90% of total Billed charges,114.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,78.93,155,,,Fee Schedule,155% of CMS OPPS Rate,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.93,140,,,Fee Schedule,140% of CMS OPPS Rate,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.93,140,,,Fee Schedule,140% of CMS OPPS Rate,160.15,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,590.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.38,590.38,
Peripheral Angio Aortagram w Runoff,3427191,CDM,960,RC,75630,HCPCS,Outpatient,,,191.1,95.55,,171.99,90,,,percent of total billed charges,90% of total Billed charges,114.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,244.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,78.93,155,,,Fee Schedule,155% of CMS OPPS Rate,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,345.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,345.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,242.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,242.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.93,140,,,Fee Schedule,140% of CMS OPPS Rate,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.93,140,,,Fee Schedule,140% of CMS OPPS Rate,160.15,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,590.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,354.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,56.38,590.38,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
Peripheral Angio Lower Extremity LT,3427218,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
Peripheral Angio Lower Extremity RT,3427219,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
Peripheral Angio Tibal Peroneal,3427225,CDM,960,RC,75710,HCPCS,Outpatient,,,169.68,84.84,,152.71,90,,,percent of total billed charges,90% of total Billed charges,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,84.84,155,,,Fee Schedule,155% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,160.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,140,,,Fee Schedule,140% of CMS OPPS Rate,171.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,503.85,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,960,RC,75716,HCPCS,Outpatient,,,247.87,123.94,,223.08,90,,,percent of total billed charges,90% of total Billed charges,127,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.1,155,,,Fee Schedule,155% of CMS OPPS Rate,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,355.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,355.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,184.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.1,140,,,Fee Schedule,140% of CMS OPPS Rate,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.1,140,,,Fee Schedule,140% of CMS OPPS Rate,177.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,537.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,402.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,402.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,537.85,
75825 - Venography caval inferior w/ serial,4241822,CDM,983,RC,75825,HCPCS,Outpatient,,,133.27,66.64,,119.94,90,,,percent of total billed charges,90% of total Billed charges,109.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.67,155,,,Fee Schedule,155% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,255.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,176.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.67,140,,,Fee Schedule,140% of CMS OPPS Rate,152.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,532.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,283.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,532.85,
75894-PF XR Transcatheter Embolization Any Meth RS&I,4345291,CDM,983,RC,75894,HCPCS,Outpatient,,,147.64,73.82,,132.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1779.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,2001.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2001.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,908.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,908.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1119.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.88,2001.65,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,960,RC,76376,HCPCS,Outpatient,,,25.03,12.52,,22.53,90,,,percent of total billed charges,90% of total Billed charges,24.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,155,,,Fee Schedule,155% of CMS OPPS Rate,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,32.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,32.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.14,140,,,Fee Schedule,140% of CMS OPPS Rate,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.14,140,,,Fee Schedule,140% of CMS OPPS Rate,34.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,109.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.96,144,
76536- US head and neck,3430613,CDM,972,RC,76536,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,514.08,
Read,4345734,CDM,972,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,181.75,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,235.02,
Read,4345740,CDM,972,RC,76536,HCPCS,Outpatient,,,201.94,100.97,,181.75,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,235.02,
SCSN US Thyroid,3370964,CDM,972,RC,76536,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,514.08,
US Neck Including Thyroid:Read,596514,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,247.47,
76641 - (TC) US Breast Complete,3896992,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,82.9,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
76641 - US Breast Complete,3896999,CDM,960,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,82.9,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
76641- US  breast complete,3430614,CDM,972,RC,76641,HCPCS,Outpatient,,,92.11,46.06,,82.9,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
Read,3370897,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.28,90,,,Percent of total Billed charges,90% of total billed charges,58.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,248.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,235.4,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,179.11,70,,,percent of total billed charges,70% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,220.05,86,,,percent of total billed charges,86% of total billed charges,204.7,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.19,97,,,percent of total billed charges,97% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.19,97,,,percent of total billed charges,97% of total billed charges,237.96,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.43,521.05,
Read,3370899,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.28,90,,,Percent of total Billed charges,90% of total billed charges,58.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,248.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,235.4,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,179.11,70,,,percent of total billed charges,70% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,220.05,86,,,percent of total billed charges,86% of total billed charges,204.7,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.19,97,,,percent of total billed charges,97% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.19,97,,,percent of total billed charges,97% of total billed charges,237.96,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.43,521.05,
76642 - (26) US Breast Limited,3897005,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,77.36,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
76642 - (TC) US Breast Limited,3897012,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,77.36,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
76642 - US Breast Limited,3897019,CDM,960,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,77.36,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
76642- US  breast limited,3430615,CDM,972,RC,76642,HCPCS,Outpatient,,,85.96,42.98,,77.36,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
"76700 (26) Ultrasound, abdominal, real time with image documentation; complete",3621069,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
76700- US abdommen complete,3430616,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
Read,3575253,CDM,983,RC,76700,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,960,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,67.75,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,960,RC,76705,HCPCS,Outpatient,,,75.28,37.64,,67.75,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,,,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3575225,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3575309,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
US Biliary Tree:Read,3351906,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
US HKBT Abdomen Limited:Read,3317839,CDM,972,RC,76705,HCPCS,Outpatient,,,161.44,80.72,,145.3,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
76770- US abdomen back wall complete,3430617,CDM,972,RC,76770,HCPCS,Outpatient,,,96.06,48.03,,86.45,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3370929,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3562999,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3569770,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3575227,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3575257,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
SCSN US Renal Bilat Interp,3575303,CDM,972,RC,76770,HCPCS,Outpatient,,,93.06,46.53,,83.75,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
76775- Us exam abdo back wall lim,3430507,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
CL Renal Artery Ultrasound LT,3427573,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
CL Renal Artery Ultrasound RT,3427574,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3370925,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3370955,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3569772,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3569774,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3575255,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
Read,3575301,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
SCSN US Renal LT Interp,3575305,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
SCSN US Renal LT Interp,3575307,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
URMC US Kidney:Read,3370977,CDM,972,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,201.21,
"76830- US Transvaginal, non-ob",3430618,CDM,972,RC,76830,HCPCS,Outpatient,,,87.65,43.83,,78.89,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,249.4,
"76831 - PF - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640911,CDM,960,RC,76831,HCPCS,Outpatient,,,70.85,35.43,,63.77,90,,,percent of total billed charges,90% of total Billed charges,141.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.19,155,,,Fee Schedule,155% of CMS OPPS Rate,70.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.19,140,,,Fee Schedule,140% of CMS OPPS Rate,70.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.19,140,,,Fee Schedule,140% of CMS OPPS Rate,198.38,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,70.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,63.77,241.49,
Read,3575335,CDM,972,RC,76857,HCPCS,Outpatient,,,107.63,53.82,,96.87,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
76870- Us exam scrotum,3430514,CDM,972,RC,76870,HCPCS,Outpatient,,,219.21,109.61,,197.29,90,,,percent of total billed charges,90% of total Billed charges,125.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.09,155,,,Fee Schedule,155% of CMS OPPS Rate,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,143.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,143.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.09,140,,,Fee Schedule,140% of CMS OPPS Rate,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.09,140,,,Fee Schedule,140% of CMS OPPS Rate,175.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.21,232.01,
"76872 Ultrasound, transrectal",3430515,CDM,960,RC,76872,HCPCS,Outpatient,,,426.34,213.17,,383.71,90,,,percent of total billed charges,90% of total Billed charges,301.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.65,155,,,Fee Schedule,155% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,140,,,Fee Schedule,140% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.65,140,,,Fee Schedule,140% of CMS OPPS Rate,422.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.73,422.46,
URMC US Prostate w/o Biopsy:URMC US Exam,3575341,CDM,972,RC,76872,HCPCS,Outpatient,,,426.34,213.17,,383.71,90,,,percent of total billed charges,90% of total Billed charges,301.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,86.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,207.65,155,,,Fee Schedule,155% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,178.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.65,140,,,Fee Schedule,140% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.65,140,,,Fee Schedule,140% of CMS OPPS Rate,422.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.73,422.46,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,960,RC,76937,HCPCS,Outpatient,,,36.14,18.07,,32.53,90,,,percent of total billed charges,90% of total Billed charges,45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,155,,,Fee Schedule,155% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31,140,,,Fee Schedule,140% of CMS OPPS Rate,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,140,,,Fee Schedule,140% of CMS OPPS Rate,63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.14,70.73,
"76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization de",3676896,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,960,RC,76942,HCPCS,Outpatient,,,81.09,40.55,,72.98,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,4345730,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
Read,4345732,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,960,RC,76965,HCPCS,Outpatient,,,172.75,86.38,,155.48,90,,,percent of total billed charges,90% of total Billed charges,47.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,155,,,Fee Schedule,155% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,181.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,65.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,304.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,171.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.74,304.5,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,97.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.4,155,,,Fee Schedule,155% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,136.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.97,223.49,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,960,RC,77001,HCPCS,Outpatient,,,48.86,24.43,,43.97,90,,,percent of total billed charges,90% of total Billed charges,97.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.4,155,,,Fee Schedule,155% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.4,140,,,Fee Schedule,140% of CMS OPPS Rate,136.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.97,223.49,
77065 (26) - DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,4037790,CDM,983,RC,77065,HCPCS,Outpatient,,,101.84,50.92,,91.66,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,238.7,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,960,RC,77080,HCPCS,Outpatient,,,25.03,12.52,,22.53,90,,,percent of total billed charges,90% of total Billed charges,49.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.04,140,,,Fee Schedule,140% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.04,140,,,Fee Schedule,140% of CMS OPPS Rate,69.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.53,188.1,
"77080(26)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3620959,CDM,960,RC,77080,HCPCS,Outpatient,,,25.03,12.52,,22.53,90,,,percent of total billed charges,90% of total Billed charges,49.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.04,140,,,Fee Schedule,140% of CMS OPPS Rate,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.04,140,,,Fee Schedule,140% of CMS OPPS Rate,69.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.53,188.1,
77316 - (TC) Brachytx Isodose Plan Simple,3898899,CDM,960,RC,77316,HCPCS,Outpatient,,,188.84,94.42,,169.96,90,,,percent of total billed charges,90% of total Billed charges,297.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.26,155,,,Fee Schedule,155% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,188.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,416.51,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.7,416.51,
77316-(26)-BRACHYTX ISODOSE PLAN SIMPLE,3537568,CDM,983,RC,77316,HCPCS,Outpatient,,,168.58,84.29,,151.72,90,,,percent of total billed charges,90% of total Billed charges,297.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,209.26,155,,,Fee Schedule,155% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,354.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,354.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,299.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.26,140,,,Fee Schedule,140% of CMS OPPS Rate,416.51,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.7,416.51,
77317 - (TC) Brachytx Isodose Intermed,3898920,CDM,960,RC,77317,HCPCS,Outpatient,,,249.1,124.55,,224.19,90,,,percent of total billed charges,90% of total Billed charges,393.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,185.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,276.14,155,,,Fee Schedule,155% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,413.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,465.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,392.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,394.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.14,140,,,Fee Schedule,140% of CMS OPPS Rate,550.8,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,197.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.42,550.8,
77318 - (TC) Bractx Isodose Complex,3898940,CDM,960,RC,77318,HCPCS,Outpatient,,,391.94,195.97,,352.75,90,,,percent of total billed charges,90% of total Billed charges,531.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,268.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,373.23,155,,,Fee Schedule,155% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,591.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,665.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,665.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,563.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,298.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,533.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,373.23,140,,,Fee Schedule,140% of CMS OPPS Rate,744.25,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,266.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.59,744.25,
77387 26 Guidance for localization of target volume for de,3623293,CDM,960,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,156.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,156.96,
77387-GUIDANCE FOR RADJ TX DLVR,3400461,CDM,983,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,156.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.99,156.96,
Hospital Outpatient Clinic Visit,3400485,CDM,983,RC,77427,HCPCS,Outpatient,,,445.2,222.60,,400.68,90,,,percent of total billed charges,90% of total Billed charges,370.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,259.53,155,,,Fee Schedule,155% of CMS OPPS Rate,185.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,312.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,283.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,283.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,144.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,205.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,259.53,140,,,Fee Schedule,140% of CMS OPPS Rate,185.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.53,140,,,Fee Schedule,140% of CMS OPPS Rate,518.36,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,185.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,349.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,137.62,518.36,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,960,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,238.37,90,,,percent of total billed charges,90% of total Billed charges,426.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,245.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.61,155,,,Fee Schedule,155% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,546.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,278.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,597.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.29,597.48,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,960,RC,77770,HCPCS,Outpatient,,,264.86,132.43,,238.37,90,,,percent of total billed charges,90% of total Billed charges,426.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,245.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.61,155,,,Fee Schedule,155% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,546.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,546.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,278.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,264.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.61,140,,,Fee Schedule,140% of CMS OPPS Rate,597.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,337.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,213.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.29,597.48,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,960,RC,77771,HCPCS,Outpatient,,,511.39,255.70,,460.25,90,,,percent of total billed charges,90% of total Billed charges,699.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,456.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,492.34,155,,,Fee Schedule,155% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,975.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,519.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,511.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,979.75,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,628.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,979.75,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,960,RC,77771,HCPCS,Outpatient,,,511.39,255.70,,460.25,90,,,percent of total billed charges,90% of total Billed charges,699.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,456.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,492.34,155,,,Fee Schedule,155% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,867.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,975.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,975.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,821.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,519.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,703.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,511.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.34,140,,,Fee Schedule,140% of CMS OPPS Rate,979.75,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,628.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,351.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.67,979.75,
78428 (26) - Cardiac shunt detection,4037737,CDM,974,RC,78428,HCPCS,Outpatient,,,96.73,48.37,,87.06,90,,,percent of total billed charges,90% of total Billed charges,193.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,135.42,155,,,Fee Schedule,155% of CMS OPPS Rate,96.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,149.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,193.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.42,140,,,Fee Schedule,140% of CMS OPPS Rate,96.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.42,140,,,Fee Schedule,140% of CMS OPPS Rate,270.84,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,96.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,96.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87.06,352.33,
82962 Gluc Bld Cluc Mntr Dev Cleared FDA Spec Home Use,3436058,CDM,761,RC,82962,HCPCS,Outpatient,,,19.47,9.74,,17.52,90,,,percent of total billed charges,90% of total Billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,15.58,80,,,Percent of total Billed charges,80% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.52,90,,,Percent of total Billed charges,90% of total billed charges,2.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,18.89,97,,,Percent of total billed charges,97% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,17.91,92,,,Percent of total billed charges,92% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,17.52,90,,,percent of total billed charges,90% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.63,70,,,percent of total billed charges,70% of total billed charges,17.52,90,,,percent of total billed charges,90% of total billed charges,18.5,95,,,percent of total billed charges,95% of total billed charges,18.5,95,,,percent of total billed charges,95% of total billed charges,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,16.74,86,,,percent of total billed charges,86% of total billed charges,15.58,80,,,percent of total billed charges,80% of total billed charges,3.64,111,,,Fee Schedule,111% of CMS OPPS Rate,18.89,97,,,percent of total billed charges,97% of total billed charges,17.52,90,,,percent of total billed charges,90% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.89,97,,,percent of total billed charges,97% of total billed charges,18.11,93,,,percent of total billed charges,93% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,18.89,97,,,percent of total billed charges,97% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2,18.89,
Smear Review Pathology,649497,CDM,971,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,49.96,90,,,percent of total billed charges,90% of total Billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,155,,,Fee Schedule,155% of CMS OPPS Rate,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.65,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.89,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.34,145,,,Fee Schedule,145% of CMS OPPS Rate,33.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,45.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.65,68.34,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,960,RC,88305,HCPCS,Outpatient,,,83.51,41.76,,75.16,90,,,percent of total billed charges,90% of total Billed charges,60.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,145,,,Fee Schedule,145% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.35,145,,,Fee Schedule,145% of CMS OPPS Rate,44.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.05,193.34,
Pathology Billing Surgical Pathology Level IV Complexity,295352,CDM,971,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,60.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.74,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,145,,,Fee Schedule,145% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.35,145,,,Fee Schedule,145% of CMS OPPS Rate,44.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.44,193.34,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,960,RC,91035,HCPCS,Outpatient,,,876.09,438.05,,788.48,90,,,percent of total billed charges,90% of total Billed charges,690.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,351.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,484.88,155,,,Fee Schedule,155% of CMS OPPS Rate,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,722.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,334.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,812.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,812.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,650.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,650.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,383.65,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,668.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,484.88,145,,,Fee Schedule,145% of CMS OPPS Rate,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.82,145,,,Fee Schedule,145% of CMS OPPS Rate,484.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,482.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,334.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,777.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,777.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,334.4,1000.82,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (6m<5y) CVX 308,4303191,CDM,636,RC,91318,HCPCS,Outpatient,,,319.99,160.00,,287.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,255.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,287.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,310.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,294.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,204.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,251.68,78.65,,,percent of total billed charges,78.65% of total billed charges,285.85,89.33,,,percent of total billed charges,89.33% of total billed charges,287.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.99,70,,,percent of total billed charges,70% of total billed charges,287.99,90,,,percent of total billed charges,90% of total billed charges,303.99,95,,,percent of total billed charges,95% of total billed charges,303.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.19,86,,,percent of total billed charges,86% of total billed charges,255.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,310.39,97,,,percent of total billed charges,97% of total billed charges,287.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,310.39,97,,,percent of total billed charges,97% of total billed charges,297.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,310.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.35,310.39,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,962,RC,92060,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34,155,,,Fee Schedule,155% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34,145,,,Fee Schedule,145% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.32,145,,,Fee Schedule,145% of CMS OPPS Rate,34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.45,109.15,
92925 Percutaneous transluminal coronary atherectomy with c,3623286,CDM,960,RC,92925,HCPCS,Outpatient,,,808.89,404.45,,728,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.67,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.67,728,
92929 Percutaneous transcatheter placement of intracoronary,3623279,CDM,960,RC,92929,HCPCS,Outpatient,,,794.67,397.34,,715.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.4,715.2,
92938 Percutaneous transluminal revascularization of or thro,3622807,CDM,960,RC,92938,HCPCS,Outpatient,,,793.82,396.91,,714.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.15,714.44,
"92944 - (PF) Percutaneous transluminal revascularization of chronic total occlusion, coronary artery",3635238,CDM,960,RC,92944,HCPCS,Outpatient,,,893.79,446.90,,804.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.14,804.41,
Cardioversion,604545,CDM,960,RC,92960,HCPCS,Outpatient,,,214.35,107.18,,192.92,90,,,percent of total billed charges,90% of total Billed charges,252.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,151.95,155,,,Fee Schedule,155% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,151.95,145,,,Fee Schedule,145% of CMS OPPS Rate,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.62,145,,,Fee Schedule,145% of CMS OPPS Rate,151.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,238.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,87,366.62,
92978 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3621299,CDM,960,RC,92978,HCPCS,Outpatient,,,252.87,126.44,,227.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,537.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,397.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,397.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,236.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,282.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.58,537.66,
92979 (26) Endoluminal imaging of coronary vessel or graft using intravascular ultrasound (IVUS) or,3623711,CDM,960,RC,92979,HCPCS,Outpatient,,,201.76,100.88,,181.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,293.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,329.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,329.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,245.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,245.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,329.6,
Clinic EKG,3527352,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,25.21,90,,,percent of total billed charges,90% of total Billed charges,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.69,90,,,Percent of total Billed charges,90% of total billed charges,19.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.73,155,,,Fee Schedule,155% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,145,,,Fee Schedule,145% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.37,145,,,Fee Schedule,145% of CMS OPPS Rate,19.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,29.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.61,43.69,
EKG Pre/Post Unit,645285,CDM,960,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,11.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.22,155,,,Fee Schedule,155% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,145,,,Fee Schedule,145% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.14,145,,,Fee Schedule,145% of CMS OPPS Rate,8.22,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.67,19.34,
Electrocardiogram-Outpatient,604550,CDM,960,RC,93005,HCPCS,Outpatient,,,14.52,7.26,,13.07,90,,,percent of total billed charges,90% of total Billed charges,11.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.22,155,,,Fee Schedule,155% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,145,,,Fee Schedule,145% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.14,145,,,Fee Schedule,145% of CMS OPPS Rate,8.22,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.67,16.14,
PAT EKG,653557,CDM,960,RC,93005,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,11.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.22,155,,,Fee Schedule,155% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,145,,,Fee Schedule,145% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.14,145,,,Fee Schedule,145% of CMS OPPS Rate,8.22,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.67,19.34,
Stress Test,,,960,RC,93017,HCPCS,Outpatient,,,68.26,34.13,,61.43,90,,,percent of total billed charges,90% of total Billed charges,62.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.6,155,,,Fee Schedule,155% of CMS OPPS Rate,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,145,,,Fee Schedule,145% of CMS OPPS Rate,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.71,145,,,Fee Schedule,145% of CMS OPPS Rate,45.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.45,90.71,
CL Holter Monitor 24-48 hour,3430958,CDM,960,RC,93225,HCPCS,Outpatient,,,33.24,16.62,,29.92,90,,,percent of total billed charges,90% of total Billed charges,33.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.43,155,,,Fee Schedule,155% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.43,145,,,Fee Schedule,145% of CMS OPPS Rate,16.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.14,145,,,Fee Schedule,145% of CMS OPPS Rate,23.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,41.62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.16,50,
93228- MCT/rec/to 30 days/interp/rept,3430961,CDM,960,RC,93228,HCPCS,Outpatient,,,49.86,24.93,,44.87,90,,,percent of total billed charges,90% of total Billed charges,49.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.79,155,,,Fee Schedule,155% of CMS OPPS Rate,24.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.79,145,,,Fee Schedule,145% of CMS OPPS Rate,24.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.17,145,,,Fee Schedule,145% of CMS OPPS Rate,35.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,43.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.25,72.17,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,960,RC,93242,HCPCS,Outpatient,,,21.88,10.94,,19.69,90,,,percent of total billed charges,90% of total Billed charges,23.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.4,155,,,Fee Schedule,155% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.56,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.4,145,,,Fee Schedule,145% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.64,145,,,Fee Schedule,145% of CMS OPPS Rate,15.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.56,33.64,
93244 - External electrocardiographic recording for more than 48 hours up to 7 days by continuous rh,3635239,CDM,960,RC,93244,HCPCS,Outpatient,,,46.13,23.07,,41.52,90,,,percent of total billed charges,90% of total Billed charges,46.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,155,,,Fee Schedule,155% of CMS OPPS Rate,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.99,145,,,Fee Schedule,145% of CMS OPPS Rate,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.45,145,,,Fee Schedule,145% of CMS OPPS Rate,32.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.84,67.45,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,960,RC,93246,HCPCS,Outpatient,,,21.88,10.94,,19.69,90,,,percent of total billed charges,90% of total Billed charges,23.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.4,155,,,Fee Schedule,155% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.56,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.4,145,,,Fee Schedule,145% of CMS OPPS Rate,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.64,145,,,Fee Schedule,145% of CMS OPPS Rate,15.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.56,33.64,
CardioMEMS recalibration,3427124,CDM,960,RC,93264,HCPCS,Outpatient,,,72.14,36.07,,64.93,90,,,percent of total billed charges,90% of total Billed charges,81.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,155,,,Fee Schedule,155% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,145,,,Fee Schedule,145% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.84,145,,,Fee Schedule,145% of CMS OPPS Rate,50.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,118.84,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,960,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,13.76,90,,,percent of total billed charges,90% of total Billed charges,14.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,155,,,Fee Schedule,155% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,145,,,Fee Schedule,145% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.69,145,,,Fee Schedule,145% of CMS OPPS Rate,10.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.42,50,
Event Monitoring,604570,CDM,985,RC,93270,HCPCS,Outpatient,,,15.29,7.65,,13.76,90,,,percent of total billed charges,90% of total Billed charges,14.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,155,,,Fee Schedule,155% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,145,,,Fee Schedule,145% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.69,145,,,Fee Schedule,145% of CMS OPPS Rate,10.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.42,50,
93279- PPM eval/test/program/sgn lead,3430968,CDM,960,RC,93279,HCPCS,Outpatient,,,61.33,30.67,,55.2,90,,,percent of total billed charges,90% of total Billed charges,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,47.1,155,,,Fee Schedule,155% of CMS OPPS Rate,32.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.1,145,,,Fee Schedule,145% of CMS OPPS Rate,32.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.9,145,,,Fee Schedule,145% of CMS OPPS Rate,47.1,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,57.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,79.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.2,95.9,
93280- PPM eval/test/program/dual lead,3430969,CDM,960,RC,93280,HCPCS,Outpatient,,,72.65,36.33,,65.39,90,,,percent of total billed charges,90% of total Billed charges,77.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,54.71,155,,,Fee Schedule,155% of CMS OPPS Rate,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,100.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,100.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,145,,,Fee Schedule,145% of CMS OPPS Rate,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.71,145,,,Fee Schedule,145% of CMS OPPS Rate,54.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,91.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.73,111.71,
93281- PPM eval/test/program/multi lead,3430970,CDM,960,RC,93281,HCPCS,Outpatient,,,81.54,40.77,,73.39,90,,,percent of total billed charges,90% of total Billed charges,78.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.55,155,,,Fee Schedule,155% of CMS OPPS Rate,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.55,145,,,Fee Schedule,145% of CMS OPPS Rate,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.4,145,,,Fee Schedule,145% of CMS OPPS Rate,55.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.31,113.4,
93282- ICD eval/test/program/single lead,3430971,CDM,960,RC,93282,HCPCS,Outpatient,,,81.54,40.77,,73.39,90,,,percent of total billed charges,90% of total Billed charges,71.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.47,155,,,Fee Schedule,155% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.47,145,,,Fee Schedule,145% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.17,145,,,Fee Schedule,145% of CMS OPPS Rate,50.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,99.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.81,104.64,
93283- ICD eval/test/program/dual lead,3430972,CDM,960,RC,93283,HCPCS,Outpatient,,,109.86,54.93,,98.87,90,,,percent of total billed charges,90% of total Billed charges,77.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.13,155,,,Fee Schedule,155% of CMS OPPS Rate,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,145,,,Fee Schedule,145% of CMS OPPS Rate,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.55,145,,,Fee Schedule,145% of CMS OPPS Rate,55.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,89.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,128.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.02,130.8,
93284- ICD eval/test/program/mult lead,3430973,CDM,960,RC,93284,HCPCS,Outpatient,,,119.19,59.60,,107.27,90,,,percent of total billed charges,90% of total Billed charges,82.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.93,155,,,Fee Schedule,155% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,141.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,141.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,141.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.93,145,,,Fee Schedule,145% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.23,145,,,Fee Schedule,145% of CMS OPPS Rate,58.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,140.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.64,141.36,
93285- ILR eval/test/program,3430974,CDM,960,RC,93285,HCPCS,Outpatient,,,49.93,24.97,,44.94,90,,,percent of total billed charges,90% of total Billed charges,64.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.41,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.41,145,,,Fee Schedule,145% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.93,145,,,Fee Schedule,145% of CMS OPPS Rate,45.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.14,92.93,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,960,RC,93288,HCPCS,Outpatient,,,40.34,20.17,,36.31,90,,,percent of total billed charges,90% of total Billed charges,65.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.26,155,,,Fee Schedule,155% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,145,,,Fee Schedule,145% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.64,145,,,Fee Schedule,145% of CMS OPPS Rate,46.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.73,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.73,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.26,94.64,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,960,RC,93289,HCPCS,Outpatient,,,71.59,35.80,,64.43,90,,,percent of total billed charges,90% of total Billed charges,65.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.68,155,,,Fee Schedule,155% of CMS OPPS Rate,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.68,145,,,Fee Schedule,145% of CMS OPPS Rate,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.48,145,,,Fee Schedule,145% of CMS OPPS Rate,46.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.19,103.78,
ICD Generator Testing,3427177,CDM,960,RC,93289,HCPCS,Outpatient,,,71.59,35.80,,64.43,90,,,percent of total billed charges,90% of total Billed charges,65.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.68,155,,,Fee Schedule,155% of CMS OPPS Rate,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.68,145,,,Fee Schedule,145% of CMS OPPS Rate,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.48,145,,,Fee Schedule,145% of CMS OPPS Rate,46.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.19,103.78,
93291- Internal loop rec/interr/in person,3430980,CDM,960,RC,93291,HCPCS,Outpatient,,,34.98,17.49,,31.48,90,,,percent of total billed charges,90% of total Billed charges,57.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.76,155,,,Fee Schedule,155% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.76,145,,,Fee Schedule,145% of CMS OPPS Rate,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.55,145,,,Fee Schedule,145% of CMS OPPS Rate,40.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.11,83.55,
93296- PM remote trans/90 day/tech review,3430985,CDM,960,RC,93296,HCPCS,Outpatient,,,38.63,19.32,,34.77,90,,,percent of total billed charges,90% of total Billed charges,40.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.51,155,,,Fee Schedule,155% of CMS OPPS Rate,19.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.51,145,,,Fee Schedule,145% of CMS OPPS Rate,19.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.38,145,,,Fee Schedule,145% of CMS OPPS Rate,28.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,19.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,39.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.66,58.38,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.49,155,,,Fee Schedule,155% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.49,145,,,Fee Schedule,145% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.3,145,,,Fee Schedule,145% of CMS OPPS Rate,163.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.75,331.3,
CL Adult Echocardiogram,3334933,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.49,155,,,Fee Schedule,155% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.49,145,,,Fee Schedule,145% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.3,145,,,Fee Schedule,145% of CMS OPPS Rate,163.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.75,331.3,
Echocardiogram,604555,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.49,155,,,Fee Schedule,155% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.49,145,,,Fee Schedule,145% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.3,145,,,Fee Schedule,145% of CMS OPPS Rate,163.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.75,331.3,
MCNH Echo Transthoracic Complete,3805223,CDM,960,RC,93306,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,228.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,163.49,155,,,Fee Schedule,155% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,284.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,284.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,284.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,205.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,225.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.49,145,,,Fee Schedule,145% of CMS OPPS Rate,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.3,145,,,Fee Schedule,145% of CMS OPPS Rate,163.49,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,112.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,305.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,112.75,331.3,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
CL Limited Echocardiogram,3334936,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
Dobutamine Valve Study,4179565,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
Limited Study-Echo,645295,CDM,960,RC,93308,HCPCS,Outpatient,,,49.42,24.71,,44.48,90,,,percent of total billed charges,90% of total Billed charges,98.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.66,155,,,Fee Schedule,155% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.66,145,,,Fee Schedule,145% of CMS OPPS Rate,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.32,145,,,Fee Schedule,145% of CMS OPPS Rate,71.66,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.5,154.52,
93325 Doppler echo color flow,4061247,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.79,155,,,Fee Schedule,155% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.79,145,,,Fee Schedule,145% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.57,145,,,Fee Schedule,145% of CMS OPPS Rate,8.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.45,105.78,
93325- Doppler echo color flow,3431006,CDM,960,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.79,155,,,Fee Schedule,155% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.79,145,,,Fee Schedule,145% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.57,145,,,Fee Schedule,145% of CMS OPPS Rate,8.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.45,105.78,
Color Flow Mapping,604586,CDM,985,RC,93325,HCPCS,Outpatient,,,6.06,3.03,,5.45,90,,,percent of total billed charges,90% of total Billed charges,12.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.79,155,,,Fee Schedule,155% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.79,145,,,Fee Schedule,145% of CMS OPPS Rate,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.57,145,,,Fee Schedule,145% of CMS OPPS Rate,8.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.45,105.78,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,209.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.83,90,,,Percent of total Billed charges,90% of total billed charges,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.55,155,,,Fee Schedule,155% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.55,145,,,Fee Schedule,145% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.46,145,,,Fee Schedule,145% of CMS OPPS Rate,149.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.5,475.83,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,209.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.83,90,,,Percent of total Billed charges,90% of total billed charges,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.55,155,,,Fee Schedule,155% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.55,145,,,Fee Schedule,145% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.46,145,,,Fee Schedule,145% of CMS OPPS Rate,149.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.5,475.83,
CL Exercise Stress Echocardiogram,3334934,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,209.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.83,90,,,Percent of total Billed charges,90% of total billed charges,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.55,155,,,Fee Schedule,155% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.55,145,,,Fee Schedule,145% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.46,145,,,Fee Schedule,145% of CMS OPPS Rate,149.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.5,475.83,
CVS Charge Stress Echo,1157011,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,209.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.83,90,,,Percent of total Billed charges,90% of total billed charges,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.55,155,,,Fee Schedule,155% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.55,145,,,Fee Schedule,145% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.46,145,,,Fee Schedule,145% of CMS OPPS Rate,149.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.5,475.83,
Stress Echocardiogram,604568,CDM,960,RC,93350,HCPCS,Outpatient,,,136.49,68.25,,122.84,90,,,percent of total billed charges,90% of total Billed charges,209.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.83,90,,,Percent of total Billed charges,90% of total billed charges,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.55,155,,,Fee Schedule,155% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,260.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,191.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.55,145,,,Fee Schedule,145% of CMS OPPS Rate,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.46,145,,,Fee Schedule,145% of CMS OPPS Rate,149.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,325.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.5,475.83,
Myocardial Strain Imaging,3824895,CDM,960,RC,93356,HCPCS,Outpatient,,,23.3,11.65,,20.97,90,,,percent of total billed charges,90% of total Billed charges,34.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.41,155,,,Fee Schedule,155% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.41,145,,,Fee Schedule,145% of CMS OPPS Rate,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.2,145,,,Fee Schedule,145% of CMS OPPS Rate,16.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,54.71,
93454- Coronary angiogram,3430771,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,976.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,155,,,Fee Schedule,155% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1599.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,737.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,145,,,Fee Schedule,145% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.46,145,,,Fee Schedule,145% of CMS OPPS Rate,707.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,790.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1467.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,439.28,1599.06,
Coronary Angiography,604572,CDM,960,RC,93454,HCPCS,Outpatient,,,488.09,244.05,,439.28,90,,,percent of total billed charges,90% of total Billed charges,976.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,155,,,Fee Schedule,155% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1421.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1599.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1599.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1258.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,737.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,976.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,707.73,145,,,Fee Schedule,145% of CMS OPPS Rate,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.46,145,,,Fee Schedule,145% of CMS OPPS Rate,707.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,790.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,488.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1467.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1467.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,439.28,1599.06,
AV Nodal Ablation,3427172,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,1173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,545.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,842.74,155,,,Fee Schedule,155% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1057.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1057.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,479.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1162.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,782.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,842.74,145,,,Fee Schedule,145% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1701.65,145,,,Fee Schedule,145% of CMS OPPS Rate,842.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,790.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,976.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,479.79,1701.65,
AV Node Ablation,651265,CDM,960,RC,93650,HCPCS,Outpatient,,,1191.21,595.61,,1072.09,90,,,percent of total billed charges,90% of total Billed charges,1173.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,545.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,842.74,155,,,Fee Schedule,155% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,939.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1057.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1057.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,923.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,479.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1162.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,831.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,782.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,842.74,145,,,Fee Schedule,145% of CMS OPPS Rate,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,1701.65,145,,,Fee Schedule,145% of CMS OPPS Rate,842.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,545.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,790.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,581.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,976.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,479.79,1701.65,
INR POC,3444194,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,25.85,90,,,percent of total billed charges,90% of total Billed charges,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,155,,,Fee Schedule,155% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,145,,,Fee Schedule,145% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.47,145,,,Fee Schedule,145% of CMS OPPS Rate,15.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,31.47,
Prothrombin and INR POC,3444204,CDM,960,RC,93793,HCPCS,Outpatient,,,28.72,14.36,,25.85,90,,,percent of total billed charges,90% of total Billed charges,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,155,,,Fee Schedule,155% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,16.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.81,145,,,Fee Schedule,145% of CMS OPPS Rate,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.47,145,,,Fee Schedule,145% of CMS OPPS Rate,15.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.62,31.47,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,983,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
CL Carotid Duplex Complete BILAT,3427518,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
CL Carotid Duplex Complete LT,3427513,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
CL Carotid Duplex Complete RT,3427515,CDM,960,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
Read,3370901,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
Read,3370939,CDM,972,RC,93880,HCPCS,Outpatient,,,76.98,38.49,,69.28,90,,,percent of total billed charges,90% of total Billed charges,153.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.62,155,,,Fee Schedule,155% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,405.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.62,145,,,Fee Schedule,145% of CMS OPPS Rate,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.24,145,,,Fee Schedule,145% of CMS OPPS Rate,111.62,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,392.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.28,405.36,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Carotid Duplex Limited BILAT,3427517,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Carotid Duplex Limited LT,3427514,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Carotid Duplex Limited RT,3427516,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Limited Carotid Post Procedure LT,3427522,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
CL Limited Carotid Post Procedure RT,3427523,CDM,960,RC,93882,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,138.07,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,215,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,286.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,286.24,
93922-PF Non-Invas Physiologic STD Extremity Art 2 Level,4345293,CDM,983,RC,93922,HCPCS,Outpatient,,,24.32,12.16,,21.89,90,,,percent of total billed charges,90% of total Billed charges,48.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.26,155,,,Fee Schedule,155% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,114.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,114.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.26,145,,,Fee Schedule,145% of CMS OPPS Rate,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.53,145,,,Fee Schedule,145% of CMS OPPS Rate,35.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.89,151.1,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,983,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Extrem Art Physiologic LT,3427526,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Extrem Art Physiologic RT,3427527,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL US Lower Extrem Art Complete LT,3427503,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
CL US Lower Extrem Art Complete RT,3427505,CDM,960,RC,93923,HCPCS,Outpatient,,,44.56,22.28,,40.1,90,,,percent of total billed charges,90% of total Billed charges,89.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.61,155,,,Fee Schedule,155% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,188.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.61,145,,,Fee Schedule,145% of CMS OPPS Rate,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.22,145,,,Fee Schedule,145% of CMS OPPS Rate,64.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.1,235.49,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,960,RC,93924,HCPCS,Outpatient,,,48.63,24.32,,43.77,90,,,percent of total billed charges,90% of total Billed charges,97.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.97,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.51,155,,,Fee Schedule,155% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,332.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,180.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.51,145,,,Fee Schedule,145% of CMS OPPS Rate,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.03,145,,,Fee Schedule,145% of CMS OPPS Rate,70.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,226,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,299.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,332.05,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,90.97,90,,,percent of total billed charges,90% of total Billed charges,202.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,146.57,155,,,Fee Schedule,155% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,515.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.57,145,,,Fee Schedule,145% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.13,145,,,Fee Schedule,145% of CMS OPPS Rate,146.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,497.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.97,515.33,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,90.97,90,,,percent of total billed charges,90% of total Billed charges,202.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,146.57,155,,,Fee Schedule,155% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,515.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.57,145,,,Fee Schedule,145% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.13,145,,,Fee Schedule,145% of CMS OPPS Rate,146.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,497.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.97,515.33,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,960,RC,93925,HCPCS,Outpatient,,,101.08,50.54,,90.97,90,,,percent of total billed charges,90% of total Billed charges,202.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.81,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,146.57,155,,,Fee Schedule,155% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,458.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,515.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,340.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,207.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.57,145,,,Fee Schedule,145% of CMS OPPS Rate,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.13,145,,,Fee Schedule,145% of CMS OPPS Rate,146.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,101.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,497.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.97,515.33,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
93926 (26) Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620983,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
CL Femoral Groin Artery BILAT,3427521,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
CL Femoral Groin Artery LT,3427519,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
CL Femoral Groin Artery RT,3427520,CDM,960,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
Read,3370912,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
Read,3569748,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
Read,3569750,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
SCSN US Arterial w Seg Pressures LT,3575261,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
US Lower Ext Arterial Rt Complete:Read,3374601,CDM,972,RC,93926,HCPCS,Outpatient,,,47.11,23.56,,42.4,90,,,percent of total billed charges,90% of total Billed charges,94.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.31,155,,,Fee Schedule,155% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,304.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,304.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,202.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.31,145,,,Fee Schedule,145% of CMS OPPS Rate,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.62,145,,,Fee Schedule,145% of CMS OPPS Rate,68.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,330.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.4,330.15,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,960,RC,93930,HCPCS,Outpatient,,,102.49,51.25,,92.24,90,,,percent of total billed charges,90% of total Billed charges,204.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,141.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,148.61,155,,,Fee Schedule,155% of CMS OPPS Rate,102.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,419.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,419.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,278.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,278.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,166.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,204.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.61,145,,,Fee Schedule,145% of CMS OPPS Rate,102.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.22,145,,,Fee Schedule,145% of CMS OPPS Rate,148.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,102.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,102.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,397.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,397.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,92.24,419.02,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,960,RC,93931,HCPCS,Outpatient,,,63.38,31.69,,57.04,90,,,percent of total billed charges,90% of total Billed charges,126.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.9,155,,,Fee Schedule,155% of CMS OPPS Rate,63.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,126.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.9,145,,,Fee Schedule,145% of CMS OPPS Rate,63.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.8,145,,,Fee Schedule,145% of CMS OPPS Rate,91.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,63.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,63.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.04,264.57,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93970-PF Dup-Scan XTR Veins Complete Bilateral Study,4345294,CDM,983,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL Periph Venous US Lower BILAT,3427536,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL Periph Venous US Upper BILAT,3427537,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,960,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,3575249,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
Read,4345742,CDM,972,RC,93970,HCPCS,Outpatient,,,325.8,162.90,,293.22,90,,,percent of total billed charges,90% of total Billed charges,275.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.13,155,,,Fee Schedule,155% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.13,145,,,Fee Schedule,145% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.52,145,,,Fee Schedule,145% of CMS OPPS Rate,198.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,136.64,411.68,
Read,4345744,CDM,972,RC,93970,HCPCS,Outpatient,,,325.8,162.90,,293.22,90,,,percent of total billed charges,90% of total Billed charges,275.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.13,155,,,Fee Schedule,155% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.13,145,,,Fee Schedule,145% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.52,145,,,Fee Schedule,145% of CMS OPPS Rate,198.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,136.64,411.68,
SCMP US Vein Mapping:Read,3575251,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
SCSN US Venous Lower Bilat Interp,3575317,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
SCSN US Venous Upper Bilat Interp,3575323,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
SCSN Venous Insufficiency Bilat Interp,3575329,CDM,983,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
WHC US Extremity Vein Complete:Read,2198104,CDM,972,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,133.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.74,155,,,Fee Schedule,155% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.74,145,,,Fee Schedule,145% of CMS OPPS Rate,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.49,145,,,Fee Schedule,145% of CMS OPPS Rate,96.74,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.05,411.68,
93971 - PB Tech Duplex scan of extremity veins including responses to compression and other maneuver,3641197,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
93971-PF Dup-Scan XTR Veins Unilat/Limited Study,4345295,CDM,983,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Periph Venous US Lower LT,3427534,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Periph Venous US Lower RT,3427535,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Periph Venous US Upper LT,3427538,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Periph Venous US Upper RT,3427569,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Upper Periph Arterial Duplex LT,3427572,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Upper Periph Arterial Duplex RT,3427570,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,960,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569778,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569780,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569784,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569786,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569790,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
Read,3569792,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN US Venous Lower LT Interp,3575319,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN US Venous Lower RT Interp,3575321,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN US Venous Upper LT,3575325,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN US Venous Upper RT Interp,3575327,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN Venous Insuff LT Interp,3575331,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
SCSN Venous Insuff RT Interp,3575333,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
WHC US Extremity Vein Rt:Read,2198108,CDM,972,RC,93971,HCPCS,Outpatient,,,42.4,21.20,,38.16,90,,,percent of total billed charges,90% of total Billed charges,84.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.48,155,,,Fee Schedule,155% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.48,145,,,Fee Schedule,145% of CMS OPPS Rate,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.96,145,,,Fee Schedule,145% of CMS OPPS Rate,61.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.16,268.56,
CL Renal Artery Ultrasound BILAT,3427575,CDM,960,RC,93975,HCPCS,Outpatient,,,111,55.50,,99.9,90,,,percent of total billed charges,90% of total Billed charges,222,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,182.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,160.95,155,,,Fee Schedule,155% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,562.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,562.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,374.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,224.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.95,145,,,Fee Schedule,145% of CMS OPPS Rate,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.9,145,,,Fee Schedule,145% of CMS OPPS Rate,160.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111,100,,,Fee Schedule,100% of CMS OPPS Rate ,598.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,598.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99.9,598.14,
Clinic Abdominal Aortic Ultrasound,3347684,CDM,960,RC,93978,HCPCS,Outpatient,,,77.95,38.98,,70.16,90,,,percent of total billed charges,90% of total Billed charges,155.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.95,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.03,155,,,Fee Schedule,155% of CMS OPPS Rate,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,255.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,255.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,152.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.03,145,,,Fee Schedule,145% of CMS OPPS Rate,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.06,145,,,Fee Schedule,145% of CMS OPPS Rate,113.03,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,77.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.17,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,387.17,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.16,387.17,
93990- Dup scan/hemodialysis access,3435559,CDM,960,RC,93990,HCPCS,Outpatient,,,64.62,32.31,,58.16,90,,,percent of total billed charges,90% of total Billed charges,129.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.7,155,,,Fee Schedule,155% of CMS OPPS Rate,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,315.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,209.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,136.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.7,145,,,Fee Schedule,145% of CMS OPPS Rate,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.4,145,,,Fee Schedule,145% of CMS OPPS Rate,93.7,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.16,351.81,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,40.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.33,90,,,Percent of total Billed charges,90% of total billed charges,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,145,,,Fee Schedule,145% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.13,145,,,Fee Schedule,145% of CMS OPPS Rate,29.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.35,100.36,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,40.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.33,90,,,Percent of total Billed charges,90% of total billed charges,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,145,,,Fee Schedule,145% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.13,145,,,Fee Schedule,145% of CMS OPPS Rate,29.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.35,100.36,
Clinic Spirometry with and without,3435734,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,40.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.33,90,,,Percent of total Billed charges,90% of total billed charges,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,145,,,Fee Schedule,145% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.13,145,,,Fee Schedule,145% of CMS OPPS Rate,29.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.35,100.36,
PFT,617666,CDM,960,RC,94060,HCPCS,Outpatient,,,20.39,10.20,,18.35,90,,,percent of total billed charges,90% of total Billed charges,40.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.33,90,,,Percent of total Billed charges,90% of total billed charges,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,145,,,Fee Schedule,145% of CMS OPPS Rate,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.13,145,,,Fee Schedule,145% of CMS OPPS Rate,29.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.35,100.36,
6 Minute Walk,658839,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.35,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,48.42,
Clinic 6 min walk,3435728,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.35,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,48.42,
Clinic 6 min walk with Oxygen titration,3435729,CDM,960,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.35,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,48.42,
Six Minute Walk Test,634111,CDM,983,RC,94618,HCPCS,Outpatient,,,44.14,22.07,,39.73,90,,,percent of total billed charges,90% of total Billed charges,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.35,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,48.42,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
94726 - PF Plethysmography/lung volume,3715330,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,983,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
94726- Plethysmography/lung volume,3435709,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
Clinic Lung Volumes,3435732,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
Lung Vol & Capacity,617686,CDM,960,RC,94726,HCPCS,Outpatient,,,23.77,11.89,,21.39,90,,,percent of total billed charges,90% of total Billed charges,47.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.47,155,,,Fee Schedule,155% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.47,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.93,145,,,Fee Schedule,145% of CMS OPPS Rate,34.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.39,76.23,
94729- Diffusing capacity/CO2/add on,3435712,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.67,155,,,Fee Schedule,155% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.67,145,,,Fee Schedule,145% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.33,145,,,Fee Schedule,145% of CMS OPPS Rate,25.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,80.27,
Carbon Monoxide Diffusing Capacity,625084,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.67,155,,,Fee Schedule,155% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.67,145,,,Fee Schedule,145% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.33,145,,,Fee Schedule,145% of CMS OPPS Rate,25.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,80.27,
Clinic Diffusion Capacity,3435730,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.67,155,,,Fee Schedule,155% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.67,145,,,Fee Schedule,145% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.33,145,,,Fee Schedule,145% of CMS OPPS Rate,25.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,80.27,
DLCO,617682,CDM,960,RC,94729,HCPCS,Outpatient,,,17.7,8.85,,15.93,90,,,percent of total billed charges,90% of total Billed charges,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.67,155,,,Fee Schedule,155% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.67,145,,,Fee Schedule,145% of CMS OPPS Rate,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.33,145,,,Fee Schedule,145% of CMS OPPS Rate,25.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.93,80.27,
94762- Noninv ear/pulse ox/cont/overnight,3435716,CDM,960,RC,94762,HCPCS,Outpatient,,,45.81,22.91,,41.23,90,,,percent of total billed charges,90% of total Billed charges,45.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.31,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.31,145,,,Fee Schedule,145% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.05,145,,,Fee Schedule,145% of CMS OPPS Rate,32.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.11,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,17.11,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.11,66.05,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,983,RC,95800,HCPCS,Outpatient,,,78.55,39.28,,70.7,90,,,percent of total billed charges,90% of total Billed charges,157.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.9,155,,,Fee Schedule,155% of CMS OPPS Rate,78.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,224.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,224.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,173.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.9,145,,,Fee Schedule,145% of CMS OPPS Rate,78.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.8,145,,,Fee Schedule,145% of CMS OPPS Rate,113.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,344.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,344.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,70.7,344.97,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,983,RC,95801,HCPCS,Outpatient,,,80.92,40.46,,72.83,90,,,percent of total billed charges,90% of total Billed charges,90.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.16,155,,,Fee Schedule,155% of CMS OPPS Rate,46.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.16,145,,,Fee Schedule,145% of CMS OPPS Rate,46.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.05,145,,,Fee Schedule,145% of CMS OPPS Rate,67.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.51,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,162.51,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,46.32,162.51,
Sleep Study - In Lab MSLT 95805,3575514,CDM,960,RC,95805,HCPCS,Outpatient,,,113.34,56.67,,102.01,90,,,percent of total billed charges,90% of total Billed charges,226.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,236.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.34,155,,,Fee Schedule,155% of CMS OPPS Rate,113.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,591.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,591.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,555.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,555.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,420.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,226.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.34,145,,,Fee Schedule,145% of CMS OPPS Rate,113.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,328.69,145,,,Fee Schedule,145% of CMS OPPS Rate,164.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,650.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.01,650.6,
Sleep Study - Home Study 95806,3575513,CDM,960,RC,95806,HCPCS,Outpatient,,,87.09,43.55,,78.38,90,,,percent of total billed charges,90% of total Billed charges,84.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.67,155,,,Fee Schedule,155% of CMS OPPS Rate,42.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,161.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,161.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,128.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.67,145,,,Fee Schedule,145% of CMS OPPS Rate,42.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.28,145,,,Fee Schedule,145% of CMS OPPS Rate,61.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,219.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,274.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,274.84,
95807 - Sleep Study - Attended,4347085,CDM,983,RC,95807,HCPCS,Outpatient,,,753.51,376.76,,678.16,90,,,percent of total billed charges,90% of total Billed charges,569.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,287.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,335.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,416.96,155,,,Fee Schedule,155% of CMS OPPS Rate,287.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,287.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,580.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,580.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,545.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,545.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,414.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,575.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,408.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.96,145,,,Fee Schedule,145% of CMS OPPS Rate,287.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,825.78,145,,,Fee Schedule,145% of CMS OPPS Rate,416.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,287.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,498,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,287.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,695.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,695.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,287.56,825.78,
95808- Polysomnography/any age/tech,3430545,CDM,960,RC,95808,HCPCS,Outpatient,,,164.64,82.32,,148.18,90,,,percent of total billed charges,90% of total Billed charges,329.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,346.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,238.73,155,,,Fee Schedule,155% of CMS OPPS Rate,164.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,826.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,929.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,929.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,871.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,871.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,512.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.73,145,,,Fee Schedule,145% of CMS OPPS Rate,164.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,477.46,145,,,Fee Schedule,145% of CMS OPPS Rate,238.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,164.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,164.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,1047.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1047.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,148.18,1047.46,
Sleep Study - In Lab PSG 95810,3575515,CDM,960,RC,95810,HCPCS,Outpatient,,,234.54,117.27,,211.09,90,,,percent of total billed charges,90% of total Billed charges,469.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,346.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,340.08,155,,,Fee Schedule,155% of CMS OPPS Rate,234.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,868.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,868.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,822,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,822,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,628.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,469.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,234.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,340.08,145,,,Fee Schedule,145% of CMS OPPS Rate,234.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.17,145,,,Fee Schedule,145% of CMS OPPS Rate,340.08,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,234.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,788,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,234.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,983.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,211.09,983.6,
Sleep Study - In Lab Titration 95811,3575516,CDM,960,RC,95811,HCPCS,Outpatient,,,244.18,122.09,,219.76,90,,,percent of total billed charges,90% of total Billed charges,488.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,647.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,354.06,155,,,Fee Schedule,155% of CMS OPPS Rate,244.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,244.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,907.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,907.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,858.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,858.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,690.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,488.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.06,145,,,Fee Schedule,145% of CMS OPPS Rate,244.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,708.12,145,,,Fee Schedule,145% of CMS OPPS Rate,354.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,244.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,647.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,850,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,244.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,1032.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1032.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,219.76,1032.06,
Clinic EEG,3435538,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,552.56,90,,,percent of total billed charges,90% of total Billed charges,509.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,367.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,259.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,319.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.17,145,,,Fee Schedule,145% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,738.96,145,,,Fee Schedule,145% of CMS OPPS Rate,367.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,621.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,621.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.48,738.96,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,960,RC,95812,HCPCS,Outpatient,,,613.96,306.98,,552.56,90,,,percent of total billed charges,90% of total Billed charges,509.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,367.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,450.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,450.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,441.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,259.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,319.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.17,145,,,Fee Schedule,145% of CMS OPPS Rate,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,738.96,145,,,Fee Schedule,145% of CMS OPPS Rate,367.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,621.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,621.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.48,738.96,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,689.15,90,,,percent of total billed charges,90% of total Billed charges,604.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,116.87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,436.89,155,,,Fee Schedule,155% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.89,145,,,Fee Schedule,145% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.28,145,,,Fee Schedule,145% of CMS OPPS Rate,436.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,660.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,116.87,876.28,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,960,RC,95813,HCPCS,Outpatient,,,765.72,382.86,,689.15,90,,,percent of total billed charges,90% of total Billed charges,604.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,116.87,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,436.89,155,,,Fee Schedule,155% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,498.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,560.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,560.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,551.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,325.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,602.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,379.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,436.89,145,,,Fee Schedule,145% of CMS OPPS Rate,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,876.28,145,,,Fee Schedule,145% of CMS OPPS Rate,436.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,301.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,660.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,660.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,116.87,876.28,
95816- EEG w/recording/awake/drowsy,3435465,CDM,960,RC,95816,HCPCS,Outpatient,,,113.76,56.88,,102.38,90,,,percent of total billed charges,90% of total Billed charges,227.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.95,155,,,Fee Schedule,155% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,444.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,499.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,499.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,487.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,487.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,289.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.95,145,,,Fee Schedule,145% of CMS OPPS Rate,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.9,145,,,Fee Schedule,145% of CMS OPPS Rate,164.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,281.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,578.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,578.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,578.75,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,960,RC,95860,HCPCS,Outpatient,,,131.45,65.73,,118.31,90,,,percent of total billed charges,90% of total Billed charges,111.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.87,90,,,Percent of total Billed charges,90% of total billed charges,30,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,79.21,155,,,Fee Schedule,155% of CMS OPPS Rate,54.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,164.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,79.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.21,145,,,Fee Schedule,145% of CMS OPPS Rate,54.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.18,145,,,Fee Schedule,145% of CMS OPPS Rate,79.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,109,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.94,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,161.94,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30,170.87,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,960,RC,95861,HCPCS,Outpatient,,,211.33,105.67,,190.2,90,,,percent of total billed charges,90% of total Billed charges,145.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.15,90,,,Percent of total Billed charges,90% of total billed charges,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,102.46,155,,,Fee Schedule,155% of CMS OPPS Rate,70.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,239.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,239.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,137.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,141.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.46,145,,,Fee Schedule,145% of CMS OPPS Rate,70.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.69,145,,,Fee Schedule,145% of CMS OPPS Rate,102.46,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,70.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,70.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,238.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,246.15,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,960,RC,95863,HCPCS,Outpatient,,,255.94,127.97,,230.35,90,,,percent of total billed charges,90% of total Billed charges,201.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,140.91,155,,,Fee Schedule,155% of CMS OPPS Rate,97.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,292.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,295.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,295.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,172.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.91,145,,,Fee Schedule,145% of CMS OPPS Rate,97.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.77,145,,,Fee Schedule,145% of CMS OPPS Rate,140.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.37,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.37,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.5,295.67,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,960,RC,95864,HCPCS,Outpatient,,,273.91,136.96,,246.52,90,,,percent of total billed charges,90% of total Billed charges,233.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.58,155,,,Fee Schedule,155% of CMS OPPS Rate,113.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,342.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,345.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,345.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,194.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.58,145,,,Fee Schedule,145% of CMS OPPS Rate,113.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.11,145,,,Fee Schedule,145% of CMS OPPS Rate,164.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,209.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,345.51,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,960,RC,95869,HCPCS,Outpatient,,,171.62,85.81,,154.46,90,,,percent of total billed charges,90% of total Billed charges,137.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.96,155,,,Fee Schedule,155% of CMS OPPS Rate,66.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.96,145,,,Fee Schedule,145% of CMS OPPS Rate,66.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.03,145,,,Fee Schedule,145% of CMS OPPS Rate,96.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,66.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,66.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.79,200.03,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,960,RC,95870,HCPCS,Outpatient,,,149.46,74.73,,134.51,90,,,percent of total billed charges,90% of total Billed charges,115.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.33,155,,,Fee Schedule,155% of CMS OPPS Rate,56.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,122.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,122.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.33,145,,,Fee Schedule,145% of CMS OPPS Rate,56.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.61,145,,,Fee Schedule,145% of CMS OPPS Rate,81.33,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,113.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.79,167.61,
95873- Electric stim/w chemodenervation,3435482,CDM,960,RC,95873,HCPCS,Outpatient,,,129.1,64.55,,116.19,90,,,percent of total billed charges,90% of total Billed charges,96.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.76,155,,,Fee Schedule,155% of CMS OPPS Rate,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.76,145,,,Fee Schedule,145% of CMS OPPS Rate,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.94,145,,,Fee Schedule,145% of CMS OPPS Rate,66.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,113.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.42,139.94,
95874- Needle EMG/chemodenervation,3435483,CDM,960,RC,95874,HCPCS,Outpatient,,,138.42,69.21,,124.58,90,,,percent of total billed charges,90% of total Billed charges,104.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,155,,,Fee Schedule,155% of CMS OPPS Rate,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,106.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,106.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,145,,,Fee Schedule,145% of CMS OPPS Rate,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.86,145,,,Fee Schedule,145% of CMS OPPS Rate,73.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,109.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.98,151.86,
Clinic EMG,3435539,CDM,960,RC,95874,HCPCS,Outpatient,,,138.42,69.21,,124.58,90,,,percent of total billed charges,90% of total Billed charges,104.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,155,,,Fee Schedule,155% of CMS OPPS Rate,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,106.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,106.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.52,145,,,Fee Schedule,145% of CMS OPPS Rate,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.86,145,,,Fee Schedule,145% of CMS OPPS Rate,73.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,109.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.98,151.86,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,960,RC,95885,HCPCS,Outpatient,,,111.42,55.71,,100.28,90,,,percent of total billed charges,90% of total Billed charges,79.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.71,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.77,155,,,Fee Schedule,155% of CMS OPPS Rate,38.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.77,145,,,Fee Schedule,145% of CMS OPPS Rate,38.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.17,145,,,Fee Schedule,145% of CMS OPPS Rate,55.77,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,48.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.46,115.17,
95886- Needle electromyography/ea ext/com,3435486,CDM,960,RC,95886,HCPCS,Outpatient,,,178.88,89.44,,160.99,90,,,percent of total billed charges,90% of total Billed charges,95.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,66.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,66.76,155,,,Fee Schedule,155% of CMS OPPS Rate,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,72.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.76,145,,,Fee Schedule,145% of CMS OPPS Rate,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.79,145,,,Fee Schedule,145% of CMS OPPS Rate,66.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.04,160.99,
95887- Needle electromyography/non-ext,3435487,CDM,960,RC,95887,HCPCS,Outpatient,,,153.56,76.78,,138.2,90,,,percent of total billed charges,90% of total Billed charges,84.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,59.58,155,,,Fee Schedule,155% of CMS OPPS Rate,41.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.58,145,,,Fee Schedule,145% of CMS OPPS Rate,41.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.86,145,,,Fee Schedule,145% of CMS OPPS Rate,59.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.09,138.2,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,960,RC,95905,HCPCS,Outpatient,,,61.06,30.53,,54.95,90,,,percent of total billed charges,90% of total Billed charges,59.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.34,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,60.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.34,145,,,Fee Schedule,145% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.14,145,,,Fee Schedule,145% of CMS OPPS Rate,40.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,65.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.41,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,141.41,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,141.41,
95907- Nerve conduction study/1-2 study,3435491,CDM,960,RC,95907,HCPCS,Outpatient,,,166.48,83.24,,149.83,90,,,percent of total billed charges,90% of total Billed charges,67.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,71.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,47.94,155,,,Fee Schedule,155% of CMS OPPS Rate,33.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,80.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.94,145,,,Fee Schedule,145% of CMS OPPS Rate,33.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.47,145,,,Fee Schedule,145% of CMS OPPS Rate,47.94,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.06,149.83,
95908- Nerve conduction study/3-4 study,3435492,CDM,960,RC,95908,HCPCS,Outpatient,,,206.74,103.37,,186.07,90,,,percent of total billed charges,90% of total Billed charges,84.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.6,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,59.35,155,,,Fee Schedule,155% of CMS OPPS Rate,40.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,166.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.35,145,,,Fee Schedule,145% of CMS OPPS Rate,40.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,145,,,Fee Schedule,145% of CMS OPPS Rate,59.35,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.93,186.07,
95909- Nerve conduction study/5-6 study,3435493,CDM,960,RC,95909,HCPCS,Outpatient,,,248.72,124.36,,223.85,90,,,percent of total billed charges,90% of total Billed charges,100.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,71.18,155,,,Fee Schedule,155% of CMS OPPS Rate,49.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,204.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,204.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,119.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.18,145,,,Fee Schedule,145% of CMS OPPS Rate,49.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.26,145,,,Fee Schedule,145% of CMS OPPS Rate,71.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,123.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.09,223.85,
95910- Nerve conduction study/7-8 study,3435494,CDM,960,RC,95910,HCPCS,Outpatient,,,325.7,162.85,,293.13,90,,,percent of total billed charges,90% of total Billed charges,128.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.05,155,,,Fee Schedule,155% of CMS OPPS Rate,62.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,262.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,262.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,157.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.05,145,,,Fee Schedule,145% of CMS OPPS Rate,62.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.35,145,,,Fee Schedule,145% of CMS OPPS Rate,91.05,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,162.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.79,293.13,
95911- Nerve conduction study/9-10 study,3435495,CDM,960,RC,95911,HCPCS,Outpatient,,,393.94,196.97,,354.55,90,,,percent of total billed charges,90% of total Billed charges,147.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,169.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.57,155,,,Fee Schedule,155% of CMS OPPS Rate,72.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,322.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,322.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,185.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.57,145,,,Fee Schedule,145% of CMS OPPS Rate,72.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.09,145,,,Fee Schedule,145% of CMS OPPS Rate,104.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.12,354.55,
95912- Nerve conduction study/11-12 study,3435496,CDM,960,RC,95912,HCPCS,Outpatient,,,461.88,230.94,,415.69,90,,,percent of total billed charges,90% of total Billed charges,166.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,198.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.87,155,,,Fee Schedule,155% of CMS OPPS Rate,81.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,320.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,360.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,360.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,370.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,370.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,222.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.87,145,,,Fee Schedule,145% of CMS OPPS Rate,81.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.9,145,,,Fee Schedule,145% of CMS OPPS Rate,117.87,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.29,415.69,
95913- Nerve conduction studies/13 >,3435497,CDM,960,RC,95913,HCPCS,Outpatient,,,534.2,267.10,,480.78,90,,,percent of total billed charges,90% of total Billed charges,183.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.55,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,130.12,155,,,Fee Schedule,155% of CMS OPPS Rate,89.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,417.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,417.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,429.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,429.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,257.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.12,145,,,Fee Schedule,145% of CMS OPPS Rate,89.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.51,145,,,Fee Schedule,145% of CMS OPPS Rate,130.12,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,89.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,268.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.74,480.78,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,960,RC,95937,HCPCS,Outpatient,,,191.14,95.57,,172.03,90,,,percent of total billed charges,90% of total Billed charges,127.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,90.63,155,,,Fee Schedule,155% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.04,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.63,145,,,Fee Schedule,145% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.64,145,,,Fee Schedule,145% of CMS OPPS Rate,90.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.17,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,119.17,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.73,184.64,
95970- VNS evaluation,3435519,CDM,960,RC,95970,HCPCS,Outpatient,,,36.48,18.24,,32.83,90,,,percent of total billed charges,90% of total Billed charges,37.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.43,155,,,Fee Schedule,155% of CMS OPPS Rate,18.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,28.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,28.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,26.43,145,,,Fee Schedule,145% of CMS OPPS Rate,18.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.71,145,,,Fee Schedule,145% of CMS OPPS Rate,26.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.23,107.77,
95972- Elec Anlys Implt Npgt Cplx Sp/Pn Prgrmg,4327334,CDM,983,RC,95972,HCPCS,Outpatient,,,76.88,38.44,,69.19,90,,,percent of total billed charges,90% of total Billed charges,94.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.2,155,,,Fee Schedule,155% of CMS OPPS Rate,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,83.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,83.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,58.2,145,,,Fee Schedule,145% of CMS OPPS Rate,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.47,145,,,Fee Schedule,145% of CMS OPPS Rate,58.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,181.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.14,181.89,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,960,RC,95976,HCPCS,Outpatient,,,104.43,52.22,,93.99,90,,,percent of total billed charges,90% of total Billed charges,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.01,155,,,Fee Schedule,155% of CMS OPPS Rate,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.01,145,,,Fee Schedule,145% of CMS OPPS Rate,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.81,145,,,Fee Schedule,145% of CMS OPPS Rate,55.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.3,112.81,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,960,RC,95976,HCPCS,Outpatient,,,75.88,37.94,,68.29,90,,,percent of total billed charges,90% of total Billed charges,77.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.01,155,,,Fee Schedule,155% of CMS OPPS Rate,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,46.2,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,55.01,145,,,Fee Schedule,145% of CMS OPPS Rate,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.81,145,,,Fee Schedule,145% of CMS OPPS Rate,55.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.3,112.81,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,960,RC,95977,HCPCS,Outpatient,,,137.41,68.71,,123.67,90,,,percent of total billed charges,90% of total Billed charges,103.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.73,155,,,Fee Schedule,155% of CMS OPPS Rate,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,59.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.73,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.93,145,,,Fee Schedule,145% of CMS OPPS Rate,73.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.06,149.93,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,960,RC,95977,HCPCS,Outpatient,,,101.72,50.86,,91.55,90,,,percent of total billed charges,90% of total Billed charges,103.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,73.73,155,,,Fee Schedule,155% of CMS OPPS Rate,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,59.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,73.73,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.93,145,,,Fee Schedule,145% of CMS OPPS Rate,73.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.06,149.93,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,960,RC,95983,HCPCS,Outpatient,,,96.48,48.24,,86.83,90,,,percent of total billed charges,90% of total Billed charges,98.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,69.95,155,,,Fee Schedule,155% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.88,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,69.95,145,,,Fee Schedule,145% of CMS OPPS Rate,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.71,145,,,Fee Schedule,145% of CMS OPPS Rate,69.95,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,56.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.82,142.71,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,960,RC,95984,HCPCS,Outpatient,,,84.4,42.20,,75.96,90,,,percent of total billed charges,90% of total Billed charges,86.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,61.18,155,,,Fee Schedule,155% of CMS OPPS Rate,42.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,61.18,145,,,Fee Schedule,145% of CMS OPPS Rate,42.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.8,145,,,Fee Schedule,145% of CMS OPPS Rate,61.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,124.8,
95992 - Epley Maneuver,3575063,CDM,960,RC,95992,HCPCS,Outpatient,,,70.58,35.29,,63.52,90,,,percent of total billed charges,90% of total Billed charges,77.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.17,155,,,Fee Schedule,155% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,56.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,56.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,41.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,51.17,145,,,Fee Schedule,145% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.3,145,,,Fee Schedule,145% of CMS OPPS Rate,51.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,71.85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.93,112.3,
96156 - Health Coach Assessment,3635244,CDM,983,RC,96156,HCPCS,Outpatient,,,180.73,90.37,,162.66,90,,,percent of total billed charges,90% of total Billed charges,178.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,155,,,Fee Schedule,155% of CMS OPPS Rate,83.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,75.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,166.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,95.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,120.86,145,,,Fee Schedule,145% of CMS OPPS Rate,83.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.77,145,,,Fee Schedule,145% of CMS OPPS Rate,120.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,83.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.24,258.77,
96158 - Health Coach Initial 30 Mins,3635247,CDM,983,RC,96158,HCPCS,Outpatient,,,121.18,60.59,,109.06,90,,,percent of total billed charges,90% of total Billed charges,122.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.19,155,,,Fee Schedule,155% of CMS OPPS Rate,56.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.19,145,,,Fee Schedule,145% of CMS OPPS Rate,56.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.23,145,,,Fee Schedule,145% of CMS OPPS Rate,82.19,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,73.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.38,177.23,
96160 - Pt Focused Hlth Risk Assmt Score Doc Stnd Instrm,4315552,CDM,960,RC,96160,HCPCS,Outpatient,,,4.94,2.47,,4.45,90,,,percent of total billed charges,90% of total Billed charges,4.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,3.38,155,,,Fee Schedule,155% of CMS OPPS Rate,2.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.38,145,,,Fee Schedule,145% of CMS OPPS Rate,2.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.82,145,,,Fee Schedule,145% of CMS OPPS Rate,3.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,2.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.33,6.82,
96372-PF Injection of drug/substance under skin or into muscle,4345296,CDM,983,RC,96372,HCPCS,Outpatient,,,27.69,13.85,,24.92,90,,,percent of total billed charges,90% of total Billed charges,26.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.11,155,,,Fee Schedule,155% of CMS OPPS Rate,13.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.11,145,,,Fee Schedule,145% of CMS OPPS Rate,13.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.57,145,,,Fee Schedule,145% of CMS OPPS Rate,19.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,23.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.77,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,38.77,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.7,38.77,
96401- Chemo admin/SQ/IM/anti-neo,3431073,CDM,960,RC,96401,HCPCS,Outpatient,,,153.84,76.92,,138.46,90,,,percent of total billed charges,90% of total Billed charges,133.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.53,90,,,Percent of total Billed charges,90% of total billed charges,50.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.93,155,,,Fee Schedule,155% of CMS OPPS Rate,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,96.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,105.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.93,145,,,Fee Schedule,145% of CMS OPPS Rate,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.14,145,,,Fee Schedule,145% of CMS OPPS Rate,93.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.23,193.14,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,960,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,72.45,90,,,percent of total billed charges,90% of total Billed charges,60.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.76,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,44.38,155,,,Fee Schedule,155% of CMS OPPS Rate,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.38,145,,,Fee Schedule,145% of CMS OPPS Rate,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.26,145,,,Fee Schedule,145% of CMS OPPS Rate,44.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,49.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.61,88.26,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,72.45,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.45,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.09,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,74.06,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,56.35,70,,,percent of total billed charges,70% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.23,86,,,percent of total billed charges,86% of total billed charges,64.4,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.09,97,,,percent of total billed charges,97% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.09,97,,,percent of total billed charges,97% of total billed charges,74.87,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.09,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,328.92,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,983,RC,96920,HCPCS,Outpatient,,,125.14,62.57,,112.63,90,,,percent of total billed charges,90% of total Billed charges,185.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.73,155,,,Fee Schedule,155% of CMS OPPS Rate,60.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,97.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,97.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,67.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,87.73,145,,,Fee Schedule,145% of CMS OPPS Rate,60.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.18,145,,,Fee Schedule,145% of CMS OPPS Rate,87.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,285.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.76,285.1,
96921- Excimer lsr psriasis 250-500,3431095,CDM,983,RC,96921,HCPCS,Outpatient,,,141.87,70.94,,127.68,90,,,percent of total billed charges,90% of total Billed charges,210.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,99.72,155,,,Fee Schedule,155% of CMS OPPS Rate,68.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.01,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.01,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,99.72,145,,,Fee Schedule,145% of CMS OPPS Rate,68.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.43,145,,,Fee Schedule,145% of CMS OPPS Rate,99.72,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,293.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,293.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,59.1,305.43,
97010-HOT/COLD PACKS,3430549,CDM,960,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,11.04,90,,,percent of total billed charges,90% of total Billed charges,11.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.63,155,,,Fee Schedule,155% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,145,,,Fee Schedule,145% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.97,145,,,Fee Schedule,145% of CMS OPPS Rate,8.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.77,85,
97010-PF Application Modality 1/> Areas Hot/Cold Packs,4345297,CDM,983,RC,97010,HCPCS,Outpatient,,,12.27,6.14,,11.04,90,,,percent of total billed charges,90% of total Billed charges,11.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.63,155,,,Fee Schedule,155% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.63,145,,,Fee Schedule,145% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.97,145,,,Fee Schedule,145% of CMS OPPS Rate,8.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.77,85,
97014-PF Appl Modality 1/> Areas Elec Stimj Unattended,4345298,CDM,983,RC,97014,HCPCS,Outpatient,,,24.19,12.10,,21.77,90,,,percent of total billed charges,90% of total Billed charges,23.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.07,155,,,Fee Schedule,155% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,145,,,Fee Schedule,145% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.44,145,,,Fee Schedule,145% of CMS OPPS Rate,17.07,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,25.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.77,34.44,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,960,RC,97014,HCPCS,Outpatient,,,24.19,12.10,,21.77,90,,,percent of total billed charges,90% of total Billed charges,23.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,17.07,155,,,Fee Schedule,155% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.07,145,,,Fee Schedule,145% of CMS OPPS Rate,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.44,145,,,Fee Schedule,145% of CMS OPPS Rate,17.07,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,25.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.77,34.44,
97016-PF Appl Modality 1/> Areas Vasopneumatic Devices,4345299,CDM,983,RC,97016,HCPCS,Outpatient,,,23,11.50,,20.7,90,,,percent of total billed charges,90% of total Billed charges,22.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,16.23,155,,,Fee Schedule,155% of CMS OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,17.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,17.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.23,145,,,Fee Schedule,145% of CMS OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.74,145,,,Fee Schedule,145% of CMS OPPS Rate,16.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,30.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.19,85,
97026-INFRARED,3430551,CDM,960,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,11.58,90,,,percent of total billed charges,90% of total Billed charges,12.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,9.06,155,,,Fee Schedule,155% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.06,145,,,Fee Schedule,145% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.84,145,,,Fee Schedule,145% of CMS OPPS Rate,9.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.25,85,
97026-PF Application Modality 1/> Areas Infrared,4345300,CDM,983,RC,97026,HCPCS,Outpatient,,,12.87,6.44,,11.58,90,,,percent of total billed charges,90% of total Billed charges,12.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,9.06,155,,,Fee Schedule,155% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,9.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.06,145,,,Fee Schedule,145% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.84,145,,,Fee Schedule,145% of CMS OPPS Rate,9.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,9.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.25,85,
97035-PF Appl Modality 1/> Areas Ultrasound Ea 15 Min,4345301,CDM,983,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,24.73,90,,,percent of total billed charges,90% of total Billed charges,27.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.81,155,,,Fee Schedule,155% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.81,145,,,Fee Schedule,145% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.56,145,,,Fee Schedule,145% of CMS OPPS Rate,19.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.9,85,
97035-PT ULTRASOUND(WOUND),3430552,CDM,960,RC,97035,HCPCS,Outpatient,,,27.48,13.74,,24.73,90,,,percent of total billed charges,90% of total Billed charges,27.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.81,155,,,Fee Schedule,155% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.81,145,,,Fee Schedule,145% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.56,145,,,Fee Schedule,145% of CMS OPPS Rate,19.81,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.9,85,
97039-LASER/OTHER,3430553,CDM,960,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,51.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,13.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,85,
97039-PF Unlist Modality Spec Type&Time Constant Attend,4345302,CDM,983,RC,97039,HCPCS,Outpatient,,,57.3,28.65,,51.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,13.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,85,
97110-PF Therapeutic Px 1/> Areas Each 15 Min Exercises,4345303,CDM,983,RC,97110,HCPCS,Outpatient,,,57.3,28.65,,51.57,90,,,percent of total billed charges,90% of total Billed charges,56.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.38,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.47,155,,,Fee Schedule,155% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.47,145,,,Fee Schedule,145% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.46,145,,,Fee Schedule,145% of CMS OPPS Rate,40.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.38,85,
97112-PF Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,4345304,CDM,983,RC,97112,HCPCS,Outpatient,,,65.55,32.78,,59,90,,,percent of total billed charges,90% of total Billed charges,64.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,46.31,155,,,Fee Schedule,155% of CMS OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.69,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.69,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,145,,,Fee Schedule,145% of CMS OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.7,145,,,Fee Schedule,145% of CMS OPPS Rate,46.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.17,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.17,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.75,93.7,
97124 Ther Px 1/> Areas Each 15 Min Massage,3436070,CDM,983,RC,97124,HCPCS,Outpatient,,,58.13,29.07,,52.32,90,,,percent of total billed charges,90% of total Billed charges,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.63,155,,,Fee Schedule,155% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.63,145,,,Fee Schedule,145% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.17,145,,,Fee Schedule,145% of CMS OPPS Rate,40.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.75,85,
97124-PF Ther Px 1/> Areas Each 15 Min Massage,4345305,CDM,983,RC,97124,HCPCS,Outpatient,,,58.13,29.07,,52.32,90,,,percent of total billed charges,90% of total Billed charges,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.63,155,,,Fee Schedule,155% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.63,145,,,Fee Schedule,145% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.17,145,,,Fee Schedule,145% of CMS OPPS Rate,40.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.75,85,
97140-PF 0 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,4345306,CDM,983,RC,97140,HCPCS,Outpatient,,,52.92,26.46,,47.63,90,,,percent of total billed charges,90% of total Billed charges,51.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.38,155,,,Fee Schedule,155% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.38,145,,,Fee Schedule,145% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.23,145,,,Fee Schedule,145% of CMS OPPS Rate,37.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.03,85,
97165-PF OT Eval Low Complex 30 Minutes,4345307,CDM,983,RC,97165,HCPCS,Outpatient,,,197.7,98.85,,177.93,90,,,percent of total billed charges,90% of total Billed charges,192.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,155,,,Fee Schedule,155% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,145,,,Fee Schedule,145% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.62,145,,,Fee Schedule,145% of CMS OPPS Rate,138.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.01,278.62,
97166-PF OT Eval Mod Complex 45 Minutes,4345308,CDM,983,RC,97166,HCPCS,Outpatient,,,197.97,98.99,,178.17,90,,,percent of total billed charges,90% of total Billed charges,192.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,155,,,Fee Schedule,155% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,145,,,Fee Schedule,145% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.62,145,,,Fee Schedule,145% of CMS OPPS Rate,138.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.01,278.62,
97167-PF OT Eval High Complex 60 Minutes,4345309,CDM,983,RC,97167,HCPCS,Outpatient,,,197.97,98.99,,178.17,90,,,percent of total billed charges,90% of total Billed charges,192.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,155,,,Fee Schedule,155% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,145,,,Fee Schedule,145% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.62,145,,,Fee Schedule,145% of CMS OPPS Rate,138.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.01,278.62,
97168-PF OT Re-Eval Est Plan Care 30 Minutes,4345310,CDM,983,RC,97168,HCPCS,Outpatient,,,135.83,67.92,,122.25,90,,,percent of total billed charges,90% of total Billed charges,131.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.87,155,,,Fee Schedule,155% of CMS OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.87,145,,,Fee Schedule,145% of CMS OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.65,145,,,Fee Schedule,145% of CMS OPPS Rate,94.87,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.69,190.65,
97530-PF Therapeut Activity Direct  Contact Each 15 Min,4345311,CDM,983,RC,97530,HCPCS,Outpatient,,,70.36,35.18,,63.32,90,,,percent of total billed charges,90% of total Billed charges,69.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.13,155,,,Fee Schedule,155% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.13,145,,,Fee Schedule,145% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.95,145,,,Fee Schedule,145% of CMS OPPS Rate,50.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13,100.95,
97535-PF Self Care Mngment Training,4345312,CDM,983,RC,97535,HCPCS,Outpatient,,,63.28,31.64,,56.95,90,,,percent of total billed charges,90% of total Billed charges,62.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.7,155,,,Fee Schedule,155% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.7,145,,,Fee Schedule,145% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,90,145,,,Fee Schedule,145% of CMS OPPS Rate,44.7,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.43,90,
97537-PF Community or Work Reint Training Ea 15 Min,4345313,CDM,983,RC,97537,HCPCS,Outpatient,,,61.78,30.89,,55.6,90,,,percent of total billed charges,90% of total Billed charges,60.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,155,,,Fee Schedule,155% of CMS OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.65,145,,,Fee Schedule,145% of CMS OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.87,145,,,Fee Schedule,145% of CMS OPPS Rate,43.65,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,49.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.73,87.87,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,960,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,107.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.85,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.85,145,,,Fee Schedule,145% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.48,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,120.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.26,155.48,
97597-PF Debrdmnt Open Wound 20 Sq Cm/<,4345314,CDM,983,RC,97597,HCPCS,Outpatient,,,72.16,36.08,,64.94,90,,,percent of total billed charges,90% of total Billed charges,107.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.85,155,,,Fee Schedule,155% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.85,145,,,Fee Schedule,145% of CMS OPPS Rate,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.48,145,,,Fee Schedule,145% of CMS OPPS Rate,50.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,120.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.26,155.48,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,960,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,45.39,90,,,percent of total billed charges,90% of total Billed charges,67.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.48,155,,,Fee Schedule,155% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.48,145,,,Fee Schedule,145% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.35,145,,,Fee Schedule,145% of CMS OPPS Rate,35.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.46,98.35,
97598-PF Debrdmnt Open Wound Each Addtl 20 Sq Cm,4345315,CDM,983,RC,97598,HCPCS,Outpatient,,,50.43,25.22,,45.39,90,,,percent of total billed charges,90% of total Billed charges,67.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.48,155,,,Fee Schedule,155% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,30.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.48,145,,,Fee Schedule,145% of CMS OPPS Rate,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.35,145,,,Fee Schedule,145% of CMS OPPS Rate,35.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.46,98.35,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,960,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,122.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,122.44,
97602-PF Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,4345316,CDM,983,RC,97602,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,122.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,19.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,122.44,
97605-PF Negative Pressure Wound Therapy DME <=50 Sq Cm,4345317,CDM,983,RC,97605,HCPCS,Outpatient,,,48.68,24.34,,43.81,90,,,percent of total billed charges,90% of total Billed charges,64.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.91,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.83,155,,,Fee Schedule,155% of CMS OPPS Rate,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,27.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.83,145,,,Fee Schedule,145% of CMS OPPS Rate,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.9,145,,,Fee Schedule,145% of CMS OPPS Rate,34.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,68.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.95,92.9,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,983,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,73.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.7,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,37.7,145,,,Fee Schedule,145% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.02,145,,,Fee Schedule,145% of CMS OPPS Rate,37.7,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.02,106.02,
97606-PF Negative Pressure Wound Therapy DME >50 Sq Cm,4345318,CDM,983,RC,97606,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,73.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.7,155,,,Fee Schedule,155% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,37.7,145,,,Fee Schedule,145% of CMS OPPS Rate,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.02,145,,,Fee Schedule,145% of CMS OPPS Rate,37.7,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.02,106.02,
97607-PF Negative Pressure Wound Therapy Non DME <=50 Sq Cm,4345319,CDM,983,RC,97607,HCPCS,Outpatient,,,43.59,21.80,,39.23,90,,,percent of total billed charges,90% of total Billed charges,65.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.68,155,,,Fee Schedule,155% of CMS OPPS Rate,21.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,31.68,145,,,Fee Schedule,145% of CMS OPPS Rate,21.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.89,145,,,Fee Schedule,145% of CMS OPPS Rate,31.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.85,133.5,
97608-PF Negative Pressure Wound Therapy Non DME >50 Sq Cm,4345320,CDM,983,RC,97608,HCPCS,Outpatient,,,51.52,25.76,,46.37,90,,,percent of total billed charges,90% of total Billed charges,76.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.84,155,,,Fee Schedule,155% of CMS OPPS Rate,25.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,135,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,135,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,36.84,145,,,Fee Schedule,145% of CMS OPPS Rate,25.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.55,145,,,Fee Schedule,145% of CMS OPPS Rate,36.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.41,135,
97750-PF Physical Perf Test/Meas w/ Reprt Ea 15 Min,4345321,CDM,983,RC,97750,HCPCS,Outpatient,,,65.68,32.84,,59.11,90,,,percent of total billed charges,90% of total Billed charges,63.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.97,155,,,Fee Schedule,155% of CMS OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.97,145,,,Fee Schedule,145% of CMS OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.13,145,,,Fee Schedule,145% of CMS OPPS Rate,45.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.17,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.17,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.75,92.13,
97760-PF Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,4345322,CDM,983,RC,97760,HCPCS,Outpatient,,,90.69,45.35,,81.62,90,,,percent of total billed charges,90% of total Billed charges,90.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.21,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.9,145,,,Fee Schedule,145% of CMS OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.79,145,,,Fee Schedule,145% of CMS OPPS Rate,64.9,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.21,130.79,
97763-PF Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,4345323,CDM,983,RC,97763,HCPCS,Outpatient,,,98.88,49.44,,88.99,90,,,percent of total billed charges,90% of total Billed charges,98.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.69,155,,,Fee Schedule,155% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.66,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.69,145,,,Fee Schedule,145% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.33,145,,,Fee Schedule,145% of CMS OPPS Rate,70.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.66,143.33,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,960,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,55.58,90,,,percent of total billed charges,90% of total Billed charges,53.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.12,155,,,Fee Schedule,155% of CMS OPPS Rate,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,25.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.12,145,,,Fee Schedule,145% of CMS OPPS Rate,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.11,145,,,Fee Schedule,145% of CMS OPPS Rate,33.12,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.61,77.11,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,960,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,55.58,90,,,percent of total billed charges,90% of total Billed charges,53.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.12,155,,,Fee Schedule,155% of CMS OPPS Rate,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,25.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.12,145,,,Fee Schedule,145% of CMS OPPS Rate,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.11,145,,,Fee Schedule,145% of CMS OPPS Rate,33.12,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.61,77.11,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,983,RC,98926,HCPCS,Outpatient,,,82.01,41.01,,73.81,90,,,percent of total billed charges,90% of total Billed charges,76.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,49.2,155,,,Fee Schedule,155% of CMS OPPS Rate,33.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.2,145,,,Fee Schedule,145% of CMS OPPS Rate,33.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.33,145,,,Fee Schedule,145% of CMS OPPS Rate,49.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.7,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.7,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,111.33,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,960,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,109.36,90,,,percent of total billed charges,90% of total Billed charges,100.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.44,155,,,Fee Schedule,155% of CMS OPPS Rate,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,64.44,145,,,Fee Schedule,145% of CMS OPPS Rate,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.74,145,,,Fee Schedule,145% of CMS OPPS Rate,64.44,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.37,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,92.37,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.06,145.74,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,960,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,109.36,90,,,percent of total billed charges,90% of total Billed charges,100.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,64.44,155,,,Fee Schedule,155% of CMS OPPS Rate,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,71.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,50.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,64.44,145,,,Fee Schedule,145% of CMS OPPS Rate,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.74,145,,,Fee Schedule,145% of CMS OPPS Rate,64.44,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.37,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,92.37,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32.06,145.74,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,960,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,138.44,90,,,percent of total billed charges,90% of total Billed charges,125.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.39,155,,,Fee Schedule,155% of CMS OPPS Rate,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.39,145,,,Fee Schedule,145% of CMS OPPS Rate,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.61,145,,,Fee Schedule,145% of CMS OPPS Rate,82.39,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.46,182.61,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,960,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,138.44,90,,,percent of total billed charges,90% of total Billed charges,125.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.46,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.39,155,,,Fee Schedule,155% of CMS OPPS Rate,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,63.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.39,145,,,Fee Schedule,145% of CMS OPPS Rate,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.61,145,,,Fee Schedule,145% of CMS OPPS Rate,82.39,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,38.46,182.61,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,983,RC,98929,HCPCS,Outpatient,,,185.36,92.68,,166.82,90,,,percent of total billed charges,90% of total Billed charges,150.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,98.69,155,,,Fee Schedule,155% of CMS OPPS Rate,68.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,109.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,109.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,136.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,98.69,145,,,Fee Schedule,145% of CMS OPPS Rate,68.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.82,145,,,Fee Schedule,145% of CMS OPPS Rate,98.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,68.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,68.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,124.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.9,217.82,
98960-PF Education Training for self-mgmt,4345324,CDM,983,RC,98960,HCPCS,Outpatient,,,23.07,11.54,,20.76,90,,,percent of total billed charges,90% of total Billed charges,46.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,155,,,Fee Schedule,155% of CMS OPPS Rate,23.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.45,145,,,Fee Schedule,145% of CMS OPPS Rate,23.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.9,145,,,Fee Schedule,145% of CMS OPPS Rate,33.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.92,66.9,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,960,RC,99152,HCPCS,Outpatient,,,33.75,16.88,,30.38,90,,,percent of total billed charges,90% of total Billed charges,46.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,18.14,155,,,Fee Schedule,155% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,18.14,145,,,Fee Schedule,145% of CMS OPPS Rate,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.08,145,,,Fee Schedule,145% of CMS OPPS Rate,18.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,54.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,67.08,
99153 - MOD SED SAME PHYS/QHP EA,3997220,CDM,960,RC,99153,HCPCS,Outpatient,,,25.91,12.96,,23.32,90,,,percent of total billed charges,90% of total Billed charges,19.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,14.34,155,,,Fee Schedule,155% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.34,145,,,Fee Schedule,145% of CMS OPPS Rate,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.45,145,,,Fee Schedule,145% of CMS OPPS Rate,14.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,11.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,28.45,
99183-PF Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,4345325,CDM,983,RC,99183,HCPCS,Outpatient,,,216.6,108.30,,194.94,90,,,percent of total billed charges,90% of total Billed charges,211.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,106.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,152.38,155,,,Fee Schedule,155% of CMS OPPS Rate,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,151.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,131.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,152.38,145,,,Fee Schedule,145% of CMS OPPS Rate,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.86,145,,,Fee Schedule,145% of CMS OPPS Rate,152.38,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,132.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,105.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,357.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.41,357.52,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,983,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,86.3,90,,,percent of total billed charges,90% of total Billed charges,116.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.23,90,,,Percent of total Billed charges,90% of total billed charges,35.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.99,155,,,Fee Schedule,155% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.99,145,,,Fee Schedule,145% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.29,145,,,Fee Schedule,145% of CMS OPPS Rate,67.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.33,168.29,
99202-PF Office/OP New SF MDM 15 Minutes,4345326,CDM,983,RC,99202,HCPCS,Outpatient,,,95.89,47.95,,86.3,90,,,percent of total billed charges,90% of total Billed charges,116.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.23,90,,,Percent of total Billed charges,90% of total billed charges,35.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.99,155,,,Fee Schedule,155% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.99,145,,,Fee Schedule,145% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.29,145,,,Fee Schedule,145% of CMS OPPS Rate,67.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.33,168.29,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,983,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,149.91,90,,,percent of total billed charges,90% of total Billed charges,188.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.1,90,,,Percent of total Billed charges,90% of total billed charges,54.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.91,155,,,Fee Schedule,155% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.91,145,,,Fee Schedule,145% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.85,145,,,Fee Schedule,145% of CMS OPPS Rate,117.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,156.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.25,273.85,
99203-PF Office/OP New SF MDM 30 Minutes,4345327,CDM,983,RC,99203,HCPCS,Outpatient,,,166.57,83.29,,149.91,90,,,percent of total billed charges,90% of total Billed charges,188.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.1,90,,,Percent of total Billed charges,90% of total billed charges,54.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.91,155,,,Fee Schedule,155% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.91,145,,,Fee Schedule,145% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.85,145,,,Fee Schedule,145% of CMS OPPS Rate,117.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,156.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.25,273.85,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,983,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,243.29,90,,,percent of total billed charges,90% of total Billed charges,291.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.94,90,,,Percent of total Billed charges,90% of total billed charges,90.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,188.96,155,,,Fee Schedule,155% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,188.96,145,,,Fee Schedule,145% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.54,145,,,Fee Schedule,145% of CMS OPPS Rate,188.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.37,422.54,
99204-PF Office/OP New SF MDM 45 Minutes,4345328,CDM,983,RC,99204,HCPCS,Outpatient,,,270.32,135.16,,243.29,90,,,percent of total billed charges,90% of total Billed charges,291.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.94,90,,,Percent of total Billed charges,90% of total billed charges,90.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,188.96,155,,,Fee Schedule,155% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,188.96,145,,,Fee Schedule,145% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.54,145,,,Fee Schedule,145% of CMS OPPS Rate,188.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.37,422.54,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,983,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,330.7,90,,,percent of total billed charges,90% of total Billed charges,390.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.45,90,,,Percent of total Billed charges,90% of total billed charges,117.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.33,155,,,Fee Schedule,155% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,187.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.33,145,,,Fee Schedule,145% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.7,145,,,Fee Schedule,145% of CMS OPPS Rate,256.33,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,297.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.54,565.7,
99205-PF Office/OP New SF MDM 60 Minutes,4345329,CDM,983,RC,99205,HCPCS,Outpatient,,,367.44,183.72,,330.7,90,,,percent of total billed charges,90% of total Billed charges,390.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.45,90,,,Percent of total Billed charges,90% of total billed charges,117.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.33,155,,,Fee Schedule,155% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,187.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.33,145,,,Fee Schedule,145% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.7,145,,,Fee Schedule,145% of CMS OPPS Rate,256.33,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,297.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.54,565.7,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,15.86,90,,,percent of total billed charges,90% of total Billed charges,26.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.41,155,,,Fee Schedule,155% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,12.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.96,145,,,Fee Schedule,145% of CMS OPPS Rate,12.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.56,37.96,
99211-EST PATIENT LEVEL 1 Profee,3438255,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,15.86,90,,,percent of total billed charges,90% of total Billed charges,26.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.41,155,,,Fee Schedule,155% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,12.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.96,145,,,Fee Schedule,145% of CMS OPPS Rate,12.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.56,37.96,
99211-PF Office/OP Established  May Not Rqr Phys/QHP,4345330,CDM,983,RC,99211,HCPCS,Outpatient,,,17.62,8.81,,15.86,90,,,percent of total billed charges,90% of total Billed charges,26.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.41,155,,,Fee Schedule,155% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,12.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.96,145,,,Fee Schedule,145% of CMS OPPS Rate,12.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.56,37.96,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,983,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,64.36,90,,,percent of total billed charges,90% of total Billed charges,88.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.06,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.02,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,128.02,
99212-PF Office/OP Est SF MDM 10 Minutes,4345331,CDM,983,RC,99212,HCPCS,Outpatient,,,71.51,35.76,,64.36,90,,,percent of total billed charges,90% of total Billed charges,88.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.06,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.02,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,128.02,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,983,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,119.71,90,,,percent of total billed charges,90% of total Billed charges,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.95,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.82,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,218.82,
99213-PF Office/OP Est SF MDM 20 Minutes,4345332,CDM,983,RC,99213,HCPCS,Outpatient,,,133.01,66.51,,119.71,90,,,percent of total billed charges,90% of total Billed charges,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.95,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.82,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,218.82,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,314.87,
99214-Office outpatient visit est Moderate or 30 39 minutes,4223209,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,314.87,
99214-PF Office/OP Est Mod MDM 30 Minutes,4345333,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,314.87,
99214-PRO FEE ESTABLISHED PATIENT LEVEL 4 (30-39 min),3435840,CDM,983,RC,99214,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,314.87,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,983,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,261.65,90,,,percent of total billed charges,90% of total Billed charges,312.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.9,90,,,Percent of total Billed charges,90% of total billed charges,78.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202,155,,,Fee Schedule,155% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202,145,,,Fee Schedule,145% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.28,145,,,Fee Schedule,145% of CMS OPPS Rate,202,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,207.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.05,453.28,
99215-PF Office/OP Est High MDM 40 Minutes,4345334,CDM,983,RC,99215,HCPCS,Outpatient,,,290.72,145.36,,261.65,90,,,percent of total billed charges,90% of total Billed charges,312.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.9,90,,,Percent of total Billed charges,90% of total billed charges,78.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202,155,,,Fee Schedule,155% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202,145,,,Fee Schedule,145% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.28,145,,,Fee Schedule,145% of CMS OPPS Rate,202,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,207.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.05,453.28,
99244-PF Office Consult New/Est PT Mod MDM Level 4 (40 min),4355204,CDM,983,RC,99244,HCPCS,Outpatient,,,603.67,301.84,,543.3,90,,,percent of total billed charges,90% of total Billed charges,304.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.93,90,,,Percent of total Billed charges,90% of total billed charges,120.56,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,190.92,155,,,Fee Schedule,155% of CMS OPPS Rate,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,131.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,218.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,218.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,233.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,233.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,156.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,263.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,209.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,190.92,145,,,Fee Schedule,145% of CMS OPPS Rate,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.87,145,,,Fee Schedule,145% of CMS OPPS Rate,190.92,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,131.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,260,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,260,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,120.56,543.3,
99245-PF Office Consult New/Est PT High MDM Level 5 (55 min),4355206,CDM,983,RC,99245,HCPCS,Outpatient,,,848.33,424.17,,763.5,90,,,percent of total billed charges,90% of total Billed charges,388.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,151.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.26,155,,,Fee Schedule,155% of CMS OPPS Rate,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,270.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,288.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,288.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,193.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,259.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,212.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.26,145,,,Fee Schedule,145% of CMS OPPS Rate,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.08,145,,,Fee Schedule,145% of CMS OPPS Rate,256.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,318,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,318,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,151.44,763.5,
99254- Initl IP/OBV Consult New/Est Pt Mod MDM (60 min),3437948,CDM,983,RC,99254,HCPCS,Outpatient,,,612.98,306.49,,551.68,90,,,percent of total billed charges,90% of total Billed charges,296.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,196.2,155,,,Fee Schedule,155% of CMS OPPS Rate,135.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,237.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,237.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.28,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,228.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,187.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,196.2,145,,,Fee Schedule,145% of CMS OPPS Rate,135.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,429.27,145,,,Fee Schedule,145% of CMS OPPS Rate,196.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,135.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,235,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,235,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,49,551.68,
99395- Periodic Comp Preventive Med 18 to 39 years Est,3438040,CDM,983,RC,99395,HCPCS,Outpatient,,,297.85,148.93,,268.07,90,,,percent of total billed charges,90% of total Billed charges,195.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.55,155,,,Fee Schedule,155% of CMS OPPS Rate,83.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,105.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,134.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,134.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,90.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,167.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,121.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,98.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.55,145,,,Fee Schedule,145% of CMS OPPS Rate,83.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.74,145,,,Fee Schedule,145% of CMS OPPS Rate,121.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,83.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,83.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,140.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,283.74,
99396- Periodic Comp Preventive Med 40 to 64 years Est,3438041,CDM,983,RC,99396,HCPCS,Outpatient,,,317.79,158.90,,286.01,90,,,percent of total billed charges,90% of total Billed charges,211.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,131.47,155,,,Fee Schedule,155% of CMS OPPS Rate,90.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,132.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,107.91,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,131.47,145,,,Fee Schedule,145% of CMS OPPS Rate,90.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.78,145,,,Fee Schedule,145% of CMS OPPS Rate,131.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,90.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,90.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,306.78,
99397- Periodic Comp Preventive Med 65+ years Est,3438042,CDM,983,RC,99397,HCPCS,Outpatient,,,315.8,157.90,,284.22,90,,,percent of total billed charges,90% of total Billed charges,225.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.27,155,,,Fee Schedule,155% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.27,145,,,Fee Schedule,145% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.51,145,,,Fee Schedule,145% of CMS OPPS Rate,138.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,173,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,326.51,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,983,RC,99406,HCPCS,Outpatient,,,23.89,11.95,,21.5,90,,,percent of total billed charges,90% of total Billed charges,26.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.83,155,,,Fee Schedule,155% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,16.83,145,,,Fee Schedule,145% of CMS OPPS Rate,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.25,145,,,Fee Schedule,145% of CMS OPPS Rate,16.83,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.61,38.25,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,66.22,33.11,,59.6,90,,,percent of total billed charges,90% of total Billed charges,52.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.5,155,,,Fee Schedule,155% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.5,145,,,Fee Schedule,145% of CMS OPPS Rate,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.47,145,,,Fee Schedule,145% of CMS OPPS Rate,35.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,75.47,
99415 - Prolonged Clinical Staff SVC Ofice/O/P 1st HR,3897052,CDM,983,RC,99415,HCPCS,Outpatient,,,24.02,12.01,,21.62,90,,,percent of total billed charges,90% of total Billed charges,25.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,155,,,Fee Schedule,155% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.85,145,,,Fee Schedule,145% of CMS OPPS Rate,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.93,145,,,Fee Schedule,145% of CMS OPPS Rate,23.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.17,36.93,
99416 - Prolonged Clinical Staff SVC Office/O/P Ea Addl 30Mi,3897058,CDM,983,RC,99416,HCPCS,Outpatient,,,13.43,6.72,,12.09,90,,,percent of total billed charges,90% of total Billed charges,12.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,155,,,Fee Schedule,155% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.18,145,,,Fee Schedule,145% of CMS OPPS Rate,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.49,145,,,Fee Schedule,145% of CMS OPPS Rate,11.18,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.39,18.49,
99417-PF Prolonged OP E/M Service ? ea addl 15 min,4355202,CDM,983,RC,99417,HCPCS,Outpatient,,,60.5,30.25,,54.45,90,,,percent of total billed charges,90% of total Billed charges,60.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,155,,,Fee Schedule,155% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,145,,,Fee Schedule,145% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.83,145,,,Fee Schedule,145% of CMS OPPS Rate,42.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.15,87.83,
ONLINE E/M PHYS CULM 7 DAYS 5-10MIN,3527888,CDM,960,RC,99421,HCPCS,Outpatient,,,38.65,19.33,,34.79,90,,,percent of total billed charges,90% of total Billed charges,27.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.17,155,,,Fee Schedule,155% of CMS OPPS Rate,12.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,18.17,145,,,Fee Schedule,145% of CMS OPPS Rate,12.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.22,145,,,Fee Schedule,145% of CMS OPPS Rate,18.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.6,39.22,
ONLINE E/M PHYS CULM 7 DAYS11-20MIN,3527889,CDM,960,RC,99422,HCPCS,Outpatient,,,75.68,37.84,,68.11,90,,,percent of total billed charges,90% of total Billed charges,53.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.92,155,,,Fee Schedule,155% of CMS OPPS Rate,24.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.7,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,30.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,35.92,145,,,Fee Schedule,145% of CMS OPPS Rate,24.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.18,145,,,Fee Schedule,145% of CMS OPPS Rate,35.92,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.7,77.18,
99423- ONLINE E/M PHYS CULM 7 DAYS 21+MIN,3514699,CDM,983,RC,99423,HCPCS,Outpatient,,,123.18,61.59,,110.86,90,,,percent of total billed charges,90% of total Billed charges,85.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.99,155,,,Fee Schedule,155% of CMS OPPS Rate,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.99,145,,,Fee Schedule,145% of CMS OPPS Rate,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.15,145,,,Fee Schedule,145% of CMS OPPS Rate,56.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.95,124.15,
99441-PF Phone E/M Phys/QHP 5-10 Min,4345335,CDM,983,RC,99441,HCPCS,Outpatient,,,70.57,35.29,,63.51,90,,,percent of total billed charges,90% of total Billed charges,86.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,155,,,Fee Schedule,155% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.17,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.57,145,,,Fee Schedule,145% of CMS OPPS Rate,49.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.69,125.57,
99442-PF Phone E/M Phys/QHP 11-20 Min,4345336,CDM,983,RC,99442,HCPCS,Outpatient,,,132.08,66.04,,118.87,90,,,percent of total billed charges,90% of total Billed charges,150.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.23,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,39.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.37,218.23,
99443-PF Phone E/M Phys/QHP 21-30 Min,4345337,CDM,983,RC,99443,HCPCS,Outpatient,,,195.91,97.96,,176.32,90,,,percent of total billed charges,90% of total Billed charges,216.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.45,155,,,Fee Schedule,155% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,42.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,136.45,145,,,Fee Schedule,145% of CMS OPPS Rate,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.62,145,,,Fee Schedule,145% of CMS OPPS Rate,136.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.77,313.62,
99495- Trans care mgmt 14 day disch,3438135,CDM,983,RC,99495,HCPCS,Outpatient,,,372.33,186.17,,335.1,90,,,percent of total billed charges,90% of total Billed charges,331.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.23,155,,,Fee Schedule,155% of CMS OPPS Rate,136.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,106.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,123.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,129.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,197.23,145,,,Fee Schedule,145% of CMS OPPS Rate,136.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.31,145,,,Fee Schedule,145% of CMS OPPS Rate,197.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.91,480.31,
99496- Trans care mgmt 7 day disch,3438136,CDM,983,RC,99496,HCPCS,Outpatient,,,503.97,251.99,,453.57,90,,,percent of total billed charges,90% of total Billed charges,448.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,185.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.96,155,,,Fee Schedule,155% of CMS OPPS Rate,185.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,240.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,240.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,162.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,370.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,216.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,172.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,268.96,145,,,Fee Schedule,145% of CMS OPPS Rate,185.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.51,145,,,Fee Schedule,145% of CMS OPPS Rate,268.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,185.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,206.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,185.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.19,650.51,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,188.51,94.26,,169.66,90,,,percent of total billed charges,90% of total Billed charges,140.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.78,155,,,Fee Schedule,155% of CMS OPPS Rate,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.55,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,79.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,100.78,145,,,Fee Schedule,145% of CMS OPPS Rate,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.41,145,,,Fee Schedule,145% of CMS OPPS Rate,100.78,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.55,204.41,
0001A - ADM SARSCOV2 30MCG/0.3ML 1ST,3999148,CDM,983,RC,0001A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0002A - ADM SARSCOV2 30MCG/0.3ML 2ND,3997221,CDM,983,RC,0002A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0003A - ADM SARSCOV2 30MCG/0.3ML 3RD,3997222,CDM,983,RC,0003A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0004A - ADM SARSCOV2 30MCG/0.3ML BST,3999149,CDM,983,RC,0004A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0011A - ADM SARSCOV2 100MCG/0.5ML1ST,3997223,CDM,983,RC,0011A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0012A - ADM SARSCOV2 100MCG/0.5ML2ND,3997224,CDM,983,RC,0012A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0013A - ADM SARSCOV2 100MCG/0.5ML3RD,3997225,CDM,983,RC,0013A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0031A - ADM SARSCOV2 VAC AD26 .5ML,3999150,CDM,983,RC,0031A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0034A - ADM SARSCOV2 VAC AD26 .5ML B,3999151,CDM,983,RC,0034A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0041A - IMM ADMN SARSCOV2 5 MCG/0.5 ML 1ST DOSE,4037470,CDM,960,RC,0041A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0064A - ADM SARSCOV2 50MCG/0.25MLBST,3997226,CDM,983,RC,0064A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0071A - ADM SARSCV2 10MCG TRS-SUCR 1,3997227,CDM,983,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0072A - ADM SARSCV2 10MCG TRS-SUCR 2,3997228,CDM,983,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
0094A - ADM SARSCOV2 50MCG/0.5 MLBST,4113121,CDM,983,RC,0094A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.99,86.96,
3354F - CLIN SIGN DEP SYMP BY STAND DEP ASSESS TOOL,3999152,CDM,983,RC,3354F,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Sacral Nerve Stim Test Lead,3966950,CDM,278,RC,A4290,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,78.65,,,percent of total billed charges,78.65% of total billed charges,0.01,89.33,,,percent of total billed charges,89.33% of total billed charges,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,960,RC,G0101,HCPCS,Outpatient,,,35.4,17.70,,31.86,90,,,percent of total billed charges,90% of total Billed charges,62.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.14,155,,,Fee Schedule,155% of CMS OPPS Rate,26.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.62,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.14,145,,,Fee Schedule,145% of CMS OPPS Rate,26.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.47,145,,,Fee Schedule,145% of CMS OPPS Rate,39.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.62,90.47,
"G0179- Home health re-certification, physician",3435919,CDM,960,RC,G0179,HCPCS,Outpatient,,,101.88,50.94,,91.69,90,,,percent of total billed charges,90% of total Billed charges,76.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.87,155,,,Fee Schedule,155% of CMS OPPS Rate,38.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.56,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.87,145,,,Fee Schedule,145% of CMS OPPS Rate,38.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.42,145,,,Fee Schedule,145% of CMS OPPS Rate,55.87,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.56,111.42,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,70.47,35.24,,63.42,90,,,percent of total billed charges,90% of total Billed charges,56.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.51,155,,,Fee Schedule,155% of CMS OPPS Rate,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,37.51,145,,,Fee Schedule,145% of CMS OPPS Rate,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.52,145,,,Fee Schedule,145% of CMS OPPS Rate,37.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.14,81.52,
"G0277-PF HBOT, Full Body Chamber, 30 Minutes",4345338,CDM,983,RC,G0277,HCPCS,Outpatient,,,382.62,191.31,,344.36,90,,,percent of total billed charges,90% of total Billed charges,303.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.06,155,,,Fee Schedule,155% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.79,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,296.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.06,145,,,Fee Schedule,145% of CMS OPPS Rate,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.13,145,,,Fee Schedule,145% of CMS OPPS Rate,215.06,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,148.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.28,440.13,
G0399- Home Sleep Test 3,3430575,CDM,960,RC,G0399,HCPCS,Outpatient,,,250,125.00,,225,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,270.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,270.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,293.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,293.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,75,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75,293.48,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,983,RC,G0400,HCPCS,Outpatient,,,109.83,54.92,,98.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,227.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,227.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,264.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,264.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.95,264.14,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,960,RC,G0500,HCPCS,Outpatient,,,14.58,7.29,,13.12,90,,,percent of total billed charges,90% of total Billed charges,19.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.84,155,,,Fee Schedule,155% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,8.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,8.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.37,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,7.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,7.84,145,,,Fee Schedule,145% of CMS OPPS Rate,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.99,145,,,Fee Schedule,145% of CMS OPPS Rate,7.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.37,61.09,
G2212 - Prolonged OP E/M Service-beyond the maximum (ea addl 15 min),3623709,CDM,983,RC,G2212,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,62.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.86,155,,,Fee Schedule,155% of CMS OPPS Rate,30.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.86,145,,,Fee Schedule,145% of CMS OPPS Rate,30.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.39,145,,,Fee Schedule,145% of CMS OPPS Rate,43.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.92,90.39,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,960,RC,Q0091,HCPCS,Outpatient,,,60,30.00,,54,90,,,percent of total billed charges,90% of total Billed charges,57.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.75,155,,,Fee Schedule,155% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,20.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,25.75,145,,,Fee Schedule,145% of CMS OPPS Rate,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.74,145,,,Fee Schedule,145% of CMS OPPS Rate,25.75,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,72.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.76,83.74,
Q0111 Wet mounts w preparations,3428512,CDM,983,RC,Q0111,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,23.37,155,,,Fee Schedule,155% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.64,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.9,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,6.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.64,34.62,
S0610 Annual gynecological examina,3428517,CDM,983,RC,S0610,HCPCS,Outpatient,,,327.11,163.56,,294.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.13,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.5,294.4,
Esophageal Manometry,3359090,CDM,750,RC,91010,HCPCS,Outpatient,,,1279.13,639.57,,1151.22,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1023.3,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.22,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1240.76,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.8,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1151.22,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,895.39,70,,,percent of total billed charges,70% of total billed charges,1151.22,90,,,percent of total billed charges,90% of total billed charges,1215.17,95,,,percent of total billed charges,95% of total billed charges,1215.17,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1100.05,86,,,percent of total billed charges,86% of total billed charges,1023.3,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1240.76,97,,,percent of total billed charges,97% of total billed charges,1151.22,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1240.76,97,,,percent of total billed charges,97% of total billed charges,1189.59,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1240.76,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,2356.78,
24 Hour pH-Impedance Monitoring,3361239,CDM,750,RC,91038,HCPCS,Outpatient,,,1279.13,639.57,,1151.22,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1023.3,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.22,90,,,Percent of total Billed charges,90% of total billed charges,57.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1240.76,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.8,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1151.22,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,895.39,70,,,percent of total billed charges,70% of total billed charges,1151.22,90,,,percent of total billed charges,90% of total billed charges,1215.17,95,,,percent of total billed charges,95% of total billed charges,1215.17,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1100.05,86,,,percent of total billed charges,86% of total billed charges,1023.3,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1240.76,97,,,percent of total billed charges,97% of total billed charges,1151.22,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1240.76,97,,,percent of total billed charges,97% of total billed charges,1189.59,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1240.76,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.29,2356.78,
Impedance > 1 Hour,3361274,CDM,750,RC,91038,HCPCS,Outpatient,,,1077.44,538.72,,969.7,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,861.95,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,969.7,90,,,Percent of total Billed charges,90% of total billed charges,57.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1045.12,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,991.24,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,969.7,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,754.21,70,,,percent of total billed charges,70% of total billed charges,969.7,90,,,percent of total billed charges,90% of total billed charges,1023.57,95,,,percent of total billed charges,95% of total billed charges,1023.57,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,926.6,86,,,percent of total billed charges,86% of total billed charges,861.95,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1045.12,97,,,percent of total billed charges,97% of total billed charges,969.7,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.12,97,,,percent of total billed charges,97% of total billed charges,1002.02,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1045.12,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.29,2356.78,
Capsule Endoscopy Intestine (Pill-Cam),3359595,CDM,750,RC,91110,HCPCS,Outpatient,,,3493.03,1746.52,,3143.73,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2794.42,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3143.73,90,,,Percent of total Billed charges,90% of total billed charges,580.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3388.24,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3213.59,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3143.73,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2445.12,70,,,percent of total billed charges,70% of total billed charges,3143.73,90,,,percent of total billed charges,90% of total billed charges,3318.38,95,,,percent of total billed charges,95% of total billed charges,3318.38,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3004.01,86,,,percent of total billed charges,86% of total billed charges,2794.42,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3388.24,97,,,percent of total billed charges,97% of total billed charges,3143.73,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3388.24,97,,,percent of total billed charges,97% of total billed charges,3248.52,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3388.24,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,527.49,4024.46,
Smart Pill,3361237,CDM,750,RC,91112,HCPCS,Outpatient,,,852.94,426.47,,767.65,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,682.35,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,767.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,827.35,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,784.7,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,767.65,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,597.06,70,,,percent of total billed charges,70% of total billed charges,767.65,90,,,percent of total billed charges,90% of total billed charges,810.29,95,,,percent of total billed charges,95% of total billed charges,810.29,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,733.53,86,,,percent of total billed charges,86% of total billed charges,682.35,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,827.35,97,,,percent of total billed charges,97% of total billed charges,767.65,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,827.35,97,,,percent of total billed charges,97% of total billed charges,793.23,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,827.35,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,597.06,4024.46,
Anorectal Manometry,3370860,CDM,750,RC,91122,HCPCS,Outpatient,,,700,350.00,,630,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,560,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,630,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,644,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,630,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,490,70,,,percent of total billed charges,70% of total billed charges,630,90,,,percent of total billed charges,90% of total billed charges,665,95,,,percent of total billed charges,95% of total billed charges,665,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,602,86,,,percent of total billed charges,86% of total billed charges,560,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,679,97,,,percent of total billed charges,97% of total billed charges,630,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,679,97,,,percent of total billed charges,97% of total billed charges,651,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,1365.32,
Aquablation,4041222,CDM,360,RC,0421T,HCPCS,Outpatient,,,36354.44,18177.22,,32719,90,,,percent of total billed charges,90% of total Billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,29083.55,80,,,Percent of total Billed charges,80% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,32719,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35263.81,97,,,Percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,33446.08,92,,,Percent of total billed charges,92% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,20660.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32936.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,41719.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,32719,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,25448.11,70,,,percent of total billed charges,70% of total billed charges,32719,90,,,percent of total billed charges,90% of total billed charges,34536.72,95,,,percent of total billed charges,95% of total billed charges,34536.72,95,,,percent of total billed charges,95% of total billed charges,7772.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15544.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,31264.82,86,,,percent of total billed charges,86% of total billed charges,29083.55,80,,,percent of total billed charges,80% of total billed charges,8341.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,35263.81,97,,,percent of total billed charges,97% of total billed charges,32719,90,,,percent of total billed charges,90% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,35263.81,97,,,percent of total billed charges,97% of total billed charges,33809.63,93,,,percent of total billed charges,93% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35263.81,97,,,percent of total billed charges,97% of total billed charges,7772.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,7772.46,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6606.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6606.59,41719.04,
O/R SUP/IMPLANT/BRACHY/NEEDLES,1221027,CDM,278,RC,C1715,HCPCS,Outpatient,,,3862.88,1931.44,,3476.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3090.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3476.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3746.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3553.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2466.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3038.24,78.65,,,percent of total billed charges,78.65% of total billed charges,3450.77,89.33,,,percent of total billed charges,89.33% of total billed charges,3476.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2704.02,70,,,percent of total billed charges,70% of total billed charges,3476.59,90,,,percent of total billed charges,90% of total billed charges,3669.74,95,,,percent of total billed charges,95% of total billed charges,3669.74,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3322.08,86,,,percent of total billed charges,86% of total billed charges,3090.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3746.99,97,,,percent of total billed charges,97% of total billed charges,3476.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3746.99,97,,,percent of total billed charges,97% of total billed charges,3592.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3746.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2466.92,3746.99,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,3736.01,1868.01,,3362.41,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2988.81,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3362.41,90,,,Percent of total Billed charges,90% of total billed charges,84.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3623.93,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3437.13,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3362.41,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2615.21,70,,,percent of total billed charges,70% of total billed charges,3362.41,90,,,percent of total billed charges,90% of total billed charges,3549.21,95,,,percent of total billed charges,95% of total billed charges,3549.21,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3212.97,86,,,percent of total billed charges,86% of total billed charges,2988.81,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3623.93,97,,,percent of total billed charges,97% of total billed charges,3362.41,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3623.93,97,,,percent of total billed charges,97% of total billed charges,3474.49,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3623.93,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.74,3623.93,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,525.17,262.59,,472.65,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,420.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,472.65,90,,,Percent of total Billed charges,90% of total billed charges,55.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,509.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,483.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,335.39,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,413.06,78.65,,,percent of total billed charges,78.65% of total billed charges,469.14,89.33,,,percent of total billed charges,89.33% of total billed charges,472.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,367.62,70,,,percent of total billed charges,70% of total billed charges,472.65,90,,,percent of total billed charges,90% of total billed charges,498.91,95,,,percent of total billed charges,95% of total billed charges,498.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.65,86,,,percent of total billed charges,86% of total billed charges,420.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,509.41,97,,,percent of total billed charges,97% of total billed charges,472.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,509.41,97,,,percent of total billed charges,97% of total billed charges,488.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,509.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,509.41,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1913,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1700.45,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913,90,,,Percent of total Billed charges,90% of total billed charges,68.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2061.79,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1955.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.89,70,,,percent of total billed charges,70% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1827.98,86,,,percent of total billed charges,86% of total billed charges,1700.45,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2061.79,97,,,percent of total billed charges,97% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2061.79,97,,,percent of total billed charges,97% of total billed charges,1976.77,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2061.79,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.24,2061.79,
SCMP US Guided Fine Needle Asp. Abdomen,3370904,CDM,510,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1913,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1700.45,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913,90,,,Percent of total Billed charges,90% of total billed charges,68.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2061.79,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1955.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.89,70,,,percent of total billed charges,70% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1827.98,86,,,percent of total billed charges,86% of total billed charges,1700.45,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2061.79,97,,,percent of total billed charges,97% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2061.79,97,,,percent of total billed charges,97% of total billed charges,1976.77,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2061.79,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.24,2061.79,
SCMP US Guided Fine Needle Asp. Breast,3370906,CDM,510,RC,10021,HCPCS,Outpatient,,,2125.56,1062.78,,1913,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1700.45,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913,90,,,Percent of total Billed charges,90% of total billed charges,68.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2061.79,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1955.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.89,70,,,percent of total billed charges,70% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,2019.28,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1827.98,86,,,percent of total billed charges,86% of total billed charges,1700.45,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2061.79,97,,,percent of total billed charges,97% of total billed charges,1913,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2061.79,97,,,percent of total billed charges,97% of total billed charges,1976.77,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2061.79,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.24,2061.79,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,1173.1,586.55,,1055.79,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,938.48,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1055.79,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1137.91,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1079.25,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1055.79,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,821.17,70,,,percent of total billed charges,70% of total billed charges,1055.79,90,,,percent of total billed charges,90% of total billed charges,1114.45,95,,,percent of total billed charges,95% of total billed charges,1114.45,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1008.87,86,,,percent of total billed charges,86% of total billed charges,938.48,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1137.91,97,,,percent of total billed charges,97% of total billed charges,1055.79,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1137.91,97,,,percent of total billed charges,97% of total billed charges,1090.98,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1137.91,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1137.91,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,1219.59,609.80,,1097.63,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,975.67,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1097.63,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1183,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1122.02,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1097.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,853.71,70,,,percent of total billed charges,70% of total billed charges,1097.63,90,,,percent of total billed charges,90% of total billed charges,1158.61,95,,,percent of total billed charges,95% of total billed charges,1158.61,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1048.85,86,,,percent of total billed charges,86% of total billed charges,975.67,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1183,97,,,percent of total billed charges,97% of total billed charges,1097.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183,97,,,percent of total billed charges,97% of total billed charges,1134.22,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1183,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,1183,
"10060- Incision and Drainage, Simple",3428468,CDM,761,RC,10060,HCPCS,Outpatient,,,208.61,104.31,,187.75,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,166.89,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.75,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.35,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,191.92,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.75,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,146.03,70,,,percent of total billed charges,70% of total billed charges,187.75,90,,,percent of total billed charges,90% of total billed charges,198.18,95,,,percent of total billed charges,95% of total billed charges,198.18,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.4,86,,,percent of total billed charges,86% of total billed charges,166.89,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.35,97,,,percent of total billed charges,97% of total billed charges,187.75,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.35,97,,,percent of total billed charges,97% of total billed charges,194.01,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.35,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,880.34,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,2380.21,1190.11,,2142.19,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1904.17,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2142.19,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2308.8,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2189.79,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2142.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1666.15,70,,,percent of total billed charges,70% of total billed charges,2142.19,90,,,percent of total billed charges,90% of total billed charges,2261.2,95,,,percent of total billed charges,95% of total billed charges,2261.2,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2046.98,86,,,percent of total billed charges,86% of total billed charges,1904.17,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2308.8,97,,,percent of total billed charges,97% of total billed charges,2142.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2308.8,97,,,percent of total billed charges,97% of total billed charges,2213.6,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2308.8,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,2308.8,
"10061- Incision and Drainage, Complex",3428467,CDM,510,RC,10061,HCPCS,Outpatient,,,528.33,264.17,,475.5,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,422.66,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.5,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,512.48,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,486.06,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,475.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,369.83,70,,,percent of total billed charges,70% of total billed charges,475.5,90,,,percent of total billed charges,90% of total billed charges,501.91,95,,,percent of total billed charges,95% of total billed charges,501.91,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,454.36,86,,,percent of total billed charges,86% of total billed charges,422.66,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,512.48,97,,,percent of total billed charges,97% of total billed charges,475.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,512.48,97,,,percent of total billed charges,97% of total billed charges,491.35,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,512.48,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1818.76,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,3761.41,1880.71,,3385.27,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3009.13,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3385.27,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3648.57,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3460.5,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3385.27,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2632.99,70,,,percent of total billed charges,70% of total billed charges,3385.27,90,,,percent of total billed charges,90% of total billed charges,3573.34,95,,,percent of total billed charges,95% of total billed charges,3573.34,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3234.81,86,,,percent of total billed charges,86% of total billed charges,3009.13,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3648.57,97,,,percent of total billed charges,97% of total billed charges,3385.27,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3648.57,97,,,percent of total billed charges,97% of total billed charges,3498.11,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3648.57,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,3648.57,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,3900.4,1950.20,,3510.36,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3120.32,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3510.36,90,,,Percent of total Billed charges,90% of total billed charges,123.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3783.39,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3588.37,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3510.36,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2730.28,70,,,percent of total billed charges,70% of total billed charges,3510.36,90,,,percent of total billed charges,90% of total billed charges,3705.38,95,,,percent of total billed charges,95% of total billed charges,3705.38,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3354.34,86,,,percent of total billed charges,86% of total billed charges,3120.32,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3783.39,97,,,percent of total billed charges,97% of total billed charges,3510.36,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3783.39,97,,,percent of total billed charges,97% of total billed charges,3627.37,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3783.39,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.5,3783.39,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,2221.06,1110.53,,1998.95,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1776.85,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1998.95,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2154.43,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2043.38,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1998.95,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1554.74,70,,,percent of total billed charges,70% of total billed charges,1998.95,90,,,percent of total billed charges,90% of total billed charges,2110.01,95,,,percent of total billed charges,95% of total billed charges,2110.01,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1910.11,86,,,percent of total billed charges,86% of total billed charges,1776.85,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2154.43,97,,,percent of total billed charges,97% of total billed charges,1998.95,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2154.43,97,,,percent of total billed charges,97% of total billed charges,2065.59,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2154.43,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,2154.43,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,8556.82,4278.41,,7701.14,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6845.46,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7701.14,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8300.12,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7872.27,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7701.14,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5989.77,70,,,percent of total billed charges,70% of total billed charges,7701.14,90,,,percent of total billed charges,90% of total billed charges,8128.98,95,,,percent of total billed charges,95% of total billed charges,8128.98,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7358.87,86,,,percent of total billed charges,86% of total billed charges,6845.46,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8300.12,97,,,percent of total billed charges,97% of total billed charges,7701.14,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8300.12,97,,,percent of total billed charges,97% of total billed charges,7957.84,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8300.12,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,8300.12,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,8422.8,4211.40,,7580.52,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6738.24,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7580.52,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8170.12,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7748.98,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7580.52,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5895.96,70,,,percent of total billed charges,70% of total billed charges,7580.52,90,,,percent of total billed charges,90% of total billed charges,8001.66,95,,,percent of total billed charges,95% of total billed charges,8001.66,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7243.61,86,,,percent of total billed charges,86% of total billed charges,6738.24,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8170.12,97,,,percent of total billed charges,97% of total billed charges,7580.52,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8170.12,97,,,percent of total billed charges,97% of total billed charges,7833.2,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8170.12,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,8170.12,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,2204.91,1102.46,,1984.42,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1763.93,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1984.42,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2138.76,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2028.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1984.42,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1543.44,70,,,percent of total billed charges,70% of total billed charges,1984.42,90,,,percent of total billed charges,90% of total billed charges,2094.66,95,,,percent of total billed charges,95% of total billed charges,2094.66,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1896.22,86,,,percent of total billed charges,86% of total billed charges,1763.93,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2138.76,97,,,percent of total billed charges,97% of total billed charges,1984.42,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2138.76,97,,,percent of total billed charges,97% of total billed charges,2050.57,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2138.76,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,2138.76,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,14710.19,7355.10,,13239.17,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11768.15,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13239.17,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14268.88,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13533.37,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13239.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10297.13,70,,,percent of total billed charges,70% of total billed charges,13239.17,90,,,percent of total billed charges,90% of total billed charges,13974.68,95,,,percent of total billed charges,95% of total billed charges,13974.68,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12650.76,86,,,percent of total billed charges,86% of total billed charges,11768.15,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14268.88,97,,,percent of total billed charges,97% of total billed charges,13239.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14268.88,97,,,percent of total billed charges,97% of total billed charges,13680.48,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14268.88,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,14268.88,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,14710.19,7355.10,,13239.17,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11768.15,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13239.17,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14268.88,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13533.37,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13239.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10297.13,70,,,percent of total billed charges,70% of total billed charges,13239.17,90,,,percent of total billed charges,90% of total billed charges,13974.68,95,,,percent of total billed charges,95% of total billed charges,13974.68,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12650.76,86,,,percent of total billed charges,86% of total billed charges,11768.15,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14268.88,97,,,percent of total billed charges,97% of total billed charges,13239.17,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14268.88,97,,,percent of total billed charges,97% of total billed charges,13680.48,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14268.88,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,14268.88,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,3227.98,1613.99,,2905.18,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.38,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2905.18,90,,,Percent of total Billed charges,90% of total billed charges,32.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3131.14,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2969.74,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2905.18,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2259.59,70,,,percent of total billed charges,70% of total billed charges,2905.18,90,,,percent of total billed charges,90% of total billed charges,3066.58,95,,,percent of total billed charges,95% of total billed charges,3066.58,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2776.06,86,,,percent of total billed charges,86% of total billed charges,2582.38,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3131.14,97,,,percent of total billed charges,97% of total billed charges,2905.18,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3131.14,97,,,percent of total billed charges,97% of total billed charges,3002.02,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3131.14,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.3,3131.14,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,1810.99,905.50,,1629.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1448.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1629.89,90,,,Percent of total Billed charges,90% of total billed charges,16.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1756.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1666.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1156.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1424.38,78.65,,,percent of total billed charges,78.65% of total billed charges,1617.79,89.33,,,percent of total billed charges,89.33% of total billed charges,1629.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1267.69,70,,,percent of total billed charges,70% of total billed charges,1629.89,90,,,percent of total billed charges,90% of total billed charges,1720.44,95,,,percent of total billed charges,95% of total billed charges,1720.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1557.45,86,,,percent of total billed charges,86% of total billed charges,1448.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1756.66,97,,,percent of total billed charges,97% of total billed charges,1629.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1756.66,97,,,percent of total billed charges,97% of total billed charges,1684.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1756.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,1756.66,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,7163.3,3581.65,,6446.97,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5730.64,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,6446.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6948.4,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,6590.24,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6446.97,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5014.31,70,,,percent of total billed charges,70% of total billed charges,6446.97,90,,,percent of total billed charges,90% of total billed charges,6805.14,95,,,percent of total billed charges,95% of total billed charges,6805.14,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6160.44,86,,,percent of total billed charges,86% of total billed charges,5730.64,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6948.4,97,,,percent of total billed charges,97% of total billed charges,6446.97,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,6948.4,97,,,percent of total billed charges,97% of total billed charges,6661.87,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6948.4,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.01,6948.4,
11042 Debridement Subcutaneous Tissue 20 Sq Cm/<,3436013,CDM,761,RC,11042,HCPCS,Outpatient,,,322.53,161.27,,290.28,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.28,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,312.85,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,296.73,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,290.28,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,225.77,70,,,percent of total billed charges,70% of total billed charges,290.28,90,,,percent of total billed charges,90% of total billed charges,306.4,95,,,percent of total billed charges,95% of total billed charges,306.4,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,277.38,86,,,percent of total billed charges,86% of total billed charges,258.02,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,312.85,97,,,percent of total billed charges,97% of total billed charges,290.28,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,312.85,97,,,percent of total billed charges,97% of total billed charges,299.95,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,312.85,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1818.76,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,2135.82,1067.91,,1922.24,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1708.66,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1922.24,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2071.75,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1964.95,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1922.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1495.07,70,,,percent of total billed charges,70% of total billed charges,1922.24,90,,,percent of total billed charges,90% of total billed charges,2029.03,95,,,percent of total billed charges,95% of total billed charges,2029.03,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1836.81,86,,,percent of total billed charges,86% of total billed charges,1708.66,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2071.75,97,,,percent of total billed charges,97% of total billed charges,1922.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2071.75,97,,,percent of total billed charges,97% of total billed charges,1986.31,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2071.75,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,2071.75,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,3484.52,1742.26,,3136.07,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2787.62,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3136.07,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3379.98,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3205.76,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3136.07,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2439.16,70,,,percent of total billed charges,70% of total billed charges,3136.07,90,,,percent of total billed charges,90% of total billed charges,3310.29,95,,,percent of total billed charges,95% of total billed charges,3310.29,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2996.69,86,,,percent of total billed charges,86% of total billed charges,2787.62,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3379.98,97,,,percent of total billed charges,97% of total billed charges,3136.07,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3379.98,97,,,percent of total billed charges,97% of total billed charges,3240.6,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3379.98,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,3379.98,
11043 Debridement Muscle & Fascia 20 Sq Cm/<,3436016,CDM,761,RC,11043,HCPCS,Outpatient,,,594.51,297.26,,535.06,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,475.61,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.06,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,576.67,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,546.95,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,535.06,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,416.16,70,,,percent of total billed charges,70% of total billed charges,535.06,90,,,percent of total billed charges,90% of total billed charges,564.78,95,,,percent of total billed charges,95% of total billed charges,564.78,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,511.28,86,,,percent of total billed charges,86% of total billed charges,475.61,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,576.67,97,,,percent of total billed charges,97% of total billed charges,535.06,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,576.67,97,,,percent of total billed charges,97% of total billed charges,552.89,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,576.67,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,2832.2,
11044 Debridement Bone Muscle & Fascia 20 Sq Cm/<,3436020,CDM,761,RC,11044,HCPCS,Outpatient,,,799.58,399.79,,719.62,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,639.66,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.62,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,775.59,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,735.61,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,719.62,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,559.71,70,,,percent of total billed charges,70% of total billed charges,719.62,90,,,percent of total billed charges,90% of total billed charges,759.6,95,,,percent of total billed charges,95% of total billed charges,759.6,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,687.64,86,,,percent of total billed charges,86% of total billed charges,639.66,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,775.59,97,,,percent of total billed charges,97% of total billed charges,719.62,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.59,97,,,percent of total billed charges,97% of total billed charges,743.61,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,775.59,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,7310.49,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,8650.14,4325.07,,7785.13,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6920.11,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7785.13,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8390.64,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7958.13,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7785.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6055.1,70,,,percent of total billed charges,70% of total billed charges,7785.13,90,,,percent of total billed charges,90% of total billed charges,8217.63,95,,,percent of total billed charges,95% of total billed charges,8217.63,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7439.12,86,,,percent of total billed charges,86% of total billed charges,6920.11,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8390.64,97,,,percent of total billed charges,97% of total billed charges,7785.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8390.64,97,,,percent of total billed charges,97% of total billed charges,8044.63,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8390.64,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,8390.64,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,701.37,350.69,,631.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,561.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,631.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,680.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,645.26,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,447.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,551.64,78.65,,,percent of total billed charges,78.65% of total billed charges,626.55,89.33,,,percent of total billed charges,89.33% of total billed charges,631.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.96,70,,,percent of total billed charges,70% of total billed charges,631.23,90,,,percent of total billed charges,90% of total billed charges,666.3,95,,,percent of total billed charges,95% of total billed charges,666.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.18,86,,,percent of total billed charges,86% of total billed charges,561.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,680.33,97,,,percent of total billed charges,97% of total billed charges,631.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,680.33,97,,,percent of total billed charges,97% of total billed charges,652.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,447.91,680.33,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,866.92,433.46,,780.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,693.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,780.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,840.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,797.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,553.63,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,681.85,78.65,,,percent of total billed charges,78.65% of total billed charges,774.43,89.33,,,percent of total billed charges,89.33% of total billed charges,780.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,606.84,70,,,percent of total billed charges,70% of total billed charges,780.23,90,,,percent of total billed charges,90% of total billed charges,823.57,95,,,percent of total billed charges,95% of total billed charges,823.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,745.55,86,,,percent of total billed charges,86% of total billed charges,693.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,840.91,97,,,percent of total billed charges,97% of total billed charges,780.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,840.91,97,,,percent of total billed charges,97% of total billed charges,806.24,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,840.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,553.63,840.91,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,2733.56,1366.78,,2460.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2186.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2460.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2651.55,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2514.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1745.71,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2150.01,78.65,,,percent of total billed charges,78.65% of total billed charges,2441.93,89.33,,,percent of total billed charges,89.33% of total billed charges,2460.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1913.49,70,,,percent of total billed charges,70% of total billed charges,2460.2,90,,,percent of total billed charges,90% of total billed charges,2596.88,95,,,percent of total billed charges,95% of total billed charges,2596.88,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2350.86,86,,,percent of total billed charges,86% of total billed charges,2186.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2651.55,97,,,percent of total billed charges,97% of total billed charges,2460.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2651.55,97,,,percent of total billed charges,97% of total billed charges,2542.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2651.55,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1745.71,2651.55,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,1042.84,521.42,,938.56,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,834.27,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,938.56,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1011.55,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,959.41,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,938.56,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,729.99,70,,,percent of total billed charges,70% of total billed charges,938.56,90,,,percent of total billed charges,90% of total billed charges,990.7,95,,,percent of total billed charges,95% of total billed charges,990.7,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,896.84,86,,,percent of total billed charges,86% of total billed charges,834.27,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1011.55,97,,,percent of total billed charges,97% of total billed charges,938.56,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.55,97,,,percent of total billed charges,97% of total billed charges,969.84,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1011.55,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1011.55,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,1055.97,527.99,,950.37,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,844.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,950.37,90,,,Percent of total Billed charges,90% of total billed charges,32.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1024.29,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,971.49,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,950.37,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,739.18,70,,,percent of total billed charges,70% of total billed charges,950.37,90,,,percent of total billed charges,90% of total billed charges,1003.17,95,,,percent of total billed charges,95% of total billed charges,1003.17,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,908.13,86,,,percent of total billed charges,86% of total billed charges,844.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1024.29,97,,,percent of total billed charges,97% of total billed charges,950.37,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1024.29,97,,,percent of total billed charges,97% of total billed charges,982.05,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1024.29,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,1024.29,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,1069.7,534.85,,962.73,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,855.76,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,962.73,90,,,Percent of total Billed charges,90% of total billed charges,42.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1037.61,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,984.12,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,962.73,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,748.79,70,,,percent of total billed charges,70% of total billed charges,962.73,90,,,percent of total billed charges,90% of total billed charges,1016.22,95,,,percent of total billed charges,95% of total billed charges,1016.22,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,919.94,86,,,percent of total billed charges,86% of total billed charges,855.76,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1037.61,97,,,percent of total billed charges,97% of total billed charges,962.73,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037.61,97,,,percent of total billed charges,97% of total billed charges,994.82,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1037.61,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.94,1037.61,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,1086.6,543.30,,977.94,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,869.28,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,977.94,90,,,Percent of total Billed charges,90% of total billed charges,35.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1054,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,999.67,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,977.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,760.62,70,,,percent of total billed charges,70% of total billed charges,977.94,90,,,percent of total billed charges,90% of total billed charges,1032.27,95,,,percent of total billed charges,95% of total billed charges,1032.27,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,934.48,86,,,percent of total billed charges,86% of total billed charges,869.28,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054,97,,,percent of total billed charges,97% of total billed charges,977.94,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054,97,,,percent of total billed charges,97% of total billed charges,1010.54,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1054,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.23,1054,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,170.08,85.04,,153.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,136.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,153.07,90,,,Percent of total Billed charges,90% of total billed charges,20.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,156.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,108.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,133.77,78.65,,,percent of total billed charges,78.65% of total billed charges,151.94,89.33,,,percent of total billed charges,89.33% of total billed charges,153.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,119.06,70,,,percent of total billed charges,70% of total billed charges,153.07,90,,,percent of total billed charges,90% of total billed charges,161.58,95,,,percent of total billed charges,95% of total billed charges,161.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.27,86,,,percent of total billed charges,86% of total billed charges,136.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,164.98,97,,,percent of total billed charges,97% of total billed charges,153.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.98,97,,,percent of total billed charges,97% of total billed charges,158.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,164.98,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,2107.98,1053.99,,1897.18,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.38,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1897.18,90,,,Percent of total Billed charges,90% of total billed charges,44.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2044.74,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1939.34,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1897.18,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1475.59,70,,,percent of total billed charges,70% of total billed charges,1897.18,90,,,percent of total billed charges,90% of total billed charges,2002.58,95,,,percent of total billed charges,95% of total billed charges,2002.58,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1812.86,86,,,percent of total billed charges,86% of total billed charges,1686.38,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2044.74,97,,,percent of total billed charges,97% of total billed charges,1897.18,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2044.74,97,,,percent of total billed charges,97% of total billed charges,1960.42,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2044.74,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.43,2044.74,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,481.7,240.85,,433.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,385.36,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,433.53,90,,,Percent of total Billed charges,90% of total billed charges,24.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,467.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,443.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,307.62,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,378.87,78.65,,,percent of total billed charges,78.65% of total billed charges,430.31,89.33,,,percent of total billed charges,89.33% of total billed charges,433.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,337.19,70,,,percent of total billed charges,70% of total billed charges,433.53,90,,,percent of total billed charges,90% of total billed charges,457.62,95,,,percent of total billed charges,95% of total billed charges,457.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.26,86,,,percent of total billed charges,86% of total billed charges,385.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,467.25,97,,,percent of total billed charges,97% of total billed charges,433.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,467.25,97,,,percent of total billed charges,97% of total billed charges,447.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,467.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,467.25,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,3285.68,1642.84,,2957.11,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2628.54,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2957.11,90,,,Percent of total Billed charges,90% of total billed charges,54.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3187.11,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3022.83,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2957.11,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2299.98,70,,,percent of total billed charges,70% of total billed charges,2957.11,90,,,percent of total billed charges,90% of total billed charges,3121.4,95,,,percent of total billed charges,95% of total billed charges,3121.4,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2825.68,86,,,percent of total billed charges,86% of total billed charges,2628.54,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3187.11,97,,,percent of total billed charges,97% of total billed charges,2957.11,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3187.11,97,,,percent of total billed charges,97% of total billed charges,3055.68,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3187.11,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.21,3187.11,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,237.28,118.64,,213.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,189.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,213.55,90,,,Percent of total Billed charges,90% of total billed charges,28.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,230.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,218.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,151.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,186.63,78.65,,,percent of total billed charges,78.65% of total billed charges,211.97,89.33,,,percent of total billed charges,89.33% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.1,70,,,percent of total billed charges,70% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.06,86,,,percent of total billed charges,86% of total billed charges,189.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,230.16,97,,,percent of total billed charges,97% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,230.16,97,,,percent of total billed charges,97% of total billed charges,220.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,230.16,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,1159.99,580.00,,1043.99,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,927.99,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.99,90,,,Percent of total Billed charges,90% of total billed charges,34.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1125.19,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1067.19,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.99,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,811.99,70,,,percent of total billed charges,70% of total billed charges,1043.99,90,,,percent of total billed charges,90% of total billed charges,1101.99,95,,,percent of total billed charges,95% of total billed charges,1101.99,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.59,86,,,percent of total billed charges,86% of total billed charges,927.99,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1125.19,97,,,percent of total billed charges,97% of total billed charges,1043.99,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1125.19,97,,,percent of total billed charges,97% of total billed charges,1078.79,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1125.19,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31,1125.19,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,80.16,40.08,,72.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.13,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.14,90,,,Percent of total Billed charges,90% of total billed charges,16.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.75,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.19,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,63.05,78.65,,,percent of total billed charges,78.65% of total billed charges,71.61,89.33,,,percent of total billed charges,89.33% of total billed charges,72.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.11,70,,,percent of total billed charges,70% of total billed charges,72.14,90,,,percent of total billed charges,90% of total billed charges,76.15,95,,,percent of total billed charges,95% of total billed charges,76.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.94,86,,,percent of total billed charges,86% of total billed charges,64.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.76,97,,,percent of total billed charges,97% of total billed charges,72.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.76,97,,,percent of total billed charges,97% of total billed charges,74.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,77.76,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,2082.06,1041.03,,1873.85,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.65,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1873.85,90,,,Percent of total Billed charges,90% of total billed charges,27.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2019.6,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1915.5,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1873.85,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1457.44,70,,,percent of total billed charges,70% of total billed charges,1873.85,90,,,percent of total billed charges,90% of total billed charges,1977.96,95,,,percent of total billed charges,95% of total billed charges,1977.96,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1790.57,86,,,percent of total billed charges,86% of total billed charges,1665.65,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2019.6,97,,,percent of total billed charges,97% of total billed charges,1873.85,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2019.6,97,,,percent of total billed charges,97% of total billed charges,1936.32,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2019.6,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25,2019.6,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,1113.82,556.91,,1002.44,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,891.06,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.44,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1080.41,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.71,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1002.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,779.67,70,,,percent of total billed charges,70% of total billed charges,1002.44,90,,,percent of total billed charges,90% of total billed charges,1058.13,95,,,percent of total billed charges,95% of total billed charges,1058.13,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,957.89,86,,,percent of total billed charges,86% of total billed charges,891.06,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1080.41,97,,,percent of total billed charges,97% of total billed charges,1002.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.41,97,,,percent of total billed charges,97% of total billed charges,1035.85,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1080.41,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,1080.41,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,1130.55,565.28,,1017.5,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,904.44,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1017.5,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1096.63,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.11,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1017.5,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,791.39,70,,,percent of total billed charges,70% of total billed charges,1017.5,90,,,percent of total billed charges,90% of total billed charges,1074.02,95,,,percent of total billed charges,95% of total billed charges,1074.02,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,972.27,86,,,percent of total billed charges,86% of total billed charges,904.44,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1096.63,97,,,percent of total billed charges,97% of total billed charges,1017.5,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.63,97,,,percent of total billed charges,97% of total billed charges,1051.41,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1096.63,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,1096.63,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,2156.38,1078.19,,1940.74,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1725.1,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1940.74,90,,,Percent of total Billed charges,90% of total billed charges,51.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2091.69,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1983.87,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1940.74,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.47,70,,,percent of total billed charges,70% of total billed charges,1940.74,90,,,percent of total billed charges,90% of total billed charges,2048.56,95,,,percent of total billed charges,95% of total billed charges,2048.56,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1854.49,86,,,percent of total billed charges,86% of total billed charges,1725.1,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2091.69,97,,,percent of total billed charges,97% of total billed charges,1940.74,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2091.69,97,,,percent of total billed charges,97% of total billed charges,2005.43,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2091.69,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47,2091.69,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,1087.34,543.67,,978.61,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,869.87,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.61,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1054.72,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1000.35,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,978.61,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,761.14,70,,,percent of total billed charges,70% of total billed charges,978.61,90,,,percent of total billed charges,90% of total billed charges,1032.97,95,,,percent of total billed charges,95% of total billed charges,1032.97,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,935.11,86,,,percent of total billed charges,86% of total billed charges,869.87,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054.72,97,,,percent of total billed charges,97% of total billed charges,978.61,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.72,97,,,percent of total billed charges,97% of total billed charges,1011.23,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1054.72,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,1054.72,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,1109.88,554.94,,998.89,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,887.9,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.89,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1076.58,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.09,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,998.89,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,776.92,70,,,percent of total billed charges,70% of total billed charges,998.89,90,,,percent of total billed charges,90% of total billed charges,1054.39,95,,,percent of total billed charges,95% of total billed charges,1054.39,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,954.5,86,,,percent of total billed charges,86% of total billed charges,887.9,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1076.58,97,,,percent of total billed charges,97% of total billed charges,998.89,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.58,97,,,percent of total billed charges,97% of total billed charges,1032.19,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1076.58,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,1076.58,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,1137.1,568.55,,1023.39,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,909.68,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1023.39,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1102.99,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.13,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1023.39,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,795.97,70,,,percent of total billed charges,70% of total billed charges,1023.39,90,,,percent of total billed charges,90% of total billed charges,1080.25,95,,,percent of total billed charges,95% of total billed charges,1080.25,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,977.91,86,,,percent of total billed charges,86% of total billed charges,909.68,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1102.99,97,,,percent of total billed charges,97% of total billed charges,1023.39,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.99,97,,,percent of total billed charges,97% of total billed charges,1057.5,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1102.99,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,1102.99,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,2155.68,1077.84,,1940.11,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1724.54,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1940.11,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2091.01,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1983.23,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1940.11,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1508.98,70,,,percent of total billed charges,70% of total billed charges,1940.11,90,,,percent of total billed charges,90% of total billed charges,2047.9,95,,,percent of total billed charges,95% of total billed charges,2047.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1853.88,86,,,percent of total billed charges,86% of total billed charges,1724.54,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2091.01,97,,,percent of total billed charges,97% of total billed charges,1940.11,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2091.01,97,,,percent of total billed charges,97% of total billed charges,2004.78,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2091.01,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,2091.01,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,1102.37,551.19,,992.13,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,881.9,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,992.13,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1069.3,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.18,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,992.13,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,771.66,70,,,percent of total billed charges,70% of total billed charges,992.13,90,,,percent of total billed charges,90% of total billed charges,1047.25,95,,,percent of total billed charges,95% of total billed charges,1047.25,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,948.04,86,,,percent of total billed charges,86% of total billed charges,881.9,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1069.3,97,,,percent of total billed charges,97% of total billed charges,992.13,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1069.3,97,,,percent of total billed charges,97% of total billed charges,1025.2,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1069.3,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,1069.3,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,1136.74,568.37,,1023.07,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,909.39,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1023.07,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1102.64,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.8,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1023.07,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,795.72,70,,,percent of total billed charges,70% of total billed charges,1023.07,90,,,percent of total billed charges,90% of total billed charges,1079.9,95,,,percent of total billed charges,95% of total billed charges,1079.9,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,977.6,86,,,percent of total billed charges,86% of total billed charges,909.39,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1102.64,97,,,percent of total billed charges,97% of total billed charges,1023.07,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.64,97,,,percent of total billed charges,97% of total billed charges,1057.17,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1102.64,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,1102.64,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,2162.26,1081.13,,1946.03,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1729.81,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1946.03,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2097.39,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1989.28,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1946.03,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1513.58,70,,,percent of total billed charges,70% of total billed charges,1946.03,90,,,percent of total billed charges,90% of total billed charges,2054.15,95,,,percent of total billed charges,95% of total billed charges,2054.15,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1859.54,86,,,percent of total billed charges,86% of total billed charges,1729.81,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2097.39,97,,,percent of total billed charges,97% of total billed charges,1946.03,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2097.39,97,,,percent of total billed charges,97% of total billed charges,2010.9,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2097.39,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,2097.39,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,2206.42,1103.21,,1985.78,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.14,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1985.78,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2140.23,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2029.91,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1985.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1544.49,70,,,percent of total billed charges,70% of total billed charges,1985.78,90,,,percent of total billed charges,90% of total billed charges,2096.1,95,,,percent of total billed charges,95% of total billed charges,2096.1,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1897.52,86,,,percent of total billed charges,86% of total billed charges,1765.14,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2140.23,97,,,percent of total billed charges,97% of total billed charges,1985.78,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2140.23,97,,,percent of total billed charges,97% of total billed charges,2051.97,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2140.23,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,2140.23,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,3718.04,1859.02,,3346.24,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2974.43,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3346.24,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3606.5,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3420.6,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3346.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2602.63,70,,,percent of total billed charges,70% of total billed charges,3346.24,90,,,percent of total billed charges,90% of total billed charges,3532.14,95,,,percent of total billed charges,95% of total billed charges,3532.14,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3197.51,86,,,percent of total billed charges,86% of total billed charges,2974.43,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3606.5,97,,,percent of total billed charges,97% of total billed charges,3346.24,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3606.5,97,,,percent of total billed charges,97% of total billed charges,3457.78,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3606.5,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,3606.5,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,2221.95,1110.98,,1999.76,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1777.56,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1999.76,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2155.29,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2044.19,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1999.76,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.37,70,,,percent of total billed charges,70% of total billed charges,1999.76,90,,,percent of total billed charges,90% of total billed charges,2110.85,95,,,percent of total billed charges,95% of total billed charges,2110.85,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1910.88,86,,,percent of total billed charges,86% of total billed charges,1777.56,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2155.29,97,,,percent of total billed charges,97% of total billed charges,1999.76,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2155.29,97,,,percent of total billed charges,97% of total billed charges,2066.41,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2155.29,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2155.29,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,3781.85,1890.93,,3403.67,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3025.48,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3403.67,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3668.39,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3479.3,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3403.67,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2647.3,70,,,percent of total billed charges,70% of total billed charges,3403.67,90,,,percent of total billed charges,90% of total billed charges,3592.76,95,,,percent of total billed charges,95% of total billed charges,3592.76,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3252.39,86,,,percent of total billed charges,86% of total billed charges,3025.48,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3668.39,97,,,percent of total billed charges,97% of total billed charges,3403.67,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3668.39,97,,,percent of total billed charges,97% of total billed charges,3517.12,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3668.39,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,3668.39,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,3849.84,1924.92,,3464.86,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.87,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3464.86,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3734.34,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3541.85,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3464.86,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2694.89,70,,,percent of total billed charges,70% of total billed charges,3464.86,90,,,percent of total billed charges,90% of total billed charges,3657.35,95,,,percent of total billed charges,95% of total billed charges,3657.35,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3310.86,86,,,percent of total billed charges,86% of total billed charges,3079.87,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3734.34,97,,,percent of total billed charges,97% of total billed charges,3464.86,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3734.34,97,,,percent of total billed charges,97% of total billed charges,3580.35,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3734.34,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,3734.34,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,8516.23,4258.12,,7664.61,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6812.98,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7664.61,90,,,Percent of total Billed charges,90% of total billed charges,88.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8260.74,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7834.93,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7664.61,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5961.36,70,,,percent of total billed charges,70% of total billed charges,7664.61,90,,,percent of total billed charges,90% of total billed charges,8090.42,95,,,percent of total billed charges,95% of total billed charges,8090.42,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7323.96,86,,,percent of total billed charges,86% of total billed charges,6812.98,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8260.74,97,,,percent of total billed charges,97% of total billed charges,7664.61,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8260.74,97,,,percent of total billed charges,97% of total billed charges,7920.09,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8260.74,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.5,8260.74,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,8690.66,4345.33,,7821.59,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6952.53,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7821.59,90,,,Percent of total Billed charges,90% of total billed charges,129.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8429.94,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7995.41,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7821.59,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6083.46,70,,,percent of total billed charges,70% of total billed charges,7821.59,90,,,percent of total billed charges,90% of total billed charges,8256.13,95,,,percent of total billed charges,95% of total billed charges,8256.13,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7473.97,86,,,percent of total billed charges,86% of total billed charges,6952.53,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8429.94,97,,,percent of total billed charges,97% of total billed charges,7821.59,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8429.94,97,,,percent of total billed charges,97% of total billed charges,8082.31,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8429.94,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.5,8429.94,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,8348.72,4174.36,,7513.85,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6678.98,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7513.85,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8098.26,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7680.82,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7513.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5844.1,70,,,percent of total billed charges,70% of total billed charges,7513.85,90,,,percent of total billed charges,90% of total billed charges,7931.28,95,,,percent of total billed charges,95% of total billed charges,7931.28,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7179.9,86,,,percent of total billed charges,86% of total billed charges,6678.98,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8098.26,97,,,percent of total billed charges,97% of total billed charges,7513.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8098.26,97,,,percent of total billed charges,97% of total billed charges,7764.31,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8098.26,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,8098.26,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,3769.43,1884.72,,3392.49,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3015.54,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3392.49,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3656.35,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3467.88,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3392.49,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2638.6,70,,,percent of total billed charges,70% of total billed charges,3392.49,90,,,percent of total billed charges,90% of total billed charges,3580.96,95,,,percent of total billed charges,95% of total billed charges,3580.96,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3241.71,86,,,percent of total billed charges,86% of total billed charges,3015.54,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3656.35,97,,,percent of total billed charges,97% of total billed charges,3392.49,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3656.35,97,,,percent of total billed charges,97% of total billed charges,3505.57,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3656.35,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,3656.35,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,8455.47,4227.74,,7609.92,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6764.38,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7609.92,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8201.81,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7779.03,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7609.92,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5918.83,70,,,percent of total billed charges,70% of total billed charges,7609.92,90,,,percent of total billed charges,90% of total billed charges,8032.7,95,,,percent of total billed charges,95% of total billed charges,8032.7,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7271.7,86,,,percent of total billed charges,86% of total billed charges,6764.38,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8201.81,97,,,percent of total billed charges,97% of total billed charges,7609.92,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8201.81,97,,,percent of total billed charges,97% of total billed charges,7863.59,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8201.81,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,8201.81,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,8499.37,4249.69,,7649.43,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6799.5,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7649.43,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8244.39,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7819.42,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7649.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5949.56,70,,,percent of total billed charges,70% of total billed charges,7649.43,90,,,percent of total billed charges,90% of total billed charges,8074.4,95,,,percent of total billed charges,95% of total billed charges,8074.4,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7309.46,86,,,percent of total billed charges,86% of total billed charges,6799.5,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8244.39,97,,,percent of total billed charges,97% of total billed charges,7649.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8244.39,97,,,percent of total billed charges,97% of total billed charges,7904.41,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8244.39,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,8244.39,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,8549.74,4274.87,,7694.77,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6839.79,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7694.77,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8293.25,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7865.76,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7694.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5984.82,70,,,percent of total billed charges,70% of total billed charges,7694.77,90,,,percent of total billed charges,90% of total billed charges,8122.25,95,,,percent of total billed charges,95% of total billed charges,8122.25,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7352.78,86,,,percent of total billed charges,86% of total billed charges,6839.79,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8293.25,97,,,percent of total billed charges,97% of total billed charges,7694.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8293.25,97,,,percent of total billed charges,97% of total billed charges,7951.26,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8293.25,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,8293.25,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,14891.04,7445.52,,13401.94,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11912.83,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13401.94,90,,,Percent of total Billed charges,90% of total billed charges,133.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14444.31,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13699.76,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13401.94,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10423.73,70,,,percent of total billed charges,70% of total billed charges,13401.94,90,,,percent of total billed charges,90% of total billed charges,14146.49,95,,,percent of total billed charges,95% of total billed charges,14146.49,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12806.29,86,,,percent of total billed charges,86% of total billed charges,11912.83,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14444.31,97,,,percent of total billed charges,97% of total billed charges,13401.94,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14444.31,97,,,percent of total billed charges,97% of total billed charges,13848.67,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14444.31,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121,14444.31,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,3760.44,1880.22,,3384.4,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3008.35,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3384.4,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3647.63,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3459.6,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3384.4,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2632.31,70,,,percent of total billed charges,70% of total billed charges,3384.4,90,,,percent of total billed charges,90% of total billed charges,3572.42,95,,,percent of total billed charges,95% of total billed charges,3572.42,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3233.98,86,,,percent of total billed charges,86% of total billed charges,3008.35,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3647.63,97,,,percent of total billed charges,97% of total billed charges,3384.4,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3647.63,97,,,percent of total billed charges,97% of total billed charges,3497.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3647.63,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,3647.63,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,3815.26,1907.63,,3433.73,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3052.21,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3433.73,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3700.8,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3510.04,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3433.73,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2670.68,70,,,percent of total billed charges,70% of total billed charges,3433.73,90,,,percent of total billed charges,90% of total billed charges,3624.5,95,,,percent of total billed charges,95% of total billed charges,3624.5,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3281.12,86,,,percent of total billed charges,86% of total billed charges,3052.21,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3700.8,97,,,percent of total billed charges,97% of total billed charges,3433.73,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3700.8,97,,,percent of total billed charges,97% of total billed charges,3548.19,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3700.8,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3700.8,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,3843.39,1921.70,,3459.05,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3074.71,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3459.05,90,,,Percent of total Billed charges,90% of total billed charges,86.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3728.09,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3535.92,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3459.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2690.37,70,,,percent of total billed charges,70% of total billed charges,3459.05,90,,,percent of total billed charges,90% of total billed charges,3651.22,95,,,percent of total billed charges,95% of total billed charges,3651.22,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3305.32,86,,,percent of total billed charges,86% of total billed charges,3074.71,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3728.09,97,,,percent of total billed charges,97% of total billed charges,3459.05,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3728.09,97,,,percent of total billed charges,97% of total billed charges,3574.35,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3728.09,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.5,3728.09,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,8543.19,4271.60,,7688.87,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6834.55,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7688.87,90,,,Percent of total Billed charges,90% of total billed charges,97.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8286.89,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7859.73,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7688.87,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5980.23,70,,,percent of total billed charges,70% of total billed charges,7688.87,90,,,percent of total billed charges,90% of total billed charges,8116.03,95,,,percent of total billed charges,95% of total billed charges,8116.03,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7347.14,86,,,percent of total billed charges,86% of total billed charges,6834.55,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8286.89,97,,,percent of total billed charges,97% of total billed charges,7688.87,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8286.89,97,,,percent of total billed charges,97% of total billed charges,7945.17,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8286.89,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89,8286.89,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,8638.42,4319.21,,7774.58,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6910.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7774.58,90,,,Percent of total Billed charges,90% of total billed charges,128.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8379.27,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7947.35,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7774.58,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6046.89,70,,,percent of total billed charges,70% of total billed charges,7774.58,90,,,percent of total billed charges,90% of total billed charges,8206.5,95,,,percent of total billed charges,95% of total billed charges,8206.5,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7429.04,86,,,percent of total billed charges,86% of total billed charges,6910.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8379.27,97,,,percent of total billed charges,97% of total billed charges,7774.58,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8379.27,97,,,percent of total billed charges,97% of total billed charges,8033.73,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8379.27,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117,8379.27,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,14987.44,7493.72,,13488.7,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11989.95,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13488.7,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14537.82,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13788.44,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13488.7,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10491.21,70,,,percent of total billed charges,70% of total billed charges,13488.7,90,,,percent of total billed charges,90% of total billed charges,14238.07,95,,,percent of total billed charges,95% of total billed charges,14238.07,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12889.2,86,,,percent of total billed charges,86% of total billed charges,11989.95,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14537.82,97,,,percent of total billed charges,97% of total billed charges,13488.7,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14537.82,97,,,percent of total billed charges,97% of total billed charges,13938.32,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14537.82,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,14537.82,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,14879.1,7439.55,,13391.19,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11903.28,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13391.19,90,,,Percent of total Billed charges,90% of total billed charges,201.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14432.73,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13688.77,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13391.19,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10415.37,70,,,percent of total billed charges,70% of total billed charges,13391.19,90,,,percent of total billed charges,90% of total billed charges,14135.15,95,,,percent of total billed charges,95% of total billed charges,14135.15,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12796.03,86,,,percent of total billed charges,86% of total billed charges,11903.28,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14432.73,97,,,percent of total billed charges,97% of total billed charges,13391.19,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14432.73,97,,,percent of total billed charges,97% of total billed charges,13837.56,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14432.73,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.24,14432.73,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,15022.03,7511.02,,13519.83,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12017.62,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13519.83,90,,,Percent of total Billed charges,90% of total billed charges,277.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14571.37,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13820.27,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13519.83,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10515.42,70,,,percent of total billed charges,70% of total billed charges,13519.83,90,,,percent of total billed charges,90% of total billed charges,14270.93,95,,,percent of total billed charges,95% of total billed charges,14270.93,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12918.95,86,,,percent of total billed charges,86% of total billed charges,12017.62,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14571.37,97,,,percent of total billed charges,97% of total billed charges,13519.83,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14571.37,97,,,percent of total billed charges,97% of total billed charges,13970.49,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14571.37,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,252.67,14571.37,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,14852.31,7426.16,,13367.08,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11881.85,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13367.08,90,,,Percent of total Billed charges,90% of total billed charges,191.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14406.74,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13664.13,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13367.08,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10396.62,70,,,percent of total billed charges,70% of total billed charges,13367.08,90,,,percent of total billed charges,90% of total billed charges,14109.69,95,,,percent of total billed charges,95% of total billed charges,14109.69,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12772.99,86,,,percent of total billed charges,86% of total billed charges,11881.85,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14406.74,97,,,percent of total billed charges,97% of total billed charges,13367.08,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14406.74,97,,,percent of total billed charges,97% of total billed charges,13812.65,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14406.74,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.95,14406.74,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,15023.71,7511.86,,13521.34,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12018.97,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13521.34,90,,,Percent of total Billed charges,90% of total billed charges,283.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14573,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13821.81,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13521.34,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10516.6,70,,,percent of total billed charges,70% of total billed charges,13521.34,90,,,percent of total billed charges,90% of total billed charges,14272.52,95,,,percent of total billed charges,95% of total billed charges,14272.52,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12920.39,86,,,percent of total billed charges,86% of total billed charges,12018.97,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14573,97,,,percent of total billed charges,97% of total billed charges,13521.34,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14573,97,,,percent of total billed charges,97% of total billed charges,13972.05,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14573,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,257.76,14573,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,14929.69,7464.85,,13436.72,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11943.75,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13436.72,90,,,Percent of total Billed charges,90% of total billed charges,234.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14481.8,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13735.31,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13436.72,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10450.78,70,,,percent of total billed charges,70% of total billed charges,13436.72,90,,,percent of total billed charges,90% of total billed charges,14183.21,95,,,percent of total billed charges,95% of total billed charges,14183.21,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12839.53,86,,,percent of total billed charges,86% of total billed charges,11943.75,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14481.8,97,,,percent of total billed charges,97% of total billed charges,13436.72,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14481.8,97,,,percent of total billed charges,97% of total billed charges,13884.61,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14481.8,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.98,14481.8,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,15061.04,7530.52,,13554.94,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12048.83,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13554.94,90,,,Percent of total Billed charges,90% of total billed charges,305.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14609.21,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13856.16,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13554.94,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10542.73,70,,,percent of total billed charges,70% of total billed charges,13554.94,90,,,percent of total billed charges,90% of total billed charges,14307.99,95,,,percent of total billed charges,95% of total billed charges,14307.99,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12952.49,86,,,percent of total billed charges,86% of total billed charges,12048.83,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14609.21,97,,,percent of total billed charges,97% of total billed charges,13554.94,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14609.21,97,,,percent of total billed charges,97% of total billed charges,14006.77,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14609.21,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.14,14609.21,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,3795.92,1897.96,,3416.33,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3036.74,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3416.33,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3682.04,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3492.25,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3416.33,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2657.14,70,,,percent of total billed charges,70% of total billed charges,3416.33,90,,,percent of total billed charges,90% of total billed charges,3606.12,95,,,percent of total billed charges,95% of total billed charges,3606.12,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3264.49,86,,,percent of total billed charges,86% of total billed charges,3036.74,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3682.04,97,,,percent of total billed charges,97% of total billed charges,3416.33,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3682.04,97,,,percent of total billed charges,97% of total billed charges,3530.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3682.04,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,3682.04,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,3847.19,1923.60,,3462.47,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3077.75,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3462.47,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3731.77,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3539.41,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3462.47,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2693.03,70,,,percent of total billed charges,70% of total billed charges,3462.47,90,,,percent of total billed charges,90% of total billed charges,3654.83,95,,,percent of total billed charges,95% of total billed charges,3654.83,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3308.58,86,,,percent of total billed charges,86% of total billed charges,3077.75,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3731.77,97,,,percent of total billed charges,97% of total billed charges,3462.47,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3731.77,97,,,percent of total billed charges,97% of total billed charges,3577.89,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3731.77,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,3731.77,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,2332.51,1166.26,,2099.26,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1866.01,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2099.26,90,,,Percent of total Billed charges,90% of total billed charges,89.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2262.53,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2145.91,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2099.26,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.76,70,,,percent of total billed charges,70% of total billed charges,2099.26,90,,,percent of total billed charges,90% of total billed charges,2215.88,95,,,percent of total billed charges,95% of total billed charges,2215.88,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2005.96,86,,,percent of total billed charges,86% of total billed charges,1866.01,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2262.53,97,,,percent of total billed charges,97% of total billed charges,2099.26,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2262.53,97,,,percent of total billed charges,97% of total billed charges,2169.23,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2262.53,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81,2262.53,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,3936.31,1968.16,,3542.68,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3149.05,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3542.68,90,,,Percent of total Billed charges,90% of total billed charges,94.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3818.22,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3621.41,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3542.68,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2755.42,70,,,percent of total billed charges,70% of total billed charges,3542.68,90,,,percent of total billed charges,90% of total billed charges,3739.49,95,,,percent of total billed charges,95% of total billed charges,3739.49,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3385.23,86,,,percent of total billed charges,86% of total billed charges,3149.05,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3818.22,97,,,percent of total billed charges,97% of total billed charges,3542.68,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3818.22,97,,,percent of total billed charges,97% of total billed charges,3660.77,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3818.22,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.5,3818.22,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,3976.97,1988.49,,3579.27,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3181.58,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3579.27,90,,,Percent of total Billed charges,90% of total billed charges,138.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3857.66,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3658.81,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3579.27,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2783.88,70,,,percent of total billed charges,70% of total billed charges,3579.27,90,,,percent of total billed charges,90% of total billed charges,3778.12,95,,,percent of total billed charges,95% of total billed charges,3778.12,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3420.19,86,,,percent of total billed charges,86% of total billed charges,3181.58,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3857.66,97,,,percent of total billed charges,97% of total billed charges,3579.27,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3857.66,97,,,percent of total billed charges,97% of total billed charges,3698.58,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3857.66,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.5,3857.66,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,8829.77,4414.89,,7946.79,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7063.82,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7946.79,90,,,Percent of total Billed charges,90% of total billed charges,270.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8564.88,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8123.39,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7946.79,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6180.84,70,,,percent of total billed charges,70% of total billed charges,7946.79,90,,,percent of total billed charges,90% of total billed charges,8388.28,95,,,percent of total billed charges,95% of total billed charges,8388.28,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7593.6,86,,,percent of total billed charges,86% of total billed charges,7063.82,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8564.88,97,,,percent of total billed charges,97% of total billed charges,7946.79,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8564.88,97,,,percent of total billed charges,97% of total billed charges,8211.69,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,246,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8564.88,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246,8564.88,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,8432.4,4216.20,,7589.16,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6745.92,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7589.16,90,,,Percent of total Billed charges,90% of total billed charges,100.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8179.43,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7757.81,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7589.16,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5902.68,70,,,percent of total billed charges,70% of total billed charges,7589.16,90,,,percent of total billed charges,90% of total billed charges,8010.78,95,,,percent of total billed charges,95% of total billed charges,8010.78,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7251.86,86,,,percent of total billed charges,86% of total billed charges,6745.92,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8179.43,97,,,percent of total billed charges,97% of total billed charges,7589.16,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8179.43,97,,,percent of total billed charges,97% of total billed charges,7842.13,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8179.43,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.5,8179.43,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,3848.82,1924.41,,3463.94,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.06,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3463.94,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3733.36,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3540.91,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3463.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2694.17,70,,,percent of total billed charges,70% of total billed charges,3463.94,90,,,percent of total billed charges,90% of total billed charges,3656.38,95,,,percent of total billed charges,95% of total billed charges,3656.38,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3309.99,86,,,percent of total billed charges,86% of total billed charges,3079.06,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3733.36,97,,,percent of total billed charges,97% of total billed charges,3463.94,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3733.36,97,,,percent of total billed charges,97% of total billed charges,3579.4,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3733.36,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,3733.36,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,3888.86,1944.43,,3499.97,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3111.09,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3499.97,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3772.19,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3577.75,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3499.97,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2722.2,70,,,percent of total billed charges,70% of total billed charges,3499.97,90,,,percent of total billed charges,90% of total billed charges,3694.42,95,,,percent of total billed charges,95% of total billed charges,3694.42,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3344.42,86,,,percent of total billed charges,86% of total billed charges,3111.09,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3772.19,97,,,percent of total billed charges,97% of total billed charges,3499.97,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3772.19,97,,,percent of total billed charges,97% of total billed charges,3616.64,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3772.19,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,3772.19,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,8604.03,4302.02,,7743.63,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6883.22,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7743.63,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8345.91,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7915.71,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7743.63,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6022.82,70,,,percent of total billed charges,70% of total billed charges,7743.63,90,,,percent of total billed charges,90% of total billed charges,8173.83,95,,,percent of total billed charges,95% of total billed charges,8173.83,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7399.47,86,,,percent of total billed charges,86% of total billed charges,6883.22,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8345.91,97,,,percent of total billed charges,97% of total billed charges,7743.63,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8345.91,97,,,percent of total billed charges,97% of total billed charges,8001.75,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8345.91,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,8345.91,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,8664.3,4332.15,,7797.87,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6931.44,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7797.87,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8404.37,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7971.16,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7797.87,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6065.01,70,,,percent of total billed charges,70% of total billed charges,7797.87,90,,,percent of total billed charges,90% of total billed charges,8231.09,95,,,percent of total billed charges,95% of total billed charges,8231.09,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7451.3,86,,,percent of total billed charges,86% of total billed charges,6931.44,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8404.37,97,,,percent of total billed charges,97% of total billed charges,7797.87,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8404.37,97,,,percent of total billed charges,97% of total billed charges,8057.8,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8404.37,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,8404.37,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,14938.29,7469.15,,13444.46,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11950.63,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13444.46,90,,,Percent of total Billed charges,90% of total billed charges,264,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14490.14,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13743.23,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13444.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10456.8,70,,,percent of total billed charges,70% of total billed charges,13444.46,90,,,percent of total billed charges,90% of total billed charges,14191.38,95,,,percent of total billed charges,95% of total billed charges,14191.38,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12846.93,86,,,percent of total billed charges,86% of total billed charges,11950.63,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14490.14,97,,,percent of total billed charges,97% of total billed charges,13444.46,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14490.14,97,,,percent of total billed charges,97% of total billed charges,13892.61,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14490.14,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,240,14490.14,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,3803.75,1901.88,,3423.38,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3043,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3423.38,90,,,Percent of total Billed charges,90% of total billed charges,84.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3689.64,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3499.45,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3423.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2662.63,70,,,percent of total billed charges,70% of total billed charges,3423.38,90,,,percent of total billed charges,90% of total billed charges,3613.56,95,,,percent of total billed charges,95% of total billed charges,3613.56,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3271.23,86,,,percent of total billed charges,86% of total billed charges,3043,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3689.64,97,,,percent of total billed charges,97% of total billed charges,3423.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3689.64,97,,,percent of total billed charges,97% of total billed charges,3537.49,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3689.64,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77,3689.64,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,3861.37,1930.69,,3475.23,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3089.1,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3475.23,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3745.53,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3552.46,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3475.23,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2702.96,70,,,percent of total billed charges,70% of total billed charges,3475.23,90,,,percent of total billed charges,90% of total billed charges,3668.3,95,,,percent of total billed charges,95% of total billed charges,3668.3,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3320.78,86,,,percent of total billed charges,86% of total billed charges,3089.1,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3745.53,97,,,percent of total billed charges,97% of total billed charges,3475.23,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3745.53,97,,,percent of total billed charges,97% of total billed charges,3591.07,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3745.53,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,3745.53,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,3915.24,1957.62,,3523.72,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3132.19,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3523.72,90,,,Percent of total Billed charges,90% of total billed charges,148.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3797.78,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3602.02,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3523.72,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2740.67,70,,,percent of total billed charges,70% of total billed charges,3523.72,90,,,percent of total billed charges,90% of total billed charges,3719.48,95,,,percent of total billed charges,95% of total billed charges,3719.48,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3367.11,86,,,percent of total billed charges,86% of total billed charges,3132.19,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3797.78,97,,,percent of total billed charges,97% of total billed charges,3523.72,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3797.78,97,,,percent of total billed charges,97% of total billed charges,3641.17,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,135,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3797.78,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135,3797.78,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,8641.28,4320.64,,7777.15,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6913.02,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7777.15,90,,,Percent of total Billed charges,90% of total billed charges,210.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8382.04,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7949.98,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7777.15,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6048.9,70,,,percent of total billed charges,70% of total billed charges,7777.15,90,,,percent of total billed charges,90% of total billed charges,8209.22,95,,,percent of total billed charges,95% of total billed charges,8209.22,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7431.5,86,,,percent of total billed charges,86% of total billed charges,6913.02,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8382.04,97,,,percent of total billed charges,97% of total billed charges,7777.15,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8382.04,97,,,percent of total billed charges,97% of total billed charges,8036.39,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8382.04,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,191.16,8382.04,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,8752.26,4376.13,,7877.03,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7001.81,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7877.03,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8489.69,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8052.08,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7877.03,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6126.58,70,,,percent of total billed charges,70% of total billed charges,7877.03,90,,,percent of total billed charges,90% of total billed charges,8314.65,95,,,percent of total billed charges,95% of total billed charges,8314.65,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7526.94,86,,,percent of total billed charges,86% of total billed charges,7001.81,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8489.69,97,,,percent of total billed charges,97% of total billed charges,7877.03,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8489.69,97,,,percent of total billed charges,97% of total billed charges,8139.6,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8489.69,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,8489.69,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,15136.01,7568.01,,13622.41,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12108.81,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13622.41,90,,,Percent of total Billed charges,90% of total billed charges,281.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,14681.93,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13925.13,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13622.41,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10595.21,70,,,percent of total billed charges,70% of total billed charges,13622.41,90,,,percent of total billed charges,90% of total billed charges,14379.21,95,,,percent of total billed charges,95% of total billed charges,14379.21,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13016.97,86,,,percent of total billed charges,86% of total billed charges,12108.81,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14681.93,97,,,percent of total billed charges,97% of total billed charges,13622.41,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,14681.93,97,,,percent of total billed charges,97% of total billed charges,14076.49,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,256,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,14681.93,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,256,14681.93,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,357.24,178.62,,321.52,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,285.79,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.52,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,346.52,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,328.66,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,321.52,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,250.07,70,,,percent of total billed charges,70% of total billed charges,321.52,90,,,percent of total billed charges,90% of total billed charges,339.38,95,,,percent of total billed charges,95% of total billed charges,339.38,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,307.23,86,,,percent of total billed charges,86% of total billed charges,285.79,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,346.52,97,,,percent of total billed charges,97% of total billed charges,321.52,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.52,97,,,percent of total billed charges,97% of total billed charges,332.23,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,346.52,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,346.52,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,1119.71,559.86,,1007.74,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,895.77,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1007.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1086.12,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1030.13,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1007.74,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,783.8,70,,,percent of total billed charges,70% of total billed charges,1007.74,90,,,percent of total billed charges,90% of total billed charges,1063.72,95,,,percent of total billed charges,95% of total billed charges,1063.72,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,962.95,86,,,percent of total billed charges,86% of total billed charges,895.77,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1086.12,97,,,percent of total billed charges,97% of total billed charges,1007.74,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1086.12,97,,,percent of total billed charges,97% of total billed charges,1041.33,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1086.12,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,1086.12,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,429.87,214.94,,386.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,343.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,386.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,416.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,395.48,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,274.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,338.1,78.65,,,percent of total billed charges,78.65% of total billed charges,384.01,89.33,,,percent of total billed charges,89.33% of total billed charges,386.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,300.91,70,,,percent of total billed charges,70% of total billed charges,386.88,90,,,percent of total billed charges,90% of total billed charges,408.38,95,,,percent of total billed charges,95% of total billed charges,408.38,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.69,86,,,percent of total billed charges,86% of total billed charges,343.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,416.97,97,,,percent of total billed charges,97% of total billed charges,386.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,416.97,97,,,percent of total billed charges,97% of total billed charges,399.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,274.52,416.97,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,1071.18,535.59,,964.06,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,856.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,964.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1039.04,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,985.49,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,964.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,749.83,70,,,percent of total billed charges,70% of total billed charges,964.06,90,,,percent of total billed charges,90% of total billed charges,1017.62,95,,,percent of total billed charges,95% of total billed charges,1017.62,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,921.21,86,,,percent of total billed charges,86% of total billed charges,856.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1039.04,97,,,percent of total billed charges,97% of total billed charges,964.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1039.04,97,,,percent of total billed charges,97% of total billed charges,996.2,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1039.04,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,1039.04,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,1102.03,551.02,,991.83,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,881.62,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,991.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1068.97,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.87,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,991.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,771.42,70,,,percent of total billed charges,70% of total billed charges,991.83,90,,,percent of total billed charges,90% of total billed charges,1046.93,95,,,percent of total billed charges,95% of total billed charges,1046.93,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,947.75,86,,,percent of total billed charges,86% of total billed charges,881.62,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1068.97,97,,,percent of total billed charges,97% of total billed charges,991.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1068.97,97,,,percent of total billed charges,97% of total billed charges,1024.89,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1068.97,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,1068.97,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,1117,558.50,,1005.3,90,,,percent of total billed charges,90% of total Billed charges,127.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.28,155,,,Fee Schedule,155% of CMS OPPS Rate,198.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,1005.3,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,1117,558.50,,1005.3,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,893.6,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1005.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1083.49,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1027.64,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1005.3,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,781.9,70,,,percent of total billed charges,70% of total billed charges,1005.3,90,,,percent of total billed charges,90% of total billed charges,1061.15,95,,,percent of total billed charges,95% of total billed charges,1061.15,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,960.62,86,,,percent of total billed charges,86% of total billed charges,893.6,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1083.49,97,,,percent of total billed charges,97% of total billed charges,1005.3,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1083.49,97,,,percent of total billed charges,97% of total billed charges,1038.81,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1083.49,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.4,1083.49,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,3319.96,1659.98,,2987.96,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2655.97,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2987.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3220.36,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3054.36,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2987.96,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2323.97,70,,,percent of total billed charges,70% of total billed charges,2987.96,90,,,percent of total billed charges,90% of total billed charges,3153.96,95,,,percent of total billed charges,95% of total billed charges,3153.96,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2855.17,86,,,percent of total billed charges,86% of total billed charges,2655.97,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3220.36,97,,,percent of total billed charges,97% of total billed charges,2987.96,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3220.36,97,,,percent of total billed charges,97% of total billed charges,3087.56,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3220.36,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3220.36,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,1975.91,987.96,,1778.32,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1580.73,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1778.32,90,,,Percent of total Billed charges,90% of total billed charges,101.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1916.63,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1817.84,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1778.32,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1383.14,70,,,percent of total billed charges,70% of total billed charges,1778.32,90,,,percent of total billed charges,90% of total billed charges,1877.11,95,,,percent of total billed charges,95% of total billed charges,1877.11,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1699.28,86,,,percent of total billed charges,86% of total billed charges,1580.73,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1916.63,97,,,percent of total billed charges,97% of total billed charges,1778.32,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1916.63,97,,,percent of total billed charges,97% of total billed charges,1837.6,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1916.63,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92.33,1916.63,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,1104.45,552.23,,994.01,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,883.56,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,994.01,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1071.32,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.09,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,994.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,773.12,70,,,percent of total billed charges,70% of total billed charges,994.01,90,,,percent of total billed charges,90% of total billed charges,1049.23,95,,,percent of total billed charges,95% of total billed charges,1049.23,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,949.83,86,,,percent of total billed charges,86% of total billed charges,883.56,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1071.32,97,,,percent of total billed charges,97% of total billed charges,994.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1071.32,97,,,percent of total billed charges,97% of total billed charges,1027.14,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1071.32,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,1071.32,
12001- Rep Superfic Wound 2.5Cm Less,3431574,CDM,761,RC,12001,HCPCS,Outpatient,,,966.27,483.14,,869.64,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,773.02,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,869.64,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,937.28,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,888.97,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,869.64,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,676.39,70,,,percent of total billed charges,70% of total billed charges,869.64,90,,,percent of total billed charges,90% of total billed charges,917.96,95,,,percent of total billed charges,95% of total billed charges,917.96,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,830.99,86,,,percent of total billed charges,86% of total billed charges,773.02,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,937.28,97,,,percent of total billed charges,97% of total billed charges,869.64,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,937.28,97,,,percent of total billed charges,97% of total billed charges,898.63,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,937.28,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,937.28,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,1134.4,567.20,,1020.96,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,907.52,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.96,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1100.37,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.65,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1020.96,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,794.08,70,,,percent of total billed charges,70% of total billed charges,1020.96,90,,,percent of total billed charges,90% of total billed charges,1077.68,95,,,percent of total billed charges,95% of total billed charges,1077.68,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,975.58,86,,,percent of total billed charges,86% of total billed charges,907.52,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1100.37,97,,,percent of total billed charges,97% of total billed charges,1020.96,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.37,97,,,percent of total billed charges,97% of total billed charges,1054.99,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1100.37,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,1100.37,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,1165.9,582.95,,1049.31,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,932.72,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.31,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1130.92,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.63,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1049.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,816.13,70,,,percent of total billed charges,70% of total billed charges,1049.31,90,,,percent of total billed charges,90% of total billed charges,1107.61,95,,,percent of total billed charges,95% of total billed charges,1107.61,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1002.67,86,,,percent of total billed charges,86% of total billed charges,932.72,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1130.92,97,,,percent of total billed charges,97% of total billed charges,1049.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.92,97,,,percent of total billed charges,97% of total billed charges,1084.29,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1130.92,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,1130.92,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,2214.87,1107.44,,1993.38,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.9,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1993.38,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2148.42,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2037.68,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1993.38,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1550.41,70,,,percent of total billed charges,70% of total billed charges,1993.38,90,,,percent of total billed charges,90% of total billed charges,2104.13,95,,,percent of total billed charges,95% of total billed charges,2104.13,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1904.79,86,,,percent of total billed charges,86% of total billed charges,1771.9,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2148.42,97,,,percent of total billed charges,97% of total billed charges,1993.38,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2148.42,97,,,percent of total billed charges,97% of total billed charges,2059.83,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2148.42,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2148.42,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,2258.88,1129.44,,2032.99,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1807.1,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2032.99,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2191.11,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2078.17,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2032.99,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.22,70,,,percent of total billed charges,70% of total billed charges,2032.99,90,,,percent of total billed charges,90% of total billed charges,2145.94,95,,,percent of total billed charges,95% of total billed charges,2145.94,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1942.64,86,,,percent of total billed charges,86% of total billed charges,1807.1,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2191.11,97,,,percent of total billed charges,97% of total billed charges,2032.99,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2191.11,97,,,percent of total billed charges,97% of total billed charges,2100.76,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2191.11,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2191.11,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,1315.03,657.52,,1183.53,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1052.02,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.53,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1275.58,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.83,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1183.53,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,920.52,70,,,percent of total billed charges,70% of total billed charges,1183.53,90,,,percent of total billed charges,90% of total billed charges,1249.28,95,,,percent of total billed charges,95% of total billed charges,1249.28,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.93,86,,,percent of total billed charges,86% of total billed charges,1052.02,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1275.58,97,,,percent of total billed charges,97% of total billed charges,1183.53,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1275.58,97,,,percent of total billed charges,97% of total billed charges,1222.98,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1275.58,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1275.58,
12011- Rep Superfic Wounds 2.5Cm Less,3431579,CDM,761,RC,12011,HCPCS,Outpatient,,,119.35,59.68,,107.42,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,95.48,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.42,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,115.77,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,109.8,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,107.42,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,83.55,70,,,percent of total billed charges,70% of total billed charges,107.42,90,,,percent of total billed charges,90% of total billed charges,113.38,95,,,percent of total billed charges,95% of total billed charges,113.38,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.64,86,,,percent of total billed charges,86% of total billed charges,95.48,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,115.77,97,,,percent of total billed charges,97% of total billed charges,107.42,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.77,97,,,percent of total billed charges,97% of total billed charges,111,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.77,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,880.35,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,1127.43,563.72,,1014.69,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,901.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1014.69,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1093.61,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1037.24,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1014.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,789.2,70,,,percent of total billed charges,70% of total billed charges,1014.69,90,,,percent of total billed charges,90% of total billed charges,1071.06,95,,,percent of total billed charges,95% of total billed charges,1071.06,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,969.59,86,,,percent of total billed charges,86% of total billed charges,901.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1093.61,97,,,percent of total billed charges,97% of total billed charges,1014.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1093.61,97,,,percent of total billed charges,97% of total billed charges,1048.51,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1093.61,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,1093.61,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,1127.43,563.72,,1014.69,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,1014.69,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,1134.02,567.01,,1020.62,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,907.22,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.62,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1100,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.3,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1020.62,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,793.81,70,,,percent of total billed charges,70% of total billed charges,1020.62,90,,,percent of total billed charges,90% of total billed charges,1077.32,95,,,percent of total billed charges,95% of total billed charges,1077.32,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,975.26,86,,,percent of total billed charges,86% of total billed charges,907.22,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1100,97,,,percent of total billed charges,97% of total billed charges,1020.62,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100,97,,,percent of total billed charges,97% of total billed charges,1054.64,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1100,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1100,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,1170.51,585.26,,1053.46,90,,,percent of total billed charges,90% of total Billed charges,214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.8,155,,,Fee Schedule,155% of CMS OPPS Rate,332.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,1053.46,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,1211.17,605.59,,1090.05,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,968.94,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1090.05,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1174.83,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1114.28,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1090.05,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,847.82,70,,,percent of total billed charges,70% of total billed charges,1090.05,90,,,percent of total billed charges,90% of total billed charges,1150.61,95,,,percent of total billed charges,95% of total billed charges,1150.61,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1041.61,86,,,percent of total billed charges,86% of total billed charges,968.94,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1174.83,97,,,percent of total billed charges,97% of total billed charges,1090.05,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1174.83,97,,,percent of total billed charges,97% of total billed charges,1126.39,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1174.83,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,1174.83,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,2284.89,1142.45,,2056.4,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1827.91,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2056.4,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2216.34,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2102.1,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2056.4,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1599.42,70,,,percent of total billed charges,70% of total billed charges,2056.4,90,,,percent of total billed charges,90% of total billed charges,2170.65,95,,,percent of total billed charges,95% of total billed charges,2170.65,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1965.01,86,,,percent of total billed charges,86% of total billed charges,1827.91,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2216.34,97,,,percent of total billed charges,97% of total billed charges,2056.4,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.34,97,,,percent of total billed charges,97% of total billed charges,2124.95,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2216.34,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2216.34,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,1380.7,690.35,,1242.63,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.56,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.63,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1339.28,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.24,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1242.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,966.49,70,,,percent of total billed charges,70% of total billed charges,1242.63,90,,,percent of total billed charges,90% of total billed charges,1311.67,95,,,percent of total billed charges,95% of total billed charges,1311.67,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.4,86,,,percent of total billed charges,86% of total billed charges,1104.56,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.28,97,,,percent of total billed charges,97% of total billed charges,1242.63,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.28,97,,,percent of total billed charges,97% of total billed charges,1284.05,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1339.28,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1339.28,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,3549.52,1774.76,,3194.57,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.62,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3194.57,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3443.03,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.56,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3194.57,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2484.66,70,,,percent of total billed charges,70% of total billed charges,3194.57,90,,,percent of total billed charges,90% of total billed charges,3372.04,95,,,percent of total billed charges,95% of total billed charges,3372.04,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3052.59,86,,,percent of total billed charges,86% of total billed charges,2839.62,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3443.03,97,,,percent of total billed charges,97% of total billed charges,3194.57,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3443.03,97,,,percent of total billed charges,97% of total billed charges,3301.05,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3443.03,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,3443.03,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,2549.52,1274.76,,2294.57,90,,,percent of total billed charges,90% of total Billed charges,466.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,332.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.74,155,,,Fee Schedule,155% of CMS OPPS Rate,723.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,2294.57,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,3549.52,1774.76,,3194.57,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2839.62,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3194.57,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3443.03,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3265.56,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3194.57,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2484.66,70,,,percent of total billed charges,70% of total billed charges,3194.57,90,,,percent of total billed charges,90% of total billed charges,3372.04,95,,,percent of total billed charges,95% of total billed charges,3372.04,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3052.59,86,,,percent of total billed charges,86% of total billed charges,2839.62,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3443.03,97,,,percent of total billed charges,97% of total billed charges,3194.57,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3443.03,97,,,percent of total billed charges,97% of total billed charges,3301.05,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3443.03,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,3443.03,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,2296.13,1148.07,,2066.52,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1836.9,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2066.52,90,,,Percent of total Billed charges,90% of total billed charges,129.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2227.25,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2112.44,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2066.52,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1607.29,70,,,percent of total billed charges,70% of total billed charges,2066.52,90,,,percent of total billed charges,90% of total billed charges,2181.32,95,,,percent of total billed charges,95% of total billed charges,2181.32,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1974.67,86,,,percent of total billed charges,86% of total billed charges,1836.9,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2227.25,97,,,percent of total billed charges,97% of total billed charges,2066.52,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2227.25,97,,,percent of total billed charges,97% of total billed charges,2135.4,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2227.25,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118,2227.25,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,2312.58,1156.29,,2081.32,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1850.06,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2081.32,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2243.2,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2127.57,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2081.32,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.81,70,,,percent of total billed charges,70% of total billed charges,2081.32,90,,,percent of total billed charges,90% of total billed charges,2196.95,95,,,percent of total billed charges,95% of total billed charges,2196.95,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1988.82,86,,,percent of total billed charges,86% of total billed charges,1850.06,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2243.2,97,,,percent of total billed charges,97% of total billed charges,2081.32,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2243.2,97,,,percent of total billed charges,97% of total billed charges,2150.7,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2243.2,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,2243.2,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,2388.29,1194.15,,2149.46,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1910.63,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2149.46,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2316.64,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2197.23,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2149.46,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.8,70,,,percent of total billed charges,70% of total billed charges,2149.46,90,,,percent of total billed charges,90% of total billed charges,2268.88,95,,,percent of total billed charges,95% of total billed charges,2268.88,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2053.93,86,,,percent of total billed charges,86% of total billed charges,1910.63,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2316.64,97,,,percent of total billed charges,97% of total billed charges,2149.46,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2316.64,97,,,percent of total billed charges,97% of total billed charges,2221.11,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2316.64,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,2316.64,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,2423.12,1211.56,,2180.81,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1938.5,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2180.81,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2350.43,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2229.27,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2180.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1696.18,70,,,percent of total billed charges,70% of total billed charges,2180.81,90,,,percent of total billed charges,90% of total billed charges,2301.96,95,,,percent of total billed charges,95% of total billed charges,2301.96,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2083.88,86,,,percent of total billed charges,86% of total billed charges,1938.5,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2350.43,97,,,percent of total billed charges,97% of total billed charges,2180.81,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2350.43,97,,,percent of total billed charges,97% of total billed charges,2253.5,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2350.43,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2350.43,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,2500.92,1250.46,,2250.83,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2000.74,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2250.83,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2425.89,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2300.85,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2250.83,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1750.64,70,,,percent of total billed charges,70% of total billed charges,2250.83,90,,,percent of total billed charges,90% of total billed charges,2375.87,95,,,percent of total billed charges,95% of total billed charges,2375.87,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2150.79,86,,,percent of total billed charges,86% of total billed charges,2000.74,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2425.89,97,,,percent of total billed charges,97% of total billed charges,2250.83,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2425.89,97,,,percent of total billed charges,97% of total billed charges,2325.86,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2425.89,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2425.89,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,9880.27,4940.14,,8892.24,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7904.22,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8892.24,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9583.86,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9089.85,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8892.24,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6916.19,70,,,percent of total billed charges,70% of total billed charges,8892.24,90,,,percent of total billed charges,90% of total billed charges,9386.26,95,,,percent of total billed charges,95% of total billed charges,9386.26,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8497.03,86,,,percent of total billed charges,86% of total billed charges,7904.22,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9583.86,97,,,percent of total billed charges,97% of total billed charges,8892.24,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9583.86,97,,,percent of total billed charges,97% of total billed charges,9188.65,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9583.86,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,9583.86,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,2302.49,1151.25,,2072.24,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1841.99,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2072.24,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2233.42,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2118.29,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2072.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1611.74,70,,,percent of total billed charges,70% of total billed charges,2072.24,90,,,percent of total billed charges,90% of total billed charges,2187.37,95,,,percent of total billed charges,95% of total billed charges,2187.37,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1980.14,86,,,percent of total billed charges,86% of total billed charges,1841.99,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2233.42,97,,,percent of total billed charges,97% of total billed charges,2072.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2233.42,97,,,percent of total billed charges,97% of total billed charges,2141.32,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2233.42,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,2233.42,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,2401.75,1200.88,,2161.58,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1921.4,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2161.58,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2329.7,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2209.61,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2161.58,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.23,70,,,percent of total billed charges,70% of total billed charges,2161.58,90,,,percent of total billed charges,90% of total billed charges,2281.66,95,,,percent of total billed charges,95% of total billed charges,2281.66,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2065.51,86,,,percent of total billed charges,86% of total billed charges,1921.4,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2329.7,97,,,percent of total billed charges,97% of total billed charges,2161.58,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2329.7,97,,,percent of total billed charges,97% of total billed charges,2233.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2329.7,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,2329.7,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,3600.95,1800.48,,3240.86,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2880.76,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3240.86,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3492.92,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3312.87,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3240.86,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2520.67,70,,,percent of total billed charges,70% of total billed charges,3240.86,90,,,percent of total billed charges,90% of total billed charges,3420.9,95,,,percent of total billed charges,95% of total billed charges,3420.9,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3096.82,86,,,percent of total billed charges,86% of total billed charges,2880.76,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3492.92,97,,,percent of total billed charges,97% of total billed charges,3240.86,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3492.92,97,,,percent of total billed charges,97% of total billed charges,3348.88,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3492.92,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,3492.92,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,3721.87,1860.94,,3349.68,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2977.5,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3349.68,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3610.21,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3424.12,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3349.68,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2605.31,70,,,percent of total billed charges,70% of total billed charges,3349.68,90,,,percent of total billed charges,90% of total billed charges,3535.78,95,,,percent of total billed charges,95% of total billed charges,3535.78,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3200.81,86,,,percent of total billed charges,86% of total billed charges,2977.5,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3610.21,97,,,percent of total billed charges,97% of total billed charges,3349.68,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3610.21,97,,,percent of total billed charges,97% of total billed charges,3461.34,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3610.21,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,3610.21,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,3822.57,1911.29,,3440.31,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3058.06,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3440.31,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3707.89,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3516.76,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3440.31,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2675.8,70,,,percent of total billed charges,70% of total billed charges,3440.31,90,,,percent of total billed charges,90% of total billed charges,3631.44,95,,,percent of total billed charges,95% of total billed charges,3631.44,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3287.41,86,,,percent of total billed charges,86% of total billed charges,3058.06,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3707.89,97,,,percent of total billed charges,97% of total billed charges,3440.31,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3707.89,97,,,percent of total billed charges,97% of total billed charges,3554.99,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3707.89,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,3707.89,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,9933.33,4966.67,,8940,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7946.66,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8940,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9635.33,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9138.66,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8940,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6953.33,70,,,percent of total billed charges,70% of total billed charges,8940,90,,,percent of total billed charges,90% of total billed charges,9436.66,95,,,percent of total billed charges,95% of total billed charges,9436.66,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8542.66,86,,,percent of total billed charges,86% of total billed charges,7946.66,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9635.33,97,,,percent of total billed charges,97% of total billed charges,8940,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9635.33,97,,,percent of total billed charges,97% of total billed charges,9238,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9635.33,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,9635.33,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,2350.02,1175.01,,2115.02,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.02,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2115.02,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2279.52,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2162.02,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2115.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1645.01,70,,,percent of total billed charges,70% of total billed charges,2115.02,90,,,percent of total billed charges,90% of total billed charges,2232.52,95,,,percent of total billed charges,95% of total billed charges,2232.52,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2021.02,86,,,percent of total billed charges,86% of total billed charges,1880.02,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2279.52,97,,,percent of total billed charges,97% of total billed charges,2115.02,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2279.52,97,,,percent of total billed charges,97% of total billed charges,2185.52,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2279.52,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,2279.52,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,2409.74,1204.87,,2168.77,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1927.79,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2168.77,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2337.45,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2216.96,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2168.77,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1686.82,70,,,percent of total billed charges,70% of total billed charges,2168.77,90,,,percent of total billed charges,90% of total billed charges,2289.25,95,,,percent of total billed charges,95% of total billed charges,2289.25,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2072.38,86,,,percent of total billed charges,86% of total billed charges,1927.79,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2337.45,97,,,percent of total billed charges,97% of total billed charges,2168.77,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2337.45,97,,,percent of total billed charges,97% of total billed charges,2241.06,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2337.45,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,2337.45,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,2442.39,1221.20,,2198.15,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1953.91,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2198.15,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2369.12,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2247,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2198.15,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1709.67,70,,,percent of total billed charges,70% of total billed charges,2198.15,90,,,percent of total billed charges,90% of total billed charges,2320.27,95,,,percent of total billed charges,95% of total billed charges,2320.27,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2100.46,86,,,percent of total billed charges,86% of total billed charges,1953.91,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2369.12,97,,,percent of total billed charges,97% of total billed charges,2198.15,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2369.12,97,,,percent of total billed charges,97% of total billed charges,2271.42,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2369.12,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,2369.12,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,2458.44,1229.22,,2212.6,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1966.75,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2212.6,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2384.69,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2261.76,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2212.6,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1720.91,70,,,percent of total billed charges,70% of total billed charges,2212.6,90,,,percent of total billed charges,90% of total billed charges,2335.52,95,,,percent of total billed charges,95% of total billed charges,2335.52,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2114.26,86,,,percent of total billed charges,86% of total billed charges,1966.75,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2384.69,97,,,percent of total billed charges,97% of total billed charges,2212.6,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2384.69,97,,,percent of total billed charges,97% of total billed charges,2286.35,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2384.69,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,2384.69,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,2624.71,1312.36,,2362.24,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2099.77,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2362.24,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2545.97,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2414.73,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2362.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1837.3,70,,,percent of total billed charges,70% of total billed charges,2362.24,90,,,percent of total billed charges,90% of total billed charges,2493.47,95,,,percent of total billed charges,95% of total billed charges,2493.47,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2257.25,86,,,percent of total billed charges,86% of total billed charges,2099.77,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2545.97,97,,,percent of total billed charges,97% of total billed charges,2362.24,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2545.97,97,,,percent of total billed charges,97% of total billed charges,2440.98,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2545.97,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2545.97,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,2785.72,1392.86,,2507.15,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.58,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.15,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.15,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.86,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.15,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1950,70,,,percent of total billed charges,70% of total billed charges,2507.15,90,,,percent of total billed charges,90% of total billed charges,2646.43,95,,,percent of total billed charges,95% of total billed charges,2646.43,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.72,86,,,percent of total billed charges,86% of total billed charges,2228.58,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.15,97,,,percent of total billed charges,97% of total billed charges,2507.15,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.15,97,,,percent of total billed charges,97% of total billed charges,2590.72,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.15,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2702.15,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,2859.84,1429.92,,2573.86,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2287.87,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2573.86,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2774.04,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2631.05,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2573.86,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2001.89,70,,,percent of total billed charges,70% of total billed charges,2573.86,90,,,percent of total billed charges,90% of total billed charges,2716.85,95,,,percent of total billed charges,95% of total billed charges,2716.85,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2459.46,86,,,percent of total billed charges,86% of total billed charges,2287.87,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2774.04,97,,,percent of total billed charges,97% of total billed charges,2573.86,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2774.04,97,,,percent of total billed charges,97% of total billed charges,2659.65,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2774.04,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,2774.04,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,3659.18,1829.59,,3293.26,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2927.34,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3293.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3549.4,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3366.45,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3293.26,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2561.43,70,,,percent of total billed charges,70% of total billed charges,3293.26,90,,,percent of total billed charges,90% of total billed charges,3476.22,95,,,percent of total billed charges,95% of total billed charges,3476.22,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3146.89,86,,,percent of total billed charges,86% of total billed charges,2927.34,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3549.4,97,,,percent of total billed charges,97% of total billed charges,3293.26,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3549.4,97,,,percent of total billed charges,97% of total billed charges,3403.04,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3549.4,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3549.4,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,1926.68,963.34,,1734.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1541.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1734.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1868.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1772.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1230.42,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1515.38,78.65,,,percent of total billed charges,78.65% of total billed charges,1721.13,89.33,,,percent of total billed charges,89.33% of total billed charges,1734.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1348.68,70,,,percent of total billed charges,70% of total billed charges,1734.01,90,,,percent of total billed charges,90% of total billed charges,1830.35,95,,,percent of total billed charges,95% of total billed charges,1830.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1656.94,86,,,percent of total billed charges,86% of total billed charges,1541.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1868.88,97,,,percent of total billed charges,97% of total billed charges,1734.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1868.88,97,,,percent of total billed charges,97% of total billed charges,1791.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1868.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1230.42,1868.88,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,3629.02,1814.51,,3266.12,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2903.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3266.12,90,,,Percent of total Billed charges,90% of total billed charges,66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3520.15,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3338.7,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3266.12,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2540.31,70,,,percent of total billed charges,70% of total billed charges,3266.12,90,,,percent of total billed charges,90% of total billed charges,3447.57,95,,,percent of total billed charges,95% of total billed charges,3447.57,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3120.96,86,,,percent of total billed charges,86% of total billed charges,2903.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3520.15,97,,,percent of total billed charges,97% of total billed charges,3266.12,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3520.15,97,,,percent of total billed charges,97% of total billed charges,3374.99,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3520.15,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60,3520.15,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,3684.77,1842.39,,3316.29,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2947.82,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3316.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3574.23,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3389.99,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3316.29,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2579.34,70,,,percent of total billed charges,70% of total billed charges,3316.29,90,,,percent of total billed charges,90% of total billed charges,3500.53,95,,,percent of total billed charges,95% of total billed charges,3500.53,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3168.9,86,,,percent of total billed charges,86% of total billed charges,2947.82,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3574.23,97,,,percent of total billed charges,97% of total billed charges,3316.29,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3574.23,97,,,percent of total billed charges,97% of total billed charges,3426.84,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3574.23,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3574.23,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,1948.39,974.20,,1753.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1558.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1753.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1889.94,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1792.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1244.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1532.45,78.65,,,percent of total billed charges,78.65% of total billed charges,1740.53,89.33,,,percent of total billed charges,89.33% of total billed charges,1753.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1363.87,70,,,percent of total billed charges,70% of total billed charges,1753.55,90,,,percent of total billed charges,90% of total billed charges,1850.97,95,,,percent of total billed charges,95% of total billed charges,1850.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1675.62,86,,,percent of total billed charges,86% of total billed charges,1558.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1889.94,97,,,percent of total billed charges,97% of total billed charges,1753.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1889.94,97,,,percent of total billed charges,97% of total billed charges,1812,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1889.94,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1244.28,1889.94,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,2495.77,1247.89,,2246.19,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1996.62,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2246.19,90,,,Percent of total Billed charges,90% of total billed charges,78.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2420.9,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2296.11,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2246.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1747.04,70,,,percent of total billed charges,70% of total billed charges,2246.19,90,,,percent of total billed charges,90% of total billed charges,2370.98,95,,,percent of total billed charges,95% of total billed charges,2370.98,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2146.36,86,,,percent of total billed charges,86% of total billed charges,1996.62,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2420.9,97,,,percent of total billed charges,97% of total billed charges,2246.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2420.9,97,,,percent of total billed charges,97% of total billed charges,2321.07,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2420.9,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,71,2420.9,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,3773.83,1886.92,,3396.45,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3019.06,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3396.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3660.62,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3471.92,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3396.45,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2641.68,70,,,percent of total billed charges,70% of total billed charges,3396.45,90,,,percent of total billed charges,90% of total billed charges,3585.14,95,,,percent of total billed charges,95% of total billed charges,3585.14,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3245.49,86,,,percent of total billed charges,86% of total billed charges,3019.06,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3660.62,97,,,percent of total billed charges,97% of total billed charges,3396.45,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3660.62,97,,,percent of total billed charges,97% of total billed charges,3509.66,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3660.62,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3660.62,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,3726.22,1863.11,,3353.6,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2980.98,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3353.6,90,,,Percent of total Billed charges,90% of total billed charges,194.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3614.43,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3428.12,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3353.6,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2608.35,70,,,percent of total billed charges,70% of total billed charges,3353.6,90,,,percent of total billed charges,90% of total billed charges,3539.91,95,,,percent of total billed charges,95% of total billed charges,3539.91,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3204.55,86,,,percent of total billed charges,86% of total billed charges,2980.98,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3614.43,97,,,percent of total billed charges,97% of total billed charges,3353.6,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3614.43,97,,,percent of total billed charges,97% of total billed charges,3465.38,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3614.43,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177,3614.43,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,3841.44,1920.72,,3457.3,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3073.15,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3457.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3726.2,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3534.12,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3457.3,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.01,70,,,percent of total billed charges,70% of total billed charges,3457.3,90,,,percent of total billed charges,90% of total billed charges,3649.37,95,,,percent of total billed charges,95% of total billed charges,3649.37,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3303.64,86,,,percent of total billed charges,86% of total billed charges,3073.15,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3726.2,97,,,percent of total billed charges,97% of total billed charges,3457.3,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3726.2,97,,,percent of total billed charges,97% of total billed charges,3572.54,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3726.2,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3726.2,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,10821.47,5410.74,,9739.32,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8657.18,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9739.32,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10496.83,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9955.75,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9739.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7575.03,70,,,percent of total billed charges,70% of total billed charges,9739.32,90,,,percent of total billed charges,90% of total billed charges,10280.4,95,,,percent of total billed charges,95% of total billed charges,10280.4,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9306.46,86,,,percent of total billed charges,86% of total billed charges,8657.18,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10496.83,97,,,percent of total billed charges,97% of total billed charges,9739.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10496.83,97,,,percent of total billed charges,97% of total billed charges,10063.97,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10496.83,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,10496.83,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,10523.37,5261.69,,9471.03,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8418.7,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9471.03,90,,,Percent of total Billed charges,90% of total billed charges,290.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10207.67,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9681.5,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9471.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7366.36,70,,,percent of total billed charges,70% of total billed charges,9471.03,90,,,percent of total billed charges,90% of total billed charges,9997.2,95,,,percent of total billed charges,95% of total billed charges,9997.2,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9050.1,86,,,percent of total billed charges,86% of total billed charges,8418.7,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10207.67,97,,,percent of total billed charges,97% of total billed charges,9471.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10207.67,97,,,percent of total billed charges,97% of total billed charges,9786.73,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,264,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10207.67,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,264,10207.67,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,10333.25,5166.63,,9299.93,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8266.6,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9299.93,90,,,Percent of total Billed charges,90% of total billed charges,165,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10023.25,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9506.59,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9299.93,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7233.28,70,,,percent of total billed charges,70% of total billed charges,9299.93,90,,,percent of total billed charges,90% of total billed charges,9816.59,95,,,percent of total billed charges,95% of total billed charges,9816.59,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8886.6,86,,,percent of total billed charges,86% of total billed charges,8266.6,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10023.25,97,,,percent of total billed charges,97% of total billed charges,9299.93,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10023.25,97,,,percent of total billed charges,97% of total billed charges,9609.92,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,150,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10023.25,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,150,10023.25,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,10619.24,5309.62,,9557.32,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8495.39,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9557.32,90,,,Percent of total Billed charges,90% of total billed charges,249.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10300.66,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9769.7,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9557.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7433.47,70,,,percent of total billed charges,70% of total billed charges,9557.32,90,,,percent of total billed charges,90% of total billed charges,10088.28,95,,,percent of total billed charges,95% of total billed charges,10088.28,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9132.55,86,,,percent of total billed charges,86% of total billed charges,8495.39,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10300.66,97,,,percent of total billed charges,97% of total billed charges,9557.32,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10300.66,97,,,percent of total billed charges,97% of total billed charges,9875.89,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10300.66,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,226.5,10300.66,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,10448.69,5224.35,,9403.82,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8358.95,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9403.82,90,,,Percent of total Billed charges,90% of total billed charges,195.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10135.23,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9612.79,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9403.82,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7314.08,70,,,percent of total billed charges,70% of total billed charges,9403.82,90,,,percent of total billed charges,90% of total billed charges,9926.26,95,,,percent of total billed charges,95% of total billed charges,9926.26,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8985.87,86,,,percent of total billed charges,86% of total billed charges,8358.95,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10135.23,97,,,percent of total billed charges,97% of total billed charges,9403.82,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10135.23,97,,,percent of total billed charges,97% of total billed charges,9717.28,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10135.23,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.5,10135.23,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,10723.16,5361.58,,9650.84,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8578.53,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9650.84,90,,,Percent of total Billed charges,90% of total billed charges,305.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10401.47,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9865.31,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9650.84,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7506.21,70,,,percent of total billed charges,70% of total billed charges,9650.84,90,,,percent of total billed charges,90% of total billed charges,10187,95,,,percent of total billed charges,95% of total billed charges,10187,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9221.92,86,,,percent of total billed charges,86% of total billed charges,8578.53,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10401.47,97,,,percent of total billed charges,97% of total billed charges,9650.84,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10401.47,97,,,percent of total billed charges,97% of total billed charges,9972.54,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10401.47,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,277.5,10401.47,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,10723.16,5361.58,,9650.84,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8578.53,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9650.84,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10401.47,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9865.31,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9650.84,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7506.21,70,,,percent of total billed charges,70% of total billed charges,9650.84,90,,,percent of total billed charges,90% of total billed charges,10187,95,,,percent of total billed charges,95% of total billed charges,10187,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9221.92,86,,,percent of total billed charges,86% of total billed charges,8578.53,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10401.47,97,,,percent of total billed charges,97% of total billed charges,9650.84,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10401.47,97,,,percent of total billed charges,97% of total billed charges,9972.54,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10401.47,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,10401.47,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,9464.62,4732.31,,8518.16,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7571.7,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8518.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9180.68,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8707.45,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8518.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6625.23,70,,,percent of total billed charges,70% of total billed charges,8518.16,90,,,percent of total billed charges,90% of total billed charges,8991.39,95,,,percent of total billed charges,95% of total billed charges,8991.39,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8139.57,86,,,percent of total billed charges,86% of total billed charges,7571.7,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9180.68,97,,,percent of total billed charges,97% of total billed charges,8518.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9180.68,97,,,percent of total billed charges,97% of total billed charges,8802.1,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9180.68,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,9180.68,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,4830.83,2415.42,,4347.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3864.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4347.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4685.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4444.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3085.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3799.55,78.65,,,percent of total billed charges,78.65% of total billed charges,4315.46,89.33,,,percent of total billed charges,89.33% of total billed charges,4347.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3381.58,70,,,percent of total billed charges,70% of total billed charges,4347.75,90,,,percent of total billed charges,90% of total billed charges,4589.29,95,,,percent of total billed charges,95% of total billed charges,4589.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4154.51,86,,,percent of total billed charges,86% of total billed charges,3864.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4685.91,97,,,percent of total billed charges,97% of total billed charges,4347.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4685.91,97,,,percent of total billed charges,97% of total billed charges,4492.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4685.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3085.07,4685.91,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,10667.98,5333.99,,9601.18,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8534.38,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9601.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10347.94,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9814.54,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9601.18,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7467.59,70,,,percent of total billed charges,70% of total billed charges,9601.18,90,,,percent of total billed charges,90% of total billed charges,10134.58,95,,,percent of total billed charges,95% of total billed charges,10134.58,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9174.46,86,,,percent of total billed charges,86% of total billed charges,8534.38,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10347.94,97,,,percent of total billed charges,97% of total billed charges,9601.18,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10347.94,97,,,percent of total billed charges,97% of total billed charges,9921.22,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10347.94,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10347.94,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,4816.63,2408.32,,4334.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3853.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4334.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4672.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4431.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3076.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3788.39,78.65,,,percent of total billed charges,78.65% of total billed charges,4302.77,89.33,,,percent of total billed charges,89.33% of total billed charges,4334.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3371.64,70,,,percent of total billed charges,70% of total billed charges,4334.97,90,,,percent of total billed charges,90% of total billed charges,4575.8,95,,,percent of total billed charges,95% of total billed charges,4575.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4142.3,86,,,percent of total billed charges,86% of total billed charges,3853.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4672.13,97,,,percent of total billed charges,97% of total billed charges,4334.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4672.13,97,,,percent of total billed charges,97% of total billed charges,4479.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3076.01,4672.13,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,10624.48,5312.24,,9562.03,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8499.58,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9562.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10305.75,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9774.52,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9562.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7437.14,70,,,percent of total billed charges,70% of total billed charges,9562.03,90,,,percent of total billed charges,90% of total billed charges,10093.26,95,,,percent of total billed charges,95% of total billed charges,10093.26,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9137.05,86,,,percent of total billed charges,86% of total billed charges,8499.58,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10305.75,97,,,percent of total billed charges,97% of total billed charges,9562.03,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10305.75,97,,,percent of total billed charges,97% of total billed charges,9880.77,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10305.75,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10305.75,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,19509.07,9754.54,,17558.16,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,15607.26,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,17558.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18923.8,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17948.34,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,17558.16,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,13656.35,70,,,percent of total billed charges,70% of total billed charges,17558.16,90,,,percent of total billed charges,90% of total billed charges,18533.62,95,,,percent of total billed charges,95% of total billed charges,18533.62,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,16777.8,86,,,percent of total billed charges,86% of total billed charges,15607.26,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,18923.8,97,,,percent of total billed charges,97% of total billed charges,17558.16,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,18923.8,97,,,percent of total billed charges,97% of total billed charges,18143.44,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18923.8,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2511.41,18923.8,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,10562.23,5281.12,,9506.01,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8449.78,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9506.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10245.36,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9717.25,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9506.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7393.56,70,,,percent of total billed charges,70% of total billed charges,9506.01,90,,,percent of total billed charges,90% of total billed charges,10034.12,95,,,percent of total billed charges,95% of total billed charges,10034.12,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9083.52,86,,,percent of total billed charges,86% of total billed charges,8449.78,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10245.36,97,,,percent of total billed charges,97% of total billed charges,9506.01,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10245.36,97,,,percent of total billed charges,97% of total billed charges,9822.87,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10245.36,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10245.36,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,10422.74,5211.37,,9380.47,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8338.19,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9380.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10110.06,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9588.92,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9380.47,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7295.92,70,,,percent of total billed charges,70% of total billed charges,9380.47,90,,,percent of total billed charges,90% of total billed charges,9901.6,95,,,percent of total billed charges,95% of total billed charges,9901.6,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8963.56,86,,,percent of total billed charges,86% of total billed charges,8338.19,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10110.06,97,,,percent of total billed charges,97% of total billed charges,9380.47,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10110.06,97,,,percent of total billed charges,97% of total billed charges,9693.15,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10110.06,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10110.06,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,4745.4,2372.70,,4270.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3796.32,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4270.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4603.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4365.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3030.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3732.36,78.65,,,percent of total billed charges,78.65% of total billed charges,4239.14,89.33,,,percent of total billed charges,89.33% of total billed charges,4270.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3321.78,70,,,percent of total billed charges,70% of total billed charges,4270.86,90,,,percent of total billed charges,90% of total billed charges,4508.13,95,,,percent of total billed charges,95% of total billed charges,4508.13,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4081.04,86,,,percent of total billed charges,86% of total billed charges,3796.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4603.04,97,,,percent of total billed charges,97% of total billed charges,4270.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4603.04,97,,,percent of total billed charges,97% of total billed charges,4413.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4603.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3030.52,4603.04,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,10787.04,5393.52,,9708.34,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8629.63,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9708.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10463.43,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9924.08,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9708.34,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7550.93,70,,,percent of total billed charges,70% of total billed charges,9708.34,90,,,percent of total billed charges,90% of total billed charges,10247.69,95,,,percent of total billed charges,95% of total billed charges,10247.69,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9276.85,86,,,percent of total billed charges,86% of total billed charges,8629.63,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10463.43,97,,,percent of total billed charges,97% of total billed charges,9708.34,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10463.43,97,,,percent of total billed charges,97% of total billed charges,10031.95,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10463.43,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10463.43,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,4822.69,2411.35,,4340.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3858.15,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4340.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4678.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4436.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3079.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3793.15,78.65,,,percent of total billed charges,78.65% of total billed charges,4308.19,89.33,,,percent of total billed charges,89.33% of total billed charges,4340.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3375.88,70,,,percent of total billed charges,70% of total billed charges,4340.42,90,,,percent of total billed charges,90% of total billed charges,4581.56,95,,,percent of total billed charges,95% of total billed charges,4581.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4147.51,86,,,percent of total billed charges,86% of total billed charges,3858.15,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4678.01,97,,,percent of total billed charges,97% of total billed charges,4340.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4678.01,97,,,percent of total billed charges,97% of total billed charges,4485.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4678.01,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3079.88,4678.01,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,10882.76,5441.38,,9794.48,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8706.21,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9794.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10556.28,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,10012.14,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9794.48,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7617.93,70,,,percent of total billed charges,70% of total billed charges,9794.48,90,,,percent of total billed charges,90% of total billed charges,10338.62,95,,,percent of total billed charges,95% of total billed charges,10338.62,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9359.17,86,,,percent of total billed charges,86% of total billed charges,8706.21,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10556.28,97,,,percent of total billed charges,97% of total billed charges,9794.48,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10556.28,97,,,percent of total billed charges,97% of total billed charges,10120.97,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10556.28,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,10556.28,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,4877.16,2438.58,,4389.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3901.73,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4389.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4730.85,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4486.99,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3114.66,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3835.99,78.65,,,percent of total billed charges,78.65% of total billed charges,4356.85,89.33,,,percent of total billed charges,89.33% of total billed charges,4389.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3414.01,70,,,percent of total billed charges,70% of total billed charges,4389.44,90,,,percent of total billed charges,90% of total billed charges,4633.3,95,,,percent of total billed charges,95% of total billed charges,4633.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4194.36,86,,,percent of total billed charges,86% of total billed charges,3901.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4730.85,97,,,percent of total billed charges,97% of total billed charges,4389.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4730.85,97,,,percent of total billed charges,97% of total billed charges,4535.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4730.85,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3114.66,4730.85,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,18518.28,9259.14,,16666.45,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14814.62,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,16666.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17962.73,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,17036.82,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16666.45,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12962.8,70,,,percent of total billed charges,70% of total billed charges,16666.45,90,,,percent of total billed charges,90% of total billed charges,17592.37,95,,,percent of total billed charges,95% of total billed charges,17592.37,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15925.72,86,,,percent of total billed charges,86% of total billed charges,14814.62,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17962.73,97,,,percent of total billed charges,97% of total billed charges,16666.45,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,17962.73,97,,,percent of total billed charges,97% of total billed charges,17222,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17962.73,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2511.41,17962.73,
15274 App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,3549034,CDM,761,RC,15274,HCPCS,Outpatient,,,214.29,107.15,,192.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,171.43,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,192.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,207.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,197.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,136.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,168.54,78.65,,,percent of total billed charges,78.65% of total billed charges,191.43,89.33,,,percent of total billed charges,89.33% of total billed charges,192.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,150,70,,,percent of total billed charges,70% of total billed charges,192.86,90,,,percent of total billed charges,90% of total billed charges,203.58,95,,,percent of total billed charges,95% of total billed charges,203.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.29,86,,,percent of total billed charges,86% of total billed charges,171.43,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.86,97,,,percent of total billed charges,97% of total billed charges,192.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,207.86,97,,,percent of total billed charges,97% of total billed charges,199.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.85,207.86,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,9398.39,4699.20,,8458.55,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7518.71,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8458.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9116.44,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8646.52,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8458.55,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6578.87,70,,,percent of total billed charges,70% of total billed charges,8458.55,90,,,percent of total billed charges,90% of total billed charges,8928.47,95,,,percent of total billed charges,95% of total billed charges,8928.47,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8082.62,86,,,percent of total billed charges,86% of total billed charges,7518.71,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9116.44,97,,,percent of total billed charges,97% of total billed charges,8458.55,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9116.44,97,,,percent of total billed charges,97% of total billed charges,8740.5,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9116.44,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,9116.44,
15275 Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,3436032,CDM,761,RC,15275,HCPCS,Outpatient,,,405.23,202.62,,364.71,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,324.18,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,393.07,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,372.81,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,364.71,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,283.66,70,,,percent of total billed charges,70% of total billed charges,364.71,90,,,percent of total billed charges,90% of total billed charges,384.97,95,,,percent of total billed charges,95% of total billed charges,384.97,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,348.5,86,,,percent of total billed charges,86% of total billed charges,324.18,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,393.07,97,,,percent of total billed charges,97% of total billed charges,364.71,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,393.07,97,,,percent of total billed charges,97% of total billed charges,376.86,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,393.07,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,283.66,8413.78,
15275-OCC Skin sub graft face/nk/hf/g,3536971,CDM,983,RC,15275,HCPCS,Outpatient,,,9398.39,4699.20,,8458.55,90,,,percent of total billed charges,90% of total Billed charges,243.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,143.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,145.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,86.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,182.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,110.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,141.72,155,,,Fee Schedule,155% of CMS OPPS Rate,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.91,155,,,Fee Schedule,155% of CMS OPPS Rate,377.91,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.44,8458.55,
15276 Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,3436033,CDM,761,RC,15276,HCPCS,Outpatient,,,85.64,42.82,,77.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,68.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,54.69,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,67.36,78.65,,,percent of total billed charges,78.65% of total billed charges,76.5,89.33,,,percent of total billed charges,89.33% of total billed charges,77.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.95,70,,,percent of total billed charges,70% of total billed charges,77.08,90,,,percent of total billed charges,90% of total billed charges,81.36,95,,,percent of total billed charges,95% of total billed charges,81.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.65,86,,,percent of total billed charges,86% of total billed charges,68.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,83.07,97,,,percent of total billed charges,97% of total billed charges,77.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.07,97,,,percent of total billed charges,97% of total billed charges,79.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.69,83.07,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,10602.96,5301.48,,9542.66,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8482.37,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9542.66,90,,,Percent of total Billed charges,90% of total billed charges,328.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10284.87,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9754.72,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9542.66,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7422.07,70,,,percent of total billed charges,70% of total billed charges,9542.66,90,,,percent of total billed charges,90% of total billed charges,10072.81,95,,,percent of total billed charges,95% of total billed charges,10072.81,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9118.55,86,,,percent of total billed charges,86% of total billed charges,8482.37,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10284.87,97,,,percent of total billed charges,97% of total billed charges,9542.66,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,10284.87,97,,,percent of total billed charges,97% of total billed charges,9860.75,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10284.87,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,298.5,10284.87,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,2432.78,1216.39,,2189.5,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.22,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2189.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2359.8,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2238.16,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2189.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1702.95,70,,,percent of total billed charges,70% of total billed charges,2189.5,90,,,percent of total billed charges,90% of total billed charges,2311.14,95,,,percent of total billed charges,95% of total billed charges,2311.14,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2092.19,86,,,percent of total billed charges,86% of total billed charges,1946.22,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2359.8,97,,,percent of total billed charges,97% of total billed charges,2189.5,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2359.8,97,,,percent of total billed charges,97% of total billed charges,2262.49,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2359.8,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.64,2359.8,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,3976.78,1988.39,,3579.1,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3181.42,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3579.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3857.48,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3658.64,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3579.1,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2783.75,70,,,percent of total billed charges,70% of total billed charges,3579.1,90,,,percent of total billed charges,90% of total billed charges,3777.94,95,,,percent of total billed charges,95% of total billed charges,3777.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3420.03,86,,,percent of total billed charges,86% of total billed charges,3181.42,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3857.48,97,,,percent of total billed charges,97% of total billed charges,3579.1,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3857.48,97,,,percent of total billed charges,97% of total billed charges,3698.41,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3857.48,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3857.48,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,3577.75,1788.88,,3219.98,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2862.2,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3219.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3470.42,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3291.53,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3219.98,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2504.43,70,,,percent of total billed charges,70% of total billed charges,3219.98,90,,,percent of total billed charges,90% of total billed charges,3398.86,95,,,percent of total billed charges,95% of total billed charges,3398.86,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3076.87,86,,,percent of total billed charges,86% of total billed charges,2862.2,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3470.42,97,,,percent of total billed charges,97% of total billed charges,3219.98,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3470.42,97,,,percent of total billed charges,97% of total billed charges,3327.31,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3470.42,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,330.33,3470.42,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,2712.65,1356.33,,2441.39,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2170.12,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2441.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2631.27,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2495.64,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2441.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1898.86,70,,,percent of total billed charges,70% of total billed charges,2441.39,90,,,percent of total billed charges,90% of total billed charges,2577.02,95,,,percent of total billed charges,95% of total billed charges,2577.02,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2332.88,86,,,percent of total billed charges,86% of total billed charges,2170.12,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2631.27,97,,,percent of total billed charges,97% of total billed charges,2441.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2631.27,97,,,percent of total billed charges,97% of total billed charges,2522.76,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2631.27,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,2631.27,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,10211.29,5105.65,,9190.16,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8169.03,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9190.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9904.95,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,9394.39,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9190.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7147.9,70,,,percent of total billed charges,70% of total billed charges,9190.16,90,,,percent of total billed charges,90% of total billed charges,9700.73,95,,,percent of total billed charges,95% of total billed charges,9700.73,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8781.71,86,,,percent of total billed charges,86% of total billed charges,8169.03,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9904.95,97,,,percent of total billed charges,97% of total billed charges,9190.16,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9904.95,97,,,percent of total billed charges,97% of total billed charges,9496.5,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9904.95,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,9904.95,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,9340.05,4670.03,,8406.05,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7472.04,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8406.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9059.85,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8592.85,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8406.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6538.04,70,,,percent of total billed charges,70% of total billed charges,8406.05,90,,,percent of total billed charges,90% of total billed charges,8873.05,95,,,percent of total billed charges,95% of total billed charges,8873.05,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8032.44,86,,,percent of total billed charges,86% of total billed charges,7472.04,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9059.85,97,,,percent of total billed charges,97% of total billed charges,8406.05,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9059.85,97,,,percent of total billed charges,97% of total billed charges,8686.25,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9059.85,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,9059.85,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,1122.23,561.12,,1010.01,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,897.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.01,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1088.56,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1032.45,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1010.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,785.56,70,,,percent of total billed charges,70% of total billed charges,1010.01,90,,,percent of total billed charges,90% of total billed charges,1066.12,95,,,percent of total billed charges,95% of total billed charges,1066.12,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,965.12,86,,,percent of total billed charges,86% of total billed charges,897.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1088.56,97,,,percent of total billed charges,97% of total billed charges,1010.01,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1088.56,97,,,percent of total billed charges,97% of total billed charges,1043.67,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1088.56,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1088.56,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,1236.99,618.50,,1113.29,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,989.59,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.29,90,,,Percent of total Billed charges,90% of total billed charges,110.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1199.88,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.03,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.29,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,865.89,70,,,percent of total billed charges,70% of total billed charges,1113.29,90,,,percent of total billed charges,90% of total billed charges,1175.14,95,,,percent of total billed charges,95% of total billed charges,1175.14,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1063.81,86,,,percent of total billed charges,86% of total billed charges,989.59,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1199.88,97,,,percent of total billed charges,97% of total billed charges,1113.29,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1199.88,97,,,percent of total billed charges,97% of total billed charges,1150.4,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1199.88,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,100.55,1199.88,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,1118.12,559.06,,1006.31,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,894.5,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1006.31,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1084.58,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1028.67,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1006.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,782.68,70,,,percent of total billed charges,70% of total billed charges,1006.31,90,,,percent of total billed charges,90% of total billed charges,1062.21,95,,,percent of total billed charges,95% of total billed charges,1062.21,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,961.58,86,,,percent of total billed charges,86% of total billed charges,894.5,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1084.58,97,,,percent of total billed charges,97% of total billed charges,1006.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1084.58,97,,,percent of total billed charges,97% of total billed charges,1039.85,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1084.58,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1084.58,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,509.45,254.73,,458.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,407.56,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,458.51,90,,,Percent of total Billed charges,90% of total billed charges,4.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,494.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,468.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,325.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,400.69,78.65,,,percent of total billed charges,78.65% of total billed charges,455.1,89.33,,,percent of total billed charges,89.33% of total billed charges,458.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,356.62,70,,,percent of total billed charges,70% of total billed charges,458.51,90,,,percent of total billed charges,90% of total billed charges,483.98,95,,,percent of total billed charges,95% of total billed charges,483.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,438.13,86,,,percent of total billed charges,86% of total billed charges,407.56,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,494.17,97,,,percent of total billed charges,97% of total billed charges,458.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,494.17,97,,,percent of total billed charges,97% of total billed charges,473.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,494.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,494.17,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,2208.13,1104.07,,1987.32,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1766.5,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1987.32,90,,,Percent of total Billed charges,90% of total billed charges,128.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2141.89,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2031.48,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1987.32,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1545.69,70,,,percent of total billed charges,70% of total billed charges,1987.32,90,,,percent of total billed charges,90% of total billed charges,2097.72,95,,,percent of total billed charges,95% of total billed charges,2097.72,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1898.99,86,,,percent of total billed charges,86% of total billed charges,1766.5,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2141.89,97,,,percent of total billed charges,97% of total billed charges,1987.32,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2141.89,97,,,percent of total billed charges,97% of total billed charges,2053.56,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2141.89,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116.39,2141.89,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,1143.84,571.92,,1029.46,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,915.07,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1029.46,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1109.52,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1052.33,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1029.46,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,800.69,70,,,percent of total billed charges,70% of total billed charges,1029.46,90,,,percent of total billed charges,90% of total billed charges,1086.65,95,,,percent of total billed charges,95% of total billed charges,1086.65,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,983.7,86,,,percent of total billed charges,86% of total billed charges,915.07,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1109.52,97,,,percent of total billed charges,97% of total billed charges,1029.46,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1109.52,97,,,percent of total billed charges,97% of total billed charges,1063.77,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1109.52,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,1109.52,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,1173.73,586.87,,1056.36,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,938.98,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1056.36,90,,,Percent of total Billed charges,90% of total billed charges,56.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1138.52,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1079.83,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1056.36,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,821.61,70,,,percent of total billed charges,70% of total billed charges,1056.36,90,,,percent of total billed charges,90% of total billed charges,1115.04,95,,,percent of total billed charges,95% of total billed charges,1115.04,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1009.41,86,,,percent of total billed charges,86% of total billed charges,938.98,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1138.52,97,,,percent of total billed charges,97% of total billed charges,1056.36,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1138.52,97,,,percent of total billed charges,97% of total billed charges,1091.57,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1138.52,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.37,1138.52,
17250 Chemical Cauterization if Granulation Tissue,3436034,CDM,761,RC,17250,HCPCS,Outpatient,,,220.96,110.48,,198.86,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,176.77,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.86,90,,,Percent of total Billed charges,90% of total billed charges,28.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,214.33,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,203.28,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,198.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,154.67,70,,,percent of total billed charges,70% of total billed charges,198.86,90,,,percent of total billed charges,90% of total billed charges,209.91,95,,,percent of total billed charges,95% of total billed charges,209.91,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,190.03,86,,,percent of total billed charges,86% of total billed charges,176.77,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,214.33,97,,,percent of total billed charges,97% of total billed charges,198.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.33,97,,,percent of total billed charges,97% of total billed charges,205.49,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,214.33,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.82,880.35,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,1086,543.00,,977.4,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,868.8,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,977.4,90,,,Percent of total Billed charges,90% of total billed charges,28.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1053.42,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,999.12,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,977.4,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,760.2,70,,,percent of total billed charges,70% of total billed charges,977.4,90,,,percent of total billed charges,90% of total billed charges,1031.7,95,,,percent of total billed charges,95% of total billed charges,1031.7,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,933.96,86,,,percent of total billed charges,86% of total billed charges,868.8,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1053.42,97,,,percent of total billed charges,97% of total billed charges,977.4,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1053.42,97,,,percent of total billed charges,97% of total billed charges,1009.98,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1053.42,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.82,1053.42,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,1150.3,575.15,,1035.27,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,920.24,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1035.27,90,,,Percent of total Billed charges,90% of total billed charges,56.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1115.79,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.28,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1035.27,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,805.21,70,,,percent of total billed charges,70% of total billed charges,1035.27,90,,,percent of total billed charges,90% of total billed charges,1092.79,95,,,percent of total billed charges,95% of total billed charges,1092.79,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,989.26,86,,,percent of total billed charges,86% of total billed charges,920.24,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1115.79,97,,,percent of total billed charges,97% of total billed charges,1035.27,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1115.79,97,,,percent of total billed charges,97% of total billed charges,1069.78,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1115.79,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.44,1115.79,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,1183.69,591.85,,1065.32,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,946.95,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1065.32,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1148.18,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.99,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1065.32,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,828.58,70,,,percent of total billed charges,70% of total billed charges,1065.32,90,,,percent of total billed charges,90% of total billed charges,1124.51,95,,,percent of total billed charges,95% of total billed charges,1124.51,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1017.97,86,,,percent of total billed charges,86% of total billed charges,946.95,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1148.18,97,,,percent of total billed charges,97% of total billed charges,1065.32,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1148.18,97,,,percent of total billed charges,97% of total billed charges,1100.83,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1148.18,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,1148.18,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,1230.2,615.10,,1107.18,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,984.16,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.18,90,,,Percent of total Billed charges,90% of total billed charges,93.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1193.29,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1131.78,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1107.18,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,861.14,70,,,percent of total billed charges,70% of total billed charges,1107.18,90,,,percent of total billed charges,90% of total billed charges,1168.69,95,,,percent of total billed charges,95% of total billed charges,1168.69,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1057.97,86,,,percent of total billed charges,86% of total billed charges,984.16,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1193.29,97,,,percent of total billed charges,97% of total billed charges,1107.18,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1193.29,97,,,percent of total billed charges,97% of total billed charges,1144.09,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1193.29,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85,1193.29,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,1253.82,626.91,,1128.44,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1003.06,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1128.44,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1216.21,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1153.51,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1128.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,877.67,70,,,percent of total billed charges,70% of total billed charges,1128.44,90,,,percent of total billed charges,90% of total billed charges,1191.13,95,,,percent of total billed charges,95% of total billed charges,1191.13,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1078.29,86,,,percent of total billed charges,86% of total billed charges,1003.06,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1216.21,97,,,percent of total billed charges,97% of total billed charges,1128.44,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1216.21,97,,,percent of total billed charges,97% of total billed charges,1166.05,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1216.21,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,1216.21,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,2273.47,1136.74,,2046.12,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1818.78,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2046.12,90,,,Percent of total Billed charges,90% of total billed charges,121.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2205.27,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.59,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2046.12,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1591.43,70,,,percent of total billed charges,70% of total billed charges,2046.12,90,,,percent of total billed charges,90% of total billed charges,2159.8,95,,,percent of total billed charges,95% of total billed charges,2159.8,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1955.18,86,,,percent of total billed charges,86% of total billed charges,1818.78,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2205.27,97,,,percent of total billed charges,97% of total billed charges,2046.12,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2205.27,97,,,percent of total billed charges,97% of total billed charges,2114.33,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2205.27,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.56,2205.27,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,2318.71,1159.36,,2086.84,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1854.97,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2086.84,90,,,Percent of total Billed charges,90% of total billed charges,141.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2249.15,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2133.21,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2086.84,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.1,70,,,percent of total billed charges,70% of total billed charges,2086.84,90,,,percent of total billed charges,90% of total billed charges,2202.77,95,,,percent of total billed charges,95% of total billed charges,2202.77,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1994.09,86,,,percent of total billed charges,86% of total billed charges,1854.97,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2249.15,97,,,percent of total billed charges,97% of total billed charges,2086.84,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2249.15,97,,,percent of total billed charges,97% of total billed charges,2156.4,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2249.15,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.61,2249.15,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,1200.74,600.37,,1080.67,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,960.59,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1080.67,90,,,Percent of total Billed charges,90% of total billed charges,62.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1164.72,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.68,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1080.67,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,840.52,70,,,percent of total billed charges,70% of total billed charges,1080.67,90,,,percent of total billed charges,90% of total billed charges,1140.7,95,,,percent of total billed charges,95% of total billed charges,1140.7,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1032.64,86,,,percent of total billed charges,86% of total billed charges,960.59,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1164.72,97,,,percent of total billed charges,97% of total billed charges,1080.67,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1164.72,97,,,percent of total billed charges,97% of total billed charges,1116.69,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1164.72,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.1,1164.72,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,1219.46,609.73,,1097.51,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,975.57,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1097.51,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1182.88,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1121.9,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1097.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,853.62,70,,,percent of total billed charges,70% of total billed charges,1097.51,90,,,percent of total billed charges,90% of total billed charges,1158.49,95,,,percent of total billed charges,95% of total billed charges,1158.49,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1048.74,86,,,percent of total billed charges,86% of total billed charges,975.57,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1182.88,97,,,percent of total billed charges,97% of total billed charges,1097.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.88,97,,,percent of total billed charges,97% of total billed charges,1134.1,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1182.88,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,1182.88,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,1251.83,625.92,,1126.65,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.46,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1126.65,90,,,Percent of total Billed charges,90% of total billed charges,112.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1214.28,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.68,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1126.65,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,876.28,70,,,percent of total billed charges,70% of total billed charges,1126.65,90,,,percent of total billed charges,90% of total billed charges,1189.24,95,,,percent of total billed charges,95% of total billed charges,1189.24,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1076.57,86,,,percent of total billed charges,86% of total billed charges,1001.46,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1214.28,97,,,percent of total billed charges,97% of total billed charges,1126.65,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1214.28,97,,,percent of total billed charges,97% of total billed charges,1164.2,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1214.28,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.26,1214.28,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,2286.23,1143.12,,2057.61,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.98,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2057.61,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2217.64,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2103.33,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2057.61,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.36,70,,,percent of total billed charges,70% of total billed charges,2057.61,90,,,percent of total billed charges,90% of total billed charges,2171.92,95,,,percent of total billed charges,95% of total billed charges,2171.92,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1966.16,86,,,percent of total billed charges,86% of total billed charges,1828.98,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2217.64,97,,,percent of total billed charges,97% of total billed charges,2057.61,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2217.64,97,,,percent of total billed charges,97% of total billed charges,2126.19,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2217.64,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,2217.64,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,2346.88,1173.44,,2112.19,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1877.5,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.19,90,,,Percent of total Billed charges,90% of total billed charges,158.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2276.47,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2159.13,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2112.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.82,70,,,percent of total billed charges,70% of total billed charges,2112.19,90,,,percent of total billed charges,90% of total billed charges,2229.54,95,,,percent of total billed charges,95% of total billed charges,2229.54,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2018.32,86,,,percent of total billed charges,86% of total billed charges,1877.5,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2276.47,97,,,percent of total billed charges,97% of total billed charges,2112.19,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2276.47,97,,,percent of total billed charges,97% of total billed charges,2182.6,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2276.47,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,144.48,2276.47,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,2416.97,1208.49,,2175.27,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1933.58,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2175.27,90,,,Percent of total Billed charges,90% of total billed charges,192.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2344.46,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2223.61,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2175.27,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1691.88,70,,,percent of total billed charges,70% of total billed charges,2175.27,90,,,percent of total billed charges,90% of total billed charges,2296.12,95,,,percent of total billed charges,95% of total billed charges,2296.12,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2078.59,86,,,percent of total billed charges,86% of total billed charges,1933.58,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2344.46,97,,,percent of total billed charges,97% of total billed charges,2175.27,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2344.46,97,,,percent of total billed charges,97% of total billed charges,2247.78,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2344.46,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,175.35,2344.46,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,1183.1,591.55,,1064.79,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,946.48,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1064.79,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1147.61,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1088.45,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1064.79,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,828.17,70,,,percent of total billed charges,70% of total billed charges,1064.79,90,,,percent of total billed charges,90% of total billed charges,1123.95,95,,,percent of total billed charges,95% of total billed charges,1123.95,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1017.47,86,,,percent of total billed charges,86% of total billed charges,946.48,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1147.61,97,,,percent of total billed charges,97% of total billed charges,1064.79,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1147.61,97,,,percent of total billed charges,97% of total billed charges,1100.28,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1147.61,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,1147.61,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,2248.58,1124.29,,2023.72,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2023.72,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2181.12,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2068.69,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2023.72,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1574.01,70,,,percent of total billed charges,70% of total billed charges,2023.72,90,,,percent of total billed charges,90% of total billed charges,2136.15,95,,,percent of total billed charges,95% of total billed charges,2136.15,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1933.78,86,,,percent of total billed charges,86% of total billed charges,1798.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2181.12,97,,,percent of total billed charges,97% of total billed charges,2023.72,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2181.12,97,,,percent of total billed charges,97% of total billed charges,2091.18,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2181.12,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,2181.12,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,2284.94,1142.47,,2056.45,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1827.95,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2056.45,90,,,Percent of total Billed charges,90% of total billed charges,129.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2216.39,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2102.14,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2056.45,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1599.46,70,,,percent of total billed charges,70% of total billed charges,2056.45,90,,,percent of total billed charges,90% of total billed charges,2170.69,95,,,percent of total billed charges,95% of total billed charges,2170.69,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1965.05,86,,,percent of total billed charges,86% of total billed charges,1827.95,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2216.39,97,,,percent of total billed charges,97% of total billed charges,2056.45,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.39,97,,,percent of total billed charges,97% of total billed charges,2124.99,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2216.39,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.39,2216.39,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,2354.01,1177.01,,2118.61,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1883.21,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2118.61,90,,,Percent of total Billed charges,90% of total billed charges,162.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2283.39,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,2165.69,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2118.61,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1647.81,70,,,percent of total billed charges,70% of total billed charges,2118.61,90,,,percent of total billed charges,90% of total billed charges,2236.31,95,,,percent of total billed charges,95% of total billed charges,2236.31,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2024.45,86,,,percent of total billed charges,86% of total billed charges,1883.21,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2283.39,97,,,percent of total billed charges,97% of total billed charges,2118.61,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2283.39,97,,,percent of total billed charges,97% of total billed charges,2189.23,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2283.39,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,147.67,2283.39,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,3568.13,1784.07,,3211.32,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2854.5,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3211.32,90,,,Percent of total Billed charges,90% of total billed charges,194.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3461.09,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3282.68,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3211.32,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2497.69,70,,,percent of total billed charges,70% of total billed charges,3211.32,90,,,percent of total billed charges,90% of total billed charges,3389.72,95,,,percent of total billed charges,95% of total billed charges,3389.72,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3068.59,86,,,percent of total billed charges,86% of total billed charges,2854.5,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3461.09,97,,,percent of total billed charges,97% of total billed charges,3211.32,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3461.09,97,,,percent of total billed charges,97% of total billed charges,3318.36,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3461.09,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.23,3461.09,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,3711.51,1855.76,,3340.36,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2969.21,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3340.36,90,,,Percent of total Billed charges,90% of total billed charges,267.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3600.16,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,3414.59,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3340.36,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2598.06,70,,,percent of total billed charges,70% of total billed charges,3340.36,90,,,percent of total billed charges,90% of total billed charges,3525.93,95,,,percent of total billed charges,95% of total billed charges,3525.93,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3191.9,86,,,percent of total billed charges,86% of total billed charges,2969.21,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3600.16,97,,,percent of total billed charges,97% of total billed charges,3340.36,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3600.16,97,,,percent of total billed charges,97% of total billed charges,3451.7,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3600.16,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,242.78,3600.16,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,1350.98,675.49,,1215.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1215.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1310.45,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1242.9,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1215.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,945.69,70,,,percent of total billed charges,70% of total billed charges,1215.88,90,,,percent of total billed charges,90% of total billed charges,1283.43,95,,,percent of total billed charges,95% of total billed charges,1283.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1161.84,86,,,percent of total billed charges,86% of total billed charges,1080.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1310.45,97,,,percent of total billed charges,97% of total billed charges,1215.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1310.45,97,,,percent of total billed charges,97% of total billed charges,1256.41,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1310.45,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,1310.45,
MA Stereotactic Lt Breast Biopsy:Read,603846,CDM,972,RC,19081,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,0.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,0.02,155,,,Fee Schedule,155% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,251.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,251.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,255.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,151.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,192.72,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,0.02,155,,,Fee Schedule,155% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.03,155,,,Fee Schedule,155% of CMS OPPS Rate,0.03,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,705.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,705.1,
Aspiration/Inj/Arthrcntsis,3428392,CDM,981,RC,20600,HCPCS,Outpatient,,,135.42,67.71,,121.88,90,,,percent of total billed charges,90% of total Billed charges,85.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.68,90,,,Percent of total Billed charges,90% of total billed charges,18,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.99,155,,,Fee Schedule,155% of CMS OPPS Rate,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.2,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,43.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,53.99,155,,,Fee Schedule,155% of CMS OPPS Rate,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.9,155,,,Fee Schedule,155% of CMS OPPS Rate,132.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18,132.9,
20604- Arthrocen/asp/inj/sm jt/bursa/w US,3434657,CDM,510,RC,20604,HCPCS,Outpatient,,,206.64,103.32,,185.98,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,165.31,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.98,90,,,Percent of total Billed charges,90% of total billed charges,40.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,200.44,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,190.11,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,185.98,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,144.65,70,,,percent of total billed charges,70% of total billed charges,185.98,90,,,percent of total billed charges,90% of total billed charges,196.31,95,,,percent of total billed charges,95% of total billed charges,196.31,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,177.71,86,,,percent of total billed charges,86% of total billed charges,165.31,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,200.44,97,,,percent of total billed charges,97% of total billed charges,185.98,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.44,97,,,percent of total billed charges,97% of total billed charges,192.18,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.44,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.05,1325.49,
20606- Arthrocen/asp/inj/int jt/burs/w US,3434659,CDM,510,RC,20606,HCPCS,Outpatient,,,224.97,112.49,,202.47,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,179.98,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.47,90,,,Percent of total Billed charges,90% of total billed charges,46.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.22,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,206.97,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,202.47,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,157.48,70,,,percent of total billed charges,70% of total billed charges,202.47,90,,,percent of total billed charges,90% of total billed charges,213.72,95,,,percent of total billed charges,95% of total billed charges,213.72,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,193.47,86,,,percent of total billed charges,86% of total billed charges,179.98,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.22,97,,,percent of total billed charges,97% of total billed charges,202.47,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.22,97,,,percent of total billed charges,97% of total billed charges,209.22,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.22,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.35,3141.23,
"Joint Aspiration, Injection",3428473,CDM,981,RC,20610,HCPCS,Outpatient,,,165.68,82.84,,149.11,90,,,percent of total billed charges,90% of total Billed charges,106.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.78,90,,,Percent of total Billed charges,90% of total billed charges,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,68.9,155,,,Fee Schedule,155% of CMS OPPS Rate,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.46,155,,,Fee Schedule,155% of CMS OPPS Rate,165.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,165.46,
20660- App/rmv cranial tong/cali/ST frame,3434662,CDM,510,RC,20660,HCPCS,Outpatient,,,652.65,326.33,,587.39,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,522.12,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,587.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,633.07,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,600.44,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,587.39,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,456.86,70,,,percent of total billed charges,70% of total billed charges,587.39,90,,,percent of total billed charges,90% of total billed charges,620.02,95,,,percent of total billed charges,95% of total billed charges,620.02,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,561.28,86,,,percent of total billed charges,86% of total billed charges,522.12,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,633.07,97,,,percent of total billed charges,97% of total billed charges,587.39,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,633.07,97,,,percent of total billed charges,97% of total billed charges,606.96,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,633.07,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,456.86,6993.46,
20665- Rmv tongs/halo/app by other indiv,3434663,CDM,510,RC,20665,HCPCS,Outpatient,,,290.96,145.48,,261.86,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,232.77,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,282.23,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,267.68,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.86,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,203.67,70,,,percent of total billed charges,70% of total billed charges,261.86,90,,,percent of total billed charges,90% of total billed charges,276.41,95,,,percent of total billed charges,95% of total billed charges,276.41,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.23,86,,,percent of total billed charges,86% of total billed charges,232.77,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.23,97,,,percent of total billed charges,97% of total billed charges,261.86,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.23,97,,,percent of total billed charges,97% of total billed charges,270.59,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,282.23,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,203.67,1840.7,
20690- App uniplane/unilat/ext fixation,3434666,CDM,510,RC,20690,HCPCS,Outpatient,,,1563.98,781.99,,1407.58,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1251.18,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1407.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1517.06,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1438.86,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1407.58,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1094.79,70,,,percent of total billed charges,70% of total billed charges,1407.58,90,,,percent of total billed charges,90% of total billed charges,1485.78,95,,,percent of total billed charges,95% of total billed charges,1485.78,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1345.02,86,,,percent of total billed charges,86% of total billed charges,1251.18,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1517.06,97,,,percent of total billed charges,97% of total billed charges,1407.58,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.06,97,,,percent of total billed charges,97% of total billed charges,1454.5,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1517.06,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1094.79,32247.16,
20692- App multiplane/unilat/ext fixation,3434667,CDM,510,RC,20692,HCPCS,Outpatient,,,2917.8,1458.90,,2626.02,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2334.24,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2626.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2830.27,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2684.38,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2626.02,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.46,70,,,percent of total billed charges,70% of total billed charges,2626.02,90,,,percent of total billed charges,90% of total billed charges,2771.91,95,,,percent of total billed charges,95% of total billed charges,2771.91,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2509.31,86,,,percent of total billed charges,86% of total billed charges,2334.24,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2830.27,97,,,percent of total billed charges,97% of total billed charges,2626.02,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2830.27,97,,,percent of total billed charges,97% of total billed charges,2713.55,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2830.27,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2042.46,63611.04,
20694- Rmv ext fixation system/anesthesia,3434668,CDM,510,RC,20694,HCPCS,Outpatient,,,1089.92,544.96,,980.93,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,871.94,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1057.22,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.73,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,980.93,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,762.94,70,,,percent of total billed charges,70% of total billed charges,980.93,90,,,percent of total billed charges,90% of total billed charges,1035.42,95,,,percent of total billed charges,95% of total billed charges,1035.42,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,937.33,86,,,percent of total billed charges,86% of total billed charges,871.94,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1057.22,97,,,percent of total billed charges,97% of total billed charges,980.93,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1057.22,97,,,percent of total billed charges,97% of total billed charges,1013.63,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1057.22,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,762.94,6993.46,
20822- Replant/digit/not thumb/comp amp,3434669,CDM,510,RC,20822,HCPCS,Outpatient,,,4660.43,2330.22,,4194.39,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3728.34,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,4194.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4520.62,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,4287.6,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4194.39,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3262.3,70,,,percent of total billed charges,70% of total billed charges,4194.39,90,,,percent of total billed charges,90% of total billed charges,4427.41,95,,,percent of total billed charges,95% of total billed charges,4427.41,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4007.97,86,,,percent of total billed charges,86% of total billed charges,3728.34,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4520.62,97,,,percent of total billed charges,97% of total billed charges,4194.39,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,4520.62,97,,,percent of total billed charges,97% of total billed charges,4334.2,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4520.62,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1107.47,6993.46,
20900- Bone graft/any donor area/minor/sm,3434670,CDM,510,RC,20900,HCPCS,Outpatient,,,986.43,493.22,,887.79,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,789.14,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,887.79,90,,,Percent of total Billed charges,90% of total billed charges,270.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,956.84,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,907.52,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,887.79,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,690.5,70,,,percent of total billed charges,70% of total billed charges,887.79,90,,,percent of total billed charges,90% of total billed charges,937.11,95,,,percent of total billed charges,95% of total billed charges,937.11,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,848.33,86,,,percent of total billed charges,86% of total billed charges,789.14,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,956.84,97,,,percent of total billed charges,97% of total billed charges,887.79,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,956.84,97,,,percent of total billed charges,97% of total billed charges,917.38,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,956.84,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246.27,32247.16,
20902- Bone graft/any donor area/large,3434671,CDM,510,RC,20902,HCPCS,Outpatient,,,732.2,366.10,,658.98,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,585.76,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.98,90,,,Percent of total Billed charges,90% of total billed charges,348.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,710.23,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,673.62,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,658.98,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,512.54,70,,,percent of total billed charges,70% of total billed charges,658.98,90,,,percent of total billed charges,90% of total billed charges,695.59,95,,,percent of total billed charges,95% of total billed charges,695.59,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,629.69,86,,,percent of total billed charges,86% of total billed charges,585.76,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,710.23,97,,,percent of total billed charges,97% of total billed charges,658.98,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,710.23,97,,,percent of total billed charges,97% of total billed charges,680.95,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,710.23,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,317.02,32247.16,
20912- Cartilage graft/nasal septum,3434672,CDM,510,RC,20912,HCPCS,Outpatient,,,1242.44,621.22,,1118.2,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,993.95,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1118.2,90,,,Percent of total Billed charges,90% of total billed charges,469.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1205.17,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.04,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1118.2,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,869.71,70,,,percent of total billed charges,70% of total billed charges,1118.2,90,,,percent of total billed charges,90% of total billed charges,1180.32,95,,,percent of total billed charges,95% of total billed charges,1180.32,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1068.5,86,,,percent of total billed charges,86% of total billed charges,993.95,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1205.17,97,,,percent of total billed charges,97% of total billed charges,1118.2,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.17,97,,,percent of total billed charges,97% of total billed charges,1155.47,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,426.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1205.17,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,426.78,15858.98,
20930 - PF Allograft for Spine Surgery Only Morselized,4363311,CDM,960,RC,20930,HCPCS,Outpatient,,,300,150.00,,270,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,190.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,190.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,178.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,178.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61,270,
20931- Allograft/structural/spine surg,3434675,CDM,510,RC,20931,HCPCS,Outpatient,,,298.59,149.30,,268.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,238.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,268.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,274.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,190.69,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,234.85,78.65,,,percent of total billed charges,78.65% of total billed charges,266.74,89.33,,,percent of total billed charges,89.33% of total billed charges,268.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.01,70,,,percent of total billed charges,70% of total billed charges,268.73,90,,,percent of total billed charges,90% of total billed charges,283.66,95,,,percent of total billed charges,95% of total billed charges,283.66,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.79,86,,,percent of total billed charges,86% of total billed charges,238.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.63,97,,,percent of total billed charges,97% of total billed charges,268.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.63,97,,,percent of total billed charges,97% of total billed charges,277.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.69,289.63,
20936-  PF Autograft Spine Surgery Local From Same Incision PF,4363312,CDM,960,RC,20936,HCPCS,Outpatient,,,325,162.50,,292.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,202.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94,292.5,
20937- Autograft/spine surg/morselized,3434677,CDM,510,RC,20937,HCPCS,Outpatient,,,448.42,224.21,,403.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,358.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,403.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,434.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,412.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,286.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,352.69,78.65,,,percent of total billed charges,78.65% of total billed charges,400.58,89.33,,,percent of total billed charges,89.33% of total billed charges,403.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,313.89,70,,,percent of total billed charges,70% of total billed charges,403.58,90,,,percent of total billed charges,90% of total billed charges,426,95,,,percent of total billed charges,95% of total billed charges,426,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.64,86,,,percent of total billed charges,86% of total billed charges,358.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,434.97,97,,,percent of total billed charges,97% of total billed charges,403.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,434.97,97,,,percent of total billed charges,97% of total billed charges,417.03,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.37,434.97,
20938- Autograft/spine surg/struct/bi/tricortical,3434678,CDM,510,RC,20938,HCPCS,Outpatient,,,497.32,248.66,,447.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,397.86,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,447.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,482.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,457.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,317.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,391.15,78.65,,,percent of total billed charges,78.65% of total billed charges,444.26,89.33,,,percent of total billed charges,89.33% of total billed charges,447.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.12,70,,,percent of total billed charges,70% of total billed charges,447.59,90,,,percent of total billed charges,90% of total billed charges,472.45,95,,,percent of total billed charges,95% of total billed charges,472.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,427.7,86,,,percent of total billed charges,86% of total billed charges,397.86,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,482.4,97,,,percent of total billed charges,97% of total billed charges,447.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,482.4,97,,,percent of total billed charges,97% of total billed charges,462.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.6,482.4,
20950- Muscle compart syn monitor/device,3434679,CDM,510,RC,20950,HCPCS,Outpatient,,,658.03,329.02,,592.23,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,526.42,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.23,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,638.29,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,605.39,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,592.23,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,460.62,70,,,percent of total billed charges,70% of total billed charges,592.23,90,,,percent of total billed charges,90% of total billed charges,625.13,95,,,percent of total billed charges,95% of total billed charges,625.13,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,565.91,86,,,percent of total billed charges,86% of total billed charges,526.42,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,638.29,97,,,percent of total billed charges,97% of total billed charges,592.23,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.29,97,,,percent of total billed charges,97% of total billed charges,611.97,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,638.29,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,3163.8,
20985- Computer assist/surg nav/musc/skel,3434680,CDM,510,RC,20985,HCPCS,Outpatient,,,386.59,193.30,,347.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,309.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,347.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,355.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,246.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,304.06,78.65,,,percent of total billed charges,78.65% of total billed charges,345.35,89.33,,,percent of total billed charges,89.33% of total billed charges,347.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.61,70,,,percent of total billed charges,70% of total billed charges,347.93,90,,,percent of total billed charges,90% of total billed charges,367.26,95,,,percent of total billed charges,95% of total billed charges,367.26,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.47,86,,,percent of total billed charges,86% of total billed charges,309.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,374.99,97,,,percent of total billed charges,97% of total billed charges,347.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.99,97,,,percent of total billed charges,97% of total billed charges,359.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.88,374.99,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,8705.82,4352.91,,7835.24,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6964.66,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7835.24,90,,,Percent of total Billed charges,90% of total billed charges,208.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8444.65,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8009.35,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7835.24,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6094.07,70,,,percent of total billed charges,70% of total billed charges,7835.24,90,,,percent of total billed charges,90% of total billed charges,8270.53,95,,,percent of total billed charges,95% of total billed charges,8270.53,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7487.01,86,,,percent of total billed charges,86% of total billed charges,6964.66,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8444.65,97,,,percent of total billed charges,97% of total billed charges,7835.24,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8444.65,97,,,percent of total billed charges,97% of total billed charges,8096.41,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8444.65,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.16,8444.65,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,8875.29,4437.65,,7987.76,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7100.23,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7987.76,90,,,Percent of total Billed charges,90% of total billed charges,285.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8609.03,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8165.27,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7987.76,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6212.7,70,,,percent of total billed charges,70% of total billed charges,7987.76,90,,,percent of total billed charges,90% of total billed charges,8431.53,95,,,percent of total billed charges,95% of total billed charges,8431.53,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7632.75,86,,,percent of total billed charges,86% of total billed charges,7100.23,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8609.03,97,,,percent of total billed charges,97% of total billed charges,7987.76,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8609.03,97,,,percent of total billed charges,97% of total billed charges,8254.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8609.03,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,259.78,8609.03,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,8998.72,4499.36,,8098.85,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7198.98,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8098.85,90,,,Percent of total Billed charges,90% of total billed charges,336.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8728.76,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,8278.82,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8098.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6299.1,70,,,percent of total billed charges,70% of total billed charges,8098.85,90,,,percent of total billed charges,90% of total billed charges,8548.78,95,,,percent of total billed charges,95% of total billed charges,8548.78,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7738.9,86,,,percent of total billed charges,86% of total billed charges,7198.98,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8728.76,97,,,percent of total billed charges,97% of total billed charges,8098.85,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,8728.76,97,,,percent of total billed charges,97% of total billed charges,8368.81,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8728.76,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,305.52,8728.76,
21026- Exc of facial bones/osteomy/abscess,3434687,CDM,510,RC,21026,HCPCS,Outpatient,,,1342.74,671.37,,1208.47,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1074.19,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1208.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1302.46,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1235.32,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1208.47,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,939.92,70,,,percent of total billed charges,70% of total billed charges,1208.47,90,,,percent of total billed charges,90% of total billed charges,1275.6,95,,,percent of total billed charges,95% of total billed charges,1275.6,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1154.76,86,,,percent of total billed charges,86% of total billed charges,1074.19,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1302.46,97,,,percent of total billed charges,97% of total billed charges,1208.47,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.46,97,,,percent of total billed charges,97% of total billed charges,1248.75,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1302.46,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,939.92,26031.56,
21029- Benign tumor/fac bone/rmv/contour,3434688,CDM,510,RC,21029,HCPCS,Outpatient,,,1936.31,968.16,,1742.68,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1549.05,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1742.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1878.22,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.41,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1742.68,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.42,70,,,percent of total billed charges,70% of total billed charges,1742.68,90,,,percent of total billed charges,90% of total billed charges,1839.49,95,,,percent of total billed charges,95% of total billed charges,1839.49,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1665.23,86,,,percent of total billed charges,86% of total billed charges,1549.05,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1878.22,97,,,percent of total billed charges,97% of total billed charges,1742.68,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1878.22,97,,,percent of total billed charges,97% of total billed charges,1800.77,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1878.22,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1355.42,13869.87,
21030- Exc bgn tum/maxilla/zygo/enuc/cure,3434689,CDM,510,RC,21030,HCPCS,Outpatient,,,1161.27,580.64,,1045.14,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,929.02,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.14,90,,,Percent of total Billed charges,90% of total billed charges,384.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1126.43,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.37,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1045.14,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,812.89,70,,,percent of total billed charges,70% of total billed charges,1045.14,90,,,percent of total billed charges,90% of total billed charges,1103.21,95,,,percent of total billed charges,95% of total billed charges,1103.21,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,998.69,86,,,percent of total billed charges,86% of total billed charges,929.02,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1126.43,97,,,percent of total billed charges,97% of total billed charges,1045.14,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1126.43,97,,,percent of total billed charges,97% of total billed charges,1079.98,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1126.43,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,349.53,26031.56,
21040- Exc bgn tum/cyst/mandib/enuc/curet,3434690,CDM,510,RC,21040,HCPCS,Outpatient,,,1177.08,588.54,,1059.37,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,941.66,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1059.37,90,,,Percent of total Billed charges,90% of total billed charges,145.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1141.77,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.91,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1059.37,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,823.96,70,,,percent of total billed charges,70% of total billed charges,1059.37,90,,,percent of total billed charges,90% of total billed charges,1118.23,95,,,percent of total billed charges,95% of total billed charges,1118.23,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1012.29,86,,,percent of total billed charges,86% of total billed charges,941.66,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1141.77,97,,,percent of total billed charges,97% of total billed charges,1059.37,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1141.77,97,,,percent of total billed charges,97% of total billed charges,1094.68,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1141.77,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,132.5,13869.87,
21085- Impress/cust prep/oral surg splint,3434691,CDM,510,RC,21085,HCPCS,Outpatient,,,1709.86,854.93,,1538.87,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1367.89,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.87,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1658.56,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1573.07,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1538.87,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.9,70,,,percent of total billed charges,70% of total billed charges,1538.87,90,,,percent of total billed charges,90% of total billed charges,1624.37,95,,,percent of total billed charges,95% of total billed charges,1624.37,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1470.48,86,,,percent of total billed charges,86% of total billed charges,1367.89,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1658.56,97,,,percent of total billed charges,97% of total billed charges,1538.87,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1658.56,97,,,percent of total billed charges,97% of total billed charges,1590.17,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1658.56,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,160.44,1658.56,
21199- Osteotomy/mandible/genioglossus ad,3434692,CDM,510,RC,21199,HCPCS,Outpatient,,,2635.48,1317.74,,2371.93,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2108.38,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2371.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2556.42,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2424.64,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2371.93,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1844.84,70,,,percent of total billed charges,70% of total billed charges,2371.93,90,,,percent of total billed charges,90% of total billed charges,2503.71,95,,,percent of total billed charges,95% of total billed charges,2503.71,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2266.51,86,,,percent of total billed charges,86% of total billed charges,2108.38,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2556.42,97,,,percent of total billed charges,97% of total billed charges,2371.93,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2556.42,97,,,percent of total billed charges,97% of total billed charges,2451,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2556.42,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1844.84,26031.56,
21315- Clsd tx/nasal bone fx w/o stable,3434695,CDM,510,RC,21315,HCPCS,Outpatient,,,373.06,186.53,,335.75,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,298.45,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.75,90,,,Percent of total Billed charges,90% of total billed charges,131.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,361.87,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,343.22,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,335.75,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,261.14,70,,,percent of total billed charges,70% of total billed charges,335.75,90,,,percent of total billed charges,90% of total billed charges,354.41,95,,,percent of total billed charges,95% of total billed charges,354.41,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,320.83,86,,,percent of total billed charges,86% of total billed charges,298.45,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,361.87,97,,,percent of total billed charges,97% of total billed charges,335.75,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.87,97,,,percent of total billed charges,97% of total billed charges,346.95,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,361.87,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.5,6767.35,
21320- Clsd tx/nasal bone fx/stabilize,3434696,CDM,510,RC,21320,HCPCS,Outpatient,,,545.49,272.75,,490.94,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,436.39,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,490.94,90,,,Percent of total Billed charges,90% of total billed charges,132.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,529.13,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,501.85,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,490.94,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,381.84,70,,,percent of total billed charges,70% of total billed charges,490.94,90,,,percent of total billed charges,90% of total billed charges,518.22,95,,,percent of total billed charges,95% of total billed charges,518.22,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,469.12,86,,,percent of total billed charges,86% of total billed charges,436.39,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,529.13,97,,,percent of total billed charges,97% of total billed charges,490.94,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,529.13,97,,,percent of total billed charges,97% of total billed charges,507.31,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,529.13,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,120.76,13869.87,
21325- Open tx/nasal fx/uncomplicated,3434697,CDM,510,RC,21325,HCPCS,Outpatient,,,1123.59,561.80,,1011.23,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,898.87,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1011.23,90,,,Percent of total Billed charges,90% of total billed charges,198.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1089.88,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1033.7,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1011.23,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,786.51,70,,,percent of total billed charges,70% of total billed charges,1011.23,90,,,percent of total billed charges,90% of total billed charges,1067.41,95,,,percent of total billed charges,95% of total billed charges,1067.41,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,966.29,86,,,percent of total billed charges,86% of total billed charges,898.87,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1089.88,97,,,percent of total billed charges,97% of total billed charges,1011.23,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1089.88,97,,,percent of total billed charges,97% of total billed charges,1044.94,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1089.88,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.5,13869.87,
21335- Open tx/nasal & septum fx uncomp,3434698,CDM,510,RC,21335,HCPCS,Outpatient,,,1839.64,919.82,,1655.68,90,,,percent of total billed charges,90% of total Billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1471.71,80,,,Percent of total Billed charges,80% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1655.68,90,,,Percent of total Billed charges,90% of total billed charges,418.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1784.45,97,,,Percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1692.47,92,,,Percent of total billed charges,92% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6868.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10950.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13869.87,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1655.68,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.75,70,,,percent of total billed charges,70% of total billed charges,1655.68,90,,,percent of total billed charges,90% of total billed charges,1747.66,95,,,percent of total billed charges,95% of total billed charges,1747.66,95,,,percent of total billed charges,95% of total billed charges,2584.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5168.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1582.09,86,,,percent of total billed charges,86% of total billed charges,1471.71,80,,,percent of total billed charges,80% of total billed charges,2708.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1784.45,97,,,percent of total billed charges,97% of total billed charges,1655.68,90,,,percent of total billed charges,90% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,1784.45,97,,,percent of total billed charges,97% of total billed charges,1710.87,93,,,percent of total billed charges,93% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1784.45,97,,,percent of total billed charges,97% of total billed charges,2584.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,2584.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2196.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,380.5,13869.87,
21344- Open tx/complicat frontal sinus fx,3434699,CDM,510,RC,21344,HCPCS,Outpatient,,,3648.68,1824.34,,3283.81,90,,,percent of total billed charges,90% of total Billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2918.94,80,,,Percent of total Billed charges,80% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3283.81,90,,,Percent of total Billed charges,90% of total billed charges,1039.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3539.22,97,,,Percent of total billed charges,97% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3356.79,92,,,Percent of total billed charges,92% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3283.81,90,,,percent of total billed charges,90% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2554.08,70,,,percent of total billed charges,70% of total billed charges,3283.81,90,,,percent of total billed charges,90% of total billed charges,3466.25,95,,,percent of total billed charges,95% of total billed charges,3466.25,95,,,percent of total billed charges,95% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3137.86,86,,,percent of total billed charges,86% of total billed charges,2918.94,80,,,percent of total billed charges,80% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3539.22,97,,,percent of total billed charges,97% of total billed charges,3283.81,90,,,percent of total billed charges,90% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3539.22,97,,,percent of total billed charges,97% of total billed charges,3393.27,93,,,percent of total billed charges,93% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,945,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3539.22,97,,,percent of total billed charges,97% of total billed charges,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3648.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,945,3648.68,
21360- Open tx/depressed malar fx,3434700,CDM,510,RC,21360,HCPCS,Outpatient,,,1347.08,673.54,,1212.37,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.66,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1212.37,90,,,Percent of total Billed charges,90% of total billed charges,440,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1306.67,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.31,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1212.37,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,942.96,70,,,percent of total billed charges,70% of total billed charges,1212.37,90,,,percent of total billed charges,90% of total billed charges,1279.73,95,,,percent of total billed charges,95% of total billed charges,1279.73,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1158.49,86,,,percent of total billed charges,86% of total billed charges,1077.66,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1306.67,97,,,percent of total billed charges,97% of total billed charges,1212.37,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1306.67,97,,,percent of total billed charges,97% of total billed charges,1252.78,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1306.67,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,400,26031.56,
21390- Orb flr blowout fx/periorb app/imp,3434701,CDM,510,RC,21390,HCPCS,Outpatient,,,2064.43,1032.22,,1857.99,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1651.54,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1857.99,90,,,Percent of total Billed charges,90% of total billed charges,727.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2002.5,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1899.28,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1857.99,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1445.1,70,,,percent of total billed charges,70% of total billed charges,1857.99,90,,,percent of total billed charges,90% of total billed charges,1961.21,95,,,percent of total billed charges,95% of total billed charges,1961.21,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1775.41,86,,,percent of total billed charges,86% of total billed charges,1651.54,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2002.5,97,,,percent of total billed charges,97% of total billed charges,1857.99,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2002.5,97,,,percent of total billed charges,97% of total billed charges,1919.92,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2002.5,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,661.45,26031.56,
21550- Biopsy/soft tissue/neck or thorax,3434704,CDM,360,RC,21550,HCPCS,Outpatient,,,669.91,334.96,,602.92,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,535.93,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,602.92,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,649.81,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,616.32,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,602.92,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,468.94,70,,,percent of total billed charges,70% of total billed charges,602.92,90,,,percent of total billed charges,90% of total billed charges,636.41,95,,,percent of total billed charges,95% of total billed charges,636.41,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,576.12,86,,,percent of total billed charges,86% of total billed charges,535.93,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,649.81,97,,,percent of total billed charges,97% of total billed charges,602.92,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.81,97,,,percent of total billed charges,97% of total billed charges,623.02,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,649.81,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,510,RC,21552,HCPCS,Outpatient,,,13385.48,6692.74,,12046.93,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10708.38,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12046.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12983.92,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,12314.64,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12046.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9369.84,70,,,percent of total billed charges,70% of total billed charges,12046.93,90,,,percent of total billed charges,90% of total billed charges,12716.21,95,,,percent of total billed charges,95% of total billed charges,12716.21,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11511.51,86,,,percent of total billed charges,86% of total billed charges,10708.38,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12983.92,97,,,percent of total billed charges,97% of total billed charges,12046.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12983.92,97,,,percent of total billed charges,97% of total billed charges,12448.5,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12983.92,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12983.92,
21557- Rad resect tumor/neck/ant thor/<5c,3434709,CDM,510,RC,21557,HCPCS,Outpatient,,,2524.52,1262.26,,2272.07,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2019.62,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2272.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2448.78,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2322.56,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2272.07,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1767.16,70,,,percent of total billed charges,70% of total billed charges,2272.07,90,,,percent of total billed charges,90% of total billed charges,2398.29,95,,,percent of total billed charges,95% of total billed charges,2398.29,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2171.09,86,,,percent of total billed charges,86% of total billed charges,2019.62,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2448.78,97,,,percent of total billed charges,97% of total billed charges,2272.07,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2448.78,97,,,percent of total billed charges,97% of total billed charges,2347.8,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2448.78,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1767.16,12593.67,
21558- Rad resect tumor/neck/ant thor/5cm,3434710,CDM,510,RC,21558,HCPCS,Outpatient,,,3572.38,1786.19,,3215.14,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2857.9,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3215.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3465.21,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3286.59,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3215.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2500.67,70,,,percent of total billed charges,70% of total billed charges,3215.14,90,,,percent of total billed charges,90% of total billed charges,3393.76,95,,,percent of total billed charges,95% of total billed charges,3393.76,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3072.25,86,,,percent of total billed charges,86% of total billed charges,2857.9,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3465.21,97,,,percent of total billed charges,97% of total billed charges,3215.14,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3465.21,97,,,percent of total billed charges,97% of total billed charges,3322.31,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3465.21,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
21600- Excision of rib/ partial,3434711,CDM,510,RC,21600,HCPCS,Outpatient,,,1461.38,730.69,,1315.24,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1169.1,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1417.54,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.47,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1315.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1022.97,70,,,percent of total billed charges,70% of total billed charges,1315.24,90,,,percent of total billed charges,90% of total billed charges,1388.31,95,,,percent of total billed charges,95% of total billed charges,1388.31,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1256.79,86,,,percent of total billed charges,86% of total billed charges,1169.1,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1417.54,97,,,percent of total billed charges,97% of total billed charges,1315.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1417.54,97,,,percent of total billed charges,97% of total billed charges,1359.08,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1417.54,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1022.97,32247.16,
21610- Costotransversectomy,3434712,CDM,510,RC,21610,HCPCS,Outpatient,,,3229.07,1614.54,,2906.16,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2583.26,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2906.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3132.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2970.74,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2906.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2260.35,70,,,percent of total billed charges,70% of total billed charges,2906.16,90,,,percent of total billed charges,90% of total billed charges,3067.62,95,,,percent of total billed charges,95% of total billed charges,3067.62,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2777,86,,,percent of total billed charges,86% of total billed charges,2583.26,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3132.2,97,,,percent of total billed charges,97% of total billed charges,2906.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,3132.2,97,,,percent of total billed charges,97% of total billed charges,3003.04,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3132.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2260.35,14511.58,
21935- Rad res sft tis tum/back/flnk/<5cm,3434722,CDM,510,RC,21935,HCPCS,Outpatient,,,2723.26,1361.63,,2450.93,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2178.61,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2450.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2641.56,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2505.4,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2450.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1906.28,70,,,percent of total billed charges,70% of total billed charges,2450.93,90,,,percent of total billed charges,90% of total billed charges,2587.1,95,,,percent of total billed charges,95% of total billed charges,2587.1,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2342,86,,,percent of total billed charges,86% of total billed charges,2178.61,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2641.56,97,,,percent of total billed charges,97% of total billed charges,2450.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2641.56,97,,,percent of total billed charges,97% of total billed charges,2532.63,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2641.56,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1906.28,12593.67,
21936- Rad res sft tis tum/back/flnk/5cm>,3434723,CDM,510,RC,21936,HCPCS,Outpatient,,,3775.79,1887.90,,3398.21,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3020.63,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3398.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3662.52,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3473.73,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3398.21,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2643.05,70,,,percent of total billed charges,70% of total billed charges,3398.21,90,,,percent of total billed charges,90% of total billed charges,3587,95,,,percent of total billed charges,95% of total billed charges,3587,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3247.18,86,,,percent of total billed charges,86% of total billed charges,3020.63,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3662.52,97,,,percent of total billed charges,97% of total billed charges,3398.21,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3662.52,97,,,percent of total billed charges,97% of total billed charges,3511.48,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3662.52,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
22015- I&D/open deep absc/lumbar/sacral,3434724,CDM,510,RC,22015,HCPCS,Outpatient,,,2505.51,1252.76,,2254.96,90,,,percent of total billed charges,90% of total Billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2004.41,80,,,Percent of total Billed charges,80% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2254.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2430.34,97,,,Percent of total billed charges,97% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2305.07,92,,,Percent of total billed charges,92% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2254.96,90,,,percent of total billed charges,90% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1753.86,70,,,percent of total billed charges,70% of total billed charges,2254.96,90,,,percent of total billed charges,90% of total billed charges,2380.23,95,,,percent of total billed charges,95% of total billed charges,2380.23,95,,,percent of total billed charges,95% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2154.74,86,,,percent of total billed charges,86% of total billed charges,2004.41,80,,,percent of total billed charges,80% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2430.34,97,,,percent of total billed charges,97% of total billed charges,2254.96,90,,,percent of total billed charges,90% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2430.34,97,,,percent of total billed charges,97% of total billed charges,2330.12,93,,,percent of total billed charges,93% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2430.34,97,,,percent of total billed charges,97% of total billed charges,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2505.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1753.86,2505.51,
22101- Part exc/post vert comp/sng/thorac,3434725,CDM,510,RC,22101,HCPCS,Outpatient,,,2253.59,1126.80,,2028.23,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1802.87,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2028.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2185.98,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.3,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2028.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1577.51,70,,,percent of total billed charges,70% of total billed charges,2028.23,90,,,percent of total billed charges,90% of total billed charges,2140.91,95,,,percent of total billed charges,95% of total billed charges,2140.91,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1938.09,86,,,percent of total billed charges,86% of total billed charges,1802.87,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2185.98,97,,,percent of total billed charges,97% of total billed charges,2028.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2185.98,97,,,percent of total billed charges,97% of total billed charges,2095.84,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2185.98,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1577.51,32247.16,
22103- Part exc/post vert comp/ea add seg,3434726,CDM,510,RC,22103,HCPCS,Outpatient,,,362.85,181.43,,326.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,290.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,326.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,351.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,333.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,231.72,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,285.39,78.65,,,percent of total billed charges,78.65% of total billed charges,324.14,89.33,,,percent of total billed charges,89.33% of total billed charges,326.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,254,70,,,percent of total billed charges,70% of total billed charges,326.57,90,,,percent of total billed charges,90% of total billed charges,344.71,95,,,percent of total billed charges,95% of total billed charges,344.71,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.05,86,,,percent of total billed charges,86% of total billed charges,290.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,351.96,97,,,percent of total billed charges,97% of total billed charges,326.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,351.96,97,,,percent of total billed charges,97% of total billed charges,337.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,351.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.72,351.96,
22206- Osteotomy/spine/1 verteb/thoracic,3434727,CDM,510,RC,22206,HCPCS,Outpatient,,,6560.27,3280.14,,5904.24,90,,,percent of total billed charges,90% of total Billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5248.22,80,,,Percent of total Billed charges,80% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5904.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6363.46,97,,,Percent of total billed charges,97% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6035.45,92,,,Percent of total billed charges,92% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5904.24,90,,,percent of total billed charges,90% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4592.19,70,,,percent of total billed charges,70% of total billed charges,5904.24,90,,,percent of total billed charges,90% of total billed charges,6232.26,95,,,percent of total billed charges,95% of total billed charges,6232.26,95,,,percent of total billed charges,95% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5641.83,86,,,percent of total billed charges,86% of total billed charges,5248.22,80,,,percent of total billed charges,80% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6363.46,97,,,percent of total billed charges,97% of total billed charges,5904.24,90,,,percent of total billed charges,90% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6363.46,97,,,percent of total billed charges,97% of total billed charges,6101.05,93,,,percent of total billed charges,93% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6363.46,97,,,percent of total billed charges,97% of total billed charges,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6560.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4592.19,6560.27,
22207- Osteotomy/spine/1 verteb/lumbar,3434728,CDM,510,RC,22207,HCPCS,Outpatient,,,6408.05,3204.03,,5767.25,90,,,percent of total billed charges,90% of total Billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5126.44,80,,,Percent of total Billed charges,80% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5767.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6215.81,97,,,Percent of total billed charges,97% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5895.41,92,,,Percent of total billed charges,92% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5767.25,90,,,percent of total billed charges,90% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4485.64,70,,,percent of total billed charges,70% of total billed charges,5767.25,90,,,percent of total billed charges,90% of total billed charges,6087.65,95,,,percent of total billed charges,95% of total billed charges,6087.65,95,,,percent of total billed charges,95% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5510.92,86,,,percent of total billed charges,86% of total billed charges,5126.44,80,,,percent of total billed charges,80% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6215.81,97,,,percent of total billed charges,97% of total billed charges,5767.25,90,,,percent of total billed charges,90% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6215.81,97,,,percent of total billed charges,97% of total billed charges,5959.49,93,,,percent of total billed charges,93% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6215.81,97,,,percent of total billed charges,97% of total billed charges,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6408.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4485.64,6408.05,
22208- Osteotomy/spine/ea add verteb seg,3434729,CDM,510,RC,22208,HCPCS,Outpatient,,,1594.67,797.34,,1435.2,90,,,percent of total billed charges,90% of total Billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1275.74,80,,,Percent of total Billed charges,80% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1435.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1546.83,97,,,Percent of total billed charges,97% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1467.1,92,,,Percent of total billed charges,92% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1435.2,90,,,percent of total billed charges,90% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1116.27,70,,,percent of total billed charges,70% of total billed charges,1435.2,90,,,percent of total billed charges,90% of total billed charges,1514.94,95,,,percent of total billed charges,95% of total billed charges,1514.94,95,,,percent of total billed charges,95% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1371.42,86,,,percent of total billed charges,86% of total billed charges,1275.74,80,,,percent of total billed charges,80% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.83,97,,,percent of total billed charges,97% of total billed charges,1435.2,90,,,percent of total billed charges,90% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1546.83,97,,,percent of total billed charges,97% of total billed charges,1483.04,93,,,percent of total billed charges,93% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1546.83,97,,,percent of total billed charges,97% of total billed charges,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1594.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1116.27,1594.67,
22212- Osteotomy/thorac spine/1 vert seg,3434730,CDM,510,RC,22212,HCPCS,Outpatient,,,4000.61,2000.31,,3600.55,90,,,percent of total billed charges,90% of total Billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.49,80,,,Percent of total Billed charges,80% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3600.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3880.59,97,,,Percent of total billed charges,97% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3680.56,92,,,Percent of total billed charges,92% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3600.55,90,,,percent of total billed charges,90% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2800.43,70,,,percent of total billed charges,70% of total billed charges,3600.55,90,,,percent of total billed charges,90% of total billed charges,3800.58,95,,,percent of total billed charges,95% of total billed charges,3800.58,95,,,percent of total billed charges,95% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3440.52,86,,,percent of total billed charges,86% of total billed charges,3200.49,80,,,percent of total billed charges,80% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3880.59,97,,,percent of total billed charges,97% of total billed charges,3600.55,90,,,percent of total billed charges,90% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3880.59,97,,,percent of total billed charges,97% of total billed charges,3720.57,93,,,percent of total billed charges,93% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3880.59,97,,,percent of total billed charges,97% of total billed charges,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4000.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2800.43,4000.61,
22214- Osteotomy/lumbar spine/1 vert seg,3434731,CDM,510,RC,22214,HCPCS,Outpatient,,,4001.17,2000.59,,3601.05,90,,,percent of total billed charges,90% of total Billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3200.94,80,,,Percent of total Billed charges,80% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3881.13,97,,,Percent of total billed charges,97% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3681.08,92,,,Percent of total billed charges,92% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3601.05,90,,,percent of total billed charges,90% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2800.82,70,,,percent of total billed charges,70% of total billed charges,3601.05,90,,,percent of total billed charges,90% of total billed charges,3801.11,95,,,percent of total billed charges,95% of total billed charges,3801.11,95,,,percent of total billed charges,95% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3441.01,86,,,percent of total billed charges,86% of total billed charges,3200.94,80,,,percent of total billed charges,80% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3881.13,97,,,percent of total billed charges,97% of total billed charges,3601.05,90,,,percent of total billed charges,90% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3881.13,97,,,percent of total billed charges,97% of total billed charges,3721.09,93,,,percent of total billed charges,93% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3881.13,97,,,percent of total billed charges,97% of total billed charges,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4001.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2800.82,4001.17,
22216- Osteotomy/spine/ea add verteb seg,3434732,CDM,510,RC,22216,HCPCS,Outpatient,,,976.56,488.28,,878.9,90,,,percent of total billed charges,90% of total Billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,781.25,80,,,Percent of total Billed charges,80% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,947.26,97,,,Percent of total billed charges,97% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,898.44,92,,,Percent of total billed charges,92% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,878.9,90,,,percent of total billed charges,90% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,683.59,70,,,percent of total billed charges,70% of total billed charges,878.9,90,,,percent of total billed charges,90% of total billed charges,927.73,95,,,percent of total billed charges,95% of total billed charges,927.73,95,,,percent of total billed charges,95% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.84,86,,,percent of total billed charges,86% of total billed charges,781.25,80,,,percent of total billed charges,80% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.26,97,,,percent of total billed charges,97% of total billed charges,878.9,90,,,percent of total billed charges,90% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,947.26,97,,,percent of total billed charges,97% of total billed charges,908.2,93,,,percent of total billed charges,93% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,947.26,97,,,percent of total billed charges,97% of total billed charges,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,976.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,683.59,976.56,
22310- Clsd tx/vert bdy fx w/o manip/cast,3434734,CDM,510,RC,22310,HCPCS,Outpatient,,,799.75,399.88,,719.78,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,639.8,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,719.78,90,,,Percent of total Billed charges,90% of total billed charges,216.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,775.76,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,735.77,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,719.78,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,559.83,70,,,percent of total billed charges,70% of total billed charges,719.78,90,,,percent of total billed charges,90% of total billed charges,759.76,95,,,percent of total billed charges,95% of total billed charges,759.76,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,687.79,86,,,percent of total billed charges,86% of total billed charges,639.8,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,775.76,97,,,percent of total billed charges,97% of total billed charges,719.78,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,775.76,97,,,percent of total billed charges,97% of total billed charges,743.77,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,775.76,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
22325- Open tx/vertebral fx/post app/1 fx,3434735,CDM,510,RC,22325,HCPCS,Outpatient,,,3901.39,1950.70,,3511.25,90,,,percent of total billed charges,90% of total Billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3121.11,80,,,Percent of total Billed charges,80% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3511.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3784.35,97,,,Percent of total billed charges,97% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3589.28,92,,,Percent of total billed charges,92% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3511.25,90,,,percent of total billed charges,90% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2730.97,70,,,percent of total billed charges,70% of total billed charges,3511.25,90,,,percent of total billed charges,90% of total billed charges,3706.32,95,,,percent of total billed charges,95% of total billed charges,3706.32,95,,,percent of total billed charges,95% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3355.2,86,,,percent of total billed charges,86% of total billed charges,3121.11,80,,,percent of total billed charges,80% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3784.35,97,,,percent of total billed charges,97% of total billed charges,3511.25,90,,,percent of total billed charges,90% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3784.35,97,,,percent of total billed charges,97% of total billed charges,3628.29,93,,,percent of total billed charges,93% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3784.35,97,,,percent of total billed charges,97% of total billed charges,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3901.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2730.97,3901.39,
22326- Open tx cervical fx/post app/1 fx,3434736,CDM,510,RC,22326,HCPCS,Outpatient,,,4027.12,2013.56,,3624.41,90,,,percent of total billed charges,90% of total Billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3221.7,80,,,Percent of total Billed charges,80% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3624.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3906.31,97,,,Percent of total billed charges,97% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3704.95,92,,,Percent of total billed charges,92% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3624.41,90,,,percent of total billed charges,90% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2818.98,70,,,percent of total billed charges,70% of total billed charges,3624.41,90,,,percent of total billed charges,90% of total billed charges,3825.76,95,,,percent of total billed charges,95% of total billed charges,3825.76,95,,,percent of total billed charges,95% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3463.32,86,,,percent of total billed charges,86% of total billed charges,3221.7,80,,,percent of total billed charges,80% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3906.31,97,,,percent of total billed charges,97% of total billed charges,3624.41,90,,,percent of total billed charges,90% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3906.31,97,,,percent of total billed charges,97% of total billed charges,3745.22,93,,,percent of total billed charges,93% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3906.31,97,,,percent of total billed charges,97% of total billed charges,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4027.12,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2818.98,4027.12,
22327- Open tx/thoracic fx/post app/1 fx,3434737,CDM,510,RC,22327,HCPCS,Outpatient,,,4068.3,2034.15,,3661.47,90,,,percent of total billed charges,90% of total Billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3254.64,80,,,Percent of total Billed charges,80% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3661.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3946.25,97,,,Percent of total billed charges,97% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3742.84,92,,,Percent of total billed charges,92% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3661.47,90,,,percent of total billed charges,90% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2847.81,70,,,percent of total billed charges,70% of total billed charges,3661.47,90,,,percent of total billed charges,90% of total billed charges,3864.89,95,,,percent of total billed charges,95% of total billed charges,3864.89,95,,,percent of total billed charges,95% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3498.74,86,,,percent of total billed charges,86% of total billed charges,3254.64,80,,,percent of total billed charges,80% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3946.25,97,,,percent of total billed charges,97% of total billed charges,3661.47,90,,,percent of total billed charges,90% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3946.25,97,,,percent of total billed charges,97% of total billed charges,3783.52,93,,,percent of total billed charges,93% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3946.25,97,,,percent of total billed charges,97% of total billed charges,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4068.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2847.81,4068.3,
22328- Open tx/ea add fx vert/dislocate seg,3434738,CDM,510,RC,22328,HCPCS,Outpatient,,,758.65,379.33,,682.79,90,,,percent of total billed charges,90% of total Billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,606.92,80,,,Percent of total Billed charges,80% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,682.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,735.89,97,,,Percent of total billed charges,97% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,697.96,92,,,Percent of total billed charges,92% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,682.79,90,,,percent of total billed charges,90% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,531.06,70,,,percent of total billed charges,70% of total billed charges,682.79,90,,,percent of total billed charges,90% of total billed charges,720.72,95,,,percent of total billed charges,95% of total billed charges,720.72,95,,,percent of total billed charges,95% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,652.44,86,,,percent of total billed charges,86% of total billed charges,606.92,80,,,percent of total billed charges,80% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,735.89,97,,,percent of total billed charges,97% of total billed charges,682.79,90,,,percent of total billed charges,90% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,735.89,97,,,percent of total billed charges,97% of total billed charges,705.54,93,,,percent of total billed charges,93% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,735.89,97,,,percent of total billed charges,97% of total billed charges,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,758.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,531.06,758.65,
22513- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/thoracic,3434740,CDM,510,RC,22513,HCPCS,Outpatient,,,14338.99,7169.50,,12905.09,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11471.19,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,12905.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13908.82,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13191.87,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12905.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,10037.29,70,,,percent of total billed charges,70% of total billed charges,12905.09,90,,,percent of total billed charges,90% of total billed charges,13622.04,95,,,percent of total billed charges,95% of total billed charges,13622.04,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12331.53,86,,,percent of total billed charges,86% of total billed charges,11471.19,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13908.82,97,,,percent of total billed charges,97% of total billed charges,12905.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,13908.82,97,,,percent of total billed charges,97% of total billed charges,13335.26,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13908.82,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5106.62,32247.16,
22514- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/lumbar,3434741,CDM,510,RC,22514,HCPCS,Outpatient,,,14256.81,7128.41,,12831.13,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,11405.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,12831.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13829.11,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,13116.27,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12831.13,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,9979.77,70,,,percent of total billed charges,70% of total billed charges,12831.13,90,,,percent of total billed charges,90% of total billed charges,13543.97,95,,,percent of total billed charges,95% of total billed charges,13543.97,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12260.86,86,,,percent of total billed charges,86% of total billed charges,11405.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13829.11,97,,,percent of total billed charges,97% of total billed charges,12831.13,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,13829.11,97,,,percent of total billed charges,97% of total billed charges,13258.83,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13829.11,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5106.62,32247.16,
22515- Perc vert augment/1 vert bdy/uni/bilat cannulat/image/ad thor/lumb,3434742,CDM,510,RC,22515,HCPCS,Outpatient,,,7376.31,3688.16,,6638.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5901.05,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6638.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7155.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6786.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4710.67,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,5801.63,78.65,,,percent of total billed charges,78.65% of total billed charges,6589.38,89.33,,,percent of total billed charges,89.33% of total billed charges,6638.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5163.42,70,,,percent of total billed charges,70% of total billed charges,6638.68,90,,,percent of total billed charges,90% of total billed charges,7007.49,95,,,percent of total billed charges,95% of total billed charges,7007.49,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6343.63,86,,,percent of total billed charges,86% of total billed charges,5901.05,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7155.02,97,,,percent of total billed charges,97% of total billed charges,6638.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7155.02,97,,,percent of total billed charges,97% of total billed charges,6859.97,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7155.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4710.67,7155.02,
22551 - PF  Arthrd Ant Interbody Decompress Cervical Below C2,4363313,CDM,960,RC,22551,HCPCS,Outpatient,,,3446.36,1723.18,,3101.72,90,,,percent of total billed charges,90% of total Billed charges,3435.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1720.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1389.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2666.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1720.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2445.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1720.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2750.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2750.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2646.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2646.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1844.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1720.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3441.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3122.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2332.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2666.84,155,,,Fee Schedule,155% of CMS OPPS Rate,1720.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,5324.93,155,,,Fee Schedule,155% of CMS OPPS Rate,5324.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1720.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1929.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1720.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,3477.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3477.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1389.62,5324.93,
22551- Arthrodesis/discect/decompres/cerv/below C2,3434747,CDM,510,RC,22551,HCPCS,Outpatient,,,4560.49,2280.25,,4104.44,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3648.39,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,4104.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4423.68,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,4195.65,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4104.44,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3192.34,70,,,percent of total billed charges,70% of total billed charges,4104.44,90,,,percent of total billed charges,90% of total billed charges,4332.47,95,,,percent of total billed charges,95% of total billed charges,4332.47,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3922.02,86,,,percent of total billed charges,86% of total billed charges,3648.39,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4423.68,97,,,percent of total billed charges,97% of total billed charges,4104.44,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,4423.68,97,,,percent of total billed charges,97% of total billed charges,4241.26,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4423.68,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3192.34,63611.04,
22552 - PF Arthrd Ant Interbdy Cervical Below C2 Ea Addl Interspace,4363314,CDM,960,RC,22552,HCPCS,Outpatient,,,806.56,403.28,,725.9,90,,,percent of total billed charges,90% of total Billed charges,806.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,403.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,324.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,625.18,155,,,Fee Schedule,155% of CMS OPPS Rate,403.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,403.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,643.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,643.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,627.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,627.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,428.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,806.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,740.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,563.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,625.18,155,,,Fee Schedule,155% of CMS OPPS Rate,403.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1249.35,155,,,Fee Schedule,155% of CMS OPPS Rate,1249.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,403.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,475.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,403.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,810.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,324.73,1249.35,
22552- Arthrodesis/cervical/below C2/add,3434749,CDM,510,RC,22552,HCPCS,Outpatient,,,1070.89,535.45,,963.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,856.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,963.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1038.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,985.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,683.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,842.28,78.65,,,percent of total billed charges,78.65% of total billed charges,956.64,89.33,,,percent of total billed charges,89.33% of total billed charges,963.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,749.62,70,,,percent of total billed charges,70% of total billed charges,963.8,90,,,percent of total billed charges,90% of total billed charges,1017.35,95,,,percent of total billed charges,95% of total billed charges,1017.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,920.97,86,,,percent of total billed charges,86% of total billed charges,856.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1038.76,97,,,percent of total billed charges,97% of total billed charges,963.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1038.76,97,,,percent of total billed charges,97% of total billed charges,995.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1038.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,683.89,1038.76,
22554- Arthrodesis/ant tech/cerv/below C2,3434750,CDM,510,RC,22554,HCPCS,Outpatient,,,3352.64,1676.32,,3017.38,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2682.11,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3017.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3252.06,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3084.43,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3017.38,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.85,70,,,percent of total billed charges,70% of total billed charges,3017.38,90,,,percent of total billed charges,90% of total billed charges,3185.01,95,,,percent of total billed charges,95% of total billed charges,3185.01,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2883.27,86,,,percent of total billed charges,86% of total billed charges,2682.11,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3252.06,97,,,percent of total billed charges,97% of total billed charges,3017.38,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3252.06,97,,,percent of total billed charges,97% of total billed charges,3117.96,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3252.06,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2346.85,63611.04,
22556- Arthrodesis/ant tech/thoracic,3434751,CDM,510,RC,22556,HCPCS,Outpatient,,,4447.36,2223.68,,4002.62,90,,,percent of total billed charges,90% of total Billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3557.89,80,,,Percent of total Billed charges,80% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4313.94,97,,,Percent of total billed charges,97% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4091.57,92,,,Percent of total billed charges,92% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.62,90,,,percent of total billed charges,90% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3113.15,70,,,percent of total billed charges,70% of total billed charges,4002.62,90,,,percent of total billed charges,90% of total billed charges,4224.99,95,,,percent of total billed charges,95% of total billed charges,4224.99,95,,,percent of total billed charges,95% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3824.73,86,,,percent of total billed charges,86% of total billed charges,3557.89,80,,,percent of total billed charges,80% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4313.94,97,,,percent of total billed charges,97% of total billed charges,4002.62,90,,,percent of total billed charges,90% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4313.94,97,,,percent of total billed charges,97% of total billed charges,4136.04,93,,,percent of total billed charges,93% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4313.94,97,,,percent of total billed charges,97% of total billed charges,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4447.36,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3113.15,4447.36,
22558- Arthrodesis/ant tech/lumbar,3434752,CDM,510,RC,22558,HCPCS,Outpatient,,,4082.84,2041.42,,3674.56,90,,,percent of total billed charges,90% of total Billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3266.27,80,,,Percent of total Billed charges,80% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3960.35,97,,,Percent of total billed charges,97% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3756.21,92,,,Percent of total billed charges,92% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3674.56,90,,,percent of total billed charges,90% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2857.99,70,,,percent of total billed charges,70% of total billed charges,3674.56,90,,,percent of total billed charges,90% of total billed charges,3878.7,95,,,percent of total billed charges,95% of total billed charges,3878.7,95,,,percent of total billed charges,95% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3511.24,86,,,percent of total billed charges,86% of total billed charges,3266.27,80,,,percent of total billed charges,80% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3960.35,97,,,percent of total billed charges,97% of total billed charges,3674.56,90,,,percent of total billed charges,90% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3960.35,97,,,percent of total billed charges,97% of total billed charges,3797.04,93,,,percent of total billed charges,93% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3960.35,97,,,percent of total billed charges,97% of total billed charges,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4082.84,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2857.99,4082.84,
22585- Arthrodesis/cerv/thor/lumb/ea add,3434753,CDM,510,RC,22585,HCPCS,Outpatient,,,878.35,439.18,,790.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,702.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,790.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,852,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,808.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,560.93,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,690.84,78.65,,,percent of total billed charges,78.65% of total billed charges,784.64,89.33,,,percent of total billed charges,89.33% of total billed charges,790.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,614.85,70,,,percent of total billed charges,70% of total billed charges,790.52,90,,,percent of total billed charges,90% of total billed charges,834.43,95,,,percent of total billed charges,95% of total billed charges,834.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.38,86,,,percent of total billed charges,86% of total billed charges,702.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,852,97,,,percent of total billed charges,97% of total billed charges,790.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,852,97,,,percent of total billed charges,97% of total billed charges,816.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,852,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,560.93,852,
22590- Arthrode/post/craniocer/Occiput-C2,3434754,CDM,510,RC,22590,HCPCS,Outpatient,,,4239.21,2119.61,,3815.29,90,,,percent of total billed charges,90% of total Billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3391.37,80,,,Percent of total Billed charges,80% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4112.03,97,,,Percent of total billed charges,97% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3900.07,92,,,Percent of total billed charges,92% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3815.29,90,,,percent of total billed charges,90% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.45,70,,,percent of total billed charges,70% of total billed charges,3815.29,90,,,percent of total billed charges,90% of total billed charges,4027.25,95,,,percent of total billed charges,95% of total billed charges,4027.25,95,,,percent of total billed charges,95% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3645.72,86,,,percent of total billed charges,86% of total billed charges,3391.37,80,,,percent of total billed charges,80% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.03,97,,,percent of total billed charges,97% of total billed charges,3815.29,90,,,percent of total billed charges,90% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4112.03,97,,,percent of total billed charges,97% of total billed charges,3942.47,93,,,percent of total billed charges,93% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4112.03,97,,,percent of total billed charges,97% of total billed charges,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4239.21,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2967.45,4239.21,
22595- Arthrodesis/post/atlas-axis C 1-2,3434755,CDM,510,RC,22595,HCPCS,Outpatient,,,4047.49,2023.75,,3642.74,90,,,percent of total billed charges,90% of total Billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3237.99,80,,,Percent of total Billed charges,80% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3642.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3926.07,97,,,Percent of total billed charges,97% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3723.69,92,,,Percent of total billed charges,92% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3642.74,90,,,percent of total billed charges,90% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2833.24,70,,,percent of total billed charges,70% of total billed charges,3642.74,90,,,percent of total billed charges,90% of total billed charges,3845.12,95,,,percent of total billed charges,95% of total billed charges,3845.12,95,,,percent of total billed charges,95% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3480.84,86,,,percent of total billed charges,86% of total billed charges,3237.99,80,,,percent of total billed charges,80% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3926.07,97,,,percent of total billed charges,97% of total billed charges,3642.74,90,,,percent of total billed charges,90% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3926.07,97,,,percent of total billed charges,97% of total billed charges,3764.17,93,,,percent of total billed charges,93% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3926.07,97,,,percent of total billed charges,97% of total billed charges,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4047.49,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2833.24,4047.49,
22600 - PF Arthrd Pst/Pstlat Tchnq Interspc CRV Below C2 Segment,4363315,CDM,960,RC,22600,HCPCS,Outpatient,,,2630.06,1315.03,,2367.05,90,,,percent of total billed charges,90% of total Billed charges,2607.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1308.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,749,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2028.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1308.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1846.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1308.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2076.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2076.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1979.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1979.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1183.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1308.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2617.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2336.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1725.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2028.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1308.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,4041.7,155,,,Fee Schedule,155% of CMS OPPS Rate,4041.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1308.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,749,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1519.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1308.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,2596.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2596.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,749,4041.7,
22600- Arthrodesis/sg level/cerv/below C2,3434756,CDM,510,RC,22600,HCPCS,Outpatient,,,3453.33,1726.67,,3108,90,,,percent of total billed charges,90% of total Billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2762.66,80,,,Percent of total Billed charges,80% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3349.73,97,,,Percent of total billed charges,97% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3177.06,92,,,Percent of total billed charges,92% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3108,90,,,percent of total billed charges,90% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2417.33,70,,,percent of total billed charges,70% of total billed charges,3108,90,,,percent of total billed charges,90% of total billed charges,3280.66,95,,,percent of total billed charges,95% of total billed charges,3280.66,95,,,percent of total billed charges,95% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2969.86,86,,,percent of total billed charges,86% of total billed charges,2762.66,80,,,percent of total billed charges,80% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3349.73,97,,,percent of total billed charges,97% of total billed charges,3108,90,,,percent of total billed charges,90% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3349.73,97,,,percent of total billed charges,97% of total billed charges,3211.6,93,,,percent of total billed charges,93% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3349.73,97,,,percent of total billed charges,97% of total billed charges,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3453.33,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2417.33,3453.33,
22610- Arthrodesis/single level/thoracic,3434757,CDM,510,RC,22610,HCPCS,Outpatient,,,3389.16,1694.58,,3050.24,90,,,percent of total billed charges,90% of total Billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2711.33,80,,,Percent of total Billed charges,80% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3050.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3287.49,97,,,Percent of total billed charges,97% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3118.03,92,,,Percent of total billed charges,92% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3050.24,90,,,percent of total billed charges,90% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2372.41,70,,,percent of total billed charges,70% of total billed charges,3050.24,90,,,percent of total billed charges,90% of total billed charges,3219.7,95,,,percent of total billed charges,95% of total billed charges,3219.7,95,,,percent of total billed charges,95% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2914.68,86,,,percent of total billed charges,86% of total billed charges,2711.33,80,,,percent of total billed charges,80% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3287.49,97,,,percent of total billed charges,97% of total billed charges,3050.24,90,,,percent of total billed charges,90% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3287.49,97,,,percent of total billed charges,97% of total billed charges,3151.92,93,,,percent of total billed charges,93% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3287.49,97,,,percent of total billed charges,97% of total billed charges,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3389.16,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2372.41,3389.16,
22612 - PF Arthrodesis Posterior/Pstlat Tchnq Interspc Lumbar,4363316,CDM,960,RC,22612,HCPCS,Outpatient,,,3170.08,1585.04,,2853.07,90,,,percent of total billed charges,90% of total Billed charges,3176.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1587.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,936,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2460.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1587.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2277.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1587.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2562.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2562.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2448.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2448.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1509.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1587.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3174.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2889.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2095.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2460.11,155,,,Fee Schedule,155% of CMS OPPS Rate,1587.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,4923.89,155,,,Fee Schedule,155% of CMS OPPS Rate,4923.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1587.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,936,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1534.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1587.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3245.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3245.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,936,4923.89,
22612- Arthrodesis/single level/lumbar,3434758,CDM,510,RC,22612,HCPCS,Outpatient,,,4227.11,2113.56,,3804.4,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3381.69,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3804.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4100.3,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3888.94,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3804.4,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2958.98,70,,,percent of total billed charges,70% of total billed charges,3804.4,90,,,percent of total billed charges,90% of total billed charges,4015.75,95,,,percent of total billed charges,95% of total billed charges,4015.75,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3635.31,86,,,percent of total billed charges,86% of total billed charges,3381.69,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4100.3,97,,,percent of total billed charges,97% of total billed charges,3804.4,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4100.3,97,,,percent of total billed charges,97% of total billed charges,3931.21,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4100.3,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2958.98,106753.72,
22614 - PF Arthrodesis Pst/Pstlat Tchnq Interspc Ea Addl Interspace,4363317,CDM,960,RC,22614,HCPCS,Outpatient,,,795.74,397.87,,716.17,90,,,percent of total billed charges,90% of total Billed charges,794.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,397.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,365.83,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,615.94,155,,,Fee Schedule,155% of CMS OPPS Rate,397.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,397.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,617,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,617,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,389.32,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,397.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,728.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,548.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,615.94,155,,,Fee Schedule,155% of CMS OPPS Rate,397.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1230.93,155,,,Fee Schedule,155% of CMS OPPS Rate,1230.93,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,397.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,365.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,522.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,397.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,807.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,807.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365.83,1230.93,
22614- Arthrodesis/sng lev/ea add ver seg,3434759,CDM,510,RC,22614,HCPCS,Outpatient,,,1055.13,527.57,,949.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,844.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,949.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1023.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,970.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,673.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,829.88,78.65,,,percent of total billed charges,78.65% of total billed charges,942.56,89.33,,,percent of total billed charges,89.33% of total billed charges,949.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,738.59,70,,,percent of total billed charges,70% of total billed charges,949.62,90,,,percent of total billed charges,90% of total billed charges,1002.37,95,,,percent of total billed charges,95% of total billed charges,1002.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.41,86,,,percent of total billed charges,86% of total billed charges,844.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1023.48,97,,,percent of total billed charges,97% of total billed charges,949.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1023.48,97,,,percent of total billed charges,97% of total billed charges,981.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1023.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,673.83,1023.48,
22630- Arthrodesis/post interbdy/sng/lum,3434760,CDM,510,RC,22630,HCPCS,Outpatient,,,4226.69,2113.35,,3804.02,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3381.35,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3804.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4099.89,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3888.55,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3804.02,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2958.68,70,,,percent of total billed charges,70% of total billed charges,3804.02,90,,,percent of total billed charges,90% of total billed charges,4015.36,95,,,percent of total billed charges,95% of total billed charges,4015.36,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3634.95,86,,,percent of total billed charges,86% of total billed charges,3381.35,80,,,percent of total billed charges,80% of total billed charges,4226.69,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4099.89,97,,,percent of total billed charges,97% of total billed charges,3804.02,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4099.89,97,,,percent of total billed charges,97% of total billed charges,3930.82,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4099.89,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2958.68,106753.72,
22632- Arthrodesis/post interbdy/ea add,3434761,CDM,510,RC,22632,HCPCS,Outpatient,,,868.37,434.19,,781.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,694.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,781.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,842.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,798.9,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,554.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,682.99,78.65,,,percent of total billed charges,78.65% of total billed charges,775.73,89.33,,,percent of total billed charges,89.33% of total billed charges,781.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,607.86,70,,,percent of total billed charges,70% of total billed charges,781.53,90,,,percent of total billed charges,90% of total billed charges,824.95,95,,,percent of total billed charges,95% of total billed charges,824.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.8,86,,,percent of total billed charges,86% of total billed charges,694.7,80,,,percent of total billed charges,80% of total billed charges,868.37,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,842.32,97,,,percent of total billed charges,97% of total billed charges,781.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,842.32,97,,,percent of total billed charges,97% of total billed charges,807.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.56,868.37,
22633 - PF Arthrodesis Combined Tchnq Interspc Lumbar,4363318,CDM,960,RC,22633,HCPCS,Outpatient,,,3649.72,1824.86,,3284.75,90,,,percent of total billed charges,90% of total Billed charges,3684.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1821.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1469.9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2823.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1821.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2657.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1821.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2989.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2989.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2871.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2871.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2006.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1821.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3643.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3388.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2498.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2823.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1821.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,5711.42,155,,,Fee Schedule,155% of CMS OPPS Rate,5711.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1821.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,1469.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1708.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1821.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1469.9,5711.42,
22633- Arthrodesis/combine app/sng/lumbar,3434762,CDM,510,RC,22633,HCPCS,Outpatient,,,4954.65,2477.33,,4459.19,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3963.72,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4459.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4806.01,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4558.28,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4459.19,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3468.26,70,,,percent of total billed charges,70% of total billed charges,4459.19,90,,,percent of total billed charges,90% of total billed charges,4706.92,95,,,percent of total billed charges,95% of total billed charges,4706.92,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4261,86,,,percent of total billed charges,86% of total billed charges,3963.72,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4806.01,97,,,percent of total billed charges,97% of total billed charges,4459.19,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4806.01,97,,,percent of total billed charges,97% of total billed charges,4607.82,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4806.01,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3468.26,106753.72,
22634 - PF Arthrodesis Combined Interspc Ea Addl,4363319,CDM,960,RC,22634,HCPCS,Outpatient,,,985.58,492.79,,887.02,90,,,percent of total billed charges,90% of total Billed charges,996.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,492.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,399.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,763.22,155,,,Fee Schedule,155% of CMS OPPS Rate,492.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,713.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,492.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,802.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,802.6,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,781.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,781.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,540.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,984.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,921.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,694.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,763.22,155,,,Fee Schedule,155% of CMS OPPS Rate,492.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1544.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,492.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,492.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,399.64,1544.19,
22634- Arthrodesis/combine app/ea add,3434765,CDM,510,RC,22634,HCPCS,Outpatient,,,1339.89,669.95,,1205.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1071.91,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1205.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1299.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1232.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,855.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1053.85,78.65,,,percent of total billed charges,78.65% of total billed charges,1196.95,89.33,,,percent of total billed charges,89.33% of total billed charges,1205.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,937.92,70,,,percent of total billed charges,70% of total billed charges,1205.9,90,,,percent of total billed charges,90% of total billed charges,1272.9,95,,,percent of total billed charges,95% of total billed charges,1272.9,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1152.31,86,,,percent of total billed charges,86% of total billed charges,1071.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1299.69,97,,,percent of total billed charges,97% of total billed charges,1205.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1299.69,97,,,percent of total billed charges,97% of total billed charges,1246.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1299.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855.68,1299.69,
22802- Arthrodesis/spine deform/7-12 seg,3434766,CDM,510,RC,22802,HCPCS,Outpatient,,,5644.29,2822.15,,5079.86,90,,,percent of total billed charges,90% of total Billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4515.43,80,,,Percent of total Billed charges,80% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5079.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5474.96,97,,,Percent of total billed charges,97% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5192.75,92,,,Percent of total billed charges,92% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5079.86,90,,,percent of total billed charges,90% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3951,70,,,percent of total billed charges,70% of total billed charges,5079.86,90,,,percent of total billed charges,90% of total billed charges,5362.08,95,,,percent of total billed charges,95% of total billed charges,5362.08,95,,,percent of total billed charges,95% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4854.09,86,,,percent of total billed charges,86% of total billed charges,4515.43,80,,,percent of total billed charges,80% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5474.96,97,,,percent of total billed charges,97% of total billed charges,5079.86,90,,,percent of total billed charges,90% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5474.96,97,,,percent of total billed charges,97% of total billed charges,5249.19,93,,,percent of total billed charges,93% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5474.96,97,,,percent of total billed charges,97% of total billed charges,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5644.29,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3951,5644.29,
22810- Arthrodesis/spine deform/4-7 vert,3434767,CDM,510,RC,22810,HCPCS,Outpatient,,,5308.47,2654.24,,4777.62,90,,,percent of total billed charges,90% of total Billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4246.78,80,,,Percent of total Billed charges,80% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4777.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5149.22,97,,,Percent of total billed charges,97% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4883.79,92,,,Percent of total billed charges,92% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4777.62,90,,,percent of total billed charges,90% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.93,70,,,percent of total billed charges,70% of total billed charges,4777.62,90,,,percent of total billed charges,90% of total billed charges,5043.05,95,,,percent of total billed charges,95% of total billed charges,5043.05,95,,,percent of total billed charges,95% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4565.28,86,,,percent of total billed charges,86% of total billed charges,4246.78,80,,,percent of total billed charges,80% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5149.22,97,,,percent of total billed charges,97% of total billed charges,4777.62,90,,,percent of total billed charges,90% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5149.22,97,,,percent of total billed charges,97% of total billed charges,4936.88,93,,,percent of total billed charges,93% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5149.22,97,,,percent of total billed charges,97% of total billed charges,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5308.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3715.93,5308.47,
22830- Exploration/spinal fusion,3434768,CDM,510,RC,22830,HCPCS,Outpatient,,,2176.4,1088.20,,1958.76,90,,,percent of total billed charges,90% of total Billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1741.12,80,,,Percent of total Billed charges,80% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1958.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2111.11,97,,,Percent of total billed charges,97% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2002.29,92,,,Percent of total billed charges,92% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1958.76,90,,,percent of total billed charges,90% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1523.48,70,,,percent of total billed charges,70% of total billed charges,1958.76,90,,,percent of total billed charges,90% of total billed charges,2067.58,95,,,percent of total billed charges,95% of total billed charges,2067.58,95,,,percent of total billed charges,95% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1871.7,86,,,percent of total billed charges,86% of total billed charges,1741.12,80,,,percent of total billed charges,80% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2111.11,97,,,percent of total billed charges,97% of total billed charges,1958.76,90,,,percent of total billed charges,90% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2111.11,97,,,percent of total billed charges,97% of total billed charges,2024.05,93,,,percent of total billed charges,93% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2111.11,97,,,percent of total billed charges,97% of total billed charges,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2176.4,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1523.48,2176.4,
22840 - PF Posterior Non-Segmental Instrumentation,4363320,CDM,960,RC,22840,HCPCS,Outpatient,,,1532.72,766.36,,1379.45,90,,,percent of total billed charges,90% of total Billed charges,1538.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,768.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,716.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1191.28,155,,,Fee Schedule,155% of CMS OPPS Rate,768.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1093.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,768.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1229.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1229.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1196.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1196.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,762.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,768.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1537.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1411.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1059.96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1191.28,155,,,Fee Schedule,155% of CMS OPPS Rate,768.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,2384.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2384.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,768.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,840.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,768.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,1573.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1573.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,716.11,2384.1,
22840- Post non-seg/spine instrumentation,3434769,CDM,510,RC,22840,HCPCS,Outpatient,,,2046.54,1023.27,,1841.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1637.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1841.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1985.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1882.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1306.97,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1609.65,78.65,,,percent of total billed charges,78.65% of total billed charges,1828.21,89.33,,,percent of total billed charges,89.33% of total billed charges,1841.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1432.58,70,,,percent of total billed charges,70% of total billed charges,1841.89,90,,,percent of total billed charges,90% of total billed charges,1944.21,95,,,percent of total billed charges,95% of total billed charges,1944.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1760.02,86,,,percent of total billed charges,86% of total billed charges,1637.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1985.14,97,,,percent of total billed charges,97% of total billed charges,1841.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1985.14,97,,,percent of total billed charges,97% of total billed charges,1903.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1985.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1306.97,1985.14,
22842 - PF Posterior Segmental Instrumentation 3-6 Vrt Seg,4363321,CDM,960,RC,22842,HCPCS,Outpatient,,,1550.14,775.07,,1395.13,90,,,percent of total billed charges,90% of total Billed charges,1549.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,775.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,716.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1201.82,155,,,Fee Schedule,155% of CMS OPPS Rate,775.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1098.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,775.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1235.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1235.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1202.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1202.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,762.12,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1550.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1418.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1067.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1201.82,155,,,Fee Schedule,155% of CMS OPPS Rate,775.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2401.76,155,,,Fee Schedule,155% of CMS OPPS Rate,2401.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,775.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,839.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,775.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,1576.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1576.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,716.17,2401.76,
22842- Post seg spine instrument/3-6 seg,3434771,CDM,510,RC,22842,HCPCS,Outpatient,,,2058.72,1029.36,,1852.85,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1646.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1852.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1996.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1894.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1314.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1619.23,78.65,,,percent of total billed charges,78.65% of total billed charges,1839.09,89.33,,,percent of total billed charges,89.33% of total billed charges,1852.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1441.1,70,,,percent of total billed charges,70% of total billed charges,1852.85,90,,,percent of total billed charges,90% of total billed charges,1955.78,95,,,percent of total billed charges,95% of total billed charges,1955.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1770.5,86,,,percent of total billed charges,86% of total billed charges,1646.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1996.96,97,,,percent of total billed charges,97% of total billed charges,1852.85,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1996.96,97,,,percent of total billed charges,97% of total billed charges,1914.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1996.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1314.74,1996.96,
22843- Post seg spine instrument/7-12 seg,3434772,CDM,510,RC,22843,HCPCS,Outpatient,,,2200.91,1100.46,,1980.82,90,,,percent of total billed charges,90% of total Billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1760.73,80,,,Percent of total Billed charges,80% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1980.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2134.88,97,,,Percent of total billed charges,97% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2024.84,92,,,Percent of total billed charges,92% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1980.82,90,,,percent of total billed charges,90% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1540.64,70,,,percent of total billed charges,70% of total billed charges,1980.82,90,,,percent of total billed charges,90% of total billed charges,2090.86,95,,,percent of total billed charges,95% of total billed charges,2090.86,95,,,percent of total billed charges,95% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1892.78,86,,,percent of total billed charges,86% of total billed charges,1760.73,80,,,percent of total billed charges,80% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2134.88,97,,,percent of total billed charges,97% of total billed charges,1980.82,90,,,percent of total billed charges,90% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2134.88,97,,,percent of total billed charges,97% of total billed charges,2046.85,93,,,percent of total billed charges,93% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2134.88,97,,,percent of total billed charges,97% of total billed charges,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1540.64,2200.91,
22844- Post seg spine instrument/13 or >,3434773,CDM,510,RC,22844,HCPCS,Outpatient,,,2645.26,1322.63,,2380.73,90,,,percent of total billed charges,90% of total Billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2116.21,80,,,Percent of total Billed charges,80% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2380.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2565.9,97,,,Percent of total billed charges,97% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2433.64,92,,,Percent of total billed charges,92% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2380.73,90,,,percent of total billed charges,90% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1851.68,70,,,percent of total billed charges,70% of total billed charges,2380.73,90,,,percent of total billed charges,90% of total billed charges,2513,95,,,percent of total billed charges,95% of total billed charges,2513,95,,,percent of total billed charges,95% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2274.92,86,,,percent of total billed charges,86% of total billed charges,2116.21,80,,,percent of total billed charges,80% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2565.9,97,,,percent of total billed charges,97% of total billed charges,2380.73,90,,,percent of total billed charges,90% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2565.9,97,,,percent of total billed charges,97% of total billed charges,2460.09,93,,,percent of total billed charges,93% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2565.9,97,,,percent of total billed charges,97% of total billed charges,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2645.26,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1851.68,2645.26,
22845 - PF Anterior Instrumentation 2-3 Vertebral Segments,4363322,CDM,960,RC,22845,HCPCS,Outpatient,,,1477.82,738.91,,1330.04,90,,,percent of total billed charges,90% of total Billed charges,1478.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,739.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,686.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1145.92,155,,,Fee Schedule,155% of CMS OPPS Rate,739.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1048.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,739.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1179.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1179.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1149.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1149.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,730.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,739.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1478.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1356.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1030.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1145.92,155,,,Fee Schedule,155% of CMS OPPS Rate,739.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2291.8,155,,,Fee Schedule,155% of CMS OPPS Rate,2291.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,739.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,811.82,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,739.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1518.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1518.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,686.27,2291.8,
22845- Ant instrumentation/2-3 vert seg,3434774,CDM,510,RC,22845,HCPCS,Outpatient,,,1965.99,983.00,,1769.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1572.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1769.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1907.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1808.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1255.52,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1546.29,78.65,,,percent of total billed charges,78.65% of total billed charges,1756.25,89.33,,,percent of total billed charges,89.33% of total billed charges,1769.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1376.19,70,,,percent of total billed charges,70% of total billed charges,1769.39,90,,,percent of total billed charges,90% of total billed charges,1867.69,95,,,percent of total billed charges,95% of total billed charges,1867.69,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1690.75,86,,,percent of total billed charges,86% of total billed charges,1572.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1907.01,97,,,percent of total billed charges,97% of total billed charges,1769.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1907.01,97,,,percent of total billed charges,97% of total billed charges,1828.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1907.01,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1255.52,1907.01,
22846 - PF Anterior Instrumentation 4-7 Vertebral Segments,4363323,CDM,960,RC,22846,HCPCS,Outpatient,,,1539.08,769.54,,1385.17,90,,,percent of total billed charges,90% of total Billed charges,1538.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,712.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1192.9,155,,,Fee Schedule,155% of CMS OPPS Rate,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1089.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,769.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1225.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1225.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1195.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1195.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,758.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,769.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1539.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1410.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1071.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1192.9,155,,,Fee Schedule,155% of CMS OPPS Rate,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,2384.13,155,,,Fee Schedule,155% of CMS OPPS Rate,2384.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,712.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,837.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,769.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1574.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1574.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,712.05,2384.13,
22846- Ant instrumentation/4-7 vert seg,3434775,CDM,510,RC,22846,HCPCS,Outpatient,,,2043.83,1021.92,,1839.45,90,,,percent of total billed charges,90% of total Billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1635.06,80,,,Percent of total Billed charges,80% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1839.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1982.52,97,,,Percent of total billed charges,97% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1880.32,92,,,Percent of total billed charges,92% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1839.45,90,,,percent of total billed charges,90% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1430.68,70,,,percent of total billed charges,70% of total billed charges,1839.45,90,,,percent of total billed charges,90% of total billed charges,1941.64,95,,,percent of total billed charges,95% of total billed charges,1941.64,95,,,percent of total billed charges,95% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1757.69,86,,,percent of total billed charges,86% of total billed charges,1635.06,80,,,percent of total billed charges,80% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.52,97,,,percent of total billed charges,97% of total billed charges,1839.45,90,,,percent of total billed charges,90% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1982.52,97,,,percent of total billed charges,97% of total billed charges,1900.76,93,,,percent of total billed charges,93% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1982.52,97,,,percent of total billed charges,97% of total billed charges,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2043.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1430.68,2043.83,
22848- Spine/pel fixation/oth than sacrum,3434776,CDM,510,RC,22848,HCPCS,Outpatient,,,966.58,483.29,,869.92,90,,,percent of total billed charges,90% of total Billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,773.26,80,,,Percent of total Billed charges,80% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,869.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,937.58,97,,,Percent of total billed charges,97% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,889.25,92,,,Percent of total billed charges,92% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,869.92,90,,,percent of total billed charges,90% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.61,70,,,percent of total billed charges,70% of total billed charges,869.92,90,,,percent of total billed charges,90% of total billed charges,918.25,95,,,percent of total billed charges,95% of total billed charges,918.25,95,,,percent of total billed charges,95% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,831.26,86,,,percent of total billed charges,86% of total billed charges,773.26,80,,,percent of total billed charges,80% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,937.58,97,,,percent of total billed charges,97% of total billed charges,869.92,90,,,percent of total billed charges,90% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,937.58,97,,,percent of total billed charges,97% of total billed charges,898.92,93,,,percent of total billed charges,93% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,937.58,97,,,percent of total billed charges,97% of total billed charges,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,966.58,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,676.61,966.58,
22849- Reinsert spinal fixation device,3434777,CDM,510,RC,22849,HCPCS,Outpatient,,,3485.5,1742.75,,3136.95,90,,,percent of total billed charges,90% of total Billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2788.4,80,,,Percent of total Billed charges,80% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3136.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3380.94,97,,,Percent of total billed charges,97% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3206.66,92,,,Percent of total billed charges,92% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3136.95,90,,,percent of total billed charges,90% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2439.85,70,,,percent of total billed charges,70% of total billed charges,3136.95,90,,,percent of total billed charges,90% of total billed charges,3311.23,95,,,percent of total billed charges,95% of total billed charges,3311.23,95,,,percent of total billed charges,95% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2997.53,86,,,percent of total billed charges,86% of total billed charges,2788.4,80,,,percent of total billed charges,80% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3380.94,97,,,percent of total billed charges,97% of total billed charges,3136.95,90,,,percent of total billed charges,90% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3380.94,97,,,percent of total billed charges,97% of total billed charges,3241.52,93,,,percent of total billed charges,93% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3380.94,97,,,percent of total billed charges,97% of total billed charges,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3485.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2439.85,3485.5,
22850- Rmv post nonseg/spine instrument,3434778,CDM,510,RC,22850,HCPCS,Outpatient,,,1947.53,973.77,,1752.78,90,,,percent of total billed charges,90% of total Billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1558.02,80,,,Percent of total Billed charges,80% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1752.78,90,,,Percent of total Billed charges,90% of total billed charges,357.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1889.1,97,,,Percent of total billed charges,97% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1791.73,92,,,Percent of total billed charges,92% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1752.78,90,,,percent of total billed charges,90% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1363.27,70,,,percent of total billed charges,70% of total billed charges,1752.78,90,,,percent of total billed charges,90% of total billed charges,1850.15,95,,,percent of total billed charges,95% of total billed charges,1850.15,95,,,percent of total billed charges,95% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1674.88,86,,,percent of total billed charges,86% of total billed charges,1558.02,80,,,percent of total billed charges,80% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1889.1,97,,,percent of total billed charges,97% of total billed charges,1752.78,90,,,percent of total billed charges,90% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1889.1,97,,,percent of total billed charges,97% of total billed charges,1811.2,93,,,percent of total billed charges,93% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,325,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1889.1,97,,,percent of total billed charges,97% of total billed charges,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1947.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,325,1947.53,
22852- Rmv posterior seg/spine instrument,3434780,CDM,510,RC,22852,HCPCS,Outpatient,,,1867.65,933.83,,1680.89,90,,,percent of total billed charges,90% of total Billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1494.12,80,,,Percent of total Billed charges,80% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1680.89,90,,,Percent of total Billed charges,90% of total billed charges,357.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1811.62,97,,,Percent of total billed charges,97% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1718.24,92,,,Percent of total billed charges,92% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1680.89,90,,,percent of total billed charges,90% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1307.36,70,,,percent of total billed charges,70% of total billed charges,1680.89,90,,,percent of total billed charges,90% of total billed charges,1774.27,95,,,percent of total billed charges,95% of total billed charges,1774.27,95,,,percent of total billed charges,95% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1606.18,86,,,percent of total billed charges,86% of total billed charges,1494.12,80,,,percent of total billed charges,80% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1811.62,97,,,percent of total billed charges,97% of total billed charges,1680.89,90,,,percent of total billed charges,90% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1811.62,97,,,percent of total billed charges,97% of total billed charges,1736.91,93,,,percent of total billed charges,93% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,325,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1811.62,97,,,percent of total billed charges,97% of total billed charges,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1867.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,325,1867.65,
22853 - PF Ins Biomechanical Dev Intervertebral Dsc Spc w/Arthrd,4363324,CDM,960,RC,22853,HCPCS,Outpatient,,,522.96,261.48,,470.66,90,,,percent of total billed charges,90% of total Billed charges,523.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,215.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,406.1,155,,,Fee Schedule,155% of CMS OPPS Rate,262,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,372.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,418.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,418.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,407.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,407.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,266.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,481.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,363.79,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,406.1,155,,,Fee Schedule,155% of CMS OPPS Rate,262,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.05,155,,,Fee Schedule,155% of CMS OPPS Rate,812.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,262,100,,,Fee Schedule,100% of CMS OPPS Rate ,215.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,296.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,262,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.14,812.05,
22855- Rmv anterior spine instrumentation,3434781,CDM,510,RC,22855,HCPCS,Outpatient,,,2951.98,1475.99,,2656.78,90,,,percent of total billed charges,90% of total Billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2361.58,80,,,Percent of total Billed charges,80% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2656.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2863.42,97,,,Percent of total billed charges,97% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2715.82,92,,,Percent of total billed charges,92% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2656.78,90,,,percent of total billed charges,90% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2066.39,70,,,percent of total billed charges,70% of total billed charges,2656.78,90,,,percent of total billed charges,90% of total billed charges,2804.38,95,,,percent of total billed charges,95% of total billed charges,2804.38,95,,,percent of total billed charges,95% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2538.7,86,,,percent of total billed charges,86% of total billed charges,2361.58,80,,,percent of total billed charges,80% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2863.42,97,,,percent of total billed charges,97% of total billed charges,2656.78,90,,,percent of total billed charges,90% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2863.42,97,,,percent of total billed charges,97% of total billed charges,2745.34,93,,,percent of total billed charges,93% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2863.42,97,,,percent of total billed charges,97% of total billed charges,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2951.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2066.39,2951.98,
22856- Tot disc arthroplasty/ant app/cerv,3434782,CDM,510,RC,22856,HCPCS,Outpatient,,,4359.71,2179.86,,3923.74,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3487.77,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3923.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4228.92,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,4010.93,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3923.74,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3051.8,70,,,percent of total billed charges,70% of total billed charges,3923.74,90,,,percent of total billed charges,90% of total billed charges,4141.72,95,,,percent of total billed charges,95% of total billed charges,4141.72,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3749.35,86,,,percent of total billed charges,86% of total billed charges,3487.77,80,,,percent of total billed charges,80% of total billed charges,16486.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4228.92,97,,,percent of total billed charges,97% of total billed charges,3923.74,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,4228.92,97,,,percent of total billed charges,97% of total billed charges,4054.53,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4228.92,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3051.8,106753.72,
22857- Tot disc arthroplasty/ant app/lumb,3434783,CDM,510,RC,22857,HCPCS,Outpatient,,,4656.75,2328.38,,4191.08,90,,,percent of total billed charges,90% of total Billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3725.4,80,,,Percent of total Billed charges,80% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4191.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4517.05,97,,,Percent of total billed charges,97% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4284.21,92,,,Percent of total billed charges,92% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4191.08,90,,,percent of total billed charges,90% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3259.73,70,,,percent of total billed charges,70% of total billed charges,4191.08,90,,,percent of total billed charges,90% of total billed charges,4423.91,95,,,percent of total billed charges,95% of total billed charges,4423.91,95,,,percent of total billed charges,95% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4004.81,86,,,percent of total billed charges,86% of total billed charges,3725.4,80,,,percent of total billed charges,80% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.05,97,,,percent of total billed charges,97% of total billed charges,4191.08,90,,,percent of total billed charges,90% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4517.05,97,,,percent of total billed charges,97% of total billed charges,4330.78,93,,,percent of total billed charges,93% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4517.05,97,,,percent of total billed charges,97% of total billed charges,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4656.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3259.73,4656.75,
22864- Rmv tot disc arthroplast/ant/cerv,3434784,CDM,510,RC,22864,HCPCS,Outpatient,,,5586.95,2793.48,,5028.26,90,,,percent of total billed charges,90% of total Billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4469.56,80,,,Percent of total Billed charges,80% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5028.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5419.34,97,,,Percent of total billed charges,97% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5139.99,92,,,Percent of total billed charges,92% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5028.26,90,,,percent of total billed charges,90% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3910.87,70,,,percent of total billed charges,70% of total billed charges,5028.26,90,,,percent of total billed charges,90% of total billed charges,5307.6,95,,,percent of total billed charges,95% of total billed charges,5307.6,95,,,percent of total billed charges,95% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4804.78,86,,,percent of total billed charges,86% of total billed charges,4469.56,80,,,percent of total billed charges,80% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5419.34,97,,,percent of total billed charges,97% of total billed charges,5028.26,90,,,percent of total billed charges,90% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5419.34,97,,,percent of total billed charges,97% of total billed charges,5195.86,93,,,percent of total billed charges,93% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5419.34,97,,,percent of total billed charges,97% of total billed charges,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5586.95,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3910.87,5586.95,
"22999 - Unlisted procedure, abdomen, musculoskeletal system",3800919,CDM,983,RC,22999,HCPCS,Outpatient,,,725.57,362.79,,653.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.67,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.67,653.01,
23030- I&D/shoulder/deep abscess/hematoma,3434790,CDM,510,RC,23030,HCPCS,Outpatient,,,1119.63,559.82,,1007.67,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,895.7,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1007.67,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1086.04,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1030.06,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1007.67,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,783.74,70,,,percent of total billed charges,70% of total billed charges,1007.67,90,,,percent of total billed charges,90% of total billed charges,1063.65,95,,,percent of total billed charges,95% of total billed charges,1063.65,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,962.88,86,,,percent of total billed charges,86% of total billed charges,895.7,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1086.04,97,,,percent of total billed charges,97% of total billed charges,1007.67,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1086.04,97,,,percent of total billed charges,97% of total billed charges,1041.26,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1086.04,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,12593.67,
23031- I&D/shoulder/infected bursa,3434791,CDM,510,RC,23031,HCPCS,Outpatient,,,1065.01,532.51,,958.51,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,852.01,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,958.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1033.06,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,979.81,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,958.51,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,745.51,70,,,percent of total billed charges,70% of total billed charges,958.51,90,,,percent of total billed charges,90% of total billed charges,1011.76,95,,,percent of total billed charges,95% of total billed charges,1011.76,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,915.91,86,,,percent of total billed charges,86% of total billed charges,852.01,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1033.06,97,,,percent of total billed charges,97% of total billed charges,958.51,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1033.06,97,,,percent of total billed charges,97% of total billed charges,990.46,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1033.06,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,745.51,12593.67,
23035- Incision/bone cortex/shoulder area,3434792,CDM,510,RC,23035,HCPCS,Outpatient,,,1785.07,892.54,,1606.56,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1428.06,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1606.56,90,,,Percent of total Billed charges,90% of total billed charges,238.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1731.52,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1642.26,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1606.56,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1249.55,70,,,percent of total billed charges,70% of total billed charges,1606.56,90,,,percent of total billed charges,90% of total billed charges,1695.82,95,,,percent of total billed charges,95% of total billed charges,1695.82,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1535.16,86,,,percent of total billed charges,86% of total billed charges,1428.06,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1731.52,97,,,percent of total billed charges,97% of total billed charges,1606.56,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1731.52,97,,,percent of total billed charges,97% of total billed charges,1660.12,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,217,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1731.52,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,217,6993.46,
23040- Arthrotomy/glenohumeral joint,3434793,CDM,510,RC,23040,HCPCS,Outpatient,,,1881.5,940.75,,1693.35,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.2,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1693.35,90,,,Percent of total Billed charges,90% of total billed charges,387.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1825.06,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1730.98,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1693.35,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1317.05,70,,,percent of total billed charges,70% of total billed charges,1693.35,90,,,percent of total billed charges,90% of total billed charges,1787.43,95,,,percent of total billed charges,95% of total billed charges,1787.43,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1618.09,86,,,percent of total billed charges,86% of total billed charges,1505.2,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1825.06,97,,,percent of total billed charges,97% of total billed charges,1693.35,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1825.06,97,,,percent of total billed charges,97% of total billed charges,1749.8,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,352,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1825.06,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,352,14511.58,
23075- Exc/tumor/shoulder/SQ/<3 cm,3434796,CDM,510,RC,23075,HCPCS,Outpatient,,,670.85,335.43,,603.77,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,536.68,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,603.77,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,650.72,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,617.18,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,603.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,469.6,70,,,percent of total billed charges,70% of total billed charges,603.77,90,,,percent of total billed charges,90% of total billed charges,637.31,95,,,percent of total billed charges,95% of total billed charges,637.31,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,576.93,86,,,percent of total billed charges,86% of total billed charges,536.68,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,650.72,97,,,percent of total billed charges,97% of total billed charges,603.77,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,650.72,97,,,percent of total billed charges,97% of total billed charges,623.89,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,650.72,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,7310.49,
23076- Exc IM tumor/shoulder area < 5 cm,3434797,CDM,960,RC,23076,HCPCS,Outpatient,,,1112.53,556.27,,1001.28,90,,,percent of total billed charges,90% of total Billed charges,1070.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,534.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,828.06,155,,,Fee Schedule,155% of CMS OPPS Rate,534.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,774.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,534.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,870.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,870.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,815.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,815.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,528.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,534.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,962.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,657.56,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,828.06,155,,,Fee Schedule,155% of CMS OPPS Rate,534.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1659.97,155,,,Fee Schedule,155% of CMS OPPS Rate,1659.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,534.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,596.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,534.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,1081.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1081.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1659.97,
23120- Partial claviculectomy,3434798,CDM,510,RC,23120,HCPCS,Outpatient,,,1525.82,762.91,,1373.24,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1220.66,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1373.24,90,,,Percent of total Billed charges,90% of total billed charges,302.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1480.05,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1403.75,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1373.24,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1068.07,70,,,percent of total billed charges,70% of total billed charges,1373.24,90,,,percent of total billed charges,90% of total billed charges,1449.53,95,,,percent of total billed charges,95% of total billed charges,1449.53,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1312.21,86,,,percent of total billed charges,86% of total billed charges,1220.66,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1480.05,97,,,percent of total billed charges,97% of total billed charges,1373.24,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1480.05,97,,,percent of total billed charges,97% of total billed charges,1419.01,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,275,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1480.05,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,275,14511.58,
23190- Ostectomy of scapula/partial,3434800,CDM,510,RC,23190,HCPCS,Outpatient,,,1501.24,750.62,,1351.12,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1200.99,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.12,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1456.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1381.14,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1351.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.87,70,,,percent of total billed charges,70% of total billed charges,1351.12,90,,,percent of total billed charges,90% of total billed charges,1426.18,95,,,percent of total billed charges,95% of total billed charges,1426.18,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1291.07,86,,,percent of total billed charges,86% of total billed charges,1200.99,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1456.2,97,,,percent of total billed charges,97% of total billed charges,1351.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1456.2,97,,,percent of total billed charges,97% of total billed charges,1396.15,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1456.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,14511.58,
23334- Rmv shoulder prosth/hum or glenoid,3434802,CDM,510,RC,23334,HCPCS,Outpatient,,,2781.95,1390.98,,2503.76,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2225.56,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2503.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2698.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2559.39,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2503.76,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1947.37,70,,,percent of total billed charges,70% of total billed charges,2503.76,90,,,percent of total billed charges,90% of total billed charges,2642.85,95,,,percent of total billed charges,95% of total billed charges,2642.85,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2392.48,86,,,percent of total billed charges,86% of total billed charges,2225.56,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2698.49,97,,,percent of total billed charges,97% of total billed charges,2503.76,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2698.49,97,,,percent of total billed charges,97% of total billed charges,2587.21,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2698.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1947.37,12593.67,
23335- Rmv shoulder prosth/hum & glenoid,3434803,CDM,510,RC,23335,HCPCS,Outpatient,,,3329.34,1664.67,,2996.41,90,,,percent of total billed charges,90% of total Billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2663.47,80,,,Percent of total Billed charges,80% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2996.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3229.46,97,,,Percent of total billed charges,97% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3062.99,92,,,Percent of total billed charges,92% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2996.41,90,,,percent of total billed charges,90% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2330.54,70,,,percent of total billed charges,70% of total billed charges,2996.41,90,,,percent of total billed charges,90% of total billed charges,3162.87,95,,,percent of total billed charges,95% of total billed charges,3162.87,95,,,percent of total billed charges,95% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2863.23,86,,,percent of total billed charges,86% of total billed charges,2663.47,80,,,percent of total billed charges,80% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3229.46,97,,,percent of total billed charges,97% of total billed charges,2996.41,90,,,percent of total billed charges,90% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3229.46,97,,,percent of total billed charges,97% of total billed charges,3096.29,93,,,percent of total billed charges,93% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3229.46,97,,,percent of total billed charges,97% of total billed charges,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3329.34,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2330.54,3329.34,
23350- Inj/shoulder arthrography,3434804,CDM,360,RC,23350,HCPCS,Outpatient,,,416.21,208.11,,374.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,332.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,374.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,403.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,382.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,265.8,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,327.36,78.65,,,percent of total billed charges,78.65% of total billed charges,371.81,89.33,,,percent of total billed charges,89.33% of total billed charges,374.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,291.35,70,,,percent of total billed charges,70% of total billed charges,374.59,90,,,percent of total billed charges,90% of total billed charges,395.4,95,,,percent of total billed charges,95% of total billed charges,395.4,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,357.94,86,,,percent of total billed charges,86% of total billed charges,332.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,403.72,97,,,percent of total billed charges,97% of total billed charges,374.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,403.72,97,,,percent of total billed charges,97% of total billed charges,387.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.8,403.72,
23395- Muscle trans/shoulder/up arm/sgn,3434805,CDM,510,RC,23395,HCPCS,Outpatient,,,3348.5,1674.25,,3013.65,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2678.8,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3013.65,90,,,Percent of total Billed charges,90% of total billed charges,700.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3248.05,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3080.62,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3013.65,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2343.95,70,,,percent of total billed charges,70% of total billed charges,3013.65,90,,,percent of total billed charges,90% of total billed charges,3181.08,95,,,percent of total billed charges,95% of total billed charges,3181.08,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2879.71,86,,,percent of total billed charges,86% of total billed charges,2678.8,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3248.05,97,,,percent of total billed charges,97% of total billed charges,3013.65,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3248.05,97,,,percent of total billed charges,97% of total billed charges,3114.11,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3248.05,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637,32247.16,
23405- Tenotomy/shoulder/single tendon,3434806,CDM,510,RC,23405,HCPCS,Outpatient,,,1616.77,808.39,,1455.09,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1293.42,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1455.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1568.27,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1487.43,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1455.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1131.74,70,,,percent of total billed charges,70% of total billed charges,1455.09,90,,,percent of total billed charges,90% of total billed charges,1535.93,95,,,percent of total billed charges,95% of total billed charges,1535.93,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1390.42,86,,,percent of total billed charges,86% of total billed charges,1293.42,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1568.27,97,,,percent of total billed charges,97% of total billed charges,1455.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1568.27,97,,,percent of total billed charges,97% of total billed charges,1503.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1568.27,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1131.74,32247.16,
23410- Rpr/rupture/musc/tend cuff/acute,3434807,CDM,510,RC,23410,HCPCS,Outpatient,,,2145.57,1072.79,,1931.01,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1716.46,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1931.01,90,,,Percent of total Billed charges,90% of total billed charges,492.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2081.2,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1973.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1931.01,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1501.9,70,,,percent of total billed charges,70% of total billed charges,1931.01,90,,,percent of total billed charges,90% of total billed charges,2038.29,95,,,percent of total billed charges,95% of total billed charges,2038.29,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1845.19,86,,,percent of total billed charges,86% of total billed charges,1716.46,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2081.2,97,,,percent of total billed charges,97% of total billed charges,1931.01,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2081.2,97,,,percent of total billed charges,97% of total billed charges,1995.38,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2081.2,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448,32247.16,
23412- Rpr/rupture/musc/tend cuff/chronic,3434808,CDM,510,RC,23412,HCPCS,Outpatient,,,2231.09,1115.55,,2007.98,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1784.87,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2007.98,90,,,Percent of total Billed charges,90% of total billed charges,636.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2164.16,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2052.6,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2007.98,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1561.76,70,,,percent of total billed charges,70% of total billed charges,2007.98,90,,,percent of total billed charges,90% of total billed charges,2119.54,95,,,percent of total billed charges,95% of total billed charges,2119.54,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1918.74,86,,,percent of total billed charges,86% of total billed charges,1784.87,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2164.16,97,,,percent of total billed charges,97% of total billed charges,2007.98,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2164.16,97,,,percent of total billed charges,97% of total billed charges,2074.91,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,579,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2164.16,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,579,32247.16,
23420- Reconstruc rotate cuff avuls/chron,3434809,CDM,510,RC,23420,HCPCS,Outpatient,,,2549.84,1274.92,,2294.86,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2039.87,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2294.86,90,,,Percent of total Billed charges,90% of total billed charges,636.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2473.34,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.85,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2294.86,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1784.89,70,,,percent of total billed charges,70% of total billed charges,2294.86,90,,,percent of total billed charges,90% of total billed charges,2422.35,95,,,percent of total billed charges,95% of total billed charges,2422.35,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2192.86,86,,,percent of total billed charges,86% of total billed charges,2039.87,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2473.34,97,,,percent of total billed charges,97% of total billed charges,2294.86,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2473.34,97,,,percent of total billed charges,97% of total billed charges,2371.35,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,579,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2473.34,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,579,32247.16,
23430- Repair/long tendon/biceps,3434810,CDM,510,RC,23430,HCPCS,Outpatient,,,1945.56,972.78,,1751,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1556.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1751,90,,,Percent of total Billed charges,90% of total billed charges,419.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1887.19,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1789.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1751,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.89,70,,,percent of total billed charges,70% of total billed charges,1751,90,,,percent of total billed charges,90% of total billed charges,1848.28,95,,,percent of total billed charges,95% of total billed charges,1848.28,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1673.18,86,,,percent of total billed charges,86% of total billed charges,1556.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1887.19,97,,,percent of total billed charges,97% of total billed charges,1751,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1887.19,97,,,percent of total billed charges,97% of total billed charges,1809.37,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,381,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1887.19,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381,32247.16,
23440- Resect/transplant/long tend/bicep,3434811,CDM,510,RC,23440,HCPCS,Outpatient,,,1985.17,992.59,,1786.65,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1588.14,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1786.65,90,,,Percent of total Billed charges,90% of total billed charges,419.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1925.61,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1826.36,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1786.65,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1389.62,70,,,percent of total billed charges,70% of total billed charges,1786.65,90,,,percent of total billed charges,90% of total billed charges,1885.91,95,,,percent of total billed charges,95% of total billed charges,1885.91,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1707.25,86,,,percent of total billed charges,86% of total billed charges,1588.14,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1925.61,97,,,percent of total billed charges,97% of total billed charges,1786.65,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.61,97,,,percent of total billed charges,97% of total billed charges,1846.21,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,381,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1925.61,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381,32247.16,
23455- Capsulorrhapy/ant/w labral repair,3434812,CDM,510,RC,23455,HCPCS,Outpatient,,,2612.25,1306.13,,2351.03,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2089.8,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2351.03,90,,,Percent of total Billed charges,90% of total billed charges,595.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2533.88,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2403.27,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2351.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.58,70,,,percent of total billed charges,70% of total billed charges,2351.03,90,,,percent of total billed charges,90% of total billed charges,2481.64,95,,,percent of total billed charges,95% of total billed charges,2481.64,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2246.54,86,,,percent of total billed charges,86% of total billed charges,2089.8,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2533.88,97,,,percent of total billed charges,97% of total billed charges,2351.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2533.88,97,,,percent of total billed charges,97% of total billed charges,2429.39,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,541,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2533.88,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,541,32247.16,
23460- Capsulorrhapy/ant/bone block,3434813,CDM,510,RC,23460,HCPCS,Outpatient,,,2866.6,1433.30,,2579.94,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2293.28,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2579.94,90,,,Percent of total Billed charges,90% of total billed charges,849.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2780.6,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2637.27,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2579.94,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.62,70,,,percent of total billed charges,70% of total billed charges,2579.94,90,,,percent of total billed charges,90% of total billed charges,2723.27,95,,,percent of total billed charges,95% of total billed charges,2723.27,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2465.28,86,,,percent of total billed charges,86% of total billed charges,2293.28,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2780.6,97,,,percent of total billed charges,97% of total billed charges,2579.94,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2780.6,97,,,percent of total billed charges,97% of total billed charges,2665.94,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,772.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2780.6,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,772.5,32247.16,
23462- Capsulorrhapy/coracoid proc trans,3434814,CDM,510,RC,23462,HCPCS,Outpatient,,,2809.11,1404.56,,2528.2,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2247.29,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2528.2,90,,,Percent of total Billed charges,90% of total billed charges,849.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2724.84,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2584.38,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2528.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1966.38,70,,,percent of total billed charges,70% of total billed charges,2528.2,90,,,percent of total billed charges,90% of total billed charges,2668.65,95,,,percent of total billed charges,95% of total billed charges,2668.65,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2415.83,86,,,percent of total billed charges,86% of total billed charges,2247.29,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2724.84,97,,,percent of total billed charges,97% of total billed charges,2528.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2724.84,97,,,percent of total billed charges,97% of total billed charges,2612.47,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,772.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2724.84,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,772.5,32247.16,
23472- Arthroplasty/total shoulder,3434815,CDM,510,RC,23472,HCPCS,Outpatient,,,3808.47,1904.24,,3427.62,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3046.78,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3427.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3694.22,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3503.79,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3427.62,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2665.93,70,,,percent of total billed charges,70% of total billed charges,3427.62,90,,,percent of total billed charges,90% of total billed charges,3618.05,95,,,percent of total billed charges,95% of total billed charges,3618.05,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3275.28,86,,,percent of total billed charges,86% of total billed charges,3046.78,80,,,percent of total billed charges,80% of total billed charges,3808.47,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3694.22,97,,,percent of total billed charges,97% of total billed charges,3427.62,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3694.22,97,,,percent of total billed charges,97% of total billed charges,3541.88,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3694.22,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2665.93,63611.04,
23473- Revis/tot shoulder arthro/hum/glen,3434816,CDM,510,RC,23473,HCPCS,Outpatient,,,4250.25,2125.13,,3825.23,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3400.2,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3825.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4122.74,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3910.23,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3825.23,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2975.18,70,,,percent of total billed charges,70% of total billed charges,3825.23,90,,,percent of total billed charges,90% of total billed charges,4037.74,95,,,percent of total billed charges,95% of total billed charges,4037.74,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3655.22,86,,,percent of total billed charges,86% of total billed charges,3400.2,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4122.74,97,,,percent of total billed charges,97% of total billed charges,3825.23,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,4122.74,97,,,percent of total billed charges,97% of total billed charges,3952.73,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4122.74,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2975.18,63611.04,
23474- Revis/tot shoulder arthro/hum&glen,3434817,CDM,510,RC,23474,HCPCS,Outpatient,,,4590.27,2295.14,,4131.24,90,,,percent of total billed charges,90% of total Billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3672.22,80,,,Percent of total Billed charges,80% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4131.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4452.56,97,,,Percent of total billed charges,97% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4223.05,92,,,Percent of total billed charges,92% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4131.24,90,,,percent of total billed charges,90% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3213.19,70,,,percent of total billed charges,70% of total billed charges,4131.24,90,,,percent of total billed charges,90% of total billed charges,4360.76,95,,,percent of total billed charges,95% of total billed charges,4360.76,95,,,percent of total billed charges,95% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3947.63,86,,,percent of total billed charges,86% of total billed charges,3672.22,80,,,percent of total billed charges,80% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4452.56,97,,,percent of total billed charges,97% of total billed charges,4131.24,90,,,percent of total billed charges,90% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4452.56,97,,,percent of total billed charges,97% of total billed charges,4268.95,93,,,percent of total billed charges,93% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4452.56,97,,,percent of total billed charges,97% of total billed charges,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4590.27,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3213.19,4590.27,
23480- Osteotomy/clavicle w/w/o int fix,3434818,CDM,510,RC,23480,HCPCS,Outpatient,,,2152.4,1076.20,,1937.16,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1721.92,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1937.16,90,,,Percent of total Billed charges,90% of total billed charges,337.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2087.83,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1980.21,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1937.16,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1506.68,70,,,percent of total billed charges,70% of total billed charges,1937.16,90,,,percent of total billed charges,90% of total billed charges,2044.78,95,,,percent of total billed charges,95% of total billed charges,2044.78,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1851.06,86,,,percent of total billed charges,86% of total billed charges,1721.92,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2087.83,97,,,percent of total billed charges,97% of total billed charges,1937.16,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2087.83,97,,,percent of total billed charges,97% of total billed charges,2001.73,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,307,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2087.83,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,307,32247.16,
23500- Clsd tx/clavicular fx w/o manip,3434819,CDM,510,RC,23500,HCPCS,Outpatient,,,570.27,285.14,,513.24,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,456.22,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,513.24,90,,,Percent of total Billed charges,90% of total billed charges,77.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,553.16,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,524.65,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,513.24,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,399.19,70,,,percent of total billed charges,70% of total billed charges,513.24,90,,,percent of total billed charges,90% of total billed charges,541.76,95,,,percent of total billed charges,95% of total billed charges,541.76,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,490.43,86,,,percent of total billed charges,86% of total billed charges,456.22,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,553.16,97,,,percent of total billed charges,97% of total billed charges,513.24,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,553.16,97,,,percent of total billed charges,97% of total billed charges,530.35,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,553.16,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.5,1009.19,
23515- Open Tx Of Clavicle fx,3434820,CDM,510,RC,23515,HCPCS,Outpatient,,,1879.48,939.74,,1691.53,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1503.58,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1691.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1823.1,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1729.12,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1691.53,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1315.64,70,,,percent of total billed charges,70% of total billed charges,1691.53,90,,,percent of total billed charges,90% of total billed charges,1785.51,95,,,percent of total billed charges,95% of total billed charges,1785.51,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1616.35,86,,,percent of total billed charges,86% of total billed charges,1503.58,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1823.1,97,,,percent of total billed charges,97% of total billed charges,1691.53,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1823.1,97,,,percent of total billed charges,97% of total billed charges,1747.92,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1823.1,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1315.64,32247.16,
23532- Open tx/sternoclavic dislocate/w gft,3434821,CDM,510,RC,23532,HCPCS,Outpatient,,,1635.51,817.76,,1471.96,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1308.41,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1471.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1586.44,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1504.67,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1471.96,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1144.86,70,,,percent of total billed charges,70% of total billed charges,1471.96,90,,,percent of total billed charges,90% of total billed charges,1553.73,95,,,percent of total billed charges,95% of total billed charges,1553.73,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1406.54,86,,,percent of total billed charges,86% of total billed charges,1308.41,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1586.44,97,,,percent of total billed charges,97% of total billed charges,1471.96,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1586.44,97,,,percent of total billed charges,97% of total billed charges,1521.02,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1586.44,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1144.86,32247.16,
23550- Open tx/acromioclavicular dislocateat,3434822,CDM,510,RC,23550,HCPCS,Outpatient,,,1493.06,746.53,,1343.75,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1343.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1448.27,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1373.62,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1343.75,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.14,70,,,percent of total billed charges,70% of total billed charges,1343.75,90,,,percent of total billed charges,90% of total billed charges,1418.41,95,,,percent of total billed charges,95% of total billed charges,1418.41,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1284.03,86,,,percent of total billed charges,86% of total billed charges,1194.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1448.27,97,,,percent of total billed charges,97% of total billed charges,1343.75,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1448.27,97,,,percent of total billed charges,97% of total billed charges,1388.55,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1448.27,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1045.14,32247.16,
23552- Open tx/acromioclav dislocate/fas gft,3434823,CDM,510,RC,23552,HCPCS,Outpatient,,,1709.13,854.57,,1538.22,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1367.3,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.22,90,,,Percent of total Billed charges,90% of total billed charges,433.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1657.86,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1572.4,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1538.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.39,70,,,percent of total billed charges,70% of total billed charges,1538.22,90,,,percent of total billed charges,90% of total billed charges,1623.67,95,,,percent of total billed charges,95% of total billed charges,1623.67,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1469.85,86,,,percent of total billed charges,86% of total billed charges,1367.3,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1657.86,97,,,percent of total billed charges,97% of total billed charges,1538.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1657.86,97,,,percent of total billed charges,97% of total billed charges,1589.49,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1657.86,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,394.5,32247.16,
23570- Clsd tx/scapular fx w/o manip,3434824,CDM,510,RC,23570,HCPCS,Outpatient,,,603.19,301.60,,542.87,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,482.55,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.87,90,,,Percent of total Billed charges,90% of total billed charges,80.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.09,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,554.93,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.87,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,422.23,70,,,percent of total billed charges,70% of total billed charges,542.87,90,,,percent of total billed charges,90% of total billed charges,573.03,95,,,percent of total billed charges,95% of total billed charges,573.03,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,518.74,86,,,percent of total billed charges,86% of total billed charges,482.55,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.09,97,,,percent of total billed charges,97% of total billed charges,542.87,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.09,97,,,percent of total billed charges,97% of total billed charges,560.97,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.09,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73,1009.19,
23585- Open tx/scapular fracture,3434825,CDM,510,RC,23585,HCPCS,Outpatient,,,2570.54,1285.27,,2313.49,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.43,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2313.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2493.42,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2364.9,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2313.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1799.38,70,,,percent of total billed charges,70% of total billed charges,2313.49,90,,,percent of total billed charges,90% of total billed charges,2442.01,95,,,percent of total billed charges,95% of total billed charges,2442.01,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2210.66,86,,,percent of total billed charges,86% of total billed charges,2056.43,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2493.42,97,,,percent of total billed charges,97% of total billed charges,2313.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2493.42,97,,,percent of total billed charges,97% of total billed charges,2390.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2493.42,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1799.38,32247.16,
23600- Open tx/acute shoulder dislocateation,3434826,CDM,510,RC,23600,HCPCS,Outpatient,,,850.75,425.38,,765.68,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,680.6,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.68,90,,,Percent of total Billed charges,90% of total billed charges,128.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,825.23,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,782.69,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,765.68,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,595.53,70,,,percent of total billed charges,70% of total billed charges,765.68,90,,,percent of total billed charges,90% of total billed charges,808.21,95,,,percent of total billed charges,95% of total billed charges,808.21,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,731.65,86,,,percent of total billed charges,86% of total billed charges,680.6,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,825.23,97,,,percent of total billed charges,97% of total billed charges,765.68,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,825.23,97,,,percent of total billed charges,97% of total billed charges,791.2,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,825.23,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116.5,1009.19,
23605- Clsd tx/prox humeral fx w/manip,3434827,CDM,510,RC,23605,HCPCS,Outpatient,,,1212.98,606.49,,1091.68,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,970.38,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1091.68,90,,,Percent of total Billed charges,90% of total billed charges,203.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1176.59,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1115.94,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1091.68,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,849.09,70,,,percent of total billed charges,70% of total billed charges,1091.68,90,,,percent of total billed charges,90% of total billed charges,1152.33,95,,,percent of total billed charges,95% of total billed charges,1152.33,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1043.16,86,,,percent of total billed charges,86% of total billed charges,970.38,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1176.59,97,,,percent of total billed charges,97% of total billed charges,1091.68,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1176.59,97,,,percent of total billed charges,97% of total billed charges,1128.07,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,185,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1176.59,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,185,6993.46,
23615- Open tx/prox humeral fracture,3434828,CDM,510,RC,23615,HCPCS,Outpatient,,,2312.18,1156.09,,2080.96,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1849.74,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2080.96,90,,,Percent of total Billed charges,90% of total billed charges,520.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2242.81,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2127.21,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2080.96,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.53,70,,,percent of total billed charges,70% of total billed charges,2080.96,90,,,percent of total billed charges,90% of total billed charges,2196.57,95,,,percent of total billed charges,95% of total billed charges,2196.57,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1988.47,86,,,percent of total billed charges,86% of total billed charges,1849.74,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2242.81,97,,,percent of total billed charges,97% of total billed charges,2080.96,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2242.81,97,,,percent of total billed charges,97% of total billed charges,2150.33,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,473,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2242.81,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,473,63611.04,
23616- Open tx prox humeral fx w/prosth,3434829,CDM,510,RC,23616,HCPCS,Outpatient,,,3245.82,1622.91,,2921.24,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2596.66,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2921.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3148.45,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2986.15,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2921.24,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2272.07,70,,,percent of total billed charges,70% of total billed charges,2921.24,90,,,percent of total billed charges,90% of total billed charges,3083.53,95,,,percent of total billed charges,95% of total billed charges,3083.53,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2791.41,86,,,percent of total billed charges,86% of total billed charges,2596.66,80,,,percent of total billed charges,80% of total billed charges,16486.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3148.45,97,,,percent of total billed charges,97% of total billed charges,2921.24,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3148.45,97,,,percent of total billed charges,97% of total billed charges,3018.61,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3148.45,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2272.07,106753.72,
23620- Clsd tx/grt hum tube fx w/o manip,3434830,CDM,510,RC,23620,HCPCS,Outpatient,,,693.61,346.81,,624.25,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,554.89,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,624.25,90,,,Percent of total Billed charges,90% of total billed charges,172.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,672.8,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,638.12,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,624.25,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,485.53,70,,,percent of total billed charges,70% of total billed charges,624.25,90,,,percent of total billed charges,90% of total billed charges,658.93,95,,,percent of total billed charges,95% of total billed charges,658.93,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,596.5,86,,,percent of total billed charges,86% of total billed charges,554.89,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,672.8,97,,,percent of total billed charges,97% of total billed charges,624.25,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,672.8,97,,,percent of total billed charges,97% of total billed charges,645.06,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,672.8,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157,1009.19,
23630- Open tx/grt humeral tuberosity fx,3434831,CDM,510,RC,23630,HCPCS,Outpatient,,,2032.26,1016.13,,1829.03,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1625.81,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1829.03,90,,,Percent of total Billed charges,90% of total billed charges,440,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1971.29,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1869.68,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1829.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.58,70,,,percent of total billed charges,70% of total billed charges,1829.03,90,,,percent of total billed charges,90% of total billed charges,1930.65,95,,,percent of total billed charges,95% of total billed charges,1930.65,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1747.74,86,,,percent of total billed charges,86% of total billed charges,1625.81,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1971.29,97,,,percent of total billed charges,97% of total billed charges,1829.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1971.29,97,,,percent of total billed charges,97% of total billed charges,1890,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1971.29,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,400,32247.16,
23650- Clsd/shoulder dislo/manip/no anest,3434832,CDM,510,RC,23650,HCPCS,Outpatient,,,700.59,350.30,,630.53,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,560.47,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.53,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679.57,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,644.54,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,630.53,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.41,70,,,percent of total billed charges,70% of total billed charges,630.53,90,,,percent of total billed charges,90% of total billed charges,665.56,95,,,percent of total billed charges,95% of total billed charges,665.56,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,602.51,86,,,percent of total billed charges,86% of total billed charges,560.47,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,679.57,97,,,percent of total billed charges,97% of total billed charges,630.53,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,679.57,97,,,percent of total billed charges,97% of total billed charges,651.55,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679.57,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,1009.19,
23655- Clsd tx/shoulder dislo/manip/anest,3434833,CDM,510,RC,23655,HCPCS,Outpatient,,,1060.77,530.39,,954.69,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,848.62,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,954.69,90,,,Percent of total Billed charges,90% of total billed charges,152.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1028.95,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,975.91,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,954.69,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,742.54,70,,,percent of total billed charges,70% of total billed charges,954.69,90,,,percent of total billed charges,90% of total billed charges,1007.73,95,,,percent of total billed charges,95% of total billed charges,1007.73,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,912.26,86,,,percent of total billed charges,86% of total billed charges,848.62,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1028.95,97,,,percent of total billed charges,97% of total billed charges,954.69,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1028.95,97,,,percent of total billed charges,97% of total billed charges,986.52,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,139,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1028.95,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139,6993.46,
23660- Open Tx Acute Shoulder dislocateation,3434834,CDM,510,RC,23660,HCPCS,Outpatient,,,1523.95,761.98,,1371.56,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1219.16,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1371.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1478.23,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.03,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1371.56,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,70,,,percent of total billed charges,70% of total billed charges,1371.56,90,,,percent of total billed charges,90% of total billed charges,1447.75,95,,,percent of total billed charges,95% of total billed charges,1447.75,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1310.6,86,,,percent of total billed charges,86% of total billed charges,1219.16,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1478.23,97,,,percent of total billed charges,97% of total billed charges,1371.56,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1478.23,97,,,percent of total billed charges,97% of total billed charges,1417.27,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1478.23,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1066.77,32247.16,
23670- Open tx/shoulder dislocate/fx >tubero,3434835,CDM,510,RC,23670,HCPCS,Outpatient,,,2273.72,1136.86,,2046.35,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1818.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2046.35,90,,,Percent of total Billed charges,90% of total billed charges,440,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2205.51,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2091.82,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2046.35,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1591.6,70,,,percent of total billed charges,70% of total billed charges,2046.35,90,,,percent of total billed charges,90% of total billed charges,2160.03,95,,,percent of total billed charges,95% of total billed charges,2160.03,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1955.4,86,,,percent of total billed charges,86% of total billed charges,1818.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2205.51,97,,,percent of total billed charges,97% of total billed charges,2046.35,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2205.51,97,,,percent of total billed charges,97% of total billed charges,2114.56,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,400,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2205.51,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,400,32247.16,
23700- Manip/anest/shoulder/fixate app,3434836,CDM,510,RC,23700,HCPCS,Outpatient,,,509.9,254.95,,458.91,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,407.92,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.91,90,,,Percent of total Billed charges,90% of total billed charges,140.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,494.6,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,469.11,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,458.91,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,356.93,70,,,percent of total billed charges,70% of total billed charges,458.91,90,,,percent of total billed charges,90% of total billed charges,484.41,95,,,percent of total billed charges,95% of total billed charges,484.41,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,438.51,86,,,percent of total billed charges,86% of total billed charges,407.92,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,494.6,97,,,percent of total billed charges,97% of total billed charges,458.91,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.6,97,,,percent of total billed charges,97% of total billed charges,474.21,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,494.6,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128,6993.46,
24101- Arthrotomy/elbow/joint exploration,3434847,CDM,510,RC,24101,HCPCS,Outpatient,,,1308.87,654.44,,1177.98,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1047.1,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1177.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1269.6,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1204.16,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1177.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,916.21,70,,,percent of total billed charges,70% of total billed charges,1177.98,90,,,percent of total billed charges,90% of total billed charges,1243.43,95,,,percent of total billed charges,95% of total billed charges,1243.43,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1125.63,86,,,percent of total billed charges,86% of total billed charges,1047.1,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1269.6,97,,,percent of total billed charges,97% of total billed charges,1177.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1269.6,97,,,percent of total billed charges,97% of total billed charges,1217.25,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1269.6,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,916.21,14511.58,
24332- Tenolysis/triceps,3434854,CDM,510,RC,24332,HCPCS,Outpatient,,,1604.88,802.44,,1444.39,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.9,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.39,90,,,Percent of total Billed charges,90% of total billed charges,414.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1556.73,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.49,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1444.39,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.42,70,,,percent of total billed charges,70% of total billed charges,1444.39,90,,,percent of total billed charges,90% of total billed charges,1524.64,95,,,percent of total billed charges,95% of total billed charges,1524.64,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1380.2,86,,,percent of total billed charges,86% of total billed charges,1283.9,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1556.73,97,,,percent of total billed charges,97% of total billed charges,1444.39,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1556.73,97,,,percent of total billed charges,97% of total billed charges,1492.54,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1556.73,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,376.81,14511.58,
24341- Rpr/tendon/musc/upper arm/elbow/ea,3434855,CDM,510,RC,24341,HCPCS,Outpatient,,,1930.59,965.30,,1737.53,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1544.47,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1737.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1872.67,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1776.14,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1737.53,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.41,70,,,percent of total billed charges,70% of total billed charges,1737.53,90,,,percent of total billed charges,90% of total billed charges,1834.06,95,,,percent of total billed charges,95% of total billed charges,1834.06,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1660.31,86,,,percent of total billed charges,86% of total billed charges,1544.47,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1872.67,97,,,percent of total billed charges,97% of total billed charges,1737.53,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1872.67,97,,,percent of total billed charges,97% of total billed charges,1795.45,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1872.67,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1351.41,32247.16,
24342- Reinsert/rup bi/tricep tend/distal,3434856,CDM,510,RC,24342,HCPCS,Outpatient,,,2030.21,1015.11,,1827.19,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1624.17,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1827.19,90,,,Percent of total Billed charges,90% of total billed charges,572,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1969.3,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1867.79,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1827.19,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.15,70,,,percent of total billed charges,70% of total billed charges,1827.19,90,,,percent of total billed charges,90% of total billed charges,1928.7,95,,,percent of total billed charges,95% of total billed charges,1928.7,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1745.98,86,,,percent of total billed charges,86% of total billed charges,1624.17,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1969.3,97,,,percent of total billed charges,97% of total billed charges,1827.19,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1969.3,97,,,percent of total billed charges,97% of total billed charges,1888.1,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,520,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1969.3,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,520,32247.16,
24343- Rpr lat collat lig/elbow/local tis,3434857,CDM,510,RC,24343,HCPCS,Outpatient,,,1854.9,927.45,,1669.41,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.92,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1669.41,90,,,Percent of total Billed charges,90% of total billed charges,542.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1799.25,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1706.51,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1669.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.43,70,,,percent of total billed charges,70% of total billed charges,1669.41,90,,,percent of total billed charges,90% of total billed charges,1762.16,95,,,percent of total billed charges,95% of total billed charges,1762.16,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1595.21,86,,,percent of total billed charges,86% of total billed charges,1483.92,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1799.25,97,,,percent of total billed charges,97% of total billed charges,1669.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1799.25,97,,,percent of total billed charges,97% of total billed charges,1725.06,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1799.25,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,493.2,14511.58,
24346- Recon med collat lig/elbow/ten gft,3434858,CDM,510,RC,24346,HCPCS,Outpatient,,,2885.85,1442.93,,2597.27,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2308.68,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2597.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2799.27,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2654.98,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2597.27,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2020.1,70,,,percent of total billed charges,70% of total billed charges,2597.27,90,,,percent of total billed charges,90% of total billed charges,2741.56,95,,,percent of total billed charges,95% of total billed charges,2741.56,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2481.83,86,,,percent of total billed charges,86% of total billed charges,2308.68,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2799.27,97,,,percent of total billed charges,97% of total billed charges,2597.27,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2799.27,97,,,percent of total billed charges,97% of total billed charges,2683.84,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2799.27,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2020.1,63611.04,
24358- Tenotomy/elbow/debride/open,3434859,CDM,510,RC,24358,HCPCS,Outpatient,,,1373.89,686.95,,1236.5,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1099.11,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1236.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1332.67,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1263.98,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1236.5,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,961.72,70,,,percent of total billed charges,70% of total billed charges,1236.5,90,,,percent of total billed charges,90% of total billed charges,1305.2,95,,,percent of total billed charges,95% of total billed charges,1305.2,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1181.55,86,,,percent of total billed charges,86% of total billed charges,1099.11,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1332.67,97,,,percent of total billed charges,97% of total billed charges,1236.5,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1332.67,97,,,percent of total billed charges,97% of total billed charges,1277.72,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1332.67,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,961.72,14511.58,
24359- Tenotomy/elbow/debride/open/tend rpr/reattch,3434860,CDM,510,RC,24359,HCPCS,Outpatient,,,1729.07,864.54,,1556.16,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1383.26,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1556.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1677.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1590.74,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1556.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1210.35,70,,,percent of total billed charges,70% of total billed charges,1556.16,90,,,percent of total billed charges,90% of total billed charges,1642.62,95,,,percent of total billed charges,95% of total billed charges,1642.62,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1487,86,,,percent of total billed charges,86% of total billed charges,1383.26,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1677.2,97,,,percent of total billed charges,97% of total billed charges,1556.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1677.2,97,,,percent of total billed charges,97% of total billed charges,1608.04,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1677.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1210.35,14511.58,
24363- Arthroplast/elbow/dis hum/prox uln,3434861,CDM,510,RC,24363,HCPCS,Outpatient,,,3802.54,1901.27,,3422.29,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3042.03,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3422.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3688.46,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3498.34,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3422.29,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2661.78,70,,,percent of total billed charges,70% of total billed charges,3422.29,90,,,percent of total billed charges,90% of total billed charges,3612.41,95,,,percent of total billed charges,95% of total billed charges,3612.41,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3270.18,86,,,percent of total billed charges,86% of total billed charges,3042.03,80,,,percent of total billed charges,80% of total billed charges,16486.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3688.46,97,,,percent of total billed charges,97% of total billed charges,3422.29,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3688.46,97,,,percent of total billed charges,97% of total billed charges,3536.36,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3688.46,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2661.78,106753.72,
24366- Arthroplasty/radial head w/implant,3434862,CDM,510,RC,24366,HCPCS,Outpatient,,,1782.18,891.09,,1603.96,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1425.74,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1603.96,90,,,Percent of total Billed charges,90% of total billed charges,666.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1728.71,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1639.61,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1603.96,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.53,70,,,percent of total billed charges,70% of total billed charges,1603.96,90,,,percent of total billed charges,90% of total billed charges,1693.07,95,,,percent of total billed charges,95% of total billed charges,1693.07,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1532.67,86,,,percent of total billed charges,86% of total billed charges,1425.74,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1728.71,97,,,percent of total billed charges,97% of total billed charges,1603.96,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1728.71,97,,,percent of total billed charges,97% of total billed charges,1657.43,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1728.71,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,605.96,63611.04,
24430- Rpr non/malunion/humerus w/o gft,3434863,CDM,510,RC,24430,HCPCS,Outpatient,,,2765.89,1382.95,,2489.3,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2212.71,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2489.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2682.91,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2544.62,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2489.3,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1936.12,70,,,percent of total billed charges,70% of total billed charges,2489.3,90,,,percent of total billed charges,90% of total billed charges,2627.6,95,,,percent of total billed charges,95% of total billed charges,2627.6,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2378.67,86,,,percent of total billed charges,86% of total billed charges,2212.71,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2682.91,97,,,percent of total billed charges,97% of total billed charges,2489.3,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2682.91,97,,,percent of total billed charges,97% of total billed charges,2572.28,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2682.91,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1936.12,63611.04,
25400- Rpr/non/malunion/radius or ulna,3434893,CDM,510,RC,24500,HCPCS,Outpatient,,,925.42,462.71,,832.88,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,740.34,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,832.88,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,897.66,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,851.39,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,832.88,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,647.79,70,,,percent of total billed charges,70% of total billed charges,832.88,90,,,percent of total billed charges,90% of total billed charges,879.15,95,,,percent of total billed charges,95% of total billed charges,879.15,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,795.86,86,,,percent of total billed charges,86% of total billed charges,740.34,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,897.66,97,,,percent of total billed charges,97% of total billed charges,832.88,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,897.66,97,,,percent of total billed charges,97% of total billed charges,860.64,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,897.66,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,1009.19,
24505- Clsd tx.humeral shaft fx w/manip,3434865,CDM,510,RC,24505,HCPCS,Outpatient,,,1300.32,650.16,,1170.29,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1040.26,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1170.29,90,,,Percent of total Billed charges,90% of total billed charges,179.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1261.31,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.29,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1170.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,910.22,70,,,percent of total billed charges,70% of total billed charges,1170.29,90,,,percent of total billed charges,90% of total billed charges,1235.3,95,,,percent of total billed charges,95% of total billed charges,1235.3,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1118.28,86,,,percent of total billed charges,86% of total billed charges,1040.26,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1261.31,97,,,percent of total billed charges,97% of total billed charges,1170.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1261.31,97,,,percent of total billed charges,97% of total billed charges,1209.3,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,163,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1261.31,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,163,6993.46,
24515- Open tx humeral fx/w plate/screw,3434866,CDM,510,RC,24515,HCPCS,Outpatient,,,2304.63,1152.32,,2074.17,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1843.7,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2074.17,90,,,Percent of total Billed charges,90% of total billed charges,431.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2235.49,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2120.26,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2074.17,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1613.24,70,,,percent of total billed charges,70% of total billed charges,2074.17,90,,,percent of total billed charges,90% of total billed charges,2189.4,95,,,percent of total billed charges,95% of total billed charges,2189.4,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1981.98,86,,,percent of total billed charges,86% of total billed charges,1843.7,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2235.49,97,,,percent of total billed charges,97% of total billed charges,2074.17,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2235.49,97,,,percent of total billed charges,97% of total billed charges,2143.31,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,392,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2235.49,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,392,63611.04,
24516- Tx humeral fx/intramedullary implt,3434867,CDM,510,RC,24516,HCPCS,Outpatient,,,2254.37,1127.19,,2028.93,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.5,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2028.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2186.74,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2074.02,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2028.93,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.06,70,,,percent of total billed charges,70% of total billed charges,2028.93,90,,,percent of total billed charges,90% of total billed charges,2141.65,95,,,percent of total billed charges,95% of total billed charges,2141.65,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1938.76,86,,,percent of total billed charges,86% of total billed charges,1803.5,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2186.74,97,,,percent of total billed charges,97% of total billed charges,2028.93,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2186.74,97,,,percent of total billed charges,97% of total billed charges,2096.56,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2186.74,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1578.06,63611.04,
24530- Clsd tx/supra/transcon hum fx w/o manip,3434868,CDM,510,RC,24530,HCPCS,Outpatient,,,979.11,489.56,,881.2,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,783.29,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,881.2,90,,,Percent of total Billed charges,90% of total billed charges,135.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,949.74,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,900.78,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,881.2,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,685.38,70,,,percent of total billed charges,70% of total billed charges,881.2,90,,,percent of total billed charges,90% of total billed charges,930.15,95,,,percent of total billed charges,95% of total billed charges,930.15,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,842.03,86,,,percent of total billed charges,86% of total billed charges,783.29,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,949.74,97,,,percent of total billed charges,97% of total billed charges,881.2,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,949.74,97,,,percent of total billed charges,97% of total billed charges,910.57,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,949.74,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,123.5,1009.19,
24535- Clsd tx/humeral fx w/ manip,3434869,CDM,510,RC,24535,HCPCS,Outpatient,,,1601.61,800.81,,1441.45,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.29,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1441.45,90,,,Percent of total Billed charges,90% of total billed charges,226.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1553.56,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1473.48,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1441.45,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1121.13,70,,,percent of total billed charges,70% of total billed charges,1441.45,90,,,percent of total billed charges,90% of total billed charges,1521.53,95,,,percent of total billed charges,95% of total billed charges,1521.53,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1377.38,86,,,percent of total billed charges,86% of total billed charges,1281.29,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1553.56,97,,,percent of total billed charges,97% of total billed charges,1441.45,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1553.56,97,,,percent of total billed charges,97% of total billed charges,1489.5,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,206,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1553.56,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,206,6993.46,
24538- Perc skel fix/supra/transcon hum f,3434870,CDM,510,RC,24538,HCPCS,Outpatient,,,2057.21,1028.61,,1851.49,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1645.77,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1851.49,90,,,Percent of total Billed charges,90% of total billed charges,226.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1995.49,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1892.63,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1851.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1440.05,70,,,percent of total billed charges,70% of total billed charges,1851.49,90,,,percent of total billed charges,90% of total billed charges,1954.35,95,,,percent of total billed charges,95% of total billed charges,1954.35,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1769.2,86,,,percent of total billed charges,86% of total billed charges,1645.77,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1995.49,97,,,percent of total billed charges,97% of total billed charges,1851.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1995.49,97,,,percent of total billed charges,97% of total billed charges,1913.21,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,206,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1995.49,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,206,32247.16,
24545- Open tx supra/transcondylar fx,3434871,CDM,510,RC,24545,HCPCS,Outpatient,,,2432.84,1216.42,,2189.56,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1946.27,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2189.56,90,,,Percent of total Billed charges,90% of total billed charges,465.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2359.85,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2238.21,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2189.56,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1702.99,70,,,percent of total billed charges,70% of total billed charges,2189.56,90,,,percent of total billed charges,90% of total billed charges,2311.2,95,,,percent of total billed charges,95% of total billed charges,2311.2,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2092.24,86,,,percent of total billed charges,86% of total billed charges,1946.27,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2359.85,97,,,percent of total billed charges,97% of total billed charges,2189.56,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2359.85,97,,,percent of total billed charges,97% of total billed charges,2262.54,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2359.85,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,423.5,63611.04,
24546- Open tx/humeral condylar fx w/ext,3434872,CDM,510,RC,24546,HCPCS,Outpatient,,,2718.35,1359.18,,2446.52,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2174.68,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2446.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2636.8,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2500.88,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2446.52,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1902.85,70,,,percent of total billed charges,70% of total billed charges,2446.52,90,,,percent of total billed charges,90% of total billed charges,2582.43,95,,,percent of total billed charges,95% of total billed charges,2582.43,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2337.78,86,,,percent of total billed charges,86% of total billed charges,2174.68,80,,,percent of total billed charges,80% of total billed charges,16486.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2636.8,97,,,percent of total billed charges,97% of total billed charges,2446.52,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2636.8,97,,,percent of total billed charges,97% of total billed charges,2528.07,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2636.8,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1902.85,63611.04,
24560- Clsd tx/hum epicon fx w/o manip,3434873,CDM,510,RC,24560,HCPCS,Outpatient,,,849.71,424.86,,764.74,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,679.77,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,764.74,90,,,Percent of total Billed charges,90% of total billed charges,122.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,824.22,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,781.73,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,764.74,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,594.8,70,,,percent of total billed charges,70% of total billed charges,764.74,90,,,percent of total billed charges,90% of total billed charges,807.22,95,,,percent of total billed charges,95% of total billed charges,807.22,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,730.75,86,,,percent of total billed charges,86% of total billed charges,679.77,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,824.22,97,,,percent of total billed charges,97% of total billed charges,764.74,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,824.22,97,,,percent of total billed charges,97% of total billed charges,790.23,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,824.22,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111,1009.19,
24565- Clsd tx/humeral epicond fx w/manip,3434874,CDM,510,RC,24565,HCPCS,Outpatient,,,1395.56,697.78,,1256,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1116.45,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256,90,,,Percent of total Billed charges,90% of total billed charges,190.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1353.69,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.92,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1256,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,976.89,70,,,percent of total billed charges,70% of total billed charges,1256,90,,,percent of total billed charges,90% of total billed charges,1325.78,95,,,percent of total billed charges,95% of total billed charges,1325.78,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1200.18,86,,,percent of total billed charges,86% of total billed charges,1116.45,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1353.69,97,,,percent of total billed charges,97% of total billed charges,1256,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1353.69,97,,,percent of total billed charges,97% of total billed charges,1297.87,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1353.69,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.5,6993.46,
24575- Open tx/hum epicon fx/med/lat,3434875,CDM,510,RC,24575,HCPCS,Outpatient,,,1908.94,954.47,,1718.05,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1527.15,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1718.05,90,,,Percent of total Billed charges,90% of total billed charges,435.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1851.67,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1756.22,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1718.05,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.26,70,,,percent of total billed charges,70% of total billed charges,1718.05,90,,,percent of total billed charges,90% of total billed charges,1813.49,95,,,percent of total billed charges,95% of total billed charges,1813.49,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1641.69,86,,,percent of total billed charges,86% of total billed charges,1527.15,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1851.67,97,,,percent of total billed charges,97% of total billed charges,1718.05,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1851.67,97,,,percent of total billed charges,97% of total billed charges,1775.31,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,396,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1851.67,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,396,63611.04,
24576- Clsd tx/hum condylar fx/med/lat,3434876,CDM,510,RC,24576,HCPCS,Outpatient,,,894.17,447.09,,804.75,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,715.34,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.75,90,,,Percent of total Billed charges,90% of total billed charges,122.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,867.34,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,822.64,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,804.75,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,625.92,70,,,percent of total billed charges,70% of total billed charges,804.75,90,,,percent of total billed charges,90% of total billed charges,849.46,95,,,percent of total billed charges,95% of total billed charges,849.46,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,768.99,86,,,percent of total billed charges,86% of total billed charges,715.34,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,867.34,97,,,percent of total billed charges,97% of total billed charges,804.75,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,867.34,97,,,percent of total billed charges,97% of total billed charges,831.58,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,867.34,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111,1009.19,
24579- Open tx/hum condylar fx/med/lat,3434877,CDM,510,RC,24579,HCPCS,Outpatient,,,2176.87,1088.44,,1959.18,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1741.5,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1959.18,90,,,Percent of total Billed charges,90% of total billed charges,435.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2111.56,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2002.72,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1959.18,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1523.81,70,,,percent of total billed charges,70% of total billed charges,1959.18,90,,,percent of total billed charges,90% of total billed charges,2068.03,95,,,percent of total billed charges,95% of total billed charges,2068.03,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1872.11,86,,,percent of total billed charges,86% of total billed charges,1741.5,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2111.56,97,,,percent of total billed charges,97% of total billed charges,1959.18,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2111.56,97,,,percent of total billed charges,97% of total billed charges,2024.49,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,396,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2111.56,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,396,63611.04,
24600- Tx/clsd elbow dislocateate w/o anesth,3434878,CDM,510,RC,24600,HCPCS,Outpatient,,,975.16,487.58,,877.64,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,780.13,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,877.64,90,,,Percent of total Billed charges,90% of total billed charges,112.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,945.91,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,897.15,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,877.64,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,682.61,70,,,percent of total billed charges,70% of total billed charges,877.64,90,,,percent of total billed charges,90% of total billed charges,926.4,95,,,percent of total billed charges,95% of total billed charges,926.4,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,838.64,86,,,percent of total billed charges,86% of total billed charges,780.13,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,945.91,97,,,percent of total billed charges,97% of total billed charges,877.64,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.91,97,,,percent of total billed charges,97% of total billed charges,906.9,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,945.91,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.5,1009.19,
TX CLOSED ELBOW DISLOCATION W/O ANESTHESIA,3428535,CDM,981,RC,24600,HCPCS,Outpatient,,,975.16,487.58,,877.64,90,,,percent of total billed charges,90% of total Billed charges,705.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,525.85,155,,,Fee Schedule,155% of CMS OPPS Rate,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,480.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,339.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,540.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,540.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,502.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,502.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,299.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,396.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,525.85,155,,,Fee Schedule,155% of CMS OPPS Rate,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.22,155,,,Fee Schedule,155% of CMS OPPS Rate,1094.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,406.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,339.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,705.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.5,1094.22,
24605- Tx/clsd elbow dislocateate/anesth,3434879,CDM,510,RC,24605,HCPCS,Outpatient,,,1240.25,620.13,,1116.23,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,992.2,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1116.23,90,,,Percent of total Billed charges,90% of total billed charges,173.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1203.04,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1141.03,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1116.23,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,868.18,70,,,percent of total billed charges,70% of total billed charges,1116.23,90,,,percent of total billed charges,90% of total billed charges,1178.24,95,,,percent of total billed charges,95% of total billed charges,1178.24,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1066.62,86,,,percent of total billed charges,86% of total billed charges,992.2,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1203.04,97,,,percent of total billed charges,97% of total billed charges,1116.23,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1203.04,97,,,percent of total billed charges,97% of total billed charges,1153.43,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1203.04,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157.5,6993.46,
24620- Clsd tx/Monteggia fx/elbow/manip,3434881,CDM,510,RC,24620,HCPCS,Outpatient,,,1472.41,736.21,,1325.17,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1177.93,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1325.17,90,,,Percent of total Billed charges,90% of total billed charges,154.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1428.24,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1354.62,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1325.17,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1030.69,70,,,percent of total billed charges,70% of total billed charges,1325.17,90,,,percent of total billed charges,90% of total billed charges,1398.79,95,,,percent of total billed charges,95% of total billed charges,1398.79,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1266.27,86,,,percent of total billed charges,86% of total billed charges,1177.93,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1428.24,97,,,percent of total billed charges,97% of total billed charges,1325.17,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1428.24,97,,,percent of total billed charges,97% of total billed charges,1369.34,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1428.24,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,140.5,6993.46,
24635- Open tx/Monteggia fx/elbow,3434882,CDM,510,RC,24635,HCPCS,Outpatient,,,1756.25,878.13,,1580.63,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1405,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1580.63,90,,,Percent of total Billed charges,90% of total billed charges,492.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1703.56,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1615.75,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1580.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.38,70,,,percent of total billed charges,70% of total billed charges,1580.63,90,,,percent of total billed charges,90% of total billed charges,1668.44,95,,,percent of total billed charges,95% of total billed charges,1668.44,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1510.38,86,,,percent of total billed charges,86% of total billed charges,1405,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1703.56,97,,,percent of total billed charges,97% of total billed charges,1580.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1703.56,97,,,percent of total billed charges,97% of total billed charges,1633.31,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,448,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1703.56,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448,32247.16,
24650- Clsd tx/radial head/neck fx/no manip,3434883,CDM,510,RC,24650,HCPCS,Outpatient,,,669.8,334.90,,602.82,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,535.84,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,602.82,90,,,Percent of total Billed charges,90% of total billed charges,113.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,649.71,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,616.22,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,602.82,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,468.86,70,,,percent of total billed charges,70% of total billed charges,602.82,90,,,percent of total billed charges,90% of total billed charges,636.31,95,,,percent of total billed charges,95% of total billed charges,636.31,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,576.03,86,,,percent of total billed charges,86% of total billed charges,535.84,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,649.71,97,,,percent of total billed charges,97% of total billed charges,602.82,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,649.71,97,,,percent of total billed charges,97% of total billed charges,622.91,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,103,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,649.71,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103,1009.19,
24670- Clsd/ulnar fx/prox end w/o manip,3434884,CDM,510,RC,24670,HCPCS,Outpatient,,,748.5,374.25,,673.65,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,598.8,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.65,90,,,Percent of total Billed charges,90% of total billed charges,110,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,726.05,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,688.62,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,673.65,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,523.95,70,,,percent of total billed charges,70% of total billed charges,673.65,90,,,percent of total billed charges,90% of total billed charges,711.08,95,,,percent of total billed charges,95% of total billed charges,711.08,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,643.71,86,,,percent of total billed charges,86% of total billed charges,598.8,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,726.05,97,,,percent of total billed charges,97% of total billed charges,673.65,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,726.05,97,,,percent of total billed charges,97% of total billed charges,696.11,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,100,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,726.05,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,100,1009.19,
24685- Open tx/ulnar fracture,3434885,CDM,510,RC,24685,HCPCS,Outpatient,,,1699.5,849.75,,1529.55,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.6,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1529.55,90,,,Percent of total Billed charges,90% of total billed charges,460.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1648.52,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1563.54,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1529.55,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.65,70,,,percent of total billed charges,70% of total billed charges,1529.55,90,,,percent of total billed charges,90% of total billed charges,1614.53,95,,,percent of total billed charges,95% of total billed charges,1614.53,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1461.57,86,,,percent of total billed charges,86% of total billed charges,1359.6,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1648.52,97,,,percent of total billed charges,97% of total billed charges,1529.55,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1648.52,97,,,percent of total billed charges,97% of total billed charges,1580.54,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,419,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1648.52,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,419,32247.16,
25065- Bx/soft tis/forearm/wrist/superfic,3434888,CDM,510,RC,25065,HCPCS,Outpatient,,,315.37,157.69,,283.83,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,252.3,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.83,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,305.91,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,290.14,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,283.83,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,220.76,70,,,percent of total billed charges,70% of total billed charges,283.83,90,,,percent of total billed charges,90% of total billed charges,299.6,95,,,percent of total billed charges,95% of total billed charges,299.6,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,271.22,86,,,percent of total billed charges,86% of total billed charges,252.3,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,305.91,97,,,percent of total billed charges,97% of total billed charges,283.83,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.91,97,,,percent of total billed charges,97% of total billed charges,293.29,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305.91,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,641.19,320.60,,577.07,90,,,percent of total billed charges,90% of total Billed charges,804.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,311.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1247.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,943.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,1247.05,
25248- Exp w remove/deep FB/forearm/wrist,3434890,CDM,510,RC,25248,HCPCS,Outpatient,,,1094.47,547.24,,985.02,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,875.58,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,985.02,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1061.64,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.91,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,985.02,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,766.13,70,,,percent of total billed charges,70% of total billed charges,985.02,90,,,percent of total billed charges,90% of total billed charges,1039.75,95,,,percent of total billed charges,95% of total billed charges,1039.75,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,941.24,86,,,percent of total billed charges,86% of total billed charges,875.58,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1061.64,97,,,percent of total billed charges,97% of total billed charges,985.02,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1061.64,97,,,percent of total billed charges,97% of total billed charges,1017.86,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1061.64,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,6993.46,
25265- Rpr flex ten/mus/forearm/wrist/gft,3434891,CDM,510,RC,25265,HCPCS,Outpatient,,,1955.42,977.71,,1759.88,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1564.34,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1759.88,90,,,Percent of total Billed charges,90% of total billed charges,393.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1896.76,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1798.99,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1759.88,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1368.79,70,,,percent of total billed charges,70% of total billed charges,1759.88,90,,,percent of total billed charges,90% of total billed charges,1857.65,95,,,percent of total billed charges,95% of total billed charges,1857.65,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1681.66,86,,,percent of total billed charges,86% of total billed charges,1564.34,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1896.76,97,,,percent of total billed charges,97% of total billed charges,1759.88,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1896.76,97,,,percent of total billed charges,97% of total billed charges,1818.54,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,358,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1896.76,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,358,14511.58,
25270- Rpr extensor ten/mus/forearm/wrist,3434892,CDM,510,RC,25270,HCPCS,Outpatient,,,1280.81,640.41,,1152.73,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.65,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1152.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1242.39,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1178.35,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1152.73,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,896.57,70,,,percent of total billed charges,70% of total billed charges,1152.73,90,,,percent of total billed charges,90% of total billed charges,1216.77,95,,,percent of total billed charges,95% of total billed charges,1216.77,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1101.5,86,,,percent of total billed charges,86% of total billed charges,1024.65,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1242.39,97,,,percent of total billed charges,97% of total billed charges,1152.73,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.39,97,,,percent of total billed charges,97% of total billed charges,1191.15,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1242.39,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,896.57,14511.58,
25500- Clsd tx/radial shaft fx w/o manip,3434894,CDM,510,RC,25500,HCPCS,Outpatient,,,726.31,363.16,,653.68,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,581.05,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,653.68,90,,,Percent of total Billed charges,90% of total billed charges,86.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,704.52,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,668.21,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,653.68,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,508.42,70,,,percent of total billed charges,70% of total billed charges,653.68,90,,,percent of total billed charges,90% of total billed charges,689.99,95,,,percent of total billed charges,95% of total billed charges,689.99,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,624.63,86,,,percent of total billed charges,86% of total billed charges,581.05,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,704.52,97,,,percent of total billed charges,97% of total billed charges,653.68,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,704.52,97,,,percent of total billed charges,97% of total billed charges,675.47,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,704.52,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.5,1009.19,
25526- Open tx/rad shaft fx/dis radiouln dislocateat/rpr triang fibrocart comp,3434895,CDM,510,RC,25526,HCPCS,Outpatient,,,2502.3,1251.15,,2252.07,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2001.84,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2252.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2427.23,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2302.12,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2252.07,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.61,70,,,percent of total billed charges,70% of total billed charges,2252.07,90,,,percent of total billed charges,90% of total billed charges,2377.19,95,,,percent of total billed charges,95% of total billed charges,2377.19,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2151.98,86,,,percent of total billed charges,86% of total billed charges,2001.84,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2427.23,97,,,percent of total billed charges,97% of total billed charges,2252.07,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2427.23,97,,,percent of total billed charges,97% of total billed charges,2327.14,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2427.23,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1751.61,32247.16,
25530- Clsd tx/ulnar shaft fx w/o manip,3434896,CDM,510,RC,25530,HCPCS,Outpatient,,,668.58,334.29,,601.72,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,534.86,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.72,90,,,Percent of total Billed charges,90% of total billed charges,118.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,648.52,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,615.09,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,601.72,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,468.01,70,,,percent of total billed charges,70% of total billed charges,601.72,90,,,percent of total billed charges,90% of total billed charges,635.15,95,,,percent of total billed charges,95% of total billed charges,635.15,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,574.98,86,,,percent of total billed charges,86% of total billed charges,534.86,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,648.52,97,,,percent of total billed charges,97% of total billed charges,601.72,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.52,97,,,percent of total billed charges,97% of total billed charges,621.78,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,648.52,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,108,1009.19,
PHY-CLOSED RADIAL/ULNAR SHAFT FX W/ MANIPULATION,3428505,CDM,981,RC,25565,HCPCS,Outpatient,,,1347.38,673.69,,1212.64,90,,,percent of total billed charges,90% of total Billed charges,966.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,200.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,712.77,155,,,Fee Schedule,155% of CMS OPPS Rate,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,662.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,459.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,745.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,745.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,689.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,689.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,440.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,919.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,814.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,542.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,712.77,155,,,Fee Schedule,155% of CMS OPPS Rate,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1498.08,155,,,Fee Schedule,155% of CMS OPPS Rate,1498.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,459.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,1034.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1034.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,200.5,1498.08,
25606- Perc skeletal fix/distal radial fx,3434897,CDM,510,RC,25606,HCPCS,Outpatient,,,1733.27,866.64,,1559.94,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1386.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1559.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1681.27,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1594.61,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1559.94,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.29,70,,,percent of total billed charges,70% of total billed charges,1559.94,90,,,percent of total billed charges,90% of total billed charges,1646.61,95,,,percent of total billed charges,95% of total billed charges,1646.61,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1490.61,86,,,percent of total billed charges,86% of total billed charges,1386.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1681.27,97,,,percent of total billed charges,97% of total billed charges,1559.94,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1681.27,97,,,percent of total billed charges,97% of total billed charges,1611.94,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1681.27,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1213.29,14511.58,
25607- Open tx/dis radial extra-artic fx,3434898,CDM,510,RC,25607,HCPCS,Outpatient,,,1918.39,959.20,,1726.55,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1534.71,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1726.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1860.84,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1764.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1726.55,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1342.87,70,,,percent of total billed charges,70% of total billed charges,1726.55,90,,,percent of total billed charges,90% of total billed charges,1822.47,95,,,percent of total billed charges,95% of total billed charges,1822.47,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1649.82,86,,,percent of total billed charges,86% of total billed charges,1534.71,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1860.84,97,,,percent of total billed charges,97% of total billed charges,1726.55,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1860.84,97,,,percent of total billed charges,97% of total billed charges,1784.1,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1860.84,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1342.87,32247.16,
25628- Open tx/carpal scaphoid fracture,3434899,CDM,510,RC,25628,HCPCS,Outpatient,,,1875.15,937.58,,1687.64,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1500.12,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1687.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1818.9,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1725.14,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1687.64,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1312.61,70,,,percent of total billed charges,70% of total billed charges,1687.64,90,,,percent of total billed charges,90% of total billed charges,1781.39,95,,,percent of total billed charges,95% of total billed charges,1781.39,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1612.63,86,,,percent of total billed charges,86% of total billed charges,1500.12,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1818.9,97,,,percent of total billed charges,97% of total billed charges,1687.64,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1818.9,97,,,percent of total billed charges,97% of total billed charges,1743.89,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1818.9,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1312.61,32247.16,
26037- Decompr fasciotomy/hand,3434902,CDM,510,RC,26037,HCPCS,Outpatient,,,1461.22,730.61,,1315.1,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1168.98,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.1,90,,,Percent of total Billed charges,90% of total billed charges,309.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1417.38,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.32,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1315.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1022.85,70,,,percent of total billed charges,70% of total billed charges,1315.1,90,,,percent of total billed charges,90% of total billed charges,1388.16,95,,,percent of total billed charges,95% of total billed charges,1388.16,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1256.65,86,,,percent of total billed charges,86% of total billed charges,1168.98,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1417.38,97,,,percent of total billed charges,97% of total billed charges,1315.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1417.38,97,,,percent of total billed charges,97% of total billed charges,1358.93,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,281,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1417.38,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281,14511.58,
26070- Arthrotomy/carpometacarpal joint,3434903,CDM,510,RC,26070,HCPCS,Outpatient,,,826.9,413.45,,744.21,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,661.52,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,744.21,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,802.09,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,760.75,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,744.21,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,578.83,70,,,percent of total billed charges,70% of total billed charges,744.21,90,,,percent of total billed charges,90% of total billed charges,785.56,95,,,percent of total billed charges,95% of total billed charges,785.56,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,711.13,86,,,percent of total billed charges,86% of total billed charges,661.52,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,802.09,97,,,percent of total billed charges,97% of total billed charges,744.21,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,802.09,97,,,percent of total billed charges,97% of total billed charges,769.02,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,802.09,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,6993.46,
26075- Arthrotomy/metacarpophalangeal/ea,3434904,CDM,510,RC,26075,HCPCS,Outpatient,,,870.67,435.34,,783.6,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,696.54,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,783.6,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,844.55,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,801.02,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,783.6,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,609.47,70,,,percent of total billed charges,70% of total billed charges,783.6,90,,,percent of total billed charges,90% of total billed charges,827.14,95,,,percent of total billed charges,95% of total billed charges,827.14,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,748.78,86,,,percent of total billed charges,86% of total billed charges,696.54,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,844.55,97,,,percent of total billed charges,97% of total billed charges,783.6,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,844.55,97,,,percent of total billed charges,97% of total billed charges,809.72,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,844.55,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,14511.58,
26080- Arthrotomy/explore/interphalangeal,3434905,CDM,510,RC,26080,HCPCS,Outpatient,,,1025.13,512.57,,922.62,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,820.1,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,922.62,90,,,Percent of total Billed charges,90% of total billed charges,172.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,994.38,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,943.12,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,922.62,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,717.59,70,,,percent of total billed charges,70% of total billed charges,922.62,90,,,percent of total billed charges,90% of total billed charges,973.87,95,,,percent of total billed charges,95% of total billed charges,973.87,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,881.61,86,,,percent of total billed charges,86% of total billed charges,820.1,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,994.38,97,,,percent of total billed charges,97% of total billed charges,922.62,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,994.38,97,,,percent of total billed charges,97% of total billed charges,953.37,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,994.38,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157,6993.46,
26111- Exc SQ tum/vasc malform/hand/fngr,3434906,CDM,510,RC,26111,HCPCS,Outpatient,,,1077.9,538.95,,970.11,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,862.32,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,970.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1045.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,991.67,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,970.11,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,754.53,70,,,percent of total billed charges,70% of total billed charges,970.11,90,,,percent of total billed charges,90% of total billed charges,1024.01,95,,,percent of total billed charges,95% of total billed charges,1024.01,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,926.99,86,,,percent of total billed charges,86% of total billed charges,862.32,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1045.56,97,,,percent of total billed charges,97% of total billed charges,970.11,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.56,97,,,percent of total billed charges,97% of total billed charges,1002.45,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1045.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,754.53,7310.49,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,672.8,336.40,,605.52,90,,,percent of total billed charges,90% of total Billed charges,842.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,333.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,574.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,374.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,1305.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1305.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,989.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,989.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,1305.16,
26123- Fasciect/part palm/rls sng digit,3434908,CDM,510,RC,26123,HCPCS,Outpatient,,,2168.04,1084.02,,1951.24,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1734.43,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2103,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1994.6,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1951.24,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1517.63,70,,,percent of total billed charges,70% of total billed charges,1951.24,90,,,percent of total billed charges,90% of total billed charges,2059.64,95,,,percent of total billed charges,95% of total billed charges,2059.64,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1864.51,86,,,percent of total billed charges,86% of total billed charges,1734.43,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2103,97,,,percent of total billed charges,97% of total billed charges,1951.24,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2103,97,,,percent of total billed charges,97% of total billed charges,2016.28,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2103,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1517.63,14511.58,
26210- Exc/curet/bone cyst/bgn tum/phalan,3434909,CDM,510,RC,26210,HCPCS,Outpatient,,,1152.9,576.45,,1037.61,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,922.32,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037.61,90,,,Percent of total Billed charges,90% of total billed charges,191.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1118.31,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1060.67,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1037.61,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,807.03,70,,,percent of total billed charges,70% of total billed charges,1037.61,90,,,percent of total billed charges,90% of total billed charges,1095.26,95,,,percent of total billed charges,95% of total billed charges,1095.26,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,991.49,86,,,percent of total billed charges,86% of total billed charges,922.32,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1118.31,97,,,percent of total billed charges,97% of total billed charges,1037.61,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1118.31,97,,,percent of total billed charges,97% of total billed charges,1072.2,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,174,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1118.31,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,174,6993.46,
26215- Exc/curet/bone cyst/bgn tum/phalanx/autogft,3434910,CDM,510,RC,26215,HCPCS,Outpatient,,,1480.03,740.02,,1332.03,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1184.02,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1332.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1435.63,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.63,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1332.03,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.02,70,,,percent of total billed charges,70% of total billed charges,1332.03,90,,,percent of total billed charges,90% of total billed charges,1406.03,95,,,percent of total billed charges,95% of total billed charges,1406.03,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1272.83,86,,,percent of total billed charges,86% of total billed charges,1184.02,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1435.63,97,,,percent of total billed charges,97% of total billed charges,1332.03,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1435.63,97,,,percent of total billed charges,97% of total billed charges,1376.43,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1435.63,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1036.02,14511.58,
26370- Repair/fngr/hand tendon/ea tendon,3434911,CDM,510,RC,26370,HCPCS,Outpatient,,,2020.13,1010.07,,1818.12,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1616.1,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1818.12,90,,,Percent of total Billed charges,90% of total billed charges,399.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1959.53,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1858.52,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1818.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1414.09,70,,,percent of total billed charges,70% of total billed charges,1818.12,90,,,percent of total billed charges,90% of total billed charges,1919.12,95,,,percent of total billed charges,95% of total billed charges,1919.12,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1737.31,86,,,percent of total billed charges,86% of total billed charges,1616.1,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1959.53,97,,,percent of total billed charges,97% of total billed charges,1818.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1959.53,97,,,percent of total billed charges,97% of total billed charges,1878.72,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,363,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1959.53,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,363,14511.58,
"26410-Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation",3783562,CDM,510,RC,26410,HCPCS,Outpatient,,,1535.51,767.76,,1381.96,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1228.41,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1381.96,90,,,Percent of total Billed charges,90% of total billed charges,243.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1489.44,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1412.67,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1381.96,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1074.86,70,,,percent of total billed charges,70% of total billed charges,1381.96,90,,,percent of total billed charges,90% of total billed charges,1458.73,95,,,percent of total billed charges,95% of total billed charges,1458.73,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1320.54,86,,,percent of total billed charges,86% of total billed charges,1228.41,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1489.44,97,,,percent of total billed charges,97% of total billed charges,1381.96,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1489.44,97,,,percent of total billed charges,97% of total billed charges,1428.02,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1489.44,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221.5,6993.46,
26440- Tenolysis/flex tend/palm/finger/ea,3434912,CDM,510,RC,26440,HCPCS,Outpatient,,,1661.87,830.94,,1495.68,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1329.5,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1495.68,90,,,Percent of total Billed charges,90% of total billed charges,196.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1612.01,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1528.92,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1495.68,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.31,70,,,percent of total billed charges,70% of total billed charges,1495.68,90,,,percent of total billed charges,90% of total billed charges,1578.78,95,,,percent of total billed charges,95% of total billed charges,1578.78,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1429.21,86,,,percent of total billed charges,86% of total billed charges,1329.5,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1612.01,97,,,percent of total billed charges,97% of total billed charges,1495.68,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1612.01,97,,,percent of total billed charges,97% of total billed charges,1545.54,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,179,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1612.01,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,179,6993.46,
26442- Tenolysis/flex ten/palm & fing/ea,3434913,CDM,510,RC,26442,HCPCS,Outpatient,,,2539.31,1269.66,,2285.38,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2031.45,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2285.38,90,,,Percent of total Billed charges,90% of total billed charges,357.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2463.13,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2336.17,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2285.38,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1777.52,70,,,percent of total billed charges,70% of total billed charges,2285.38,90,,,percent of total billed charges,90% of total billed charges,2412.34,95,,,percent of total billed charges,95% of total billed charges,2412.34,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2183.81,86,,,percent of total billed charges,86% of total billed charges,2031.45,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2463.13,97,,,percent of total billed charges,97% of total billed charges,2285.38,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2463.13,97,,,percent of total billed charges,97% of total billed charges,2361.56,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,325,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2463.13,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,325,14511.58,
26445- Tenolysis/ext tend/hand/finger/ea,3434914,CDM,510,RC,26445,HCPCS,Outpatient,,,1547.28,773.64,,1392.55,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1237.82,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1392.55,90,,,Percent of total Billed charges,90% of total billed charges,215.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1500.86,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1423.5,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1392.55,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1083.1,70,,,percent of total billed charges,70% of total billed charges,1392.55,90,,,percent of total billed charges,90% of total billed charges,1469.92,95,,,percent of total billed charges,95% of total billed charges,1469.92,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1330.66,86,,,percent of total billed charges,86% of total billed charges,1237.82,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1500.86,97,,,percent of total billed charges,97% of total billed charges,1392.55,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1500.86,97,,,percent of total billed charges,97% of total billed charges,1438.97,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1500.86,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,195.5,14511.58,
26546- Repair non-union/metacarp/phalanx,3434915,CDM,510,RC,26546,HCPCS,Outpatient,,,2665.64,1332.82,,2399.08,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2132.51,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2399.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2585.67,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2452.39,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2399.08,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1865.95,70,,,percent of total billed charges,70% of total billed charges,2399.08,90,,,percent of total billed charges,90% of total billed charges,2532.36,95,,,percent of total billed charges,95% of total billed charges,2532.36,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2292.45,86,,,percent of total billed charges,86% of total billed charges,2132.51,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2585.67,97,,,percent of total billed charges,97% of total billed charges,2399.08,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2585.67,97,,,percent of total billed charges,97% of total billed charges,2479.05,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2585.67,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1865.95,32247.16,
26548- Repair/reconst/finger/volar plate,3434916,CDM,510,RC,26548,HCPCS,Outpatient,,,2062.68,1031.34,,1856.41,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1650.14,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1856.41,90,,,Percent of total Billed charges,90% of total billed charges,412.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2000.8,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1897.67,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1856.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1443.88,70,,,percent of total billed charges,70% of total billed charges,1856.41,90,,,percent of total billed charges,90% of total billed charges,1959.55,95,,,percent of total billed charges,95% of total billed charges,1959.55,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1773.9,86,,,percent of total billed charges,86% of total billed charges,1650.14,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2000.8,97,,,percent of total billed charges,97% of total billed charges,1856.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2000.8,97,,,percent of total billed charges,97% of total billed charges,1918.29,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2000.8,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,374.6,14511.58,
26567- Osteotomy/phalanx of finger/each,3434917,CDM,510,RC,26567,HCPCS,Outpatient,,,1854.64,927.32,,1669.18,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.71,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1669.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1799,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1706.27,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1669.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.25,70,,,percent of total billed charges,70% of total billed charges,1669.18,90,,,percent of total billed charges,90% of total billed charges,1761.91,95,,,percent of total billed charges,95% of total billed charges,1761.91,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1594.99,86,,,percent of total billed charges,86% of total billed charges,1483.71,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1799,97,,,percent of total billed charges,97% of total billed charges,1669.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1799,97,,,percent of total billed charges,97% of total billed charges,1724.82,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1799,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1298.25,14511.58,
26591- Rpr/intrinsic muscles/hand/ea,3434918,CDM,510,RC,26591,HCPCS,Outpatient,,,1233.61,616.81,,1110.25,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,986.89,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1110.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1196.6,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.92,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1110.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,863.53,70,,,percent of total billed charges,70% of total billed charges,1110.25,90,,,percent of total billed charges,90% of total billed charges,1171.93,95,,,percent of total billed charges,95% of total billed charges,1171.93,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1060.9,86,,,percent of total billed charges,86% of total billed charges,986.89,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1196.6,97,,,percent of total billed charges,97% of total billed charges,1110.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.6,97,,,percent of total billed charges,97% of total billed charges,1147.26,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1196.6,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,863.53,14511.58,
26600- Clsd tx/metacarpal fx/sg w/o manip,3434919,CDM,510,RC,26600,HCPCS,Outpatient,,,765.01,382.51,,688.51,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,612.01,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,688.51,90,,,Percent of total Billed charges,90% of total billed charges,76.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,742.06,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,703.81,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,688.51,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,535.51,70,,,percent of total billed charges,70% of total billed charges,688.51,90,,,percent of total billed charges,90% of total billed charges,726.76,95,,,percent of total billed charges,95% of total billed charges,726.76,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,657.91,86,,,percent of total billed charges,86% of total billed charges,612.01,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,742.06,97,,,percent of total billed charges,97% of total billed charges,688.51,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.06,97,,,percent of total billed charges,97% of total billed charges,711.46,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,742.06,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69.5,1009.19,
26605- Clsd tx/metacarpal fx/sng/w manip,3434920,CDM,510,RC,26605,HCPCS,Outpatient,,,846.41,423.21,,761.77,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,677.13,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.77,90,,,Percent of total Billed charges,90% of total billed charges,116.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,821.02,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,778.7,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,761.77,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,592.49,70,,,percent of total billed charges,70% of total billed charges,761.77,90,,,percent of total billed charges,90% of total billed charges,804.09,95,,,percent of total billed charges,95% of total billed charges,804.09,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,727.91,86,,,percent of total billed charges,86% of total billed charges,677.13,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,821.02,97,,,percent of total billed charges,97% of total billed charges,761.77,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,821.02,97,,,percent of total billed charges,97% of total billed charges,787.16,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,106,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,821.02,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,106,1009.19,
26608- Perc skel fix/metacarpal fx/each,3434921,CDM,510,RC,26608,HCPCS,Outpatient,,,1244.01,622.01,,1119.61,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,995.21,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1119.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1206.69,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1144.49,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1119.61,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,870.81,70,,,percent of total billed charges,70% of total billed charges,1119.61,90,,,percent of total billed charges,90% of total billed charges,1181.81,95,,,percent of total billed charges,95% of total billed charges,1181.81,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1069.85,86,,,percent of total billed charges,86% of total billed charges,995.21,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1206.69,97,,,percent of total billed charges,97% of total billed charges,1119.61,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1206.69,97,,,percent of total billed charges,97% of total billed charges,1156.93,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1206.69,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,870.81,14511.58,
26615- Open tx/metacarpal fx/single,3434922,CDM,510,RC,26615,HCPCS,Outpatient,,,1488.19,744.10,,1339.37,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1190.55,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.37,90,,,Percent of total Billed charges,90% of total billed charges,255.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1443.54,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1369.13,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1339.37,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1041.73,70,,,percent of total billed charges,70% of total billed charges,1339.37,90,,,percent of total billed charges,90% of total billed charges,1413.78,95,,,percent of total billed charges,95% of total billed charges,1413.78,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1279.84,86,,,percent of total billed charges,86% of total billed charges,1190.55,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1443.54,97,,,percent of total billed charges,97% of total billed charges,1339.37,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1443.54,97,,,percent of total billed charges,97% of total billed charges,1384.02,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,232,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1443.54,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,232,14511.58,
26641- Clsd tx/carpometa dislocate/thum,3434923,CDM,510,RC,26641,HCPCS,Outpatient,,,1078.17,539.09,,970.35,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,862.54,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,970.35,90,,,Percent of total Billed charges,90% of total billed charges,42.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1045.82,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,991.92,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,970.35,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,754.72,70,,,percent of total billed charges,70% of total billed charges,970.35,90,,,percent of total billed charges,90% of total billed charges,1024.26,95,,,percent of total billed charges,95% of total billed charges,1024.26,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,927.23,86,,,percent of total billed charges,86% of total billed charges,862.54,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1045.82,97,,,percent of total billed charges,97% of total billed charges,970.35,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1045.82,97,,,percent of total billed charges,97% of total billed charges,1002.7,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1045.82,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.5,1045.82,
26645- Clsd tx/carpometa fx disloc/manip,3434924,CDM,510,RC,26645,HCPCS,Outpatient,,,1120.8,560.40,,1008.72,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,896.64,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1008.72,90,,,Percent of total Billed charges,90% of total billed charges,97.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1087.18,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.14,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1008.72,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,784.56,70,,,percent of total billed charges,70% of total billed charges,1008.72,90,,,percent of total billed charges,90% of total billed charges,1064.76,95,,,percent of total billed charges,95% of total billed charges,1064.76,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,963.89,86,,,percent of total billed charges,86% of total billed charges,896.64,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1087.18,97,,,percent of total billed charges,97% of total billed charges,1008.72,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1087.18,97,,,percent of total billed charges,97% of total billed charges,1042.34,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1087.18,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89,6993.46,
26650- Perc skel fix/thumb fx/manipulatio,3434925,CDM,510,RC,26650,HCPCS,Outpatient,,,1239.35,619.68,,1115.42,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,991.48,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1115.42,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1202.17,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.2,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1115.42,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,867.55,70,,,percent of total billed charges,70% of total billed charges,1115.42,90,,,percent of total billed charges,90% of total billed charges,1177.38,95,,,percent of total billed charges,95% of total billed charges,1177.38,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1065.84,86,,,percent of total billed charges,86% of total billed charges,991.48,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1202.17,97,,,percent of total billed charges,97% of total billed charges,1115.42,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.17,97,,,percent of total billed charges,97% of total billed charges,1152.6,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1202.17,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,14511.58,
26675- Clsd tx/carpometacar disloc/anesth,3434926,CDM,510,RC,26675,HCPCS,Outpatient,,,1192.75,596.38,,1073.48,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,954.2,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1073.48,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1156.97,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1097.33,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1073.48,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,834.93,70,,,percent of total billed charges,70% of total billed charges,1073.48,90,,,percent of total billed charges,90% of total billed charges,1133.11,95,,,percent of total billed charges,95% of total billed charges,1133.11,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1025.77,86,,,percent of total billed charges,86% of total billed charges,954.2,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1156.97,97,,,percent of total billed charges,97% of total billed charges,1073.48,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1156.97,97,,,percent of total billed charges,97% of total billed charges,1109.26,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1156.97,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,6993.46,
26676- Perc fix/carpomet/not thumb/ea jnt,3434927,CDM,510,RC,26676,HCPCS,Outpatient,,,1311.07,655.54,,1179.96,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.86,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.96,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1271.74,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.18,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1179.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,917.75,70,,,percent of total billed charges,70% of total billed charges,1179.96,90,,,percent of total billed charges,90% of total billed charges,1245.52,95,,,percent of total billed charges,95% of total billed charges,1245.52,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1127.52,86,,,percent of total billed charges,86% of total billed charges,1048.86,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1271.74,97,,,percent of total billed charges,97% of total billed charges,1179.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1271.74,97,,,percent of total billed charges,97% of total billed charges,1219.3,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1271.74,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,14511.58,
26686- Open tx/carpometacarp dislocate/compl,3434928,CDM,510,RC,26686,HCPCS,Outpatient,,,1629.59,814.80,,1466.63,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1303.67,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1466.63,90,,,Percent of total Billed charges,90% of total billed charges,536.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1580.7,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1499.22,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1466.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.71,70,,,percent of total billed charges,70% of total billed charges,1466.63,90,,,percent of total billed charges,90% of total billed charges,1548.11,95,,,percent of total billed charges,95% of total billed charges,1548.11,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1401.45,86,,,percent of total billed charges,86% of total billed charges,1303.67,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1580.7,97,,,percent of total billed charges,97% of total billed charges,1466.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1580.7,97,,,percent of total billed charges,97% of total billed charges,1515.52,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,488,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1580.7,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,488,14511.58,
26700- Clsd tx/metacarpophalan/dislocat,3434929,CDM,510,RC,26700,HCPCS,Outpatient,,,878.45,439.23,,790.61,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,702.76,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,790.61,90,,,Percent of total Billed charges,90% of total billed charges,42.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,852.1,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.17,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,790.61,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,614.92,70,,,percent of total billed charges,70% of total billed charges,790.61,90,,,percent of total billed charges,90% of total billed charges,834.53,95,,,percent of total billed charges,95% of total billed charges,834.53,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,755.47,86,,,percent of total billed charges,86% of total billed charges,702.76,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,852.1,97,,,percent of total billed charges,97% of total billed charges,790.61,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,852.1,97,,,percent of total billed charges,97% of total billed charges,816.96,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,852.1,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39,1009.19,
26705- Clsd tx/metacarpophalan/anesth,3434930,CDM,510,RC,26705,HCPCS,Outpatient,,,1088.69,544.35,,979.82,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,870.95,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,979.82,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1056.03,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1001.59,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,979.82,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,762.08,70,,,percent of total billed charges,70% of total billed charges,979.82,90,,,percent of total billed charges,90% of total billed charges,1034.26,95,,,percent of total billed charges,95% of total billed charges,1034.26,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,936.27,86,,,percent of total billed charges,86% of total billed charges,870.95,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1056.03,97,,,percent of total billed charges,97% of total billed charges,979.82,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1056.03,97,,,percent of total billed charges,97% of total billed charges,1012.48,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1056.03,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,6993.46,
26706- Perc fix/metacarphalang/sng/manip,3434931,CDM,510,RC,26706,HCPCS,Outpatient,,,1156.38,578.19,,1040.74,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,925.1,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1040.74,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1121.69,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1063.87,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1040.74,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,809.47,70,,,percent of total billed charges,70% of total billed charges,1040.74,90,,,percent of total billed charges,90% of total billed charges,1098.56,95,,,percent of total billed charges,95% of total billed charges,1098.56,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,994.49,86,,,percent of total billed charges,86% of total billed charges,925.1,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1121.69,97,,,percent of total billed charges,97% of total billed charges,1040.74,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1121.69,97,,,percent of total billed charges,97% of total billed charges,1075.43,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1121.69,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,14511.58,
26715- Open tx/metacarpophalan/int fix,3434932,CDM,510,RC,26715,HCPCS,Outpatient,,,1482.92,741.46,,1334.63,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.34,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1334.63,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1438.43,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1364.29,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1334.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1038.04,70,,,percent of total billed charges,70% of total billed charges,1334.63,90,,,percent of total billed charges,90% of total billed charges,1408.77,95,,,percent of total billed charges,95% of total billed charges,1408.77,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1275.31,86,,,percent of total billed charges,86% of total billed charges,1186.34,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1438.43,97,,,percent of total billed charges,97% of total billed charges,1334.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1438.43,97,,,percent of total billed charges,97% of total billed charges,1379.12,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1438.43,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,14511.58,
26720- Clsd tx/prox/mid phalnx fx/no manp,3434933,CDM,510,RC,26720,HCPCS,Outpatient,,,509,254.50,,458.1,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,407.2,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.1,90,,,Percent of total Billed charges,90% of total billed charges,61.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,493.73,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,468.28,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,458.1,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,356.3,70,,,percent of total billed charges,70% of total billed charges,458.1,90,,,percent of total billed charges,90% of total billed charges,483.55,95,,,percent of total billed charges,95% of total billed charges,483.55,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,437.74,86,,,percent of total billed charges,86% of total billed charges,407.2,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,493.73,97,,,percent of total billed charges,97% of total billed charges,458.1,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.73,97,,,percent of total billed charges,97% of total billed charges,473.37,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,493.73,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,56,1009.19,
26725- Clsd tx/prox/mid phalanx w/manip,3434934,CDM,510,RC,26725,HCPCS,Outpatient,,,879.73,439.87,,791.76,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,703.78,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.76,90,,,Percent of total Billed charges,90% of total billed charges,84.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,853.34,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,809.35,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,791.76,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,615.81,70,,,percent of total billed charges,70% of total billed charges,791.76,90,,,percent of total billed charges,90% of total billed charges,835.74,95,,,percent of total billed charges,95% of total billed charges,835.74,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,756.57,86,,,percent of total billed charges,86% of total billed charges,703.78,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,853.34,97,,,percent of total billed charges,97% of total billed charges,791.76,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,853.34,97,,,percent of total billed charges,97% of total billed charges,818.15,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,853.34,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77,1009.19,
26727- Perc fix/unstab phalang fx/manip,3434935,CDM,510,RC,26727,HCPCS,Outpatient,,,1222.89,611.45,,1100.6,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,978.31,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.6,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1186.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1125.06,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.6,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,856.02,70,,,percent of total billed charges,70% of total billed charges,1100.6,90,,,percent of total billed charges,90% of total billed charges,1161.75,95,,,percent of total billed charges,95% of total billed charges,1161.75,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.69,86,,,percent of total billed charges,86% of total billed charges,978.31,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1186.2,97,,,percent of total billed charges,97% of total billed charges,1100.6,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1186.2,97,,,percent of total billed charges,97% of total billed charges,1137.29,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1186.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,14511.58,
26735- Open tx/phalan fx/prox/mid phalanx,3434936,CDM,510,RC,26735,HCPCS,Outpatient,,,1539.97,769.99,,1385.97,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.98,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1385.97,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1493.77,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1416.77,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1385.97,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.98,70,,,percent of total billed charges,70% of total billed charges,1385.97,90,,,percent of total billed charges,90% of total billed charges,1462.97,95,,,percent of total billed charges,95% of total billed charges,1462.97,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1324.37,86,,,percent of total billed charges,86% of total billed charges,1231.98,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1493.77,97,,,percent of total billed charges,97% of total billed charges,1385.97,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1493.77,97,,,percent of total billed charges,97% of total billed charges,1432.17,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1493.77,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,14511.58,
26740- Clsd tx/metacar/interphal artic fx,3434937,CDM,510,RC,26740,HCPCS,Outpatient,,,592,296.00,,532.8,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,473.6,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.8,90,,,Percent of total Billed charges,90% of total billed charges,42.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,574.24,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,544.64,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,532.8,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,414.4,70,,,percent of total billed charges,70% of total billed charges,532.8,90,,,percent of total billed charges,90% of total billed charges,562.4,95,,,percent of total billed charges,95% of total billed charges,562.4,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,509.12,86,,,percent of total billed charges,86% of total billed charges,473.6,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,574.24,97,,,percent of total billed charges,97% of total billed charges,532.8,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.24,97,,,percent of total billed charges,97% of total billed charges,550.56,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,574.24,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39,1009.19,
26746- Open tx/articular fx,3434938,CDM,510,RC,26746,HCPCS,Outpatient,,,1929.26,964.63,,1736.33,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1543.41,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1736.33,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1871.38,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1774.92,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1736.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1350.48,70,,,percent of total billed charges,70% of total billed charges,1736.33,90,,,percent of total billed charges,90% of total billed charges,1832.8,95,,,percent of total billed charges,95% of total billed charges,1832.8,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1659.16,86,,,percent of total billed charges,86% of total billed charges,1543.41,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1871.38,97,,,percent of total billed charges,97% of total billed charges,1736.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1871.38,97,,,percent of total billed charges,97% of total billed charges,1794.21,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1871.38,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,14511.58,
26750- Clsd tx/dis phalan fx w/o manip/ea,3434939,CDM,510,RC,26750,HCPCS,Outpatient,,,478.71,239.36,,430.84,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,382.97,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,430.84,90,,,Percent of total Billed charges,90% of total billed charges,52.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,464.35,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,440.41,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,430.84,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,335.1,70,,,percent of total billed charges,70% of total billed charges,430.84,90,,,percent of total billed charges,90% of total billed charges,454.77,95,,,percent of total billed charges,95% of total billed charges,454.77,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,411.69,86,,,percent of total billed charges,86% of total billed charges,382.97,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,464.35,97,,,percent of total billed charges,97% of total billed charges,430.84,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.35,97,,,percent of total billed charges,97% of total billed charges,445.2,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,464.35,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48,1009.19,
26755- Clsd tx/distal phalangeal fx,3434940,CDM,510,RC,26755,HCPCS,Outpatient,,,823.43,411.72,,741.09,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,658.74,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.09,90,,,Percent of total Billed charges,90% of total billed charges,80.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,798.73,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,757.56,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,741.09,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,576.4,70,,,percent of total billed charges,70% of total billed charges,741.09,90,,,percent of total billed charges,90% of total billed charges,782.26,95,,,percent of total billed charges,95% of total billed charges,782.26,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,708.15,86,,,percent of total billed charges,86% of total billed charges,658.74,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,798.73,97,,,percent of total billed charges,97% of total billed charges,741.09,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,798.73,97,,,percent of total billed charges,97% of total billed charges,765.79,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,798.73,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73,1009.19,
26765- Open tx/dis phalan fx/finger/thumb,3434941,CDM,510,RC,26765,HCPCS,Outpatient,,,1293.53,646.77,,1164.18,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1034.82,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1164.18,90,,,Percent of total Billed charges,90% of total billed charges,195.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1254.72,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1190.05,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1164.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,905.47,70,,,percent of total billed charges,70% of total billed charges,1164.18,90,,,percent of total billed charges,90% of total billed charges,1228.85,95,,,percent of total billed charges,95% of total billed charges,1228.85,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1112.44,86,,,percent of total billed charges,86% of total billed charges,1034.82,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1254.72,97,,,percent of total billed charges,97% of total billed charges,1164.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1254.72,97,,,percent of total billed charges,97% of total billed charges,1202.98,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,178,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1254.72,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,178,14511.58,
26770- Closed tx/interpha dislocate/manipulation w/o anesthesia,3434942,CDM,510,RC,26770,HCPCS,Outpatient,,,739.32,369.66,,665.39,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,591.46,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.39,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,717.14,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,680.17,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,665.39,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,517.52,70,,,percent of total billed charges,70% of total billed charges,665.39,90,,,percent of total billed charges,90% of total billed charges,702.35,95,,,percent of total billed charges,95% of total billed charges,702.35,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,635.82,86,,,percent of total billed charges,86% of total billed charges,591.46,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,717.14,97,,,percent of total billed charges,97% of total billed charges,665.39,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,717.14,97,,,percent of total billed charges,97% of total billed charges,687.57,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,717.14,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,1009.19,
26775- Clsd tx/interpha dislo/manip/anest,3434943,CDM,510,RC,26775,HCPCS,Outpatient,,,1007.14,503.57,,906.43,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,805.71,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,906.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,976.93,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,926.57,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,906.43,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,705,70,,,percent of total billed charges,70% of total billed charges,906.43,90,,,percent of total billed charges,90% of total billed charges,956.78,95,,,percent of total billed charges,95% of total billed charges,956.78,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,866.14,86,,,percent of total billed charges,86% of total billed charges,805.71,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,976.93,97,,,percent of total billed charges,97% of total billed charges,906.43,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.93,97,,,percent of total billed charges,97% of total billed charges,936.64,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,976.93,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,185.21,1169.58,
26776- Perc fix/interphalan jnt/sng/manip,3434944,CDM,510,RC,26776,HCPCS,Outpatient,,,1160.13,580.07,,1044.12,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,928.1,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.12,90,,,Percent of total Billed charges,90% of total billed charges,138.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1125.33,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1067.32,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1044.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,812.09,70,,,percent of total billed charges,70% of total billed charges,1044.12,90,,,percent of total billed charges,90% of total billed charges,1102.12,95,,,percent of total billed charges,95% of total billed charges,1102.12,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.71,86,,,percent of total billed charges,86% of total billed charges,928.1,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1125.33,97,,,percent of total billed charges,97% of total billed charges,1044.12,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1125.33,97,,,percent of total billed charges,97% of total billed charges,1078.92,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,126,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1125.33,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,126,14511.58,
26785- Open tx/interphalang dislocateate/sng,3434945,CDM,510,RC,26785,HCPCS,Outpatient,,,1411.33,705.67,,1270.2,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.06,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1270.2,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1368.99,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.42,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1270.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,987.93,70,,,percent of total billed charges,70% of total billed charges,1270.2,90,,,percent of total billed charges,90% of total billed charges,1340.76,95,,,percent of total billed charges,95% of total billed charges,1340.76,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1213.74,86,,,percent of total billed charges,86% of total billed charges,1129.06,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1368.99,97,,,percent of total billed charges,97% of total billed charges,1270.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1368.99,97,,,percent of total billed charges,97% of total billed charges,1312.54,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1368.99,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,14511.58,
26852- Arthrode/metacarpophalang/autogft,3434946,CDM,510,RC,26852,HCPCS,Outpatient,,,2150.22,1075.11,,1935.2,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1720.18,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1935.2,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2085.71,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1978.2,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1935.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1505.15,70,,,percent of total billed charges,70% of total billed charges,1935.2,90,,,percent of total billed charges,90% of total billed charges,2042.71,95,,,percent of total billed charges,95% of total billed charges,2042.71,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1849.19,86,,,percent of total billed charges,86% of total billed charges,1720.18,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2085.71,97,,,percent of total billed charges,97% of total billed charges,1935.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2085.71,97,,,percent of total billed charges,97% of total billed charges,1999.7,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2085.71,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,32247.16,
26860- Arthrodesis/interphalangeal joint,3434947,CDM,510,RC,26860,HCPCS,Outpatient,,,1559.03,779.52,,1403.13,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.22,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1403.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1512.26,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1434.31,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1403.13,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.32,70,,,percent of total billed charges,70% of total billed charges,1403.13,90,,,percent of total billed charges,90% of total billed charges,1481.08,95,,,percent of total billed charges,95% of total billed charges,1481.08,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1340.77,86,,,percent of total billed charges,86% of total billed charges,1247.22,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1512.26,97,,,percent of total billed charges,97% of total billed charges,1403.13,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1512.26,97,,,percent of total billed charges,97% of total billed charges,1449.9,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1512.26,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1091.32,14511.58,
26862- Arthrodesis/interphalan jnt/autogft,3434948,CDM,510,RC,26862,HCPCS,Outpatient,,,1973.09,986.55,,1775.78,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.47,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1775.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1913.9,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1815.24,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1775.78,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1381.16,70,,,percent of total billed charges,70% of total billed charges,1775.78,90,,,percent of total billed charges,90% of total billed charges,1874.44,95,,,percent of total billed charges,95% of total billed charges,1874.44,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1696.86,86,,,percent of total billed charges,86% of total billed charges,1578.47,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1913.9,97,,,percent of total billed charges,97% of total billed charges,1775.78,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913.9,97,,,percent of total billed charges,97% of total billed charges,1834.97,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1913.9,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1381.16,14511.58,
26863- Arthrode/interphal jnt/autogft/add,3434949,CDM,510,RC,26863,HCPCS,Outpatient,,,600.99,300.50,,540.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,480.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,540.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,582.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,552.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,383.81,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,472.69,78.65,,,percent of total billed charges,78.65% of total billed charges,536.87,89.33,,,percent of total billed charges,89.33% of total billed charges,540.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,420.69,70,,,percent of total billed charges,70% of total billed charges,540.89,90,,,percent of total billed charges,90% of total billed charges,570.94,95,,,percent of total billed charges,95% of total billed charges,570.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.85,86,,,percent of total billed charges,86% of total billed charges,480.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,582.96,97,,,percent of total billed charges,97% of total billed charges,540.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,582.96,97,,,percent of total billed charges,97% of total billed charges,558.92,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,582.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.81,582.96,
26910- Amputate metacarpal w/finger/thumb,3434950,CDM,510,RC,26910,HCPCS,Outpatient,,,1969.26,984.63,,1772.33,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1575.41,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1772.33,90,,,Percent of total Billed charges,90% of total billed charges,276.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1910.18,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1811.72,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1772.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1378.48,70,,,percent of total billed charges,70% of total billed charges,1772.33,90,,,percent of total billed charges,90% of total billed charges,1870.8,95,,,percent of total billed charges,95% of total billed charges,1870.8,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1693.56,86,,,percent of total billed charges,86% of total billed charges,1575.41,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1910.18,97,,,percent of total billed charges,97% of total billed charges,1772.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1910.18,97,,,percent of total billed charges,97% of total billed charges,1831.41,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1910.18,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.5,14511.58,
26951- Amputate finger/thumb/direct close,3434951,CDM,510,RC,26951,HCPCS,Outpatient,,,1787.15,893.58,,1608.44,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1429.72,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1608.44,90,,,Percent of total Billed charges,90% of total billed charges,200.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1733.54,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1644.18,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1608.44,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1251.01,70,,,percent of total billed charges,70% of total billed charges,1608.44,90,,,percent of total billed charges,90% of total billed charges,1697.79,95,,,percent of total billed charges,95% of total billed charges,1697.79,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1536.95,86,,,percent of total billed charges,86% of total billed charges,1429.72,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1733.54,97,,,percent of total billed charges,97% of total billed charges,1608.44,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1733.54,97,,,percent of total billed charges,97% of total billed charges,1662.05,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1733.54,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,182.5,14511.58,
26952- Amputate finger/thumb/loc adv flap,3434952,CDM,510,RC,26952,HCPCS,Outpatient,,,1758.61,879.31,,1582.75,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.89,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1582.75,90,,,Percent of total Billed charges,90% of total billed charges,321.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1705.85,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1617.92,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1582.75,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.03,70,,,percent of total billed charges,70% of total billed charges,1582.75,90,,,percent of total billed charges,90% of total billed charges,1670.68,95,,,percent of total billed charges,95% of total billed charges,1670.68,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1512.4,86,,,percent of total billed charges,86% of total billed charges,1406.89,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1705.85,97,,,percent of total billed charges,97% of total billed charges,1582.75,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1705.85,97,,,percent of total billed charges,97% of total billed charges,1635.51,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,292,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1705.85,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292,14511.58,
26990- I&D/pelvis/hip joint/deep absc/hem,3434954,CDM,510,RC,26990,HCPCS,Outpatient,,,1770.42,885.21,,1593.38,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1416.34,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1593.38,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1717.31,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1628.79,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1593.38,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1239.29,70,,,percent of total billed charges,70% of total billed charges,1593.38,90,,,percent of total billed charges,90% of total billed charges,1681.9,95,,,percent of total billed charges,95% of total billed charges,1681.9,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1522.56,86,,,percent of total billed charges,86% of total billed charges,1416.34,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1717.31,97,,,percent of total billed charges,97% of total billed charges,1593.38,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1717.31,97,,,percent of total billed charges,97% of total billed charges,1646.49,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1717.31,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,14511.58,
27030- Arthrotomy/hip w/drainage,3434955,CDM,510,RC,27030,HCPCS,Outpatient,,,2463.46,1231.73,,2217.11,90,,,percent of total billed charges,90% of total Billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1970.77,80,,,Percent of total Billed charges,80% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2389.56,97,,,Percent of total billed charges,97% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2266.38,92,,,Percent of total billed charges,92% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2217.11,90,,,percent of total billed charges,90% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1724.42,70,,,percent of total billed charges,70% of total billed charges,2217.11,90,,,percent of total billed charges,90% of total billed charges,2340.29,95,,,percent of total billed charges,95% of total billed charges,2340.29,95,,,percent of total billed charges,95% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2118.58,86,,,percent of total billed charges,86% of total billed charges,1970.77,80,,,percent of total billed charges,80% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2389.56,97,,,percent of total billed charges,97% of total billed charges,2217.11,90,,,percent of total billed charges,90% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2389.56,97,,,percent of total billed charges,97% of total billed charges,2291.02,93,,,percent of total billed charges,93% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2389.56,97,,,percent of total billed charges,97% of total billed charges,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2463.46,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1724.42,2463.46,
27033- Arthrotomy/hip/explore/remove FB,3434956,CDM,510,RC,27033,HCPCS,Outpatient,,,2553.33,1276.67,,2298,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2042.66,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2298,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2476.73,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2349.06,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2298,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1787.33,70,,,percent of total billed charges,70% of total billed charges,2298,90,,,percent of total billed charges,90% of total billed charges,2425.66,95,,,percent of total billed charges,95% of total billed charges,2425.66,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2195.86,86,,,percent of total billed charges,86% of total billed charges,2042.66,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2476.73,97,,,percent of total billed charges,97% of total billed charges,2298,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2476.73,97,,,percent of total billed charges,97% of total billed charges,2374.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2476.73,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1787.33,32247.16,
27035- Denervation/hip joint,3434957,CDM,510,RC,27035,HCPCS,Outpatient,,,2931.61,1465.81,,2638.45,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2345.29,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2638.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2843.66,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2697.08,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2638.45,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2052.13,70,,,percent of total billed charges,70% of total billed charges,2638.45,90,,,percent of total billed charges,90% of total billed charges,2785.03,95,,,percent of total billed charges,95% of total billed charges,2785.03,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2521.18,86,,,percent of total billed charges,86% of total billed charges,2345.29,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2843.66,97,,,percent of total billed charges,97% of total billed charges,2638.45,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2843.66,97,,,percent of total billed charges,97% of total billed charges,2726.4,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2843.66,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2052.13,14511.58,
27062- Exc/trochanteric bursa/calcific,3434961,CDM,510,RC,27062,HCPCS,Outpatient,,,1184.52,592.26,,1066.07,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,947.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.07,90,,,Percent of total Billed charges,90% of total billed charges,172.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1148.98,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1089.76,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1066.07,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,829.16,70,,,percent of total billed charges,70% of total billed charges,1066.07,90,,,percent of total billed charges,90% of total billed charges,1125.29,95,,,percent of total billed charges,95% of total billed charges,1125.29,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1018.69,86,,,percent of total billed charges,86% of total billed charges,947.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1148.98,97,,,percent of total billed charges,97% of total billed charges,1066.07,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1148.98,97,,,percent of total billed charges,97% of total billed charges,1101.6,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1148.98,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157,14511.58,
27080- Remove coccyx/tail bone,3434962,CDM,510,RC,27080,HCPCS,Outpatient,,,1346.31,673.16,,1211.68,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1077.05,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1305.92,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1238.61,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1211.68,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,942.42,70,,,percent of total billed charges,70% of total billed charges,1211.68,90,,,percent of total billed charges,90% of total billed charges,1278.99,95,,,percent of total billed charges,95% of total billed charges,1278.99,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1157.83,86,,,percent of total billed charges,86% of total billed charges,1077.05,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1305.92,97,,,percent of total billed charges,97% of total billed charges,1211.68,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1305.92,97,,,percent of total billed charges,97% of total billed charges,1252.07,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1305.92,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,942.42,14511.58,
27091- Remove/hip prosthesis/complicated,3434963,CDM,510,RC,27091,HCPCS,Outpatient,,,4197.98,2098.99,,3778.18,90,,,percent of total billed charges,90% of total Billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3358.38,80,,,Percent of total Billed charges,80% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3778.18,90,,,Percent of total Billed charges,90% of total billed charges,577.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4072.04,97,,,Percent of total billed charges,97% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3862.14,92,,,Percent of total billed charges,92% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3778.18,90,,,percent of total billed charges,90% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2938.59,70,,,percent of total billed charges,70% of total billed charges,3778.18,90,,,percent of total billed charges,90% of total billed charges,3988.08,95,,,percent of total billed charges,95% of total billed charges,3988.08,95,,,percent of total billed charges,95% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3610.26,86,,,percent of total billed charges,86% of total billed charges,3358.38,80,,,percent of total billed charges,80% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4072.04,97,,,percent of total billed charges,97% of total billed charges,3778.18,90,,,percent of total billed charges,90% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4072.04,97,,,percent of total billed charges,97% of total billed charges,3904.12,93,,,percent of total billed charges,93% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4072.04,97,,,percent of total billed charges,97% of total billed charges,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4197.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,525,4197.98,
27093- Inj/hip arthography w/o anesthesia,3434964,CDM,510,RC,27093,HCPCS,Outpatient,,,591.62,295.81,,532.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,473.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,532.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,573.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,544.29,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,377.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,465.32,78.65,,,percent of total billed charges,78.65% of total billed charges,528.5,89.33,,,percent of total billed charges,89.33% of total billed charges,532.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,414.13,70,,,percent of total billed charges,70% of total billed charges,532.46,90,,,percent of total billed charges,90% of total billed charges,562.04,95,,,percent of total billed charges,95% of total billed charges,562.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.79,86,,,percent of total billed charges,86% of total billed charges,473.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,573.87,97,,,percent of total billed charges,97% of total billed charges,532.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,573.87,97,,,percent of total billed charges,97% of total billed charges,550.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,573.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,377.82,573.87,
27096- Inj/sacroiliac w/image guide,3434965,CDM,510,RC,27096,HCPCS,Outpatient,,,406.05,203.03,,365.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,324.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,365.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,393.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,373.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,259.31,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,319.37,78.65,,,percent of total billed charges,78.65% of total billed charges,362.73,89.33,,,percent of total billed charges,89.33% of total billed charges,365.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,284.24,70,,,percent of total billed charges,70% of total billed charges,365.45,90,,,percent of total billed charges,90% of total billed charges,385.75,95,,,percent of total billed charges,95% of total billed charges,385.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,349.2,86,,,percent of total billed charges,86% of total billed charges,324.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,393.87,97,,,percent of total billed charges,97% of total billed charges,365.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,393.87,97,,,percent of total billed charges,97% of total billed charges,377.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.31,393.87,
27125- Hemiarthroplasty/hip/partial,3434966,CDM,510,RC,27125,HCPCS,Outpatient,,,2972.52,1486.26,,2675.27,90,,,percent of total billed charges,90% of total Billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2378.02,80,,,Percent of total Billed charges,80% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2675.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2883.34,97,,,Percent of total billed charges,97% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2734.72,92,,,Percent of total billed charges,92% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2675.27,90,,,percent of total billed charges,90% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2080.76,70,,,percent of total billed charges,70% of total billed charges,2675.27,90,,,percent of total billed charges,90% of total billed charges,2823.89,95,,,percent of total billed charges,95% of total billed charges,2823.89,95,,,percent of total billed charges,95% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2556.37,86,,,percent of total billed charges,86% of total billed charges,2378.02,80,,,percent of total billed charges,80% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2883.34,97,,,percent of total billed charges,97% of total billed charges,2675.27,90,,,percent of total billed charges,90% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2883.34,97,,,percent of total billed charges,97% of total billed charges,2764.44,93,,,percent of total billed charges,93% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2883.34,97,,,percent of total billed charges,97% of total billed charges,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2972.52,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2080.76,2972.52,
27130- Arthroplas/acetab/prox fem replac,3434967,CDM,510,RC,27130,HCPCS,Outpatient,,,3383.7,1691.85,,3045.33,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.96,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3045.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3282.19,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3113,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3045.33,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2368.59,70,,,percent of total billed charges,70% of total billed charges,3045.33,90,,,percent of total billed charges,90% of total billed charges,3214.52,95,,,percent of total billed charges,95% of total billed charges,3214.52,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2909.98,86,,,percent of total billed charges,86% of total billed charges,2706.96,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3282.19,97,,,percent of total billed charges,97% of total billed charges,3045.33,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3282.19,97,,,percent of total billed charges,97% of total billed charges,3146.84,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3282.19,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2368.59,63611.04,
27130- Total Hip Arthroplasty,3434968,CDM,510,RC,27130,HCPCS,Outpatient,,,3383.7,1691.85,,3045.33,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2706.96,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3045.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3282.19,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3113,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3045.33,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2368.59,70,,,percent of total billed charges,70% of total billed charges,3045.33,90,,,percent of total billed charges,90% of total billed charges,3214.52,95,,,percent of total billed charges,95% of total billed charges,3214.52,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2909.98,86,,,percent of total billed charges,86% of total billed charges,2706.96,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3282.19,97,,,percent of total billed charges,97% of total billed charges,3045.33,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3282.19,97,,,percent of total billed charges,97% of total billed charges,3146.84,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3282.19,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2368.59,63611.04,
27132- Prev hip surg/total arthroplasty,3434969,CDM,510,RC,27132,HCPCS,Outpatient,,,4403.98,2201.99,,3963.58,90,,,percent of total billed charges,90% of total Billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3523.18,80,,,Percent of total Billed charges,80% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3963.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4271.86,97,,,Percent of total billed charges,97% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4051.66,92,,,Percent of total billed charges,92% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3963.58,90,,,percent of total billed charges,90% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.79,70,,,percent of total billed charges,70% of total billed charges,3963.58,90,,,percent of total billed charges,90% of total billed charges,4183.78,95,,,percent of total billed charges,95% of total billed charges,4183.78,95,,,percent of total billed charges,95% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3787.42,86,,,percent of total billed charges,86% of total billed charges,3523.18,80,,,percent of total billed charges,80% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4271.86,97,,,percent of total billed charges,97% of total billed charges,3963.58,90,,,percent of total billed charges,90% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4271.86,97,,,percent of total billed charges,97% of total billed charges,4095.7,93,,,percent of total billed charges,93% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4271.86,97,,,percent of total billed charges,97% of total billed charges,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4403.98,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3082.79,4403.98,
27134- Revise hip arthroplast/both comp,3434970,CDM,510,RC,27134,HCPCS,Outpatient,,,5037.41,2518.71,,4533.67,90,,,percent of total billed charges,90% of total Billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4029.93,80,,,Percent of total Billed charges,80% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4533.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4886.29,97,,,Percent of total billed charges,97% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4634.42,92,,,Percent of total billed charges,92% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4533.67,90,,,percent of total billed charges,90% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3526.19,70,,,percent of total billed charges,70% of total billed charges,4533.67,90,,,percent of total billed charges,90% of total billed charges,4785.54,95,,,percent of total billed charges,95% of total billed charges,4785.54,95,,,percent of total billed charges,95% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4332.17,86,,,percent of total billed charges,86% of total billed charges,4029.93,80,,,percent of total billed charges,80% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4886.29,97,,,percent of total billed charges,97% of total billed charges,4533.67,90,,,percent of total billed charges,90% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4886.29,97,,,percent of total billed charges,97% of total billed charges,4684.79,93,,,percent of total billed charges,93% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4886.29,97,,,percent of total billed charges,97% of total billed charges,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5037.41,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3526.19,5037.41,
27137- Revise hip arthroplast/acetab comp,3434971,CDM,510,RC,27137,HCPCS,Outpatient,,,3866.53,1933.27,,3479.88,90,,,percent of total billed charges,90% of total Billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3093.22,80,,,Percent of total Billed charges,80% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3750.53,97,,,Percent of total billed charges,97% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3557.21,92,,,Percent of total billed charges,92% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3479.88,90,,,percent of total billed charges,90% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2706.57,70,,,percent of total billed charges,70% of total billed charges,3479.88,90,,,percent of total billed charges,90% of total billed charges,3673.2,95,,,percent of total billed charges,95% of total billed charges,3673.2,95,,,percent of total billed charges,95% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3325.22,86,,,percent of total billed charges,86% of total billed charges,3093.22,80,,,percent of total billed charges,80% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3750.53,97,,,percent of total billed charges,97% of total billed charges,3479.88,90,,,percent of total billed charges,90% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3750.53,97,,,percent of total billed charges,97% of total billed charges,3595.87,93,,,percent of total billed charges,93% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3750.53,97,,,percent of total billed charges,97% of total billed charges,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3866.53,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2706.57,3866.53,
27140- Osteot/transf/grt trochanter/femur,3434972,CDM,510,RC,27140,HCPCS,Outpatient,,,2346.19,1173.10,,2111.57,90,,,percent of total billed charges,90% of total Billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1876.95,80,,,Percent of total Billed charges,80% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2111.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2275.8,97,,,Percent of total billed charges,97% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2158.49,92,,,Percent of total billed charges,92% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2111.57,90,,,percent of total billed charges,90% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1642.33,70,,,percent of total billed charges,70% of total billed charges,2111.57,90,,,percent of total billed charges,90% of total billed charges,2228.88,95,,,percent of total billed charges,95% of total billed charges,2228.88,95,,,percent of total billed charges,95% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2017.72,86,,,percent of total billed charges,86% of total billed charges,1876.95,80,,,percent of total billed charges,80% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2275.8,97,,,percent of total billed charges,97% of total billed charges,2111.57,90,,,percent of total billed charges,90% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2275.8,97,,,percent of total billed charges,97% of total billed charges,2181.96,93,,,percent of total billed charges,93% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2275.8,97,,,percent of total billed charges,97% of total billed charges,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2346.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1642.33,2346.19,
27220- Closed tx/acetabululm w/o manip,3434976,CDM,510,RC,27220,HCPCS,Outpatient,,,1094.42,547.21,,984.98,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,875.54,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,984.98,90,,,Percent of total Billed charges,90% of total billed charges,313.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1061.59,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.87,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,984.98,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,766.09,70,,,percent of total billed charges,70% of total billed charges,984.98,90,,,percent of total billed charges,90% of total billed charges,1039.7,95,,,percent of total billed charges,95% of total billed charges,1039.7,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,941.2,86,,,percent of total billed charges,86% of total billed charges,875.54,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1061.59,97,,,percent of total billed charges,97% of total billed charges,984.98,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1061.59,97,,,percent of total billed charges,97% of total billed charges,1017.81,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,285,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1061.59,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1061.59,
27222- Clsd tx/acetabulum/w manipulation,3434977,CDM,510,RC,27222,HCPCS,Outpatient,,,2585.05,1292.53,,2326.55,90,,,percent of total billed charges,90% of total Billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2068.04,80,,,Percent of total Billed charges,80% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2326.55,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2507.5,97,,,Percent of total billed charges,97% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2378.25,92,,,Percent of total billed charges,92% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2326.55,90,,,percent of total billed charges,90% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1809.54,70,,,percent of total billed charges,70% of total billed charges,2326.55,90,,,percent of total billed charges,90% of total billed charges,2455.8,95,,,percent of total billed charges,95% of total billed charges,2455.8,95,,,percent of total billed charges,95% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2223.14,86,,,percent of total billed charges,86% of total billed charges,2068.04,80,,,percent of total billed charges,80% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2507.5,97,,,percent of total billed charges,97% of total billed charges,2326.55,90,,,percent of total billed charges,90% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2507.5,97,,,percent of total billed charges,97% of total billed charges,2404.1,93,,,percent of total billed charges,93% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2507.5,97,,,percent of total billed charges,97% of total billed charges,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2585.05,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,301,2585.05,
27226- Open tx/post/ant acetab wall fx,3434978,CDM,510,RC,27226,HCPCS,Outpatient,,,2775.86,1387.93,,2498.27,90,,,percent of total billed charges,90% of total Billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2220.69,80,,,Percent of total Billed charges,80% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2498.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2692.58,97,,,Percent of total billed charges,97% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2553.79,92,,,Percent of total billed charges,92% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2498.27,90,,,percent of total billed charges,90% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1943.1,70,,,percent of total billed charges,70% of total billed charges,2498.27,90,,,percent of total billed charges,90% of total billed charges,2637.07,95,,,percent of total billed charges,95% of total billed charges,2637.07,95,,,percent of total billed charges,95% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2387.24,86,,,percent of total billed charges,86% of total billed charges,2220.69,80,,,percent of total billed charges,80% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2692.58,97,,,percent of total billed charges,97% of total billed charges,2498.27,90,,,percent of total billed charges,90% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2692.58,97,,,percent of total billed charges,97% of total billed charges,2581.55,93,,,percent of total billed charges,93% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2692.58,97,,,percent of total billed charges,97% of total billed charges,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2775.86,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1943.1,2775.86,
27227- Open tx/post/ant acetab column fx,3434979,CDM,510,RC,27227,HCPCS,Outpatient,,,4350.45,2175.23,,3915.41,90,,,percent of total billed charges,90% of total Billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3480.36,80,,,Percent of total Billed charges,80% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3915.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4219.94,97,,,Percent of total billed charges,97% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4002.41,92,,,Percent of total billed charges,92% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3915.41,90,,,percent of total billed charges,90% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.32,70,,,percent of total billed charges,70% of total billed charges,3915.41,90,,,percent of total billed charges,90% of total billed charges,4132.93,95,,,percent of total billed charges,95% of total billed charges,4132.93,95,,,percent of total billed charges,95% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3741.39,86,,,percent of total billed charges,86% of total billed charges,3480.36,80,,,percent of total billed charges,80% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4219.94,97,,,percent of total billed charges,97% of total billed charges,3915.41,90,,,percent of total billed charges,90% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4219.94,97,,,percent of total billed charges,97% of total billed charges,4045.92,93,,,percent of total billed charges,93% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4219.94,97,,,percent of total billed charges,97% of total billed charges,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4350.45,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3045.32,4350.45,
27235- Perc fx/femoral fx/proximal /neck,3434980,CDM,510,RC,27235,HCPCS,Outpatient,,,2381.9,1190.95,,2143.71,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1905.52,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2143.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2310.44,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2191.35,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2143.71,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1667.33,70,,,percent of total billed charges,70% of total billed charges,2143.71,90,,,percent of total billed charges,90% of total billed charges,2262.81,95,,,percent of total billed charges,95% of total billed charges,2262.81,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2048.43,86,,,percent of total billed charges,86% of total billed charges,1905.52,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2310.44,97,,,percent of total billed charges,97% of total billed charges,2143.71,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2310.44,97,,,percent of total billed charges,97% of total billed charges,2215.17,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2310.44,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1667.33,32247.16,
27236- Open tx/femoral fx/proximal/neck,3434981,CDM,510,RC,27236,HCPCS,Outpatient,,,3135.65,1567.83,,2822.09,90,,,percent of total billed charges,90% of total Billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2508.52,80,,,Percent of total Billed charges,80% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2822.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3041.58,97,,,Percent of total billed charges,97% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2884.8,92,,,Percent of total billed charges,92% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2822.09,90,,,percent of total billed charges,90% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.96,70,,,percent of total billed charges,70% of total billed charges,2822.09,90,,,percent of total billed charges,90% of total billed charges,2978.87,95,,,percent of total billed charges,95% of total billed charges,2978.87,95,,,percent of total billed charges,95% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2696.66,86,,,percent of total billed charges,86% of total billed charges,2508.52,80,,,percent of total billed charges,80% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3041.58,97,,,percent of total billed charges,97% of total billed charges,2822.09,90,,,percent of total billed charges,90% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3041.58,97,,,percent of total billed charges,97% of total billed charges,2916.15,93,,,percent of total billed charges,93% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3041.58,97,,,percent of total billed charges,97% of total billed charges,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3135.65,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2194.96,3135.65,
27238- Clsd tx/trochanter fem fx w/o manip,3434982,CDM,510,RC,27238,HCPCS,Outpatient,,,1215.63,607.82,,1094.07,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,972.5,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1094.07,90,,,Percent of total Billed charges,90% of total billed charges,267.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1179.16,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.38,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1094.07,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,850.94,70,,,percent of total billed charges,70% of total billed charges,1094.07,90,,,percent of total billed charges,90% of total billed charges,1154.85,95,,,percent of total billed charges,95% of total billed charges,1154.85,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1045.44,86,,,percent of total billed charges,86% of total billed charges,972.5,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1179.16,97,,,percent of total billed charges,97% of total billed charges,1094.07,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.16,97,,,percent of total billed charges,97% of total billed charges,1130.54,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,243,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1179.16,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243,6993.46,
27240- Clsd tx/trochanter fem fx w/manip,3434983,CDM,510,RC,27240,HCPCS,Outpatient,,,2519.42,1259.71,,2267.48,90,,,percent of total billed charges,90% of total Billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2015.54,80,,,Percent of total Billed charges,80% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.48,90,,,Percent of total Billed charges,90% of total billed charges,320.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2443.84,97,,,Percent of total billed charges,97% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2317.87,92,,,Percent of total billed charges,92% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2267.48,90,,,percent of total billed charges,90% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1763.59,70,,,percent of total billed charges,70% of total billed charges,2267.48,90,,,percent of total billed charges,90% of total billed charges,2393.45,95,,,percent of total billed charges,95% of total billed charges,2393.45,95,,,percent of total billed charges,95% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2166.7,86,,,percent of total billed charges,86% of total billed charges,2015.54,80,,,percent of total billed charges,80% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2443.84,97,,,percent of total billed charges,97% of total billed charges,2267.48,90,,,percent of total billed charges,90% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2443.84,97,,,percent of total billed charges,97% of total billed charges,2343.06,93,,,percent of total billed charges,93% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,291,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2443.84,97,,,percent of total billed charges,97% of total billed charges,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2519.42,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,291,2519.42,
27245- Treat Thigh Fracture,3434984,CDM,510,RC,27245,HCPCS,Outpatient,,,3223.91,1611.96,,2901.52,90,,,percent of total billed charges,90% of total Billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2579.13,80,,,Percent of total Billed charges,80% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2901.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3127.19,97,,,Percent of total billed charges,97% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2966,92,,,Percent of total billed charges,92% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2901.52,90,,,percent of total billed charges,90% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2256.74,70,,,percent of total billed charges,70% of total billed charges,2901.52,90,,,percent of total billed charges,90% of total billed charges,3062.71,95,,,percent of total billed charges,95% of total billed charges,3062.71,95,,,percent of total billed charges,95% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2772.56,86,,,percent of total billed charges,86% of total billed charges,2579.13,80,,,percent of total billed charges,80% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3127.19,97,,,percent of total billed charges,97% of total billed charges,2901.52,90,,,percent of total billed charges,90% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3127.19,97,,,percent of total billed charges,97% of total billed charges,2998.24,93,,,percent of total billed charges,93% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3127.19,97,,,percent of total billed charges,97% of total billed charges,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223.91,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2256.74,3223.91,
27246- Clsd tx/great trochan fx w/o manip,3434985,CDM,510,RC,27246,HCPCS,Outpatient,,,1018.42,509.21,,916.58,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,814.74,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.58,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,987.87,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,936.95,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,916.58,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,712.89,70,,,percent of total billed charges,70% of total billed charges,916.58,90,,,percent of total billed charges,90% of total billed charges,967.5,95,,,percent of total billed charges,95% of total billed charges,967.5,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,875.84,86,,,percent of total billed charges,86% of total billed charges,814.74,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,987.87,97,,,percent of total billed charges,97% of total billed charges,916.58,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,987.87,97,,,percent of total billed charges,97% of total billed charges,947.13,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,987.87,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,1009.19,
27248- Open tx/great trochan fx/int fix,3434986,CDM,510,RC,27248,HCPCS,Outpatient,,,1962.63,981.32,,1766.37,90,,,percent of total billed charges,90% of total Billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1570.1,80,,,Percent of total Billed charges,80% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.37,90,,,Percent of total Billed charges,90% of total billed charges,288.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1903.75,97,,,Percent of total billed charges,97% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1805.62,92,,,Percent of total billed charges,92% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1766.37,90,,,percent of total billed charges,90% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1373.84,70,,,percent of total billed charges,70% of total billed charges,1766.37,90,,,percent of total billed charges,90% of total billed charges,1864.5,95,,,percent of total billed charges,95% of total billed charges,1864.5,95,,,percent of total billed charges,95% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1687.86,86,,,percent of total billed charges,86% of total billed charges,1570.1,80,,,percent of total billed charges,80% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1903.75,97,,,percent of total billed charges,97% of total billed charges,1766.37,90,,,percent of total billed charges,90% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1903.75,97,,,percent of total billed charges,97% of total billed charges,1825.25,93,,,percent of total billed charges,93% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1903.75,97,,,percent of total billed charges,97% of total billed charges,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1962.63,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,262.5,1962.63,
27250- Clsd tx/hip dislo/traumat w/o anes,3434987,CDM,510,RC,27250,HCPCS,Outpatient,,,495.19,247.60,,445.67,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,396.15,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.67,90,,,Percent of total Billed charges,90% of total billed charges,225.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,480.33,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,455.57,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,445.67,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,346.63,70,,,percent of total billed charges,70% of total billed charges,445.67,90,,,percent of total billed charges,90% of total billed charges,470.43,95,,,percent of total billed charges,95% of total billed charges,470.43,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,425.86,86,,,percent of total billed charges,86% of total billed charges,396.15,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,480.33,97,,,percent of total billed charges,97% of total billed charges,445.67,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.33,97,,,percent of total billed charges,97% of total billed charges,460.53,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,480.33,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27252- Clsd tx/hip dislo/traumat w/anes,3434988,CDM,510,RC,27252,HCPCS,Outpatient,,,1988.96,994.48,,1790.06,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1591.17,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1790.06,90,,,Percent of total Billed charges,90% of total billed charges,309.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1929.29,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1829.84,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1790.06,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1392.27,70,,,percent of total billed charges,70% of total billed charges,1790.06,90,,,percent of total billed charges,90% of total billed charges,1889.51,95,,,percent of total billed charges,95% of total billed charges,1889.51,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1710.51,86,,,percent of total billed charges,86% of total billed charges,1591.17,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1929.29,97,,,percent of total billed charges,97% of total billed charges,1790.06,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1929.29,97,,,percent of total billed charges,97% of total billed charges,1849.73,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1929.29,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281.5,6993.46,
27253- Open tx/hip dislocateate/traumatic,3434989,CDM,510,RC,27253,HCPCS,Outpatient,,,2471.74,1235.87,,2224.57,90,,,percent of total billed charges,90% of total Billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1977.39,80,,,Percent of total Billed charges,80% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.57,90,,,Percent of total Billed charges,90% of total billed charges,700.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2397.59,97,,,Percent of total billed charges,97% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2274,92,,,Percent of total billed charges,92% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2224.57,90,,,percent of total billed charges,90% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1730.22,70,,,percent of total billed charges,70% of total billed charges,2224.57,90,,,percent of total billed charges,90% of total billed charges,2348.15,95,,,percent of total billed charges,95% of total billed charges,2348.15,95,,,percent of total billed charges,95% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2125.7,86,,,percent of total billed charges,86% of total billed charges,1977.39,80,,,percent of total billed charges,80% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2397.59,97,,,percent of total billed charges,97% of total billed charges,2224.57,90,,,percent of total billed charges,90% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2397.59,97,,,percent of total billed charges,97% of total billed charges,2298.72,93,,,percent of total billed charges,93% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2397.59,97,,,percent of total billed charges,97% of total billed charges,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637,2471.74,
27254- Open tx/hip dislocate/trauma/acetab fx,3434990,CDM,510,RC,27254,HCPCS,Outpatient,,,3347.17,1673.59,,3012.45,90,,,percent of total billed charges,90% of total Billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2677.74,80,,,Percent of total Billed charges,80% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3012.45,90,,,Percent of total Billed charges,90% of total billed charges,700.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3246.75,97,,,Percent of total billed charges,97% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3079.4,92,,,Percent of total billed charges,92% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3012.45,90,,,percent of total billed charges,90% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2343.02,70,,,percent of total billed charges,70% of total billed charges,3012.45,90,,,percent of total billed charges,90% of total billed charges,3179.81,95,,,percent of total billed charges,95% of total billed charges,3179.81,95,,,percent of total billed charges,95% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2878.57,86,,,percent of total billed charges,86% of total billed charges,2677.74,80,,,percent of total billed charges,80% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3246.75,97,,,percent of total billed charges,97% of total billed charges,3012.45,90,,,percent of total billed charges,90% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3246.75,97,,,percent of total billed charges,97% of total billed charges,3112.87,93,,,percent of total billed charges,93% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3246.75,97,,,percent of total billed charges,97% of total billed charges,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3347.17,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,637,3347.17,
27266- Clsd tx/post hip arthro dislocat/anesth,3434991,CDM,510,RC,27266,HCPCS,Outpatient,,,1530.08,765.04,,1377.07,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.06,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1377.07,90,,,Percent of total Billed charges,90% of total billed charges,260.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1484.18,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.67,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1377.07,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.06,70,,,percent of total billed charges,70% of total billed charges,1377.07,90,,,percent of total billed charges,90% of total billed charges,1453.58,95,,,percent of total billed charges,95% of total billed charges,1453.58,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1315.87,86,,,percent of total billed charges,86% of total billed charges,1224.06,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1484.18,97,,,percent of total billed charges,97% of total billed charges,1377.07,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1484.18,97,,,percent of total billed charges,97% of total billed charges,1422.97,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1484.18,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,237,6993.46,
27275- Manipulate/hip jnt/gen anesthesia,3434992,CDM,510,RC,27275,HCPCS,Outpatient,,,473.33,236.67,,426,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,378.66,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,426,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,459.13,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,435.46,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,426,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,331.33,70,,,percent of total billed charges,70% of total billed charges,426,90,,,percent of total billed charges,90% of total billed charges,449.66,95,,,percent of total billed charges,95% of total billed charges,449.66,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,407.06,86,,,percent of total billed charges,86% of total billed charges,378.66,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,459.13,97,,,percent of total billed charges,97% of total billed charges,426,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,459.13,97,,,percent of total billed charges,97% of total billed charges,440.2,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,459.13,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,6993.46,
27279- Arthrodes/sacroiliac/transfix dev,3434993,CDM,510,RC,27279,HCPCS,Outpatient,,,2210.35,1105.18,,1989.32,90,,,percent of total billed charges,90% of total Billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1768.28,80,,,Percent of total Billed charges,80% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,1989.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2144.04,97,,,Percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2033.52,92,,,Percent of total billed charges,92% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,52866.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84280.32,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,106753.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1989.32,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1547.25,70,,,percent of total billed charges,70% of total billed charges,1989.32,90,,,percent of total billed charges,90% of total billed charges,2099.83,95,,,percent of total billed charges,95% of total billed charges,2099.83,95,,,percent of total billed charges,95% of total billed charges,19888.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39777.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1900.9,86,,,percent of total billed charges,86% of total billed charges,1768.28,80,,,percent of total billed charges,80% of total billed charges,16486.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2144.04,97,,,percent of total billed charges,97% of total billed charges,1989.32,90,,,percent of total billed charges,90% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,2144.04,97,,,percent of total billed charges,97% of total billed charges,2055.63,93,,,percent of total billed charges,93% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2144.04,97,,,percent of total billed charges,97% of total billed charges,19888.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,19888.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16905.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1547.25,106753.72,
27280- Arthrode/open/sacroiliac jnt/gft,3434994,CDM,510,RC,27280,HCPCS,Outpatient,,,3632.75,1816.38,,3269.48,90,,,percent of total billed charges,90% of total Billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2906.2,80,,,Percent of total Billed charges,80% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3269.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3523.77,97,,,Percent of total billed charges,97% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3342.13,92,,,Percent of total billed charges,92% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3269.48,90,,,percent of total billed charges,90% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2542.93,70,,,percent of total billed charges,70% of total billed charges,3269.48,90,,,percent of total billed charges,90% of total billed charges,3451.11,95,,,percent of total billed charges,95% of total billed charges,3451.11,95,,,percent of total billed charges,95% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3124.17,86,,,percent of total billed charges,86% of total billed charges,2906.2,80,,,percent of total billed charges,80% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3523.77,97,,,percent of total billed charges,97% of total billed charges,3269.48,90,,,percent of total billed charges,90% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3523.77,97,,,percent of total billed charges,97% of total billed charges,3378.46,93,,,percent of total billed charges,93% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3523.77,97,,,percent of total billed charges,97% of total billed charges,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3632.75,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2542.93,3632.75,
27282- Arthrodesis/symphysis pubis/graft,3434995,CDM,510,RC,27282,HCPCS,Outpatient,,,2252.13,1126.07,,2026.92,90,,,percent of total billed charges,90% of total Billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1801.7,80,,,Percent of total Billed charges,80% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2026.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2184.57,97,,,Percent of total billed charges,97% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2071.96,92,,,Percent of total billed charges,92% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2026.92,90,,,percent of total billed charges,90% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1576.49,70,,,percent of total billed charges,70% of total billed charges,2026.92,90,,,percent of total billed charges,90% of total billed charges,2139.52,95,,,percent of total billed charges,95% of total billed charges,2139.52,95,,,percent of total billed charges,95% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1936.83,86,,,percent of total billed charges,86% of total billed charges,1801.7,80,,,percent of total billed charges,80% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2184.57,97,,,percent of total billed charges,97% of total billed charges,2026.92,90,,,percent of total billed charges,90% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2184.57,97,,,percent of total billed charges,97% of total billed charges,2094.48,93,,,percent of total billed charges,93% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2184.57,97,,,percent of total billed charges,97% of total billed charges,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2252.13,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1576.49,2252.13,
27307- Tenotomy/perc/adductor/hamstring,3434998,CDM,510,RC,27307,HCPCS,Outpatient,,,1080.22,540.11,,972.2,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,864.18,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,972.2,90,,,Percent of total Billed charges,90% of total billed charges,155.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1047.81,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,993.8,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,972.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,756.15,70,,,percent of total billed charges,70% of total billed charges,972.2,90,,,percent of total billed charges,90% of total billed charges,1026.21,95,,,percent of total billed charges,95% of total billed charges,1026.21,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,928.99,86,,,percent of total billed charges,86% of total billed charges,864.18,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1047.81,97,,,percent of total billed charges,97% of total billed charges,972.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1047.81,97,,,percent of total billed charges,97% of total billed charges,1004.6,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,141,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1047.81,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141,14511.58,
27310- Arthrotomy/knee/explore/drain,3434999,CDM,510,RC,27310,HCPCS,Outpatient,,,1915.54,957.77,,1723.99,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1532.43,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1723.99,90,,,Percent of total Billed charges,90% of total billed charges,419.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1858.07,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1762.3,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1723.99,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1340.88,70,,,percent of total billed charges,70% of total billed charges,1723.99,90,,,percent of total billed charges,90% of total billed charges,1819.76,95,,,percent of total billed charges,95% of total billed charges,1819.76,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1647.36,86,,,percent of total billed charges,86% of total billed charges,1532.43,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1858.07,97,,,percent of total billed charges,97% of total billed charges,1723.99,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1858.07,97,,,percent of total billed charges,97% of total billed charges,1781.45,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,381,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1858.07,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,381,14511.58,
27324- Biopsy/soft tissue/thigh/knee/deep,3435001,CDM,510,RC,27324,HCPCS,Outpatient,,,1058.39,529.20,,952.55,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,846.71,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,952.55,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1026.64,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,973.72,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,952.55,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,740.87,70,,,percent of total billed charges,70% of total billed charges,952.55,90,,,percent of total billed charges,90% of total billed charges,1005.47,95,,,percent of total billed charges,95% of total billed charges,1005.47,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,910.22,86,,,percent of total billed charges,86% of total billed charges,846.71,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1026.64,97,,,percent of total billed charges,97% of total billed charges,952.55,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1026.64,97,,,percent of total billed charges,97% of total billed charges,984.3,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1026.64,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,12593.67,
27327- Exc/tumor/thigh/knee/SQ/<3cm,3435002,CDM,510,RC,27327,HCPCS,Outpatient,,,1281.56,640.78,,1153.4,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.25,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1153.4,90,,,Percent of total Billed charges,90% of total billed charges,129.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1243.11,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1179.04,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1153.4,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,897.09,70,,,percent of total billed charges,70% of total billed charges,1153.4,90,,,percent of total billed charges,90% of total billed charges,1217.48,95,,,percent of total billed charges,95% of total billed charges,1217.48,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1102.14,86,,,percent of total billed charges,86% of total billed charges,1025.25,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1243.11,97,,,percent of total billed charges,97% of total billed charges,1153.4,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1243.11,97,,,percent of total billed charges,97% of total billed charges,1191.85,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1243.11,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.5,7310.49,
27331- Arthrot/knee/jnt explore/bx/rmv FB,3435003,CDM,510,RC,27331,HCPCS,Outpatient,,,1239.35,619.68,,1115.42,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,991.48,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1115.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1202.17,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.2,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1115.42,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,867.55,70,,,percent of total billed charges,70% of total billed charges,1115.42,90,,,percent of total billed charges,90% of total billed charges,1177.38,95,,,percent of total billed charges,95% of total billed charges,1177.38,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1065.84,86,,,percent of total billed charges,86% of total billed charges,991.48,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1202.17,97,,,percent of total billed charges,97% of total billed charges,1115.42,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.17,97,,,percent of total billed charges,97% of total billed charges,1152.6,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1202.17,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,867.55,14511.58,
27340- Remove/prepatellar bursa,3435006,CDM,510,RC,27340,HCPCS,Outpatient,,,969.45,484.73,,872.51,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,775.56,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,872.51,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,940.37,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,891.89,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,872.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,678.62,70,,,percent of total billed charges,70% of total billed charges,872.51,90,,,percent of total billed charges,90% of total billed charges,920.98,95,,,percent of total billed charges,95% of total billed charges,920.98,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,833.73,86,,,percent of total billed charges,86% of total billed charges,775.56,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,940.37,97,,,percent of total billed charges,97% of total billed charges,872.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,940.37,97,,,percent of total billed charges,97% of total billed charges,901.59,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,940.37,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,14511.58,
27345- Exc/synov cyst/popliteal space,3435007,CDM,510,RC,27345,HCPCS,Outpatient,,,1264.1,632.05,,1137.69,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1011.28,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1137.69,90,,,Percent of total Billed charges,90% of total billed charges,315.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1226.18,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1162.97,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1137.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,884.87,70,,,percent of total billed charges,70% of total billed charges,1137.69,90,,,percent of total billed charges,90% of total billed charges,1200.9,95,,,percent of total billed charges,95% of total billed charges,1200.9,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1087.13,86,,,percent of total billed charges,86% of total billed charges,1011.28,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1226.18,97,,,percent of total billed charges,97% of total billed charges,1137.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1226.18,97,,,percent of total billed charges,97% of total billed charges,1175.61,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,287,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1226.18,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,287,14511.58,
27347- Exc lesion/meniscus/capsule/knee,3435008,CDM,510,RC,27347,HCPCS,Outpatient,,,1370.52,685.26,,1233.47,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1096.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1233.47,90,,,Percent of total Billed charges,90% of total billed charges,304.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1329.4,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.88,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1233.47,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,959.36,70,,,percent of total billed charges,70% of total billed charges,1233.47,90,,,percent of total billed charges,90% of total billed charges,1301.99,95,,,percent of total billed charges,95% of total billed charges,1301.99,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1178.65,86,,,percent of total billed charges,86% of total billed charges,1096.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1329.4,97,,,percent of total billed charges,97% of total billed charges,1233.47,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1329.4,97,,,percent of total billed charges,97% of total billed charges,1274.58,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1329.4,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,276.52,14511.58,
27350- Remove patella/total or partial,3435009,CDM,510,RC,27350,HCPCS,Outpatient,,,1709.55,854.78,,1538.6,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1367.64,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.6,90,,,Percent of total Billed charges,90% of total billed charges,551.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1658.26,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1572.79,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1538.6,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.69,70,,,percent of total billed charges,70% of total billed charges,1538.6,90,,,percent of total billed charges,90% of total billed charges,1624.07,95,,,percent of total billed charges,95% of total billed charges,1624.07,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1470.21,86,,,percent of total billed charges,86% of total billed charges,1367.64,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1658.26,97,,,percent of total billed charges,97% of total billed charges,1538.6,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1658.26,97,,,percent of total billed charges,97% of total billed charges,1589.88,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,501,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1658.26,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501,32247.16,
27355- Exc/bone cyst/bgn tumor/femur,3435010,CDM,510,RC,27355,HCPCS,Outpatient,,,1589.8,794.90,,1430.82,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.84,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1430.82,90,,,Percent of total Billed charges,90% of total billed charges,392.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1542.11,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1462.62,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1430.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.86,70,,,percent of total billed charges,70% of total billed charges,1430.82,90,,,percent of total billed charges,90% of total billed charges,1510.31,95,,,percent of total billed charges,95% of total billed charges,1510.31,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1367.23,86,,,percent of total billed charges,86% of total billed charges,1271.84,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1542.11,97,,,percent of total billed charges,97% of total billed charges,1430.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1542.11,97,,,percent of total billed charges,97% of total billed charges,1478.51,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1542.11,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,356.5,14511.58,
27360- Part exc/bone/fem/prox tib/fib,3435011,CDM,510,RC,27360,HCPCS,Outpatient,,,2358.87,1179.44,,2122.98,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1887.1,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2122.98,90,,,Percent of total Billed charges,90% of total billed charges,389.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2288.1,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2170.16,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2122.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1651.21,70,,,percent of total billed charges,70% of total billed charges,2122.98,90,,,percent of total billed charges,90% of total billed charges,2240.93,95,,,percent of total billed charges,95% of total billed charges,2240.93,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2028.63,86,,,percent of total billed charges,86% of total billed charges,1887.1,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2288.1,97,,,percent of total billed charges,97% of total billed charges,2122.98,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2288.1,97,,,percent of total billed charges,97% of total billed charges,2193.75,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2288.1,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,354.5,14511.58,
27364- Resect/sft tis tum/thigh/knee/5cm>,3435012,CDM,510,RC,27364,HCPCS,Outpatient,,,4146.79,2073.40,,3732.11,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3317.43,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3732.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4022.39,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3815.05,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3732.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2902.75,70,,,percent of total billed charges,70% of total billed charges,3732.11,90,,,percent of total billed charges,90% of total billed charges,3939.45,95,,,percent of total billed charges,95% of total billed charges,3939.45,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3566.24,86,,,percent of total billed charges,86% of total billed charges,3317.43,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4022.39,97,,,percent of total billed charges,97% of total billed charges,3732.11,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,4022.39,97,,,percent of total billed charges,97% of total billed charges,3856.51,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4022.39,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
27372- Rmv/foreign body/deep/thigh/knee,3435013,CDM,510,RC,27372,HCPCS,Outpatient,,,1511.03,755.52,,1359.93,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1208.82,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1359.93,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1465.7,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1390.15,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1359.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.72,70,,,percent of total billed charges,70% of total billed charges,1359.93,90,,,percent of total billed charges,90% of total billed charges,1435.48,95,,,percent of total billed charges,95% of total billed charges,1435.48,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1299.49,86,,,percent of total billed charges,86% of total billed charges,1208.82,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1465.7,97,,,percent of total billed charges,97% of total billed charges,1359.93,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1465.7,97,,,percent of total billed charges,97% of total billed charges,1405.26,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1465.7,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,12593.67,
27380- Suture/infrapatellar ten/primary,3435014,CDM,510,RC,27380,HCPCS,Outpatient,,,1620.09,810.05,,1458.08,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.07,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1458.08,90,,,Percent of total Billed charges,90% of total billed charges,471.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1571.49,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1490.48,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1458.08,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.06,70,,,percent of total billed charges,70% of total billed charges,1458.08,90,,,percent of total billed charges,90% of total billed charges,1539.09,95,,,percent of total billed charges,95% of total billed charges,1539.09,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1393.28,86,,,percent of total billed charges,86% of total billed charges,1296.07,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1571.49,97,,,percent of total billed charges,97% of total billed charges,1458.08,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1571.49,97,,,percent of total billed charges,97% of total billed charges,1506.68,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,428.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1571.49,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,428.5,32247.16,
27385- Suture/quadricep/hamstring mus rup,3435015,CDM,510,RC,27385,HCPCS,Outpatient,,,1571.93,785.97,,1414.74,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1257.54,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1414.74,90,,,Percent of total Billed charges,90% of total billed charges,535.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1524.77,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1446.18,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1414.74,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1100.35,70,,,percent of total billed charges,70% of total billed charges,1414.74,90,,,percent of total billed charges,90% of total billed charges,1493.33,95,,,percent of total billed charges,95% of total billed charges,1493.33,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1351.86,86,,,percent of total billed charges,86% of total billed charges,1257.54,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1524.77,97,,,percent of total billed charges,97% of total billed charges,1414.74,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.77,97,,,percent of total billed charges,97% of total billed charges,1461.89,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,486.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1524.77,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,486.5,32247.16,
27386- Suture/quadricep/hamstring rup/sec,3435016,CDM,510,RC,27386,HCPCS,Outpatient,,,2241.36,1120.68,,2017.22,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1793.09,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2017.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2174.12,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2062.05,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2017.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1568.95,70,,,percent of total billed charges,70% of total billed charges,2017.22,90,,,percent of total billed charges,90% of total billed charges,2129.29,95,,,percent of total billed charges,95% of total billed charges,2129.29,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1927.57,86,,,percent of total billed charges,86% of total billed charges,1793.09,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2174.12,97,,,percent of total billed charges,97% of total billed charges,2017.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2174.12,97,,,percent of total billed charges,97% of total billed charges,2084.46,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2174.12,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1568.95,32247.16,
"27400 - (50) Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure)",3698911,CDM,510,RC,27400,HCPCS,Outpatient,,,1821.08,910.54,,1638.97,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.86,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1638.97,90,,,Percent of total Billed charges,90% of total billed charges,651.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1766.45,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.39,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1638.97,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1274.76,70,,,percent of total billed charges,70% of total billed charges,1638.97,90,,,percent of total billed charges,90% of total billed charges,1730.03,95,,,percent of total billed charges,95% of total billed charges,1730.03,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1566.13,86,,,percent of total billed charges,86% of total billed charges,1456.86,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1766.45,97,,,percent of total billed charges,97% of total billed charges,1638.97,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1766.45,97,,,percent of total billed charges,97% of total billed charges,1693.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1766.45,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,592.63,32247.16,
"27400 - PF Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure)",3698908,CDM,510,RC,27400,HCPCS,Outpatient,,,1821.08,910.54,,1638.97,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1456.86,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1638.97,90,,,Percent of total Billed charges,90% of total billed charges,651.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1766.45,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1675.39,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1638.97,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1274.76,70,,,percent of total billed charges,70% of total billed charges,1638.97,90,,,percent of total billed charges,90% of total billed charges,1730.03,95,,,percent of total billed charges,95% of total billed charges,1730.03,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1566.13,86,,,percent of total billed charges,86% of total billed charges,1456.86,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1766.45,97,,,percent of total billed charges,97% of total billed charges,1638.97,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1766.45,97,,,percent of total billed charges,97% of total billed charges,1693.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,592.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1766.45,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,592.63,32247.16,
27403- Arthrotomy/meniscus repair/knee,3435017,CDM,510,RC,27403,HCPCS,Outpatient,,,1685.82,842.91,,1517.24,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.66,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1517.24,90,,,Percent of total Billed charges,90% of total billed charges,596.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1635.25,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1550.95,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1517.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1180.07,70,,,percent of total billed charges,70% of total billed charges,1517.24,90,,,percent of total billed charges,90% of total billed charges,1601.53,95,,,percent of total billed charges,95% of total billed charges,1601.53,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1449.81,86,,,percent of total billed charges,86% of total billed charges,1348.66,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1635.25,97,,,percent of total billed charges,97% of total billed charges,1517.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1635.25,97,,,percent of total billed charges,97% of total billed charges,1567.81,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,542,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1635.25,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,542,32247.16,
27405- Rpr/torn lig/capsule/knee/collater,3435018,CDM,510,RC,27405,HCPCS,Outpatient,,,1769.35,884.68,,1592.42,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1415.48,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1592.42,90,,,Percent of total Billed charges,90% of total billed charges,488.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1716.27,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1627.8,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1592.42,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1238.55,70,,,percent of total billed charges,70% of total billed charges,1592.42,90,,,percent of total billed charges,90% of total billed charges,1680.88,95,,,percent of total billed charges,95% of total billed charges,1680.88,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1521.64,86,,,percent of total billed charges,86% of total billed charges,1415.48,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1716.27,97,,,percent of total billed charges,97% of total billed charges,1592.42,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1716.27,97,,,percent of total billed charges,97% of total billed charges,1645.5,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,444.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1716.27,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,444.5,32247.16,
27407- Rpr/torn lig/capsule/knee/cruciate,3435019,CDM,510,RC,27407,HCPCS,Outpatient,,,2086.11,1043.06,,1877.5,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1668.89,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1877.5,90,,,Percent of total Billed charges,90% of total billed charges,434.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2023.53,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1919.22,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1877.5,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1460.28,70,,,percent of total billed charges,70% of total billed charges,1877.5,90,,,percent of total billed charges,90% of total billed charges,1981.8,95,,,percent of total billed charges,95% of total billed charges,1981.8,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1794.05,86,,,percent of total billed charges,86% of total billed charges,1668.89,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2023.53,97,,,percent of total billed charges,97% of total billed charges,1877.5,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2023.53,97,,,percent of total billed charges,97% of total billed charges,1940.08,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,395,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2023.53,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,395,32247.16,
27415- Osteochondral allograft/knee/open,3435020,CDM,510,RC,27415,HCPCS,Outpatient,,,3600.84,1800.42,,3240.76,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2880.67,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3240.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3492.81,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3312.77,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3240.76,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2520.59,70,,,percent of total billed charges,70% of total billed charges,3240.76,90,,,percent of total billed charges,90% of total billed charges,3420.8,95,,,percent of total billed charges,95% of total billed charges,3420.8,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3096.72,86,,,percent of total billed charges,86% of total billed charges,2880.67,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3492.81,97,,,percent of total billed charges,97% of total billed charges,3240.76,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3492.81,97,,,percent of total billed charges,97% of total billed charges,3348.78,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3492.81,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2520.59,63611.04,
27418- Repair/upper end/tibia at knee jnt,3435021,CDM,510,RC,27418,HCPCS,Outpatient,,,2177.37,1088.69,,1959.63,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1741.9,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1959.63,90,,,Percent of total Billed charges,90% of total billed charges,626.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2112.05,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2003.18,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1959.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.16,70,,,percent of total billed charges,70% of total billed charges,1959.63,90,,,percent of total billed charges,90% of total billed charges,2068.5,95,,,percent of total billed charges,95% of total billed charges,2068.5,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1872.54,86,,,percent of total billed charges,86% of total billed charges,1741.9,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2112.05,97,,,percent of total billed charges,97% of total billed charges,1959.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2112.05,97,,,percent of total billed charges,97% of total billed charges,2024.95,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2112.05,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,569.5,32247.16,
27420- Revise dislocateating patella,3435022,CDM,510,RC,27420,HCPCS,Outpatient,,,1943.73,971.87,,1749.36,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1554.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1749.36,90,,,Percent of total Billed charges,90% of total billed charges,429,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1885.42,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1788.23,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1749.36,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.61,70,,,percent of total billed charges,70% of total billed charges,1749.36,90,,,percent of total billed charges,90% of total billed charges,1846.54,95,,,percent of total billed charges,95% of total billed charges,1846.54,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1671.61,86,,,percent of total billed charges,86% of total billed charges,1554.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1885.42,97,,,percent of total billed charges,97% of total billed charges,1749.36,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1885.42,97,,,percent of total billed charges,97% of total billed charges,1807.67,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,390,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1885.42,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,390,32247.16,
27422- Revise dislocateat patella/ext realig,3435023,CDM,510,RC,27422,HCPCS,Outpatient,,,1943.88,971.94,,1749.49,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.1,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1749.49,90,,,Percent of total Billed charges,90% of total billed charges,484.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1885.56,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1788.37,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1749.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1360.72,70,,,percent of total billed charges,70% of total billed charges,1749.49,90,,,percent of total billed charges,90% of total billed charges,1846.69,95,,,percent of total billed charges,95% of total billed charges,1846.69,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1671.74,86,,,percent of total billed charges,86% of total billed charges,1555.1,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1885.56,97,,,percent of total billed charges,97% of total billed charges,1749.49,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1885.56,97,,,percent of total billed charges,97% of total billed charges,1807.81,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1885.56,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,440.5,32247.16,
27425- Lateral retinacular release/open,3435024,CDM,510,RC,27425,HCPCS,Outpatient,,,1174.46,587.23,,1057.01,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,939.57,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1057.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1139.23,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1080.5,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1057.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,822.12,70,,,percent of total billed charges,70% of total billed charges,1057.01,90,,,percent of total billed charges,90% of total billed charges,1115.74,95,,,percent of total billed charges,95% of total billed charges,1115.74,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1010.04,86,,,percent of total billed charges,86% of total billed charges,939.57,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1139.23,97,,,percent of total billed charges,97% of total billed charges,1057.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1139.23,97,,,percent of total billed charges,97% of total billed charges,1092.25,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1139.23,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,822.12,14511.58,
27427- Reconstruct knee/extra-articular,3435025,CDM,510,RC,27427,HCPCS,Outpatient,,,1860.25,930.13,,1674.23,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.2,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1674.23,90,,,Percent of total Billed charges,90% of total billed charges,698.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1804.44,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1711.43,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1674.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.18,70,,,percent of total billed charges,70% of total billed charges,1674.23,90,,,percent of total billed charges,90% of total billed charges,1767.24,95,,,percent of total billed charges,95% of total billed charges,1767.24,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1599.82,86,,,percent of total billed charges,86% of total billed charges,1488.2,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1804.44,97,,,percent of total billed charges,97% of total billed charges,1674.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1804.44,97,,,percent of total billed charges,97% of total billed charges,1730.03,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,635.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1804.44,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,635.12,32247.16,
27428- Reconstruct knee/intra-articular,3435026,CDM,510,RC,27428,HCPCS,Outpatient,,,2923.8,1461.90,,2631.42,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2339.04,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2631.42,90,,,Percent of total Billed charges,90% of total billed charges,783.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2836.09,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.9,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2631.42,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2046.66,70,,,percent of total billed charges,70% of total billed charges,2631.42,90,,,percent of total billed charges,90% of total billed charges,2777.61,95,,,percent of total billed charges,95% of total billed charges,2777.61,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2514.47,86,,,percent of total billed charges,86% of total billed charges,2339.04,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2836.09,97,,,percent of total billed charges,97% of total billed charges,2631.42,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2836.09,97,,,percent of total billed charges,97% of total billed charges,2719.13,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,712,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2836.09,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,712,63611.04,
27438- Arthroplasty/patella/with prosth,3435027,CDM,510,RC,27438,HCPCS,Outpatient,,,2202.62,1101.31,,1982.36,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1762.1,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1982.36,90,,,Percent of total Billed charges,90% of total billed charges,818.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2136.54,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2026.41,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1982.36,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1541.83,70,,,percent of total billed charges,70% of total billed charges,1982.36,90,,,percent of total billed charges,90% of total billed charges,2092.49,95,,,percent of total billed charges,95% of total billed charges,2092.49,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1894.25,86,,,percent of total billed charges,86% of total billed charges,1762.1,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2136.54,97,,,percent of total billed charges,97% of total billed charges,1982.36,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2136.54,97,,,percent of total billed charges,97% of total billed charges,2048.44,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,743.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2136.54,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,743.79,63611.04,
27441- Arthroplas/knee/debrd/part synovec,3435028,CDM,510,RC,27441,HCPCS,Outpatient,,,2160.3,1080.15,,1944.27,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1728.24,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1944.27,90,,,Percent of total Billed charges,90% of total billed charges,626.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2095.49,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1987.48,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1944.27,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1512.21,70,,,percent of total billed charges,70% of total billed charges,1944.27,90,,,percent of total billed charges,90% of total billed charges,2052.29,95,,,percent of total billed charges,95% of total billed charges,2052.29,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1857.86,86,,,percent of total billed charges,86% of total billed charges,1728.24,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2095.49,97,,,percent of total billed charges,97% of total billed charges,1944.27,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2095.49,97,,,percent of total billed charges,97% of total billed charges,2009.08,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2095.49,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,569.5,63611.04,
27442- Arthroplast/fem cond/tib plat/knee,3435029,CDM,510,RC,27442,HCPCS,Outpatient,,,2285.43,1142.72,,2056.89,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.34,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2056.89,90,,,Percent of total Billed charges,90% of total billed charges,749.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2216.87,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2102.6,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2056.89,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1599.8,70,,,percent of total billed charges,70% of total billed charges,2056.89,90,,,percent of total billed charges,90% of total billed charges,2171.16,95,,,percent of total billed charges,95% of total billed charges,2171.16,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1965.47,86,,,percent of total billed charges,86% of total billed charges,1828.34,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2216.87,97,,,percent of total billed charges,97% of total billed charges,2056.89,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2216.87,97,,,percent of total billed charges,97% of total billed charges,2125.45,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2216.87,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,681.5,63611.04,
27446- Arthroplast/knee/med or lat comp,3435030,CDM,510,RC,27446,HCPCS,Outpatient,,,3039.03,1519.52,,2735.13,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2431.22,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2735.13,90,,,Percent of total Billed charges,90% of total billed charges,1017.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2947.86,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2795.91,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2735.13,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2127.32,70,,,percent of total billed charges,70% of total billed charges,2735.13,90,,,percent of total billed charges,90% of total billed charges,2887.08,95,,,percent of total billed charges,95% of total billed charges,2887.08,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2613.57,86,,,percent of total billed charges,86% of total billed charges,2431.22,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2947.86,97,,,percent of total billed charges,97% of total billed charges,2735.13,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2947.86,97,,,percent of total billed charges,97% of total billed charges,2826.3,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,925,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2947.86,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,925,63611.04,
27447- Total Knee Arthroplasty,3435031,CDM,510,RC,27447,HCPCS,Outpatient,,,3380.24,1690.12,,3042.22,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2704.19,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3042.22,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3278.83,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3109.82,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3042.22,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2366.17,70,,,percent of total billed charges,70% of total billed charges,3042.22,90,,,percent of total billed charges,90% of total billed charges,3211.23,95,,,percent of total billed charges,95% of total billed charges,3211.23,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2907.01,86,,,percent of total billed charges,86% of total billed charges,2704.19,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3278.83,97,,,percent of total billed charges,97% of total billed charges,3042.22,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3278.83,97,,,percent of total billed charges,97% of total billed charges,3143.62,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3278.83,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1000,63611.04,
27472- Rpr/non/malun/femor w/autogen gft,3435032,CDM,510,RC,27472,HCPCS,Outpatient,,,3322.68,1661.34,,2990.41,90,,,percent of total billed charges,90% of total Billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2658.14,80,,,Percent of total Billed charges,80% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2990.41,90,,,Percent of total Billed charges,90% of total billed charges,860.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3223,97,,,Percent of total billed charges,97% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3056.87,92,,,Percent of total billed charges,92% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2990.41,90,,,percent of total billed charges,90% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2325.88,70,,,percent of total billed charges,70% of total billed charges,2990.41,90,,,percent of total billed charges,90% of total billed charges,3156.55,95,,,percent of total billed charges,95% of total billed charges,3156.55,95,,,percent of total billed charges,95% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2857.5,86,,,percent of total billed charges,86% of total billed charges,2658.14,80,,,percent of total billed charges,80% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223,97,,,percent of total billed charges,97% of total billed charges,2990.41,90,,,percent of total billed charges,90% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3223,97,,,percent of total billed charges,97% of total billed charges,3090.09,93,,,percent of total billed charges,93% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,782,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3223,97,,,percent of total billed charges,97% of total billed charges,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3322.68,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,782,3322.68,
27486- Revise total knee/1 component,3435033,CDM,510,RC,27486,HCPCS,Outpatient,,,3692.8,1846.40,,3323.52,90,,,percent of total billed charges,90% of total Billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2954.24,80,,,Percent of total Billed charges,80% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3323.52,90,,,Percent of total Billed charges,90% of total billed charges,781.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3582.02,97,,,Percent of total billed charges,97% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3397.38,92,,,Percent of total billed charges,92% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3323.52,90,,,percent of total billed charges,90% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2584.96,70,,,percent of total billed charges,70% of total billed charges,3323.52,90,,,percent of total billed charges,90% of total billed charges,3508.16,95,,,percent of total billed charges,95% of total billed charges,3508.16,95,,,percent of total billed charges,95% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3175.81,86,,,percent of total billed charges,86% of total billed charges,2954.24,80,,,percent of total billed charges,80% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3582.02,97,,,percent of total billed charges,97% of total billed charges,3323.52,90,,,percent of total billed charges,90% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3582.02,97,,,percent of total billed charges,97% of total billed charges,3434.3,93,,,percent of total billed charges,93% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,710.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3582.02,97,,,percent of total billed charges,97% of total billed charges,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3692.8,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,710.5,3692.8,
27487- Revise tot knee/fem/tibial comp,3435034,CDM,510,RC,27487,HCPCS,Outpatient,,,4622.38,2311.19,,4160.14,90,,,percent of total billed charges,90% of total Billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3697.9,80,,,Percent of total Billed charges,80% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4160.14,90,,,Percent of total Billed charges,90% of total billed charges,957.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4483.71,97,,,Percent of total billed charges,97% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4252.59,92,,,Percent of total billed charges,92% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4160.14,90,,,percent of total billed charges,90% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3235.67,70,,,percent of total billed charges,70% of total billed charges,4160.14,90,,,percent of total billed charges,90% of total billed charges,4391.26,95,,,percent of total billed charges,95% of total billed charges,4391.26,95,,,percent of total billed charges,95% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3975.25,86,,,percent of total billed charges,86% of total billed charges,3697.9,80,,,percent of total billed charges,80% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4483.71,97,,,percent of total billed charges,97% of total billed charges,4160.14,90,,,percent of total billed charges,90% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4483.71,97,,,percent of total billed charges,97% of total billed charges,4298.81,93,,,percent of total billed charges,93% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,870.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4483.71,97,,,percent of total billed charges,97% of total billed charges,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4622.38,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,870.5,4622.38,
27488- Remove/total knee prosthesis,3435035,CDM,510,RC,27488,HCPCS,Outpatient,,,3150.83,1575.42,,2835.75,90,,,percent of total billed charges,90% of total Billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2520.66,80,,,Percent of total Billed charges,80% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2835.75,90,,,Percent of total Billed charges,90% of total billed charges,792,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3056.31,97,,,Percent of total billed charges,97% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2898.76,92,,,Percent of total billed charges,92% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2835.75,90,,,percent of total billed charges,90% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2205.58,70,,,percent of total billed charges,70% of total billed charges,2835.75,90,,,percent of total billed charges,90% of total billed charges,2993.29,95,,,percent of total billed charges,95% of total billed charges,2993.29,95,,,percent of total billed charges,95% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2709.71,86,,,percent of total billed charges,86% of total billed charges,2520.66,80,,,percent of total billed charges,80% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3056.31,97,,,percent of total billed charges,97% of total billed charges,2835.75,90,,,percent of total billed charges,90% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3056.31,97,,,percent of total billed charges,97% of total billed charges,2930.27,93,,,percent of total billed charges,93% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,720,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3056.31,97,,,percent of total billed charges,97% of total billed charges,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3150.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,720,3150.83,
27499- Decompr fasciot/thigh/knee/debrid,3435036,CDM,510,RC,27499,HCPCS,Outpatient,,,1834.22,917.11,,1650.8,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1467.38,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1779.19,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1687.48,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1650.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1283.95,70,,,percent of total billed charges,70% of total billed charges,1650.8,90,,,percent of total billed charges,90% of total billed charges,1742.51,95,,,percent of total billed charges,95% of total billed charges,1742.51,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1577.43,86,,,percent of total billed charges,86% of total billed charges,1467.38,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1779.19,97,,,percent of total billed charges,97% of total billed charges,1650.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1779.19,97,,,percent of total billed charges,97% of total billed charges,1705.82,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1779.19,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1283.95,32247.16,
27500- Clsd tx/fem shaft fx w/o manip,3435037,CDM,510,RC,27500,HCPCS,Outpatient,,,1354.67,677.34,,1219.2,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1083.74,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1219.2,90,,,Percent of total Billed charges,90% of total billed charges,256.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1314.03,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1246.3,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1219.2,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,948.27,70,,,percent of total billed charges,70% of total billed charges,1219.2,90,,,percent of total billed charges,90% of total billed charges,1286.94,95,,,percent of total billed charges,95% of total billed charges,1286.94,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1165.02,86,,,percent of total billed charges,86% of total billed charges,1083.74,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1314.03,97,,,percent of total billed charges,97% of total billed charges,1219.2,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1314.03,97,,,percent of total billed charges,97% of total billed charges,1259.84,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1314.03,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1314.03,
27501- Clsd tx/supracond fem fx w/o manip,3435038,CDM,510,RC,27501,HCPCS,Outpatient,,,1323.44,661.72,,1191.1,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.75,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1191.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1283.74,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.56,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1191.1,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,926.41,70,,,percent of total billed charges,70% of total billed charges,1191.1,90,,,percent of total billed charges,90% of total billed charges,1257.27,95,,,percent of total billed charges,95% of total billed charges,1257.27,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1138.16,86,,,percent of total billed charges,86% of total billed charges,1058.75,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1283.74,97,,,percent of total billed charges,97% of total billed charges,1191.1,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1283.74,97,,,percent of total billed charges,97% of total billed charges,1230.8,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1283.74,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1283.74,
27502- Clsd tx/fem shaft fx/manipulation,3435039,CDM,510,RC,27502,HCPCS,Outpatient,,,2005.88,1002.94,,1805.29,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.7,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1805.29,90,,,Percent of total Billed charges,90% of total billed charges,434.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1945.7,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1845.41,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1805.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1404.12,70,,,percent of total billed charges,70% of total billed charges,1805.29,90,,,percent of total billed charges,90% of total billed charges,1905.59,95,,,percent of total billed charges,95% of total billed charges,1905.59,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1725.06,86,,,percent of total billed charges,86% of total billed charges,1604.7,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1945.7,97,,,percent of total billed charges,97% of total billed charges,1805.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1945.7,97,,,percent of total billed charges,97% of total billed charges,1865.47,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,395,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1945.7,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,395,6993.46,
27506- Open tx/fem sft fx/intrmedu implnt,3435040,CDM,510,RC,27506,HCPCS,Outpatient,,,3510.39,1755.20,,3159.35,90,,,percent of total billed charges,90% of total Billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2808.31,80,,,Percent of total Billed charges,80% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3159.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3405.08,97,,,Percent of total billed charges,97% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3229.56,92,,,Percent of total billed charges,92% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3159.35,90,,,percent of total billed charges,90% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2457.27,70,,,percent of total billed charges,70% of total billed charges,3159.35,90,,,percent of total billed charges,90% of total billed charges,3334.87,95,,,percent of total billed charges,95% of total billed charges,3334.87,95,,,percent of total billed charges,95% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3018.94,86,,,percent of total billed charges,86% of total billed charges,2808.31,80,,,percent of total billed charges,80% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3405.08,97,,,percent of total billed charges,97% of total billed charges,3159.35,90,,,percent of total billed charges,90% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3405.08,97,,,percent of total billed charges,97% of total billed charges,3264.66,93,,,percent of total billed charges,93% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3405.08,97,,,percent of total billed charges,97% of total billed charges,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3510.39,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2457.27,3510.39,
27507- Open tx/fem shaft fx/plate/screws,3435041,CDM,510,RC,27507,HCPCS,Outpatient,,,2549.93,1274.97,,2294.94,90,,,percent of total billed charges,90% of total Billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2039.94,80,,,Percent of total Billed charges,80% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2294.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2473.43,97,,,Percent of total billed charges,97% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2345.94,92,,,Percent of total billed charges,92% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2294.94,90,,,percent of total billed charges,90% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1784.95,70,,,percent of total billed charges,70% of total billed charges,2294.94,90,,,percent of total billed charges,90% of total billed charges,2422.43,95,,,percent of total billed charges,95% of total billed charges,2422.43,95,,,percent of total billed charges,95% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2192.94,86,,,percent of total billed charges,86% of total billed charges,2039.94,80,,,percent of total billed charges,80% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.43,97,,,percent of total billed charges,97% of total billed charges,2294.94,90,,,percent of total billed charges,90% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2473.43,97,,,percent of total billed charges,97% of total billed charges,2371.43,93,,,percent of total billed charges,93% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2473.43,97,,,percent of total billed charges,97% of total billed charges,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2549.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1784.95,2549.93,
27508- Clsd tx/fem fx/dis/med/lat condyle,3435042,CDM,510,RC,27508,HCPCS,Outpatient,,,1363.79,681.90,,1227.41,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.03,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1227.41,90,,,Percent of total Billed charges,90% of total billed charges,268.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1322.88,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1254.69,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1227.41,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,954.65,70,,,percent of total billed charges,70% of total billed charges,1227.41,90,,,percent of total billed charges,90% of total billed charges,1295.6,95,,,percent of total billed charges,95% of total billed charges,1295.6,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1172.86,86,,,percent of total billed charges,86% of total billed charges,1091.03,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1322.88,97,,,percent of total billed charges,97% of total billed charges,1227.41,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1322.88,97,,,percent of total billed charges,97% of total billed charges,1268.32,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1322.88,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1322.88,
27509- Perc skeletal fix/distal fem fx/med/lat condyle or supra/trans,3435043,CDM,510,RC,27509,HCPCS,Outpatient,,,1759.34,879.67,,1583.41,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.47,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1583.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1706.56,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1618.59,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1583.41,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.54,70,,,percent of total billed charges,70% of total billed charges,1583.41,90,,,percent of total billed charges,90% of total billed charges,1671.37,95,,,percent of total billed charges,95% of total billed charges,1671.37,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1513.03,86,,,percent of total billed charges,86% of total billed charges,1407.47,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1706.56,97,,,percent of total billed charges,97% of total billed charges,1583.41,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1706.56,97,,,percent of total billed charges,97% of total billed charges,1636.19,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1706.56,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1231.54,32247.16,
27511- Open tx/fem supr/transcon fx/no ex,3435044,CDM,510,RC,27511,HCPCS,Outpatient,,,2625.72,1312.86,,2363.15,90,,,percent of total billed charges,90% of total Billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2100.58,80,,,Percent of total Billed charges,80% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2546.95,97,,,Percent of total billed charges,97% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2415.66,92,,,Percent of total billed charges,92% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.15,90,,,percent of total billed charges,90% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1838,70,,,percent of total billed charges,70% of total billed charges,2363.15,90,,,percent of total billed charges,90% of total billed charges,2494.43,95,,,percent of total billed charges,95% of total billed charges,2494.43,95,,,percent of total billed charges,95% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2258.12,86,,,percent of total billed charges,86% of total billed charges,2100.58,80,,,percent of total billed charges,80% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2546.95,97,,,percent of total billed charges,97% of total billed charges,2363.15,90,,,percent of total billed charges,90% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2546.95,97,,,percent of total billed charges,97% of total billed charges,2441.92,93,,,percent of total billed charges,93% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2546.95,97,,,percent of total billed charges,97% of total billed charges,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2625.72,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1838,2625.72,
27513- Open tx/fem supra/transcondylar fx,3435045,CDM,510,RC,27513,HCPCS,Outpatient,,,3268.76,1634.38,,2941.88,90,,,percent of total billed charges,90% of total Billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2615.01,80,,,Percent of total Billed charges,80% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2941.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3170.7,97,,,Percent of total billed charges,97% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3007.26,92,,,Percent of total billed charges,92% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2941.88,90,,,percent of total billed charges,90% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2288.13,70,,,percent of total billed charges,70% of total billed charges,2941.88,90,,,percent of total billed charges,90% of total billed charges,3105.32,95,,,percent of total billed charges,95% of total billed charges,3105.32,95,,,percent of total billed charges,95% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2811.13,86,,,percent of total billed charges,86% of total billed charges,2615.01,80,,,percent of total billed charges,80% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3170.7,97,,,percent of total billed charges,97% of total billed charges,2941.88,90,,,percent of total billed charges,90% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3170.7,97,,,percent of total billed charges,97% of total billed charges,3039.95,93,,,percent of total billed charges,93% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3170.7,97,,,percent of total billed charges,97% of total billed charges,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3268.76,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2288.13,3268.76,
27514- Open tx/fem fx/distal/internal fix,3435046,CDM,510,RC,27514,HCPCS,Outpatient,,,2548.32,1274.16,,2293.49,90,,,percent of total billed charges,90% of total Billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2038.66,80,,,Percent of total Billed charges,80% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2293.49,90,,,Percent of total Billed charges,90% of total billed charges,555.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2471.87,97,,,Percent of total billed charges,97% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2344.45,92,,,Percent of total billed charges,92% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2293.49,90,,,percent of total billed charges,90% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1783.82,70,,,percent of total billed charges,70% of total billed charges,2293.49,90,,,percent of total billed charges,90% of total billed charges,2420.9,95,,,percent of total billed charges,95% of total billed charges,2420.9,95,,,percent of total billed charges,95% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2191.56,86,,,percent of total billed charges,86% of total billed charges,2038.66,80,,,percent of total billed charges,80% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.87,97,,,percent of total billed charges,97% of total billed charges,2293.49,90,,,percent of total billed charges,90% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2471.87,97,,,percent of total billed charges,97% of total billed charges,2369.94,93,,,percent of total billed charges,93% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2471.87,97,,,percent of total billed charges,97% of total billed charges,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2548.32,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505,2548.32,
27516- Clsd tx/dis fem epiphyseal separat,3435047,CDM,510,RC,27516,HCPCS,Outpatient,,,1336.4,668.20,,1202.76,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1069.12,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1202.76,90,,,Percent of total Billed charges,90% of total billed charges,268.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1296.31,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1229.49,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1202.76,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,935.48,70,,,percent of total billed charges,70% of total billed charges,1202.76,90,,,percent of total billed charges,90% of total billed charges,1269.58,95,,,percent of total billed charges,95% of total billed charges,1269.58,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1149.3,86,,,percent of total billed charges,86% of total billed charges,1069.12,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1296.31,97,,,percent of total billed charges,97% of total billed charges,1202.76,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1296.31,97,,,percent of total billed charges,97% of total billed charges,1242.85,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1296.31,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1296.31,
27519- Open tx/dis fem epiphyseal separat,3435048,CDM,510,RC,27519,HCPCS,Outpatient,,,2347.57,1173.79,,2112.81,90,,,percent of total billed charges,90% of total Billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1878.06,80,,,Percent of total Billed charges,80% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2112.81,90,,,Percent of total Billed charges,90% of total billed charges,555.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2277.14,97,,,Percent of total billed charges,97% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2159.76,92,,,Percent of total billed charges,92% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2112.81,90,,,percent of total billed charges,90% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1643.3,70,,,percent of total billed charges,70% of total billed charges,2112.81,90,,,percent of total billed charges,90% of total billed charges,2230.19,95,,,percent of total billed charges,95% of total billed charges,2230.19,95,,,percent of total billed charges,95% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2018.91,86,,,percent of total billed charges,86% of total billed charges,1878.06,80,,,percent of total billed charges,80% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.14,97,,,percent of total billed charges,97% of total billed charges,2112.81,90,,,percent of total billed charges,90% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2277.14,97,,,percent of total billed charges,97% of total billed charges,2183.24,93,,,percent of total billed charges,93% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2277.14,97,,,percent of total billed charges,97% of total billed charges,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2347.57,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,505,2347.57,
27520- Clsd tx/patellar fx w/o manip,3435049,CDM,510,RC,27520,HCPCS,Outpatient,,,832.32,416.16,,749.09,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,665.86,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.09,90,,,Percent of total Billed charges,90% of total billed charges,144.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,807.35,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,765.73,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,749.09,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,582.62,70,,,percent of total billed charges,70% of total billed charges,749.09,90,,,percent of total billed charges,90% of total billed charges,790.7,95,,,percent of total billed charges,95% of total billed charges,790.7,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,715.8,86,,,percent of total billed charges,86% of total billed charges,665.86,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,807.35,97,,,percent of total billed charges,97% of total billed charges,749.09,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,807.35,97,,,percent of total billed charges,97% of total billed charges,774.06,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,807.35,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131,1009.19,
27524- Open tx/patellar fx/internal fix,3435050,CDM,510,RC,27524,HCPCS,Outpatient,,,1972.64,986.32,,1775.38,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.11,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1775.38,90,,,Percent of total Billed charges,90% of total billed charges,446.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1913.46,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1814.83,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1775.38,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1380.85,70,,,percent of total billed charges,70% of total billed charges,1775.38,90,,,percent of total billed charges,90% of total billed charges,1874.01,95,,,percent of total billed charges,95% of total billed charges,1874.01,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1696.47,86,,,percent of total billed charges,86% of total billed charges,1578.11,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1913.46,97,,,percent of total billed charges,97% of total billed charges,1775.38,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1913.46,97,,,percent of total billed charges,97% of total billed charges,1834.56,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,406,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1913.46,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,406,32247.16,
27530- Clsd tx/tib fx/prox w/o manip,3435051,CDM,510,RC,27530,HCPCS,Outpatient,,,784.28,392.14,,705.85,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,627.42,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.85,90,,,Percent of total Billed charges,90% of total billed charges,141.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,760.75,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,721.54,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,705.85,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,549,70,,,percent of total billed charges,70% of total billed charges,705.85,90,,,percent of total billed charges,90% of total billed charges,745.07,95,,,percent of total billed charges,95% of total billed charges,745.07,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.48,86,,,percent of total billed charges,86% of total billed charges,627.42,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,760.75,97,,,percent of total billed charges,97% of total billed charges,705.85,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,760.75,97,,,percent of total billed charges,97% of total billed charges,729.38,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,760.75,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.5,1009.19,
27532- Clsd tx/tib fx/prox w/skel trac,3435052,CDM,510,RC,27532,HCPCS,Outpatient,,,1612.38,806.19,,1451.14,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1289.9,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1451.14,90,,,Percent of total Billed charges,90% of total billed charges,250.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1564.01,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1483.39,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1451.14,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.67,70,,,percent of total billed charges,70% of total billed charges,1451.14,90,,,percent of total billed charges,90% of total billed charges,1531.76,95,,,percent of total billed charges,95% of total billed charges,1531.76,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1386.65,86,,,percent of total billed charges,86% of total billed charges,1289.9,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1564.01,97,,,percent of total billed charges,97% of total billed charges,1451.14,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1564.01,97,,,percent of total billed charges,97% of total billed charges,1499.51,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1564.01,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,227.5,14511.58,
27535- Open tx/tib fx/prox unicondylar,3435053,CDM,510,RC,27535,HCPCS,Outpatient,,,2363.08,1181.54,,2126.77,90,,,percent of total billed charges,90% of total Billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1890.46,80,,,Percent of total Billed charges,80% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2292.19,97,,,Percent of total billed charges,97% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2174.03,92,,,Percent of total billed charges,92% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2126.77,90,,,percent of total billed charges,90% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1654.16,70,,,percent of total billed charges,70% of total billed charges,2126.77,90,,,percent of total billed charges,90% of total billed charges,2244.93,95,,,percent of total billed charges,95% of total billed charges,2244.93,95,,,percent of total billed charges,95% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2032.25,86,,,percent of total billed charges,86% of total billed charges,1890.46,80,,,percent of total billed charges,80% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2292.19,97,,,percent of total billed charges,97% of total billed charges,2126.77,90,,,percent of total billed charges,90% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2292.19,97,,,percent of total billed charges,97% of total billed charges,2197.66,93,,,percent of total billed charges,93% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2292.19,97,,,percent of total billed charges,97% of total billed charges,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2363.08,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1654.16,2363.08,
27536- Open tx/tib fx/prox bicondylar,3435054,CDM,510,RC,27536,HCPCS,Outpatient,,,3116.5,1558.25,,2804.85,90,,,percent of total billed charges,90% of total Billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2493.2,80,,,Percent of total Billed charges,80% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2804.85,90,,,Percent of total Billed charges,90% of total billed charges,598.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3023.01,97,,,Percent of total billed charges,97% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2867.18,92,,,Percent of total billed charges,92% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2804.85,90,,,percent of total billed charges,90% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2181.55,70,,,percent of total billed charges,70% of total billed charges,2804.85,90,,,percent of total billed charges,90% of total billed charges,2960.68,95,,,percent of total billed charges,95% of total billed charges,2960.68,95,,,percent of total billed charges,95% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2680.19,86,,,percent of total billed charges,86% of total billed charges,2493.2,80,,,percent of total billed charges,80% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3023.01,97,,,percent of total billed charges,97% of total billed charges,2804.85,90,,,percent of total billed charges,90% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3023.01,97,,,percent of total billed charges,97% of total billed charges,2898.35,93,,,percent of total billed charges,93% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3023.01,97,,,percent of total billed charges,97% of total billed charges,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3116.5,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544,3116.5,
27538- Clsd tx/intercondyl spine fx/knee,3435055,CDM,510,RC,27538,HCPCS,Outpatient,,,1253.47,626.74,,1128.12,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.78,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1128.12,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1215.87,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1153.19,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1128.12,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,877.43,70,,,percent of total billed charges,70% of total billed charges,1128.12,90,,,percent of total billed charges,90% of total billed charges,1190.8,95,,,percent of total billed charges,95% of total billed charges,1190.8,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1077.98,86,,,percent of total billed charges,86% of total billed charges,1002.78,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1215.87,97,,,percent of total billed charges,97% of total billed charges,1128.12,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1215.87,97,,,percent of total billed charges,97% of total billed charges,1165.73,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1215.87,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,1215.87,
27540- Open tx/intercondyl spine fx/knee,3435056,CDM,510,RC,27540,HCPCS,Outpatient,,,2131.61,1065.81,,1918.45,90,,,percent of total billed charges,90% of total Billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1705.29,80,,,Percent of total Billed charges,80% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1918.45,90,,,Percent of total Billed charges,90% of total billed charges,577.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2067.66,97,,,Percent of total billed charges,97% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1961.08,92,,,Percent of total billed charges,92% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1918.45,90,,,percent of total billed charges,90% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1492.13,70,,,percent of total billed charges,70% of total billed charges,1918.45,90,,,percent of total billed charges,90% of total billed charges,2025.03,95,,,percent of total billed charges,95% of total billed charges,2025.03,95,,,percent of total billed charges,95% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1833.18,86,,,percent of total billed charges,86% of total billed charges,1705.29,80,,,percent of total billed charges,80% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2067.66,97,,,percent of total billed charges,97% of total billed charges,1918.45,90,,,percent of total billed charges,90% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2067.66,97,,,percent of total billed charges,97% of total billed charges,1982.4,93,,,percent of total billed charges,93% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,525,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2067.66,97,,,percent of total billed charges,97% of total billed charges,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2131.61,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,525,2131.61,
27550- Clsd tx/knee dislocate w/o anesth,3435057,CDM,510,RC,27550,HCPCS,Outpatient,,,1337.69,668.85,,1203.92,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1070.15,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1203.92,90,,,Percent of total Billed charges,90% of total billed charges,172.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1297.56,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1230.67,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1203.92,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,936.38,70,,,percent of total billed charges,70% of total billed charges,1203.92,90,,,percent of total billed charges,90% of total billed charges,1270.81,95,,,percent of total billed charges,95% of total billed charges,1270.81,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1150.41,86,,,percent of total billed charges,86% of total billed charges,1070.15,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1297.56,97,,,percent of total billed charges,97% of total billed charges,1203.92,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1297.56,97,,,percent of total billed charges,97% of total billed charges,1244.05,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,157,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1297.56,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,157,1297.56,
27558- Open tx/knee dislocatet/ligament rpr,3435058,CDM,510,RC,27558,HCPCS,Outpatient,,,3143.89,1571.95,,2829.5,90,,,percent of total billed charges,90% of total Billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2515.11,80,,,Percent of total Billed charges,80% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2829.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3049.57,97,,,Percent of total billed charges,97% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2892.38,92,,,Percent of total billed charges,92% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2829.5,90,,,percent of total billed charges,90% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.72,70,,,percent of total billed charges,70% of total billed charges,2829.5,90,,,percent of total billed charges,90% of total billed charges,2986.7,95,,,percent of total billed charges,95% of total billed charges,2986.7,95,,,percent of total billed charges,95% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2703.75,86,,,percent of total billed charges,86% of total billed charges,2515.11,80,,,percent of total billed charges,80% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3049.57,97,,,percent of total billed charges,97% of total billed charges,2829.5,90,,,percent of total billed charges,90% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3049.57,97,,,percent of total billed charges,97% of total billed charges,2923.82,93,,,percent of total billed charges,93% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3049.57,97,,,percent of total billed charges,97% of total billed charges,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3143.89,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2200.72,3143.89,
27570- Manip/knee jnt/general anesthesia,3435059,CDM,510,RC,27570,HCPCS,Outpatient,,,393.45,196.73,,354.11,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,314.76,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,354.11,90,,,Percent of total Billed charges,90% of total billed charges,109.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,381.65,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,361.97,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,354.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,275.42,70,,,percent of total billed charges,70% of total billed charges,354.11,90,,,percent of total billed charges,90% of total billed charges,373.78,95,,,percent of total billed charges,95% of total billed charges,373.78,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,338.37,86,,,percent of total billed charges,86% of total billed charges,314.76,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,381.65,97,,,percent of total billed charges,97% of total billed charges,354.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,381.65,97,,,percent of total billed charges,97% of total billed charges,365.91,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,381.65,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99.5,6993.46,
27594- Amputate thigh/sec close/scar rev,3435061,CDM,510,RC,27594,HCPCS,Outpatient,,,1340.94,670.47,,1206.85,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.75,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1206.85,90,,,Percent of total Billed charges,90% of total billed charges,348.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1300.71,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1233.66,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1206.85,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,938.66,70,,,percent of total billed charges,70% of total billed charges,1206.85,90,,,percent of total billed charges,90% of total billed charges,1273.89,95,,,percent of total billed charges,95% of total billed charges,1273.89,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1153.21,86,,,percent of total billed charges,86% of total billed charges,1072.75,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1300.71,97,,,percent of total billed charges,97% of total billed charges,1206.85,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1300.71,97,,,percent of total billed charges,97% of total billed charges,1247.07,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,317,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1300.71,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,317,14511.58,
"27596 - (50) Amputation, thigh, through femur, any level; re-amputation",3698912,CDM,510,RC,27596,HCPCS,Outpatient,,,1907.11,953.56,,1716.4,90,,,percent of total billed charges,90% of total Billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1525.69,80,,,Percent of total Billed charges,80% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1716.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1849.9,97,,,Percent of total billed charges,97% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1754.54,92,,,Percent of total billed charges,92% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1716.4,90,,,percent of total billed charges,90% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1334.98,70,,,percent of total billed charges,70% of total billed charges,1716.4,90,,,percent of total billed charges,90% of total billed charges,1811.75,95,,,percent of total billed charges,95% of total billed charges,1811.75,95,,,percent of total billed charges,95% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1640.11,86,,,percent of total billed charges,86% of total billed charges,1525.69,80,,,percent of total billed charges,80% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.9,97,,,percent of total billed charges,97% of total billed charges,1716.4,90,,,percent of total billed charges,90% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1849.9,97,,,percent of total billed charges,97% of total billed charges,1773.61,93,,,percent of total billed charges,93% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,1849.9,97,,,percent of total billed charges,97% of total billed charges,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1907.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,1334.98,1907.11,
27601- Decompress fasciotomy/leg/posterio,3435064,CDM,510,RC,27601,HCPCS,Outpatient,,,1168.37,584.19,,1051.53,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,934.7,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1051.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1133.32,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1074.9,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1051.53,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,817.86,70,,,percent of total billed charges,70% of total billed charges,1051.53,90,,,percent of total billed charges,90% of total billed charges,1109.95,95,,,percent of total billed charges,95% of total billed charges,1109.95,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1004.8,86,,,percent of total billed charges,86% of total billed charges,934.7,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1133.32,97,,,percent of total billed charges,97% of total billed charges,1051.53,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1133.32,97,,,percent of total billed charges,97% of total billed charges,1086.58,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1133.32,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,817.86,14511.58,
27603- I&D leg/ankle/deep abscess/hema,3435065,CDM,510,RC,27603,HCPCS,Outpatient,,,1358.89,679.45,,1223,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1087.11,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1223,90,,,Percent of total Billed charges,90% of total billed charges,97.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1318.12,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1250.18,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1223,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,951.22,70,,,percent of total billed charges,70% of total billed charges,1223,90,,,percent of total billed charges,90% of total billed charges,1290.95,95,,,percent of total billed charges,95% of total billed charges,1290.95,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1168.65,86,,,percent of total billed charges,86% of total billed charges,1087.11,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1318.12,97,,,percent of total billed charges,97% of total billed charges,1223,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.12,97,,,percent of total billed charges,97% of total billed charges,1263.77,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1318.12,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,88.5,12593.67,
27604- I&D/leg/ankle/infected bursa,3435066,CDM,510,RC,27604,HCPCS,Outpatient,,,1137.61,568.81,,1023.85,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,910.09,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1023.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1103.48,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.6,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1023.85,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,796.33,70,,,percent of total billed charges,70% of total billed charges,1023.85,90,,,percent of total billed charges,90% of total billed charges,1080.73,95,,,percent of total billed charges,95% of total billed charges,1080.73,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,978.34,86,,,percent of total billed charges,86% of total billed charges,910.09,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1103.48,97,,,percent of total billed charges,97% of total billed charges,1023.85,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1103.48,97,,,percent of total billed charges,97% of total billed charges,1057.98,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1103.48,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,796.33,14511.58,
27605- Tenotomy/perc/Achilles/local anes,3435067,CDM,510,RC,27605,HCPCS,Outpatient,,,827.52,413.76,,744.77,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,662.02,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,744.77,90,,,Percent of total Billed charges,90% of total billed charges,200.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,802.69,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,761.32,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,744.77,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,579.26,70,,,percent of total billed charges,70% of total billed charges,744.77,90,,,percent of total billed charges,90% of total billed charges,786.14,95,,,percent of total billed charges,95% of total billed charges,786.14,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,711.67,86,,,percent of total billed charges,86% of total billed charges,662.02,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,802.69,97,,,percent of total billed charges,97% of total billed charges,744.77,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,802.69,97,,,percent of total billed charges,97% of total billed charges,769.59,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,802.69,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,182.06,6993.46,
27606- Tenotomy/perc/Achilles/gen anesth,3435068,CDM,510,RC,27606,HCPCS,Outpatient,,,712.96,356.48,,641.66,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,570.37,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.66,90,,,Percent of total Billed charges,90% of total billed charges,262.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,691.57,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,655.92,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,641.66,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,499.07,70,,,percent of total billed charges,70% of total billed charges,641.66,90,,,percent of total billed charges,90% of total billed charges,677.31,95,,,percent of total billed charges,95% of total billed charges,677.31,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,613.15,86,,,percent of total billed charges,86% of total billed charges,570.37,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,691.57,97,,,percent of total billed charges,97% of total billed charges,641.66,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,691.57,97,,,percent of total billed charges,97% of total billed charges,663.05,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,239,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,691.57,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,239,14511.58,
27610- Arthrot/ankle/explore/drain/rmv FB,3435069,CDM,510,RC,27610,HCPCS,Outpatient,,,1690.32,845.16,,1521.29,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.26,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.29,90,,,Percent of total Billed charges,90% of total billed charges,378.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1639.61,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.09,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1521.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.22,70,,,percent of total billed charges,70% of total billed charges,1521.29,90,,,percent of total billed charges,90% of total billed charges,1605.8,95,,,percent of total billed charges,95% of total billed charges,1605.8,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1453.68,86,,,percent of total billed charges,86% of total billed charges,1352.26,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1639.61,97,,,percent of total billed charges,97% of total billed charges,1521.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1639.61,97,,,percent of total billed charges,97% of total billed charges,1572,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,344.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1639.61,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,344.5,14511.58,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,510,RC,27613,HCPCS,Outpatient,,,634.25,317.13,,570.83,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,507.4,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,570.83,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,615.22,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,583.51,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,570.83,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,443.98,70,,,percent of total billed charges,70% of total billed charges,570.83,90,,,percent of total billed charges,90% of total billed charges,602.54,95,,,percent of total billed charges,95% of total billed charges,602.54,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,545.46,86,,,percent of total billed charges,86% of total billed charges,507.4,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,615.22,97,,,percent of total billed charges,97% of total billed charges,570.83,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,615.22,97,,,percent of total billed charges,97% of total billed charges,589.85,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,615.22,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
27615- Rad resect/tumor/leg/ankle/<5 cm,3435070,CDM,510,RC,27615,HCPCS,Outpatient,,,2702.65,1351.33,,2432.39,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2162.12,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2432.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2621.57,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2486.44,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2432.39,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1891.86,70,,,percent of total billed charges,70% of total billed charges,2432.39,90,,,percent of total billed charges,90% of total billed charges,2567.52,95,,,percent of total billed charges,95% of total billed charges,2567.52,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2324.28,86,,,percent of total billed charges,86% of total billed charges,2162.12,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2621.57,97,,,percent of total billed charges,97% of total billed charges,2432.39,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2621.57,97,,,percent of total billed charges,97% of total billed charges,2513.46,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2621.57,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1891.86,12593.67,
27616- Resect/sft tis tum/leg/ankle/5cm/>,3435071,CDM,510,RC,27616,HCPCS,Outpatient,,,3362.7,1681.35,,3026.43,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2690.16,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3026.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3261.82,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,3093.68,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3026.43,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2353.89,70,,,percent of total billed charges,70% of total billed charges,3026.43,90,,,percent of total billed charges,90% of total billed charges,3194.57,95,,,percent of total billed charges,95% of total billed charges,3194.57,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2891.92,86,,,percent of total billed charges,86% of total billed charges,2690.16,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3261.82,97,,,percent of total billed charges,97% of total billed charges,3026.43,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,3261.82,97,,,percent of total billed charges,97% of total billed charges,3127.31,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3261.82,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
27618- Exc SQ tum/leg or ankle area <3 cm,3435072,CDM,510,RC,27618,HCPCS,Outpatient,,,620.48,310.24,,558.43,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,496.38,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.43,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,601.87,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,570.84,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,558.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,434.34,70,,,percent of total billed charges,70% of total billed charges,558.43,90,,,percent of total billed charges,90% of total billed charges,589.46,95,,,percent of total billed charges,95% of total billed charges,589.46,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,533.61,86,,,percent of total billed charges,86% of total billed charges,496.38,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,601.87,97,,,percent of total billed charges,97% of total billed charges,558.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.87,97,,,percent of total billed charges,97% of total billed charges,577.05,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,601.87,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,7310.49,
27620- Arthrot/ankle w/joint exploration,3435073,CDM,510,RC,27620,HCPCS,Outpatient,,,1167.53,583.77,,1050.78,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,934.02,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1050.78,90,,,Percent of total Billed charges,90% of total billed charges,369.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1132.5,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1074.13,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1050.78,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,817.27,70,,,percent of total billed charges,70% of total billed charges,1050.78,90,,,percent of total billed charges,90% of total billed charges,1109.15,95,,,percent of total billed charges,95% of total billed charges,1109.15,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1004.08,86,,,percent of total billed charges,86% of total billed charges,934.02,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1132.5,97,,,percent of total billed charges,97% of total billed charges,1050.78,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1132.5,97,,,percent of total billed charges,97% of total billed charges,1085.8,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,336,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1132.5,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,336,14511.58,
27630- Exc/tendon sheath lesion/leg/ankle,3435074,CDM,510,RC,27630,HCPCS,Outpatient,,,1364.98,682.49,,1228.48,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.98,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1228.48,90,,,Percent of total Billed charges,90% of total billed charges,188.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1324.03,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1255.78,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1228.48,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,955.49,70,,,percent of total billed charges,70% of total billed charges,1228.48,90,,,percent of total billed charges,90% of total billed charges,1296.73,95,,,percent of total billed charges,95% of total billed charges,1296.73,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1173.88,86,,,percent of total billed charges,86% of total billed charges,1091.98,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1324.03,97,,,percent of total billed charges,97% of total billed charges,1228.48,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1324.03,97,,,percent of total billed charges,97% of total billed charges,1269.43,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1324.03,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,171.5,14511.58,
27635- Exc/bone cyst/bgn tumor/tib/fibula,3435076,CDM,510,RC,27635,HCPCS,Outpatient,,,1508.76,754.38,,1357.88,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1207.01,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1357.88,90,,,Percent of total Billed charges,90% of total billed charges,385.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1463.5,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1388.06,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1357.88,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1056.13,70,,,percent of total billed charges,70% of total billed charges,1357.88,90,,,percent of total billed charges,90% of total billed charges,1433.32,95,,,percent of total billed charges,95% of total billed charges,1433.32,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1297.53,86,,,percent of total billed charges,86% of total billed charges,1207.01,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1463.5,97,,,percent of total billed charges,97% of total billed charges,1357.88,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1463.5,97,,,percent of total billed charges,97% of total billed charges,1403.15,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1463.5,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,350.5,14511.58,
27640- Partial excision/bone/tibia,3435077,CDM,510,RC,27640,HCPCS,Outpatient,,,2179.74,1089.87,,1961.77,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1743.79,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1961.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2114.35,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2005.36,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1961.77,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1525.82,70,,,percent of total billed charges,70% of total billed charges,1961.77,90,,,percent of total billed charges,90% of total billed charges,2070.75,95,,,percent of total billed charges,95% of total billed charges,2070.75,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1874.58,86,,,percent of total billed charges,86% of total billed charges,1743.79,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2114.35,97,,,percent of total billed charges,97% of total billed charges,1961.77,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2114.35,97,,,percent of total billed charges,97% of total billed charges,2027.16,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2114.35,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1525.82,14511.58,
27650- Repair/open/perc/Achilles tendon,3435078,CDM,510,RC,27650,HCPCS,Outpatient,,,1709.09,854.55,,1538.18,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1367.27,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1538.18,90,,,Percent of total Billed charges,90% of total billed charges,460.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1657.82,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1572.36,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1538.18,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.36,70,,,percent of total billed charges,70% of total billed charges,1538.18,90,,,percent of total billed charges,90% of total billed charges,1623.64,95,,,percent of total billed charges,95% of total billed charges,1623.64,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1469.82,86,,,percent of total billed charges,86% of total billed charges,1367.27,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1657.82,97,,,percent of total billed charges,97% of total billed charges,1538.18,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1657.82,97,,,percent of total billed charges,97% of total billed charges,1589.45,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,419,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1657.82,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,419,32247.16,
27652- Rpr/open/per/Achilles tend w/graft,3435079,CDM,510,RC,27652,HCPCS,Outpatient,,,1722.07,861.04,,1549.86,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1377.66,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1549.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1670.41,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1584.3,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1549.86,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.45,70,,,percent of total billed charges,70% of total billed charges,1549.86,90,,,percent of total billed charges,90% of total billed charges,1635.97,95,,,percent of total billed charges,95% of total billed charges,1635.97,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1480.98,86,,,percent of total billed charges,86% of total billed charges,1377.66,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1670.41,97,,,percent of total billed charges,97% of total billed charges,1549.86,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1670.41,97,,,percent of total billed charges,97% of total billed charges,1601.53,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1670.41,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1205.45,32247.16,
27654- Rpr/secondary/Achilles tendon,3435080,CDM,510,RC,27654,HCPCS,Outpatient,,,1855.18,927.59,,1669.66,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1484.14,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1669.66,90,,,Percent of total Billed charges,90% of total billed charges,524.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1799.52,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1706.77,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1669.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1298.63,70,,,percent of total billed charges,70% of total billed charges,1669.66,90,,,percent of total billed charges,90% of total billed charges,1762.42,95,,,percent of total billed charges,95% of total billed charges,1762.42,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1595.45,86,,,percent of total billed charges,86% of total billed charges,1484.14,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1799.52,97,,,percent of total billed charges,97% of total billed charges,1669.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1799.52,97,,,percent of total billed charges,97% of total billed charges,1725.32,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,477,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1799.52,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,477,32247.16,
27658- Rpr/flexor ten/leg/pri w/o graft,3435081,CDM,510,RC,27658,HCPCS,Outpatient,,,952.79,476.40,,857.51,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,762.23,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,924.21,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,876.57,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,857.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,666.95,70,,,percent of total billed charges,70% of total billed charges,857.51,90,,,percent of total billed charges,90% of total billed charges,905.15,95,,,percent of total billed charges,95% of total billed charges,905.15,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,819.4,86,,,percent of total billed charges,86% of total billed charges,762.23,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,924.21,97,,,percent of total billed charges,97% of total billed charges,857.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.21,97,,,percent of total billed charges,97% of total billed charges,886.09,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,924.21,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,666.95,14511.58,
27659- Rpr/flexor ten/leg/secondary,3435082,CDM,510,RC,27659,HCPCS,Outpatient,,,1222.75,611.38,,1100.48,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,978.2,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1100.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1186.07,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1124.93,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1100.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,855.93,70,,,percent of total billed charges,70% of total billed charges,1100.48,90,,,percent of total billed charges,90% of total billed charges,1161.61,95,,,percent of total billed charges,95% of total billed charges,1161.61,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1051.57,86,,,percent of total billed charges,86% of total billed charges,978.2,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1186.07,97,,,percent of total billed charges,97% of total billed charges,1100.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1186.07,97,,,percent of total billed charges,97% of total billed charges,1137.16,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1186.07,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,855.93,32247.16,
27664- Rpr/extensor ten/leg/pri w/o graft,3435083,CDM,510,RC,27664,HCPCS,Outpatient,,,941.85,470.93,,847.67,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,753.48,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,847.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,913.59,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,866.5,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,847.67,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,659.3,70,,,percent of total billed charges,70% of total billed charges,847.67,90,,,percent of total billed charges,90% of total billed charges,894.76,95,,,percent of total billed charges,95% of total billed charges,894.76,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,809.99,86,,,percent of total billed charges,86% of total billed charges,753.48,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,913.59,97,,,percent of total billed charges,97% of total billed charges,847.67,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,913.59,97,,,percent of total billed charges,97% of total billed charges,875.92,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,913.59,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,659.3,32247.16,
27665- Rpr/extensor ten/leg/secondary,3435084,CDM,510,RC,27665,HCPCS,Outpatient,,,1092.05,546.03,,982.85,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,873.64,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,982.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1059.29,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1004.69,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,982.85,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,764.44,70,,,percent of total billed charges,70% of total billed charges,982.85,90,,,percent of total billed charges,90% of total billed charges,1037.45,95,,,percent of total billed charges,95% of total billed charges,1037.45,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,939.16,86,,,percent of total billed charges,86% of total billed charges,873.64,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1059.29,97,,,percent of total billed charges,97% of total billed charges,982.85,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1059.29,97,,,percent of total billed charges,97% of total billed charges,1015.61,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1059.29,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,764.44,32247.16,
27675- Rpr/peroneal ten w/o fib osteotomy,3435085,CDM,510,RC,27675,HCPCS,Outpatient,,,1278.9,639.45,,1151.01,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1023.12,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1151.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1240.53,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.59,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1151.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,895.23,70,,,percent of total billed charges,70% of total billed charges,1151.01,90,,,percent of total billed charges,90% of total billed charges,1214.96,95,,,percent of total billed charges,95% of total billed charges,1214.96,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1099.85,86,,,percent of total billed charges,86% of total billed charges,1023.12,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1240.53,97,,,percent of total billed charges,97% of total billed charges,1151.01,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1240.53,97,,,percent of total billed charges,97% of total billed charges,1189.38,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1240.53,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,895.23,14511.58,
27676- Rpr/peroneal ten/fibular osteotomy,3435086,CDM,510,RC,27676,HCPCS,Outpatient,,,1585.33,792.67,,1426.8,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.26,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.8,90,,,Percent of total Billed charges,90% of total billed charges,321.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.77,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.5,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.73,70,,,percent of total billed charges,70% of total billed charges,1426.8,90,,,percent of total billed charges,90% of total billed charges,1506.06,95,,,percent of total billed charges,95% of total billed charges,1506.06,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.38,86,,,percent of total billed charges,86% of total billed charges,1268.26,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.77,97,,,percent of total billed charges,97% of total billed charges,1426.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.77,97,,,percent of total billed charges,97% of total billed charges,1474.36,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,292,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.77,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292,32247.16,
27680-Tenolysis/flex/externalten/leg/ankle ea,3435087,CDM,510,RC,27680,HCPCS,Outpatient,,,1083.81,541.91,,975.43,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,867.05,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,975.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1051.3,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,997.11,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,975.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,758.67,70,,,percent of total billed charges,70% of total billed charges,975.43,90,,,percent of total billed charges,90% of total billed charges,1029.62,95,,,percent of total billed charges,95% of total billed charges,1029.62,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,932.08,86,,,percent of total billed charges,86% of total billed charges,867.05,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1051.3,97,,,percent of total billed charges,97% of total billed charges,975.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1051.3,97,,,percent of total billed charges,97% of total billed charges,1007.94,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1051.3,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,758.67,14511.58,
27685- Revise tendon/leg/ankle/sng tendon,3435088,CDM,510,RC,27685,HCPCS,Outpatient,,,1657.85,828.93,,1492.07,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1326.28,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1492.07,90,,,Percent of total Billed charges,90% of total billed charges,358.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1608.11,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1525.22,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1492.07,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.5,70,,,percent of total billed charges,70% of total billed charges,1492.07,90,,,percent of total billed charges,90% of total billed charges,1574.96,95,,,percent of total billed charges,95% of total billed charges,1574.96,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1425.75,86,,,percent of total billed charges,86% of total billed charges,1326.28,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1608.11,97,,,percent of total billed charges,97% of total billed charges,1492.07,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1608.11,97,,,percent of total billed charges,97% of total billed charges,1541.8,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1608.11,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,325.5,14511.58,
27686- Revise tendon/leg/ankle/multip/ea,3435089,CDM,510,RC,27686,HCPCS,Outpatient,,,1385.62,692.81,,1247.06,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1108.5,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1344.05,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1274.77,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.06,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,969.93,70,,,percent of total billed charges,70% of total billed charges,1247.06,90,,,percent of total billed charges,90% of total billed charges,1316.34,95,,,percent of total billed charges,95% of total billed charges,1316.34,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1191.63,86,,,percent of total billed charges,86% of total billed charges,1108.5,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.05,97,,,percent of total billed charges,97% of total billed charges,1247.06,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.05,97,,,percent of total billed charges,97% of total billed charges,1288.63,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1344.05,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,969.93,14511.58,
27690- Transfer/transplt/low leg ten/spfc,3435091,CDM,510,RC,27690,HCPCS,Outpatient,,,1662.96,831.48,,1496.66,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.37,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1496.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1613.07,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1529.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1496.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.07,70,,,percent of total billed charges,70% of total billed charges,1496.66,90,,,percent of total billed charges,90% of total billed charges,1579.81,95,,,percent of total billed charges,95% of total billed charges,1579.81,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1430.15,86,,,percent of total billed charges,86% of total billed charges,1330.37,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1613.07,97,,,percent of total billed charges,97% of total billed charges,1496.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1613.07,97,,,percent of total billed charges,97% of total billed charges,1546.55,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1613.07,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1164.07,32247.16,
27691- Transfer/transplt/low leg ten/deep,3435092,CDM,510,RC,27691,HCPCS,Outpatient,,,1936.23,968.12,,1742.61,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1548.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1742.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1878.14,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1781.33,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1742.61,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.36,70,,,percent of total billed charges,70% of total billed charges,1742.61,90,,,percent of total billed charges,90% of total billed charges,1839.42,95,,,percent of total billed charges,95% of total billed charges,1839.42,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1665.16,86,,,percent of total billed charges,86% of total billed charges,1548.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1878.14,97,,,percent of total billed charges,97% of total billed charges,1742.61,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1878.14,97,,,percent of total billed charges,97% of total billed charges,1800.69,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1878.14,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1355.36,32247.16,
27692- Transfr/transplt/low leg ten/ea ad,3435093,CDM,510,RC,27692,HCPCS,Outpatient,,,268.64,134.32,,241.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,214.91,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,241.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,260.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,247.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,171.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,211.29,78.65,,,percent of total billed charges,78.65% of total billed charges,239.98,89.33,,,percent of total billed charges,89.33% of total billed charges,241.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,188.05,70,,,percent of total billed charges,70% of total billed charges,241.78,90,,,percent of total billed charges,90% of total billed charges,255.21,95,,,percent of total billed charges,95% of total billed charges,255.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.03,86,,,percent of total billed charges,86% of total billed charges,214.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,260.58,97,,,percent of total billed charges,97% of total billed charges,241.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,260.58,97,,,percent of total billed charges,97% of total billed charges,249.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,260.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.56,260.58,
27695- Rpr/primary/disrupt ligament/ankle,3435094,CDM,510,RC,27695,HCPCS,Outpatient,,,1242.47,621.24,,1118.22,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,993.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1118.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1205.2,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.07,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1118.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,869.73,70,,,percent of total billed charges,70% of total billed charges,1118.22,90,,,percent of total billed charges,90% of total billed charges,1180.35,95,,,percent of total billed charges,95% of total billed charges,1180.35,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1068.52,86,,,percent of total billed charges,86% of total billed charges,993.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1205.2,97,,,percent of total billed charges,97% of total billed charges,1118.22,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.2,97,,,percent of total billed charges,97% of total billed charges,1155.5,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1205.2,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,869.73,32247.16,
27696- Rpr/pri lig/ankle/both collat lig,3435095,CDM,510,RC,27696,HCPCS,Outpatient,,,1432.35,716.18,,1289.12,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1145.88,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1289.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1389.38,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1317.76,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1289.12,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1002.65,70,,,percent of total billed charges,70% of total billed charges,1289.12,90,,,percent of total billed charges,90% of total billed charges,1360.73,95,,,percent of total billed charges,95% of total billed charges,1360.73,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1231.82,86,,,percent of total billed charges,86% of total billed charges,1145.88,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1389.38,97,,,percent of total billed charges,97% of total billed charges,1289.12,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.38,97,,,percent of total billed charges,97% of total billed charges,1332.09,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1389.38,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1002.65,32247.16,
27698- Rpr/secondary/disrupt lig/ankle,3435096,CDM,510,RC,27698,HCPCS,Outpatient,,,1663.78,831.89,,1497.4,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1331.02,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1497.4,90,,,Percent of total Billed charges,90% of total billed charges,470.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1613.87,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1530.68,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1497.4,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1164.65,70,,,percent of total billed charges,70% of total billed charges,1497.4,90,,,percent of total billed charges,90% of total billed charges,1580.59,95,,,percent of total billed charges,95% of total billed charges,1580.59,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1430.85,86,,,percent of total billed charges,86% of total billed charges,1331.02,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1613.87,97,,,percent of total billed charges,97% of total billed charges,1497.4,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1613.87,97,,,percent of total billed charges,97% of total billed charges,1547.32,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,427.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1613.87,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,427.5,32247.16,
27705- Osteotomy/tibia,3435097,CDM,510,RC,27705,HCPCS,Outpatient,,,1986.95,993.48,,1788.26,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1589.56,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1788.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1927.34,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1827.99,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1788.26,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1390.87,70,,,percent of total billed charges,70% of total billed charges,1788.26,90,,,percent of total billed charges,90% of total billed charges,1887.6,95,,,percent of total billed charges,95% of total billed charges,1887.6,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1708.78,86,,,percent of total billed charges,86% of total billed charges,1589.56,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1927.34,97,,,percent of total billed charges,97% of total billed charges,1788.26,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1927.34,97,,,percent of total billed charges,97% of total billed charges,1847.86,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1927.34,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1390.87,32247.16,
27720- Rpr/non/malunion/tibia w/o graft,3435098,CDM,510,RC,27720,HCPCS,Outpatient,,,2290.69,1145.35,,2061.62,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1832.55,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2061.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2221.97,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2107.43,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2061.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1603.48,70,,,percent of total billed charges,70% of total billed charges,2061.62,90,,,percent of total billed charges,90% of total billed charges,2176.16,95,,,percent of total billed charges,95% of total billed charges,2176.16,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1969.99,86,,,percent of total billed charges,86% of total billed charges,1832.55,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2221.97,97,,,percent of total billed charges,97% of total billed charges,2061.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2221.97,97,,,percent of total billed charges,97% of total billed charges,2130.34,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2221.97,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1603.48,32247.16,
27726- Repair/fib/mal/nonunion/intern fix,3435099,CDM,510,RC,27726,HCPCS,Outpatient,,,2521.92,1260.96,,2269.73,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2017.54,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2269.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2446.26,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2320.17,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2269.73,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1765.34,70,,,percent of total billed charges,70% of total billed charges,2269.73,90,,,percent of total billed charges,90% of total billed charges,2395.82,95,,,percent of total billed charges,95% of total billed charges,2395.82,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2168.85,86,,,percent of total billed charges,86% of total billed charges,2017.54,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2446.26,97,,,percent of total billed charges,97% of total billed charges,2269.73,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2446.26,97,,,percent of total billed charges,97% of total billed charges,2345.39,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2446.26,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1765.34,32247.16,
27750- Clsd tx/tibial shaft fx w/o manip,3435100,CDM,510,RC,27750,HCPCS,Outpatient,,,889.84,444.92,,800.86,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,711.87,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,800.86,90,,,Percent of total Billed charges,90% of total billed charges,156.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,863.14,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,818.65,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,800.86,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,622.89,70,,,percent of total billed charges,70% of total billed charges,800.86,90,,,percent of total billed charges,90% of total billed charges,845.35,95,,,percent of total billed charges,95% of total billed charges,845.35,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,765.26,86,,,percent of total billed charges,86% of total billed charges,711.87,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,863.14,97,,,percent of total billed charges,97% of total billed charges,800.86,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.14,97,,,percent of total billed charges,97% of total billed charges,827.55,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,863.14,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,142.5,1009.19,
27752- Clsd tx/tibial shaft fx w/manip,3435101,CDM,510,RC,27752,HCPCS,Outpatient,,,1390.12,695.06,,1251.11,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1112.1,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1251.11,90,,,Percent of total Billed charges,90% of total billed charges,256.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1348.42,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1278.91,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1251.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,973.08,70,,,percent of total billed charges,70% of total billed charges,1251.11,90,,,percent of total billed charges,90% of total billed charges,1320.61,95,,,percent of total billed charges,95% of total billed charges,1320.61,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1195.5,86,,,percent of total billed charges,86% of total billed charges,1112.1,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1348.42,97,,,percent of total billed charges,97% of total billed charges,1251.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1348.42,97,,,percent of total billed charges,97% of total billed charges,1292.81,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1348.42,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,233.5,6993.46,
27758- Open tx/tib shaft fx/plate/screws,3435102,CDM,510,RC,27758,HCPCS,Outpatient,,,2347.97,1173.99,,2113.17,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1878.38,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2113.17,90,,,Percent of total Billed charges,90% of total billed charges,556.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2277.53,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2160.13,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2113.17,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1643.58,70,,,percent of total billed charges,70% of total billed charges,2113.17,90,,,percent of total billed charges,90% of total billed charges,2230.57,95,,,percent of total billed charges,95% of total billed charges,2230.57,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2019.25,86,,,percent of total billed charges,86% of total billed charges,1878.38,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2277.53,97,,,percent of total billed charges,97% of total billed charges,2113.17,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2277.53,97,,,percent of total billed charges,97% of total billed charges,2183.61,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2277.53,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,505.5,63611.04,
27759- Tx/tib shaft fx/intramedul implant,3435103,CDM,510,RC,27759,HCPCS,Outpatient,,,2619.48,1309.74,,2357.53,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2095.58,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2357.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2540.9,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2409.92,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2357.53,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1833.64,70,,,percent of total billed charges,70% of total billed charges,2357.53,90,,,percent of total billed charges,90% of total billed charges,2488.51,95,,,percent of total billed charges,95% of total billed charges,2488.51,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2252.75,86,,,percent of total billed charges,86% of total billed charges,2095.58,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2540.9,97,,,percent of total billed charges,97% of total billed charges,2357.53,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2540.9,97,,,percent of total billed charges,97% of total billed charges,2436.12,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2540.9,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1833.64,63611.04,
27760- Clsd tx/med malleolus fx w/o manip,3435104,CDM,510,RC,27760,HCPCS,Outpatient,,,849.4,424.70,,764.46,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,679.52,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,764.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,823.92,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,781.45,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,764.46,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,594.58,70,,,percent of total billed charges,70% of total billed charges,764.46,90,,,percent of total billed charges,90% of total billed charges,806.93,95,,,percent of total billed charges,95% of total billed charges,806.93,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,730.48,86,,,percent of total billed charges,86% of total billed charges,679.52,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,823.92,97,,,percent of total billed charges,97% of total billed charges,764.46,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,823.92,97,,,percent of total billed charges,97% of total billed charges,789.94,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,823.92,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27762- Clsd tx/med malleolus fx w/manip,3435105,CDM,510,RC,27762,HCPCS,Outpatient,,,1249.73,624.87,,1124.76,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,999.78,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1212.24,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1149.75,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1124.76,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,874.81,70,,,percent of total billed charges,70% of total billed charges,1124.76,90,,,percent of total billed charges,90% of total billed charges,1187.24,95,,,percent of total billed charges,95% of total billed charges,1187.24,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1074.77,86,,,percent of total billed charges,86% of total billed charges,999.78,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1212.24,97,,,percent of total billed charges,97% of total billed charges,1124.76,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1212.24,97,,,percent of total billed charges,97% of total billed charges,1162.25,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1212.24,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,874.81,6993.46,
27766- Open tx/medial malleolus fx,3435106,CDM,510,RC,27766,HCPCS,Outpatient,,,1571.82,785.91,,1414.64,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1257.46,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1414.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1524.67,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1446.07,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1414.64,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1100.27,70,,,percent of total billed charges,70% of total billed charges,1414.64,90,,,percent of total billed charges,90% of total billed charges,1493.23,95,,,percent of total billed charges,95% of total billed charges,1493.23,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1351.77,86,,,percent of total billed charges,86% of total billed charges,1257.46,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1524.67,97,,,percent of total billed charges,97% of total billed charges,1414.64,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.67,97,,,percent of total billed charges,97% of total billed charges,1461.79,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1524.67,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1100.27,32247.16,
27767- Clsd tx/post malleolus fx w/o mani,3435107,CDM,510,RC,27767,HCPCS,Outpatient,,,744.2,372.10,,669.78,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,595.36,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,669.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,721.87,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,684.66,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,669.78,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,520.94,70,,,percent of total billed charges,70% of total billed charges,669.78,90,,,percent of total billed charges,90% of total billed charges,706.99,95,,,percent of total billed charges,95% of total billed charges,706.99,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,640.01,86,,,percent of total billed charges,86% of total billed charges,595.36,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,721.87,97,,,percent of total billed charges,97% of total billed charges,669.78,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,721.87,97,,,percent of total billed charges,97% of total billed charges,692.11,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,721.87,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27769- Open tx/post malleolus fx,3435108,CDM,510,RC,27769,HCPCS,Outpatient,,,1906.65,953.33,,1715.99,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1525.32,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1715.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1849.45,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1754.12,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1715.99,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1334.66,70,,,percent of total billed charges,70% of total billed charges,1715.99,90,,,percent of total billed charges,90% of total billed charges,1811.32,95,,,percent of total billed charges,95% of total billed charges,1811.32,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1639.72,86,,,percent of total billed charges,86% of total billed charges,1525.32,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1849.45,97,,,percent of total billed charges,97% of total billed charges,1715.99,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1849.45,97,,,percent of total billed charges,97% of total billed charges,1773.18,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1849.45,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1334.66,32247.16,
27780- Clsd tx/prox fib/shft fx w/o manip,3435109,CDM,510,RC,27780,HCPCS,Outpatient,,,791.19,395.60,,712.07,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,632.95,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,712.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,767.45,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,727.89,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,712.07,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,553.83,70,,,percent of total billed charges,70% of total billed charges,712.07,90,,,percent of total billed charges,90% of total billed charges,751.63,95,,,percent of total billed charges,95% of total billed charges,751.63,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,680.42,86,,,percent of total billed charges,86% of total billed charges,632.95,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,767.45,97,,,percent of total billed charges,97% of total billed charges,712.07,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,767.45,97,,,percent of total billed charges,97% of total billed charges,735.81,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,767.45,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27784- Open tx/prox fibula shaft fracture,3435110,CDM,510,RC,27784,HCPCS,Outpatient,,,1846.09,923.05,,1661.48,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.87,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1661.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1790.71,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.4,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1661.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1292.26,70,,,percent of total billed charges,70% of total billed charges,1661.48,90,,,percent of total billed charges,90% of total billed charges,1753.79,95,,,percent of total billed charges,95% of total billed charges,1753.79,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1587.64,86,,,percent of total billed charges,86% of total billed charges,1476.87,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1790.71,97,,,percent of total billed charges,97% of total billed charges,1661.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1790.71,97,,,percent of total billed charges,97% of total billed charges,1716.86,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1790.71,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1292.26,32247.16,
27786- Clsd tx/dis fibular fx w/o manip,3435111,CDM,510,RC,27786,HCPCS,Outpatient,,,803.97,401.99,,723.57,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,643.18,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,723.57,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,779.85,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,739.65,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,723.57,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,562.78,70,,,percent of total billed charges,70% of total billed charges,723.57,90,,,percent of total billed charges,90% of total billed charges,763.77,95,,,percent of total billed charges,95% of total billed charges,763.77,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,691.41,86,,,percent of total billed charges,86% of total billed charges,643.18,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,779.85,97,,,percent of total billed charges,97% of total billed charges,723.57,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,779.85,97,,,percent of total billed charges,97% of total billed charges,747.69,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,779.85,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,1009.19,
27792- Open tx/distal fibular fx,3435112,CDM,510,RC,27792,HCPCS,Outpatient,,,1682.18,841.09,,1513.96,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1345.74,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1513.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1631.71,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1547.61,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1513.96,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1177.53,70,,,percent of total billed charges,70% of total billed charges,1513.96,90,,,percent of total billed charges,90% of total billed charges,1598.07,95,,,percent of total billed charges,95% of total billed charges,1598.07,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1446.67,86,,,percent of total billed charges,86% of total billed charges,1345.74,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1631.71,97,,,percent of total billed charges,97% of total billed charges,1513.96,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1631.71,97,,,percent of total billed charges,97% of total billed charges,1564.43,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1631.71,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1177.53,32247.16,
27808- Clsd tx/bimalleol ank fx w/o manip,3435113,CDM,510,RC,27808,HCPCS,Outpatient,,,854.95,427.48,,769.46,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,683.96,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,769.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,829.3,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,786.55,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,769.46,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,598.47,70,,,percent of total billed charges,70% of total billed charges,769.46,90,,,percent of total billed charges,90% of total billed charges,812.2,95,,,percent of total billed charges,95% of total billed charges,812.2,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,735.26,86,,,percent of total billed charges,86% of total billed charges,683.96,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,829.3,97,,,percent of total billed charges,97% of total billed charges,769.46,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,829.3,97,,,percent of total billed charges,97% of total billed charges,795.1,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,829.3,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27810- Clsd tx/bimalleol ankle fx w/manip,3435114,CDM,510,RC,27810,HCPCS,Outpatient,,,1221.55,610.78,,1099.4,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,977.24,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1099.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1184.9,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.83,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1099.4,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,855.09,70,,,percent of total billed charges,70% of total billed charges,1099.4,90,,,percent of total billed charges,90% of total billed charges,1160.47,95,,,percent of total billed charges,95% of total billed charges,1160.47,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1050.53,86,,,percent of total billed charges,86% of total billed charges,977.24,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1184.9,97,,,percent of total billed charges,97% of total billed charges,1099.4,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1184.9,97,,,percent of total billed charges,97% of total billed charges,1136.04,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1184.9,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,855.09,6993.46,
27814- Open tx/bimalleolar ankle fracture,3435115,CDM,510,RC,27814,HCPCS,Outpatient,,,1998.51,999.26,,1798.66,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1598.81,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1798.66,90,,,Percent of total Billed charges,90% of total billed charges,495,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1938.55,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1838.63,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1798.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1398.96,70,,,percent of total billed charges,70% of total billed charges,1798.66,90,,,percent of total billed charges,90% of total billed charges,1898.58,95,,,percent of total billed charges,95% of total billed charges,1898.58,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1718.72,86,,,percent of total billed charges,86% of total billed charges,1598.81,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1938.55,97,,,percent of total billed charges,97% of total billed charges,1798.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.55,97,,,percent of total billed charges,97% of total billed charges,1858.61,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,450,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1938.55,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,450,32247.16,
27822- Open tx/trimalleo ankle fx w/o fix,3435116,CDM,510,RC,27822,HCPCS,Outpatient,,,2280.8,1140.40,,2052.72,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1824.64,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2052.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2212.38,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2098.34,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2052.72,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1596.56,70,,,percent of total billed charges,70% of total billed charges,2052.72,90,,,percent of total billed charges,90% of total billed charges,2166.76,95,,,percent of total billed charges,95% of total billed charges,2166.76,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1961.49,86,,,percent of total billed charges,86% of total billed charges,1824.64,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2212.38,97,,,percent of total billed charges,97% of total billed charges,2052.72,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2212.38,97,,,percent of total billed charges,97% of total billed charges,2121.14,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2212.38,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1596.56,32247.16,
27823- Open tx/trimalleo ankle fx w/fix,3435117,CDM,510,RC,27823,HCPCS,Outpatient,,,2572.13,1286.07,,2314.92,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.7,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2314.92,90,,,Percent of total Billed charges,90% of total billed charges,547.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2494.97,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2366.36,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2314.92,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1800.49,70,,,percent of total billed charges,70% of total billed charges,2314.92,90,,,percent of total billed charges,90% of total billed charges,2443.52,95,,,percent of total billed charges,95% of total billed charges,2443.52,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2212.03,86,,,percent of total billed charges,86% of total billed charges,2057.7,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2494.97,97,,,percent of total billed charges,97% of total billed charges,2314.92,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2494.97,97,,,percent of total billed charges,97% of total billed charges,2392.08,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,497.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2494.97,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,497.5,32247.16,
27824- Clsd tx/dis tib/wt bear no manip,3435118,CDM,510,RC,27824,HCPCS,Outpatient,,,816.41,408.21,,734.77,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,653.13,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,791.92,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,751.1,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,734.77,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,571.49,70,,,percent of total billed charges,70% of total billed charges,734.77,90,,,percent of total billed charges,90% of total billed charges,775.59,95,,,percent of total billed charges,95% of total billed charges,775.59,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,702.11,86,,,percent of total billed charges,86% of total billed charges,653.13,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,791.92,97,,,percent of total billed charges,97% of total billed charges,734.77,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,791.92,97,,,percent of total billed charges,97% of total billed charges,759.26,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,791.92,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
27825- Clsd tx/articulr/dis tib/traction,3435119,CDM,510,RC,27825,HCPCS,Outpatient,,,1412.96,706.48,,1271.66,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1130.37,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1271.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1370.57,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1299.92,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1271.66,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,989.07,70,,,percent of total billed charges,70% of total billed charges,1271.66,90,,,percent of total billed charges,90% of total billed charges,1342.31,95,,,percent of total billed charges,95% of total billed charges,1342.31,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1215.15,86,,,percent of total billed charges,86% of total billed charges,1130.37,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1370.57,97,,,percent of total billed charges,97% of total billed charges,1271.66,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1370.57,97,,,percent of total billed charges,97% of total billed charges,1314.05,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1370.57,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,989.07,6993.46,
27827- Open tx/artic dis tib/int fix tib,3435120,CDM,510,RC,27827,HCPCS,Outpatient,,,2923.06,1461.53,,2630.75,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2338.45,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2835.37,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2689.22,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.75,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2046.14,70,,,percent of total billed charges,70% of total billed charges,2630.75,90,,,percent of total billed charges,90% of total billed charges,2776.91,95,,,percent of total billed charges,95% of total billed charges,2776.91,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.83,86,,,percent of total billed charges,86% of total billed charges,2338.45,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2835.37,97,,,percent of total billed charges,97% of total billed charges,2630.75,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2835.37,97,,,percent of total billed charges,97% of total billed charges,2718.45,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2835.37,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2046.14,63611.04,
27828- Open tx/ artic dis tib/fix tib/fib,3435121,CDM,510,RC,27828,HCPCS,Outpatient,,,3483.32,1741.66,,3134.99,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2786.66,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3134.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3378.82,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.65,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3134.99,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2438.32,70,,,percent of total billed charges,70% of total billed charges,3134.99,90,,,percent of total billed charges,90% of total billed charges,3309.15,95,,,percent of total billed charges,95% of total billed charges,3309.15,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2995.66,86,,,percent of total billed charges,86% of total billed charges,2786.66,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3378.82,97,,,percent of total billed charges,97% of total billed charges,3134.99,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3378.82,97,,,percent of total billed charges,97% of total billed charges,3239.49,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3378.82,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2438.32,63611.04,
27829- Open tx/dist tibiofib jnt disrupt,3435122,CDM,510,RC,27829,HCPCS,Outpatient,,,1837.45,918.73,,1653.71,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.96,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1653.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1782.33,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1690.45,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1653.71,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1286.22,70,,,percent of total billed charges,70% of total billed charges,1653.71,90,,,percent of total billed charges,90% of total billed charges,1745.58,95,,,percent of total billed charges,95% of total billed charges,1745.58,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1580.21,86,,,percent of total billed charges,86% of total billed charges,1469.96,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1782.33,97,,,percent of total billed charges,97% of total billed charges,1653.71,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1782.33,97,,,percent of total billed charges,97% of total billed charges,1708.83,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1782.33,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1286.22,32247.16,
27830- Clsd tx/tibiofib dislocat w/o anes,3435123,CDM,510,RC,27830,HCPCS,Outpatient,,,1006.32,503.16,,905.69,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,805.06,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,905.69,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,976.13,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,925.81,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,905.69,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,704.42,70,,,percent of total billed charges,70% of total billed charges,905.69,90,,,percent of total billed charges,90% of total billed charges,956,95,,,percent of total billed charges,95% of total billed charges,956,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,865.44,86,,,percent of total billed charges,86% of total billed charges,805.06,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,976.13,97,,,percent of total billed charges,97% of total billed charges,905.69,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,976.13,97,,,percent of total billed charges,97% of total billed charges,935.88,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,976.13,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,1009.19,
27840- Clsd tx/ankle dislocate w/o anest,3435124,CDM,510,RC,27840,HCPCS,Outpatient,,,996.95,498.48,,897.26,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,797.56,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,897.26,90,,,Percent of total Billed charges,90% of total billed charges,98.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,967.04,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,917.19,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,897.26,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,697.87,70,,,percent of total billed charges,70% of total billed charges,897.26,90,,,percent of total billed charges,90% of total billed charges,947.1,95,,,percent of total billed charges,95% of total billed charges,947.1,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,857.38,86,,,percent of total billed charges,86% of total billed charges,797.56,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,967.04,97,,,percent of total billed charges,97% of total billed charges,897.26,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,967.04,97,,,percent of total billed charges,97% of total billed charges,927.16,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,967.04,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.5,1009.19,
27842- Clsd tx/ankle dislocate/anesthesia,3435125,CDM,510,RC,27842,HCPCS,Outpatient,,,1295.31,647.66,,1165.78,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.25,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1165.78,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1256.45,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1191.69,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1165.78,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,906.72,70,,,percent of total billed charges,70% of total billed charges,1165.78,90,,,percent of total billed charges,90% of total billed charges,1230.54,95,,,percent of total billed charges,95% of total billed charges,1230.54,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1113.97,86,,,percent of total billed charges,86% of total billed charges,1036.25,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1256.45,97,,,percent of total billed charges,97% of total billed charges,1165.78,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256.45,97,,,percent of total billed charges,97% of total billed charges,1204.64,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1256.45,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,6993.46,
27846- Open tx/ankle dislocate w/o repair/int fix,3435126,CDM,510,RC,27846,HCPCS,Outpatient,,,1893.49,946.75,,1704.14,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1514.79,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1704.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1836.69,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.01,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1704.14,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.44,70,,,percent of total billed charges,70% of total billed charges,1704.14,90,,,percent of total billed charges,90% of total billed charges,1798.82,95,,,percent of total billed charges,95% of total billed charges,1798.82,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1628.4,86,,,percent of total billed charges,86% of total billed charges,1514.79,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1836.69,97,,,percent of total billed charges,97% of total billed charges,1704.14,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.69,97,,,percent of total billed charges,97% of total billed charges,1760.95,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1836.69,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1325.44,32247.16,
27870- Arthrodesis/ankle/open,3435127,CDM,510,RC,27870,HCPCS,Outpatient,,,2653.42,1326.71,,2388.08,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2122.74,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2388.08,90,,,Percent of total Billed charges,90% of total billed charges,638.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2573.82,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2441.15,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2388.08,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1857.39,70,,,percent of total billed charges,70% of total billed charges,2388.08,90,,,percent of total billed charges,90% of total billed charges,2520.75,95,,,percent of total billed charges,95% of total billed charges,2520.75,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2281.94,86,,,percent of total billed charges,86% of total billed charges,2122.74,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2573.82,97,,,percent of total billed charges,97% of total billed charges,2388.08,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2573.82,97,,,percent of total billed charges,97% of total billed charges,2467.68,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2573.82,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,580.5,63611.04,
27871- Arthrodesis/tibiofib jnt/prox/dist,3435128,CDM,510,RC,27871,HCPCS,Outpatient,,,1802.23,901.12,,1622.01,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1441.78,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1622.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1748.16,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1658.05,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1622.01,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1261.56,70,,,percent of total billed charges,70% of total billed charges,1622.01,90,,,percent of total billed charges,90% of total billed charges,1712.12,95,,,percent of total billed charges,95% of total billed charges,1712.12,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1549.92,86,,,percent of total billed charges,86% of total billed charges,1441.78,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1748.16,97,,,percent of total billed charges,97% of total billed charges,1622.01,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1748.16,97,,,percent of total billed charges,97% of total billed charges,1676.07,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1748.16,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1261.56,63611.04,
27884 - Amputate Leg thru Tibia/Fibula Sec Closure/Scar Rev,3899017,CDM,983,RC,27884,HCPCS,Outpatient,,,1533.77,766.89,,1380.39,90,,,percent of total billed charges,90% of total Billed charges,1148.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,572.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,886.94,155,,,Fee Schedule,155% of CMS OPPS Rate,572.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,820.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,572.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,922.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,922.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,877.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,877.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,561.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1144.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1035.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,727.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,886.94,155,,,Fee Schedule,155% of CMS OPPS Rate,572.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1780.89,155,,,Fee Schedule,155% of CMS OPPS Rate,1780.89,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,572.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,703.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,572.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,1198.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1198.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131,1780.89,
27894- Decompr fasciot/leg/ant/lat/post,3435131,CDM,510,RC,27894,HCPCS,Outpatient,,,2167.89,1083.95,,1951.1,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1734.31,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.1,90,,,Percent of total Billed charges,90% of total billed charges,378.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2102.85,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1994.46,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1951.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1517.52,70,,,percent of total billed charges,70% of total billed charges,1951.1,90,,,percent of total billed charges,90% of total billed charges,2059.5,95,,,percent of total billed charges,95% of total billed charges,2059.5,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1864.39,86,,,percent of total billed charges,86% of total billed charges,1734.31,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2102.85,97,,,percent of total billed charges,97% of total billed charges,1951.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2102.85,97,,,percent of total billed charges,97% of total billed charges,2016.14,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,344,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2102.85,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,344,14511.58,
28005- Incision/bone cortex/foot,3435136,CDM,510,RC,28005,HCPCS,Outpatient,,,1483.59,741.80,,1335.23,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1186.87,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1335.23,90,,,Percent of total Billed charges,90% of total billed charges,238.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1439.08,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1364.9,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1335.23,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1038.51,70,,,percent of total billed charges,70% of total billed charges,1335.23,90,,,percent of total billed charges,90% of total billed charges,1409.41,95,,,percent of total billed charges,95% of total billed charges,1409.41,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1275.89,86,,,percent of total billed charges,86% of total billed charges,1186.87,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1439.08,97,,,percent of total billed charges,97% of total billed charges,1335.23,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1439.08,97,,,percent of total billed charges,97% of total billed charges,1379.74,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,217,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1439.08,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,217,14511.58,
28008- Fasciotomy/foot and/or toe,3435137,CDM,510,RC,28008,HCPCS,Outpatient,,,1073.25,536.63,,965.93,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,858.6,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,965.93,90,,,Percent of total Billed charges,90% of total billed charges,150.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1041.05,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,987.39,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,965.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,751.28,70,,,percent of total billed charges,70% of total billed charges,965.93,90,,,percent of total billed charges,90% of total billed charges,1019.59,95,,,percent of total billed charges,95% of total billed charges,1019.59,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,923,86,,,percent of total billed charges,86% of total billed charges,858.6,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1041.05,97,,,percent of total billed charges,97% of total billed charges,965.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1041.05,97,,,percent of total billed charges,97% of total billed charges,998.12,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1041.05,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,136.5,14511.58,
28010- Tenotomy/perc/toe/single tendon,3435138,CDM,510,RC,28010,HCPCS,Outpatient,,,587.53,293.77,,528.78,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,470.02,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.78,90,,,Percent of total Billed charges,90% of total billed charges,144.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,569.9,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,540.53,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,528.78,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,411.27,70,,,percent of total billed charges,70% of total billed charges,528.78,90,,,percent of total billed charges,90% of total billed charges,558.15,95,,,percent of total billed charges,95% of total billed charges,558.15,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,505.28,86,,,percent of total billed charges,86% of total billed charges,470.02,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,569.9,97,,,percent of total billed charges,97% of total billed charges,528.78,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,569.9,97,,,percent of total billed charges,97% of total billed charges,546.4,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,569.9,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131,6993.46,
28011- Tenotomy/perc/toe/mult tendons,3435139,CDM,510,RC,28011,HCPCS,Outpatient,,,798.83,399.42,,718.95,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,639.06,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,718.95,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,774.87,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,734.92,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,718.95,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,559.18,70,,,percent of total billed charges,70% of total billed charges,718.95,90,,,percent of total billed charges,90% of total billed charges,758.89,95,,,percent of total billed charges,95% of total billed charges,758.89,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,686.99,86,,,percent of total billed charges,86% of total billed charges,639.06,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,774.87,97,,,percent of total billed charges,97% of total billed charges,718.95,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,774.87,97,,,percent of total billed charges,97% of total billed charges,742.91,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,774.87,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,6993.46,
28020- Arthrotomy/exp/intertar/tarsometat,3435140,CDM,510,RC,28020,HCPCS,Outpatient,,,1381.15,690.58,,1243.04,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1104.92,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1243.04,90,,,Percent of total Billed charges,90% of total billed charges,183.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1339.72,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1270.66,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1243.04,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,966.81,70,,,percent of total billed charges,70% of total billed charges,1243.04,90,,,percent of total billed charges,90% of total billed charges,1312.09,95,,,percent of total billed charges,95% of total billed charges,1312.09,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1187.79,86,,,percent of total billed charges,86% of total billed charges,1104.92,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1339.72,97,,,percent of total billed charges,97% of total billed charges,1243.04,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1339.72,97,,,percent of total billed charges,97% of total billed charges,1284.47,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1339.72,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,166.5,14511.58,
28022- Arthrotomy/metatarsopalangeal jnt,3435141,CDM,510,RC,28022,HCPCS,Outpatient,,,1217.89,608.95,,1096.1,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,974.31,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.1,90,,,Percent of total Billed charges,90% of total billed charges,151.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1181.35,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.46,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1096.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,852.52,70,,,percent of total billed charges,70% of total billed charges,1096.1,90,,,percent of total billed charges,90% of total billed charges,1157,95,,,percent of total billed charges,95% of total billed charges,1157,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1047.39,86,,,percent of total billed charges,86% of total billed charges,974.31,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1181.35,97,,,percent of total billed charges,97% of total billed charges,1096.1,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1181.35,97,,,percent of total billed charges,97% of total billed charges,1132.64,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1181.35,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.5,14511.58,
28024- Arthrotomy/interphalangeal joint,3435142,CDM,510,RC,28024,HCPCS,Outpatient,,,1136.12,568.06,,1022.51,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,908.9,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1022.51,90,,,Percent of total Billed charges,90% of total billed charges,151.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1102.04,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.23,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1022.51,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,795.28,70,,,percent of total billed charges,70% of total billed charges,1022.51,90,,,percent of total billed charges,90% of total billed charges,1079.31,95,,,percent of total billed charges,95% of total billed charges,1079.31,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,977.06,86,,,percent of total billed charges,86% of total billed charges,908.9,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1102.04,97,,,percent of total billed charges,97% of total billed charges,1022.51,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.04,97,,,percent of total billed charges,97% of total billed charges,1056.59,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1102.04,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.5,6993.46,
28035- Decompress posterior tibial nerve,3435143,CDM,510,RC,28035,HCPCS,Outpatient,,,1313.84,656.92,,1182.46,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.07,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.46,90,,,Percent of total Billed charges,90% of total billed charges,321.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1274.42,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1208.73,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.46,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,919.69,70,,,percent of total billed charges,70% of total billed charges,1182.46,90,,,percent of total billed charges,90% of total billed charges,1248.15,95,,,percent of total billed charges,95% of total billed charges,1248.15,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1129.9,86,,,percent of total billed charges,86% of total billed charges,1051.07,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.42,97,,,percent of total billed charges,97% of total billed charges,1182.46,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.42,97,,,percent of total billed charges,97% of total billed charges,1221.87,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,292,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.42,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,292,8763.12,
28039- Exc SQ tumor/foot or toe < 1.5 cm,3435144,CDM,510,RC,28039,HCPCS,Outpatient,,,1243.34,621.67,,1119.01,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,994.67,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1119.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1206.04,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.87,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1119.01,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,870.34,70,,,percent of total billed charges,70% of total billed charges,1119.01,90,,,percent of total billed charges,90% of total billed charges,1181.17,95,,,percent of total billed charges,95% of total billed charges,1181.17,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1069.27,86,,,percent of total billed charges,86% of total billed charges,994.67,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1206.04,97,,,percent of total billed charges,97% of total billed charges,1119.01,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1206.04,97,,,percent of total billed charges,97% of total billed charges,1156.31,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1206.04,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,870.34,12593.67,
28045- Exc IM tumor/foot/toe < 1.5 cm,3435145,CDM,510,RC,28045,HCPCS,Outpatient,,,1202.42,601.21,,1082.18,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,961.94,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1082.18,90,,,Percent of total Billed charges,90% of total billed charges,132,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1166.35,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1106.23,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1082.18,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,841.69,70,,,percent of total billed charges,70% of total billed charges,1082.18,90,,,percent of total billed charges,90% of total billed charges,1142.3,95,,,percent of total billed charges,95% of total billed charges,1142.3,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1034.08,86,,,percent of total billed charges,86% of total billed charges,961.94,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1166.35,97,,,percent of total billed charges,97% of total billed charges,1082.18,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1166.35,97,,,percent of total billed charges,97% of total billed charges,1118.25,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,120,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1166.35,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,120,12593.67,
28046- Rad resec soft tis tum/ft/toe/<3cm,3435146,CDM,510,RC,28046,HCPCS,Outpatient,,,1860.91,930.46,,1674.82,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.73,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1674.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1805.08,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1674.82,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.64,70,,,percent of total billed charges,70% of total billed charges,1674.82,90,,,percent of total billed charges,90% of total billed charges,1767.86,95,,,percent of total billed charges,95% of total billed charges,1767.86,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1600.38,86,,,percent of total billed charges,86% of total billed charges,1488.73,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1805.08,97,,,percent of total billed charges,97% of total billed charges,1674.82,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1805.08,97,,,percent of total billed charges,97% of total billed charges,1730.65,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1805.08,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1302.64,12593.67,
28052- Arthrotomy/bx metatarsophalang jnt,3435147,CDM,510,RC,28052,HCPCS,Outpatient,,,973.02,486.51,,875.72,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,778.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,875.72,90,,,Percent of total Billed charges,90% of total billed charges,155.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,943.83,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,895.18,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,875.72,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,681.11,70,,,percent of total billed charges,70% of total billed charges,875.72,90,,,percent of total billed charges,90% of total billed charges,924.37,95,,,percent of total billed charges,95% of total billed charges,924.37,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,836.8,86,,,percent of total billed charges,86% of total billed charges,778.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,943.83,97,,,percent of total billed charges,97% of total billed charges,875.72,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.83,97,,,percent of total billed charges,97% of total billed charges,904.91,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,141,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,943.83,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141,14511.58,
28062- Fasciectomy/plantar fascia/radical,3435148,CDM,510,RC,28062,HCPCS,Outpatient,,,1433.53,716.77,,1290.18,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1146.82,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1290.18,90,,,Percent of total Billed charges,90% of total billed charges,306.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1390.52,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1318.85,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1290.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1003.47,70,,,percent of total billed charges,70% of total billed charges,1290.18,90,,,percent of total billed charges,90% of total billed charges,1361.85,95,,,percent of total billed charges,95% of total billed charges,1361.85,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1232.84,86,,,percent of total billed charges,86% of total billed charges,1146.82,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1390.52,97,,,percent of total billed charges,97% of total billed charges,1290.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1390.52,97,,,percent of total billed charges,97% of total billed charges,1333.18,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1390.52,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.5,14511.58,
28072- Synovect/metatarsophalang jnt/ea,3435149,CDM,510,RC,28072,HCPCS,Outpatient,,,1226.19,613.10,,1103.57,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,980.95,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1103.57,90,,,Percent of total Billed charges,90% of total billed charges,260.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1189.4,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1128.09,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1103.57,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,858.33,70,,,percent of total billed charges,70% of total billed charges,1103.57,90,,,percent of total billed charges,90% of total billed charges,1164.88,95,,,percent of total billed charges,95% of total billed charges,1164.88,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1054.52,86,,,percent of total billed charges,86% of total billed charges,980.95,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1189.4,97,,,percent of total billed charges,97% of total billed charges,1103.57,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1189.4,97,,,percent of total billed charges,97% of total billed charges,1140.36,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1189.4,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,237,14511.58,
28080- Exc/interdigital neuroma/sng/ea,3435150,CDM,510,RC,28080,HCPCS,Outpatient,,,1322.46,661.23,,1190.21,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.97,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1190.21,90,,,Percent of total Billed charges,90% of total billed charges,193.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1282.79,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1216.66,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1190.21,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,925.72,70,,,percent of total billed charges,70% of total billed charges,1190.21,90,,,percent of total billed charges,90% of total billed charges,1256.34,95,,,percent of total billed charges,95% of total billed charges,1256.34,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1137.32,86,,,percent of total billed charges,86% of total billed charges,1057.97,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1282.79,97,,,percent of total billed charges,97% of total billed charges,1190.21,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1282.79,97,,,percent of total billed charges,97% of total billed charges,1229.89,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1282.79,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,175.5,6993.46,
28086- Synovect/tendon sheath/foot/flex,3435151,CDM,510,RC,28086,HCPCS,Outpatient,,,1342.32,671.16,,1208.09,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.86,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1208.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1302.05,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1234.93,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1208.09,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,939.62,70,,,percent of total billed charges,70% of total billed charges,1208.09,90,,,percent of total billed charges,90% of total billed charges,1275.2,95,,,percent of total billed charges,95% of total billed charges,1275.2,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1154.4,86,,,percent of total billed charges,86% of total billed charges,1073.86,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1302.05,97,,,percent of total billed charges,97% of total billed charges,1208.09,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.05,97,,,percent of total billed charges,97% of total billed charges,1248.36,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1302.05,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,939.62,14511.58,
28090- Exc/lesion/ten/sheath/capsule/foot,3435152,CDM,510,RC,28090,HCPCS,Outpatient,,,1158.29,579.15,,1042.46,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,926.63,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1042.46,90,,,Percent of total Billed charges,90% of total billed charges,169.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1123.54,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1065.63,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1042.46,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,810.8,70,,,percent of total billed charges,70% of total billed charges,1042.46,90,,,percent of total billed charges,90% of total billed charges,1100.38,95,,,percent of total billed charges,95% of total billed charges,1100.38,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,996.13,86,,,percent of total billed charges,86% of total billed charges,926.63,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1123.54,97,,,percent of total billed charges,97% of total billed charges,1042.46,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1123.54,97,,,percent of total billed charges,97% of total billed charges,1077.21,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1123.54,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.5,6993.46,
28092- Exc toe les/tendon/sheath/caps/ea,3435153,CDM,510,RC,28092,HCPCS,Outpatient,,,1038.37,519.19,,934.53,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,830.7,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,934.53,90,,,Percent of total Billed charges,90% of total billed charges,106.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1007.22,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,955.3,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,934.53,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,726.86,70,,,percent of total billed charges,70% of total billed charges,934.53,90,,,percent of total billed charges,90% of total billed charges,986.45,95,,,percent of total billed charges,95% of total billed charges,986.45,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,893,86,,,percent of total billed charges,86% of total billed charges,830.7,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1007.22,97,,,percent of total billed charges,97% of total billed charges,934.53,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1007.22,97,,,percent of total billed charges,97% of total billed charges,965.68,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1007.22,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,96.5,6993.46,
28104- Exc bone cyst/bgn tum/tarsal/meta,3435154,CDM,510,RC,28104,HCPCS,Outpatient,,,1311.42,655.71,,1180.28,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.14,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1180.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1272.08,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1206.51,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1180.28,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,917.99,70,,,percent of total billed charges,70% of total billed charges,1180.28,90,,,percent of total billed charges,90% of total billed charges,1245.85,95,,,percent of total billed charges,95% of total billed charges,1245.85,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1127.82,86,,,percent of total billed charges,86% of total billed charges,1049.14,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1272.08,97,,,percent of total billed charges,97% of total billed charges,1180.28,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1272.08,97,,,percent of total billed charges,97% of total billed charges,1219.62,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1272.08,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,917.99,14511.58,
"28108- Excision/Curettage Bone Cyst or Benign Tumor, Phalanges",3435155,CDM,510,RC,28108,HCPCS,Outpatient,,,1081.79,540.90,,973.61,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,865.43,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,973.61,90,,,Percent of total Billed charges,90% of total billed charges,146.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1049.34,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,995.25,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,973.61,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,757.25,70,,,percent of total billed charges,70% of total billed charges,973.61,90,,,percent of total billed charges,90% of total billed charges,1027.7,95,,,percent of total billed charges,95% of total billed charges,1027.7,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,930.34,86,,,percent of total billed charges,86% of total billed charges,865.43,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1049.34,97,,,percent of total billed charges,97% of total billed charges,973.61,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.34,97,,,percent of total billed charges,97% of total billed charges,1006.06,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,133,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1049.34,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133,6993.46,
28110- Ostectomy/part/5th metatar head,3435156,CDM,510,RC,28110,HCPCS,Outpatient,,,1141.39,570.70,,1027.25,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,913.11,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1027.25,90,,,Percent of total Billed charges,90% of total billed charges,293.11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1107.15,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.08,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1027.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,798.97,70,,,percent of total billed charges,70% of total billed charges,1027.25,90,,,percent of total billed charges,90% of total billed charges,1084.32,95,,,percent of total billed charges,95% of total billed charges,1084.32,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,981.6,86,,,percent of total billed charges,86% of total billed charges,913.11,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1107.15,97,,,percent of total billed charges,97% of total billed charges,1027.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.15,97,,,percent of total billed charges,97% of total billed charges,1061.49,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1107.15,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,266.46,14511.58,
"28112- Ostectomy/comp/2,3,4 metatar head",3435157,CDM,510,RC,28112,HCPCS,Outpatient,,,1205.92,602.96,,1085.33,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,964.74,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1085.33,90,,,Percent of total Billed charges,90% of total billed charges,251.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1169.74,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.45,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1085.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,844.14,70,,,percent of total billed charges,70% of total billed charges,1085.33,90,,,percent of total billed charges,90% of total billed charges,1145.62,95,,,percent of total billed charges,95% of total billed charges,1145.62,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1037.09,86,,,percent of total billed charges,86% of total billed charges,964.74,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1169.74,97,,,percent of total billed charges,97% of total billed charges,1085.33,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1169.74,97,,,percent of total billed charges,97% of total billed charges,1121.51,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,229,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1169.74,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,229,14511.58,
28116- Ostectromy/exc tarsal coalition,3435158,CDM,510,RC,28116,HCPCS,Outpatient,,,1960,980.00,,1764,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1568,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1764,90,,,Percent of total Billed charges,90% of total billed charges,306.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1901.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1803.2,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1764,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1372,70,,,percent of total billed charges,70% of total billed charges,1764,90,,,percent of total billed charges,90% of total billed charges,1862,95,,,percent of total billed charges,95% of total billed charges,1862,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1685.6,86,,,percent of total billed charges,86% of total billed charges,1568,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1901.2,97,,,percent of total billed charges,97% of total billed charges,1764,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1901.2,97,,,percent of total billed charges,97% of total billed charges,1822.8,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1901.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.5,14511.58,
28118- Ostectomy/calcaneus,3435159,CDM,510,RC,28118,HCPCS,Outpatient,,,1516.33,758.17,,1364.7,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1213.06,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1364.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1470.84,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.02,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1364.7,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.43,70,,,percent of total billed charges,70% of total billed charges,1364.7,90,,,percent of total billed charges,90% of total billed charges,1440.51,95,,,percent of total billed charges,95% of total billed charges,1440.51,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1304.04,86,,,percent of total billed charges,86% of total billed charges,1213.06,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1470.84,97,,,percent of total billed charges,97% of total billed charges,1364.7,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1470.84,97,,,percent of total billed charges,97% of total billed charges,1410.19,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1470.84,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1061.43,14511.58,
28119- Ostectomy/calcaneus/for spur,3435160,CDM,510,RC,28119,HCPCS,Outpatient,,,1318.34,659.17,,1186.51,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1054.67,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1186.51,90,,,Percent of total Billed charges,90% of total billed charges,317.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1278.79,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1212.87,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1186.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,922.84,70,,,percent of total billed charges,70% of total billed charges,1186.51,90,,,percent of total billed charges,90% of total billed charges,1252.42,95,,,percent of total billed charges,95% of total billed charges,1252.42,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1133.77,86,,,percent of total billed charges,86% of total billed charges,1054.67,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1278.79,97,,,percent of total billed charges,97% of total billed charges,1186.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1278.79,97,,,percent of total billed charges,97% of total billed charges,1226.06,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,289,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1278.79,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,289,14511.58,
28120- Part excision bone/talus/calcaneus,3435161,CDM,510,RC,28120,HCPCS,Outpatient,,,1701.46,850.73,,1531.31,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.17,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1531.31,90,,,Percent of total Billed charges,90% of total billed charges,243.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1650.42,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.34,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1531.31,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1191.02,70,,,percent of total billed charges,70% of total billed charges,1531.31,90,,,percent of total billed charges,90% of total billed charges,1616.39,95,,,percent of total billed charges,95% of total billed charges,1616.39,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1463.26,86,,,percent of total billed charges,86% of total billed charges,1361.17,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1650.42,97,,,percent of total billed charges,97% of total billed charges,1531.31,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.42,97,,,percent of total billed charges,97% of total billed charges,1582.36,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,221.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1650.42,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221.5,14511.58,
28124- Part excision/bone/phalanx of toe,3435163,CDM,510,RC,28124,HCPCS,Outpatient,,,1188.5,594.25,,1069.65,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,950.8,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1069.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1152.85,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1093.42,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1069.65,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,831.95,70,,,percent of total billed charges,70% of total billed charges,1069.65,90,,,percent of total billed charges,90% of total billed charges,1129.08,95,,,percent of total billed charges,95% of total billed charges,1129.08,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1022.11,86,,,percent of total billed charges,86% of total billed charges,950.8,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1152.85,97,,,percent of total billed charges,97% of total billed charges,1069.65,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1152.85,97,,,percent of total billed charges,97% of total billed charges,1105.31,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1152.85,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,831.95,14511.58,
28130- Talectomy,3435164,CDM,510,RC,28130,HCPCS,Outpatient,,,1591.21,795.61,,1432.09,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1272.97,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1432.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1543.47,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1463.91,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1432.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1113.85,70,,,percent of total billed charges,70% of total billed charges,1432.09,90,,,percent of total billed charges,90% of total billed charges,1511.65,95,,,percent of total billed charges,95% of total billed charges,1511.65,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1368.44,86,,,percent of total billed charges,86% of total billed charges,1272.97,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1543.47,97,,,percent of total billed charges,97% of total billed charges,1432.09,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1543.47,97,,,percent of total billed charges,97% of total billed charges,1479.83,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1543.47,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1113.85,32247.16,
28200- Rpr/tendon/flexor/foot/ea tendon,3435168,CDM,510,RC,28200,HCPCS,Outpatient,,,1240.21,620.11,,1116.19,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,992.17,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1116.19,90,,,Percent of total Billed charges,90% of total billed charges,260.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1203,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1140.99,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1116.19,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,868.15,70,,,percent of total billed charges,70% of total billed charges,1116.19,90,,,percent of total billed charges,90% of total billed charges,1178.2,95,,,percent of total billed charges,95% of total billed charges,1178.2,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1066.58,86,,,percent of total billed charges,86% of total billed charges,992.17,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1203,97,,,percent of total billed charges,97% of total billed charges,1116.19,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1203,97,,,percent of total billed charges,97% of total billed charges,1153.4,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,237,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1203,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,237,14511.58,
28202- Rpr flx tend ft/secondary/free gft,3435169,CDM,510,RC,28202,HCPCS,Outpatient,,,1501.81,750.91,,1351.63,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1201.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.63,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1456.76,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1381.67,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1351.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.27,70,,,percent of total billed charges,70% of total billed charges,1351.63,90,,,percent of total billed charges,90% of total billed charges,1426.72,95,,,percent of total billed charges,95% of total billed charges,1426.72,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1291.56,86,,,percent of total billed charges,86% of total billed charges,1201.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1456.76,97,,,percent of total billed charges,97% of total billed charges,1351.63,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1456.76,97,,,percent of total billed charges,97% of total billed charges,1396.68,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1456.76,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,32247.16,
28208- Rpr/tendon/extension/foot/ea tendon,3435170,CDM,510,RC,28208,HCPCS,Outpatient,,,1205.6,602.80,,1085.04,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,964.48,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1085.04,90,,,Percent of total Billed charges,90% of total billed charges,261.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1169.43,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.15,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1085.04,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,843.92,70,,,percent of total billed charges,70% of total billed charges,1085.04,90,,,percent of total billed charges,90% of total billed charges,1145.32,95,,,percent of total billed charges,95% of total billed charges,1145.32,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1036.82,86,,,percent of total billed charges,86% of total billed charges,964.48,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1169.43,97,,,percent of total billed charges,97% of total billed charges,1085.04,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1169.43,97,,,percent of total billed charges,97% of total billed charges,1121.21,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,238,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1169.43,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,238,14511.58,
28220- Tenolysis/flexor/foot/sng tendon,3435171,CDM,510,RC,28220,HCPCS,Outpatient,,,1124.66,562.33,,1012.19,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,899.73,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1012.19,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1090.92,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1034.69,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1012.19,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,787.26,70,,,percent of total billed charges,70% of total billed charges,1012.19,90,,,percent of total billed charges,90% of total billed charges,1068.43,95,,,percent of total billed charges,95% of total billed charges,1068.43,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,967.21,86,,,percent of total billed charges,86% of total billed charges,899.73,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1090.92,97,,,percent of total billed charges,97% of total billed charges,1012.19,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1090.92,97,,,percent of total billed charges,97% of total billed charges,1045.93,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1090.92,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,6993.46,
28225- Tenolysis/extensor/foot/sng tendon,3435172,CDM,510,RC,28225,HCPCS,Outpatient,,,1031.07,515.54,,927.96,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,824.86,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,927.96,90,,,Percent of total Billed charges,90% of total billed charges,116.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1000.14,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,948.58,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,927.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,721.75,70,,,percent of total billed charges,70% of total billed charges,927.96,90,,,percent of total billed charges,90% of total billed charges,979.52,95,,,percent of total billed charges,95% of total billed charges,979.52,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,886.72,86,,,percent of total billed charges,86% of total billed charges,824.86,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1000.14,97,,,percent of total billed charges,97% of total billed charges,927.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000.14,97,,,percent of total billed charges,97% of total billed charges,958.9,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1000.14,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.5,14511.58,
28230- Tenotomy/open/flex/foot/sng/multi,3435173,CDM,510,RC,28230,HCPCS,Outpatient,,,1078.94,539.47,,971.05,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,863.15,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,971.05,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1046.57,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,992.62,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,971.05,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,755.26,70,,,percent of total billed charges,70% of total billed charges,971.05,90,,,percent of total billed charges,90% of total billed charges,1024.99,95,,,percent of total billed charges,95% of total billed charges,1024.99,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,927.89,86,,,percent of total billed charges,86% of total billed charges,863.15,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1046.57,97,,,percent of total billed charges,97% of total billed charges,971.05,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1046.57,97,,,percent of total billed charges,97% of total billed charges,1003.41,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1046.57,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,6993.46,
28232- Tenotomy/open/tendon flex/toe/sng,3435174,CDM,510,RC,28232,HCPCS,Outpatient,,,939.46,469.73,,845.51,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,751.57,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,845.51,90,,,Percent of total Billed charges,90% of total billed charges,91.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,911.28,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,864.3,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,845.51,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,657.62,70,,,percent of total billed charges,70% of total billed charges,845.51,90,,,percent of total billed charges,90% of total billed charges,892.49,95,,,percent of total billed charges,95% of total billed charges,892.49,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,807.94,86,,,percent of total billed charges,86% of total billed charges,751.57,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,911.28,97,,,percent of total billed charges,97% of total billed charges,845.51,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,911.28,97,,,percent of total billed charges,97% of total billed charges,873.7,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,911.28,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,83,6993.46,
28234- Tenotomy/open/extensor/ft/toe/each,3435175,CDM,510,RC,28234,HCPCS,Outpatient,,,1009.16,504.58,,908.24,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,807.33,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,908.24,90,,,Percent of total Billed charges,90% of total billed charges,123.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,978.89,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,928.43,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,908.24,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,706.41,70,,,percent of total billed charges,70% of total billed charges,908.24,90,,,percent of total billed charges,90% of total billed charges,958.7,95,,,percent of total billed charges,95% of total billed charges,958.7,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,867.88,86,,,percent of total billed charges,86% of total billed charges,807.33,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,978.89,97,,,percent of total billed charges,97% of total billed charges,908.24,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,978.89,97,,,percent of total billed charges,97% of total billed charges,938.52,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,978.89,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.5,6993.46,
28238- Revise post tib ten/exc navic bone,3435176,CDM,510,RC,28238,HCPCS,Outpatient,,,1698.78,849.39,,1528.9,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1359.02,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1528.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1647.82,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1562.88,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1528.9,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.15,70,,,percent of total billed charges,70% of total billed charges,1528.9,90,,,percent of total billed charges,90% of total billed charges,1613.84,95,,,percent of total billed charges,95% of total billed charges,1613.84,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1460.95,86,,,percent of total billed charges,86% of total billed charges,1359.02,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1647.82,97,,,percent of total billed charges,97% of total billed charges,1528.9,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1647.82,97,,,percent of total billed charges,97% of total billed charges,1579.87,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1647.82,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1189.15,32247.16,
28250- Division of plantar fascia/muscle,3435177,CDM,510,RC,28250,HCPCS,Outpatient,,,1459.05,729.53,,1313.15,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.24,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1313.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1415.28,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1342.33,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1313.15,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.34,70,,,percent of total billed charges,70% of total billed charges,1313.15,90,,,percent of total billed charges,90% of total billed charges,1386.1,95,,,percent of total billed charges,95% of total billed charges,1386.1,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1254.78,86,,,percent of total billed charges,86% of total billed charges,1167.24,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1415.28,97,,,percent of total billed charges,97% of total billed charges,1313.15,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1415.28,97,,,percent of total billed charges,97% of total billed charges,1356.92,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1415.28,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1021.34,14511.58,
28270- Capsulotomy/metaphalang jnt/ea jnt,3435178,CDM,510,RC,28270,HCPCS,Outpatient,,,1215.52,607.76,,1093.97,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,972.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1093.97,90,,,Percent of total Billed charges,90% of total billed charges,141.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1179.05,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.28,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1093.97,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,850.86,70,,,percent of total billed charges,70% of total billed charges,1093.97,90,,,percent of total billed charges,90% of total billed charges,1154.74,95,,,percent of total billed charges,95% of total billed charges,1154.74,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1045.35,86,,,percent of total billed charges,86% of total billed charges,972.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1179.05,97,,,percent of total billed charges,97% of total billed charges,1093.97,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.05,97,,,percent of total billed charges,97% of total billed charges,1130.43,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1179.05,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129,14511.58,
28272- Capsulotomy/interphalan jnt/ea jnt,3435179,CDM,510,RC,28272,HCPCS,Outpatient,,,955.88,477.94,,860.29,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,764.7,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.29,90,,,Percent of total Billed charges,90% of total billed charges,116.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,927.2,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,879.41,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,860.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,669.12,70,,,percent of total billed charges,70% of total billed charges,860.29,90,,,percent of total billed charges,90% of total billed charges,908.09,95,,,percent of total billed charges,95% of total billed charges,908.09,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,822.06,86,,,percent of total billed charges,86% of total billed charges,764.7,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,927.2,97,,,percent of total billed charges,97% of total billed charges,860.29,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,927.2,97,,,percent of total billed charges,97% of total billed charges,888.97,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,106,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,927.2,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,106,6993.46,
28280- Syndactylization/toes,3435180,CDM,510,RC,28280,HCPCS,Outpatient,,,1280.6,640.30,,1152.54,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.48,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1152.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1242.18,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1178.15,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1152.54,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,896.42,70,,,percent of total billed charges,70% of total billed charges,1152.54,90,,,percent of total billed charges,90% of total billed charges,1216.57,95,,,percent of total billed charges,95% of total billed charges,1216.57,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1101.32,86,,,percent of total billed charges,86% of total billed charges,1024.48,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1242.18,97,,,percent of total billed charges,97% of total billed charges,1152.54,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1242.18,97,,,percent of total billed charges,97% of total billed charges,1190.96,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1242.18,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,896.42,14511.58,
28285- Correction/hammertoe,3435181,CDM,510,RC,28285,HCPCS,Outpatient,,,1344.53,672.27,,1210.08,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1075.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1210.08,90,,,Percent of total Billed charges,90% of total billed charges,254.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1304.19,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.97,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1210.08,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,941.17,70,,,percent of total billed charges,70% of total billed charges,1210.08,90,,,percent of total billed charges,90% of total billed charges,1277.3,95,,,percent of total billed charges,95% of total billed charges,1277.3,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1156.3,86,,,percent of total billed charges,86% of total billed charges,1075.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1304.19,97,,,percent of total billed charges,97% of total billed charges,1210.08,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1304.19,97,,,percent of total billed charges,97% of total billed charges,1250.41,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1304.19,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,231.5,14511.58,
28286- Correct cock-up 5th toe/plast clos,3435182,CDM,510,RC,28286,HCPCS,Outpatient,,,1104.39,552.20,,993.95,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,883.51,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,993.95,90,,,Percent of total Billed charges,90% of total billed charges,254.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1071.26,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1016.04,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,993.95,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,773.07,70,,,percent of total billed charges,70% of total billed charges,993.95,90,,,percent of total billed charges,90% of total billed charges,1049.17,95,,,percent of total billed charges,95% of total billed charges,1049.17,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,949.78,86,,,percent of total billed charges,86% of total billed charges,883.51,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1071.26,97,,,percent of total billed charges,97% of total billed charges,993.95,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1071.26,97,,,percent of total billed charges,97% of total billed charges,1027.08,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1071.26,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,231.5,14511.58,
28288- Ostectomy/part/ea metatarsal head,3435183,CDM,510,RC,28288,HCPCS,Outpatient,,,1510.65,755.33,,1359.59,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1208.52,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1359.59,90,,,Percent of total Billed charges,90% of total billed charges,271.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1465.33,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1389.8,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1359.59,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.46,70,,,percent of total billed charges,70% of total billed charges,1359.59,90,,,percent of total billed charges,90% of total billed charges,1435.12,95,,,percent of total billed charges,95% of total billed charges,1435.12,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1299.16,86,,,percent of total billed charges,86% of total billed charges,1208.52,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1465.33,97,,,percent of total billed charges,97% of total billed charges,1359.59,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1465.33,97,,,percent of total billed charges,97% of total billed charges,1404.9,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1465.33,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246.5,14511.58,
28289- Correction of hallux rigidus,3435184,CDM,510,RC,28289,HCPCS,Outpatient,,,1720.95,860.48,,1548.86,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1376.76,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1548.86,90,,,Percent of total Billed charges,90% of total billed charges,352.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1669.32,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1583.27,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1548.86,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1204.67,70,,,percent of total billed charges,70% of total billed charges,1548.86,90,,,percent of total billed charges,90% of total billed charges,1634.9,95,,,percent of total billed charges,95% of total billed charges,1634.9,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1480.02,86,,,percent of total billed charges,86% of total billed charges,1376.76,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1669.32,97,,,percent of total billed charges,97% of total billed charges,1548.86,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1669.32,97,,,percent of total billed charges,97% of total billed charges,1600.48,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1669.32,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,320.55,14511.58,
28292-Cor hlx vlgs rsc prx phlx bs,3435186,CDM,510,RC,28292,HCPCS,Outpatient,,,1739.57,869.79,,1565.61,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.66,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.61,90,,,Percent of total Billed charges,90% of total billed charges,329.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1687.38,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1600.4,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1565.61,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.7,70,,,percent of total billed charges,70% of total billed charges,1565.61,90,,,percent of total billed charges,90% of total billed charges,1652.59,95,,,percent of total billed charges,95% of total billed charges,1652.59,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1496.03,86,,,percent of total billed charges,86% of total billed charges,1391.66,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1687.38,97,,,percent of total billed charges,97% of total billed charges,1565.61,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1687.38,97,,,percent of total billed charges,97% of total billed charges,1617.8,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1687.38,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,299.5,14511.58,
28296- Cor hlx vlgs dstl mtar osteo,3435187,CDM,510,RC,28296,HCPCS,Outpatient,,,2214.9,1107.45,,1993.41,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1771.92,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1993.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2148.45,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2037.71,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1993.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1550.43,70,,,percent of total billed charges,70% of total billed charges,1993.41,90,,,percent of total billed charges,90% of total billed charges,2104.16,95,,,percent of total billed charges,95% of total billed charges,2104.16,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1904.81,86,,,percent of total billed charges,86% of total billed charges,1771.92,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2148.45,97,,,percent of total billed charges,97% of total billed charges,1993.41,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2148.45,97,,,percent of total billed charges,97% of total billed charges,2059.86,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2148.45,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1550.43,14511.58,
28297- Cor hlx vlgs jt arthrd,3435188,CDM,510,RC,28297,HCPCS,Outpatient,,,2591.28,1295.64,,2332.15,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2073.02,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2332.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2513.54,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2383.98,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2332.15,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1813.9,70,,,percent of total billed charges,70% of total billed charges,2332.15,90,,,percent of total billed charges,90% of total billed charges,2461.72,95,,,percent of total billed charges,95% of total billed charges,2461.72,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2228.5,86,,,percent of total billed charges,86% of total billed charges,2073.02,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2513.54,97,,,percent of total billed charges,97% of total billed charges,2332.15,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2513.54,97,,,percent of total billed charges,97% of total billed charges,2409.89,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2513.54,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1813.9,32247.16,
28299- Cor hlx vlgs double osteot,3435189,CDM,510,RC,28299,HCPCS,Outpatient,,,2512.67,1256.34,,2261.4,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2010.14,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2261.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2437.29,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2311.66,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2261.4,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1758.87,70,,,percent of total billed charges,70% of total billed charges,2261.4,90,,,percent of total billed charges,90% of total billed charges,2387.04,95,,,percent of total billed charges,95% of total billed charges,2387.04,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2160.9,86,,,percent of total billed charges,86% of total billed charges,2010.14,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2437.29,97,,,percent of total billed charges,97% of total billed charges,2261.4,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2437.29,97,,,percent of total billed charges,97% of total billed charges,2336.78,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2437.29,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1758.87,32247.16,
28300- Osteotomy/calcaneus w/w/o int fix,3435190,CDM,510,RC,28300,HCPCS,Outpatient,,,1694.07,847.04,,1524.66,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1355.26,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1643.25,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1558.54,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1524.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1185.85,70,,,percent of total billed charges,70% of total billed charges,1524.66,90,,,percent of total billed charges,90% of total billed charges,1609.37,95,,,percent of total billed charges,95% of total billed charges,1609.37,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1456.9,86,,,percent of total billed charges,86% of total billed charges,1355.26,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1643.25,97,,,percent of total billed charges,97% of total billed charges,1524.66,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1643.25,97,,,percent of total billed charges,97% of total billed charges,1575.49,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1643.25,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1185.85,32247.16,
28304- Osteotomy/tarsal bones,3435191,CDM,510,RC,28304,HCPCS,Outpatient,,,2099.28,1049.64,,1889.35,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1679.42,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1889.35,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2036.3,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1931.34,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1889.35,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.5,70,,,percent of total billed charges,70% of total billed charges,1889.35,90,,,percent of total billed charges,90% of total billed charges,1994.32,95,,,percent of total billed charges,95% of total billed charges,1994.32,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1805.38,86,,,percent of total billed charges,86% of total billed charges,1679.42,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2036.3,97,,,percent of total billed charges,97% of total billed charges,1889.35,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2036.3,97,,,percent of total billed charges,97% of total billed charges,1952.33,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2036.3,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,32247.16,
28306- Osteotomy/first metatarsal,3435192,CDM,510,RC,28306,HCPCS,Outpatient,,,1517.81,758.91,,1366.03,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.25,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.03,90,,,Percent of total Billed charges,90% of total billed charges,338.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1472.28,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.39,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1366.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1062.47,70,,,percent of total billed charges,70% of total billed charges,1366.03,90,,,percent of total billed charges,90% of total billed charges,1441.92,95,,,percent of total billed charges,95% of total billed charges,1441.92,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1305.32,86,,,percent of total billed charges,86% of total billed charges,1214.25,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1472.28,97,,,percent of total billed charges,97% of total billed charges,1366.03,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1472.28,97,,,percent of total billed charges,97% of total billed charges,1411.56,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1472.28,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,307.5,32247.16,
28308- Osteotomy/not first metatarsal/ea,3435193,CDM,510,RC,28308,HCPCS,Outpatient,,,1423.25,711.63,,1280.93,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.6,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1280.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1380.55,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1309.39,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1280.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,996.28,70,,,percent of total billed charges,70% of total billed charges,1280.93,90,,,percent of total billed charges,90% of total billed charges,1352.09,95,,,percent of total billed charges,95% of total billed charges,1352.09,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1224,86,,,percent of total billed charges,86% of total billed charges,1138.6,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1380.55,97,,,percent of total billed charges,97% of total billed charges,1280.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1380.55,97,,,percent of total billed charges,97% of total billed charges,1323.62,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1380.55,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,996.28,14511.58,
28309- Osteotomy/multiple metatarsal,3435194,CDM,510,RC,28309,HCPCS,Outpatient,,,2333.56,1166.78,,2100.2,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1866.85,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2100.2,90,,,Percent of total Billed charges,90% of total billed charges,287.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2263.55,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2146.88,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2100.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1633.49,70,,,percent of total billed charges,70% of total billed charges,2100.2,90,,,percent of total billed charges,90% of total billed charges,2216.88,95,,,percent of total billed charges,95% of total billed charges,2216.88,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2006.86,86,,,percent of total billed charges,86% of total billed charges,1866.85,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2263.55,97,,,percent of total billed charges,97% of total billed charges,2100.2,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2263.55,97,,,percent of total billed charges,97% of total billed charges,2170.21,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,261,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2263.55,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,261,32247.16,
28310- Osteot/shorten/prox phalan/1st toe,3435195,CDM,510,RC,28310,HCPCS,Outpatient,,,1364.26,682.13,,1227.83,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1091.41,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1227.83,90,,,Percent of total Billed charges,90% of total billed charges,274.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1323.33,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1255.12,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1227.83,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,954.98,70,,,percent of total billed charges,70% of total billed charges,1227.83,90,,,percent of total billed charges,90% of total billed charges,1296.05,95,,,percent of total billed charges,95% of total billed charges,1296.05,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1173.26,86,,,percent of total billed charges,86% of total billed charges,1091.41,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1323.33,97,,,percent of total billed charges,97% of total billed charges,1227.83,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.33,97,,,percent of total billed charges,97% of total billed charges,1268.76,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1323.33,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,249.5,32247.16,
28313- Repair/deformity/toe/soft tis only,3435196,CDM,510,RC,28313,HCPCS,Outpatient,,,1320.55,660.28,,1188.5,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1056.44,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1188.5,90,,,Percent of total Billed charges,90% of total billed charges,343.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1280.93,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.91,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1188.5,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,924.39,70,,,percent of total billed charges,70% of total billed charges,1188.5,90,,,percent of total billed charges,90% of total billed charges,1254.52,95,,,percent of total billed charges,95% of total billed charges,1254.52,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1135.67,86,,,percent of total billed charges,86% of total billed charges,1056.44,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1280.93,97,,,percent of total billed charges,97% of total billed charges,1188.5,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1280.93,97,,,percent of total billed charges,97% of total billed charges,1228.11,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,312,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1280.93,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,312,14511.58,
28322- Repair metatarsal,3435197,CDM,510,RC,28322,HCPCS,Outpatient,,,1987.69,993.85,,1788.92,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1590.15,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1788.92,90,,,Percent of total Billed charges,90% of total billed charges,306.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1928.06,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1828.67,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1788.92,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1391.38,70,,,percent of total billed charges,70% of total billed charges,1788.92,90,,,percent of total billed charges,90% of total billed charges,1888.31,95,,,percent of total billed charges,95% of total billed charges,1888.31,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1709.41,86,,,percent of total billed charges,86% of total billed charges,1590.15,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1928.06,97,,,percent of total billed charges,97% of total billed charges,1788.92,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1928.06,97,,,percent of total billed charges,97% of total billed charges,1848.55,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1928.06,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.5,32247.16,
28400- Clsd tx/calcaneal fx w/o manip,3435198,CDM,510,RC,28400,HCPCS,Outpatient,,,625.28,312.64,,562.75,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,500.22,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,562.75,90,,,Percent of total Billed charges,90% of total billed charges,154,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,606.52,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,575.26,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,562.75,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,437.7,70,,,percent of total billed charges,70% of total billed charges,562.75,90,,,percent of total billed charges,90% of total billed charges,594.02,95,,,percent of total billed charges,95% of total billed charges,594.02,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,537.74,86,,,percent of total billed charges,86% of total billed charges,500.22,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,606.52,97,,,percent of total billed charges,97% of total billed charges,562.75,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,606.52,97,,,percent of total billed charges,97% of total billed charges,581.51,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,140,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,606.52,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,140,1009.19,
28406- Perc skel fix/calcaneal fx/manip,3435199,CDM,510,RC,28406,HCPCS,Outpatient,,,1453.77,726.89,,1308.39,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1163.02,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1308.39,90,,,Percent of total Billed charges,90% of total billed charges,238.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1410.16,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1337.47,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1308.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1017.64,70,,,percent of total billed charges,70% of total billed charges,1308.39,90,,,percent of total billed charges,90% of total billed charges,1381.08,95,,,percent of total billed charges,95% of total billed charges,1381.08,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1250.24,86,,,percent of total billed charges,86% of total billed charges,1163.02,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1410.16,97,,,percent of total billed charges,97% of total billed charges,1308.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1410.16,97,,,percent of total billed charges,97% of total billed charges,1352.01,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1410.16,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.5,32247.16,
28415- Open tx/calcaneal fracture,3435200,CDM,510,RC,28415,HCPCS,Outpatient,,,2937.63,1468.82,,2643.87,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2350.1,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2643.87,90,,,Percent of total Billed charges,90% of total billed charges,331.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2849.5,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2702.62,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2643.87,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2056.34,70,,,percent of total billed charges,70% of total billed charges,2643.87,90,,,percent of total billed charges,90% of total billed charges,2790.75,95,,,percent of total billed charges,95% of total billed charges,2790.75,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2526.36,86,,,percent of total billed charges,86% of total billed charges,2350.1,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2849.5,97,,,percent of total billed charges,97% of total billed charges,2643.87,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2849.5,97,,,percent of total billed charges,97% of total billed charges,2732,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2849.5,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.5,32247.16,
28430- Clsd tx talus ankle fx w/o manip,3435201,CDM,510,RC,28430,HCPCS,Outpatient,,,607.68,303.84,,546.91,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,486.14,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,546.91,90,,,Percent of total Billed charges,90% of total billed charges,122.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,589.45,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,559.07,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,546.91,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,425.38,70,,,percent of total billed charges,70% of total billed charges,546.91,90,,,percent of total billed charges,90% of total billed charges,577.3,95,,,percent of total billed charges,95% of total billed charges,577.3,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,522.6,86,,,percent of total billed charges,86% of total billed charges,486.14,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,589.45,97,,,percent of total billed charges,97% of total billed charges,546.91,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.45,97,,,percent of total billed charges,97% of total billed charges,565.14,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,111,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,589.45,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111,1009.19,
28445- Open tx/talus fracture,3435202,CDM,510,RC,28445,HCPCS,Outpatient,,,2675.13,1337.57,,2407.62,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2140.1,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2407.62,90,,,Percent of total Billed charges,90% of total billed charges,295.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2594.88,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2461.12,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2407.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1872.59,70,,,percent of total billed charges,70% of total billed charges,2407.62,90,,,percent of total billed charges,90% of total billed charges,2541.37,95,,,percent of total billed charges,95% of total billed charges,2541.37,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2300.61,86,,,percent of total billed charges,86% of total billed charges,2140.1,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2594.88,97,,,percent of total billed charges,97% of total billed charges,2407.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2594.88,97,,,percent of total billed charges,97% of total billed charges,2487.87,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,269,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2594.88,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,269,32247.16,
28450- Tx tarsal bone fx w/o manip,3435203,CDM,510,RC,28450,HCPCS,Outpatient,,,533.54,266.77,,480.19,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,426.83,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.19,90,,,Percent of total Billed charges,90% of total billed charges,125.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,517.53,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,490.86,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,480.19,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,373.48,70,,,percent of total billed charges,70% of total billed charges,480.19,90,,,percent of total billed charges,90% of total billed charges,506.86,95,,,percent of total billed charges,95% of total billed charges,506.86,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,458.84,86,,,percent of total billed charges,86% of total billed charges,426.83,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,517.53,97,,,percent of total billed charges,97% of total billed charges,480.19,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.53,97,,,percent of total billed charges,97% of total billed charges,496.19,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,114,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,517.53,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114,1009.19,
28465- Open tx/tarsal fx/internal fix/ea,3435204,CDM,510,RC,28465,HCPCS,Outpatient,,,1646.32,823.16,,1481.69,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1317.06,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1481.69,90,,,Percent of total Billed charges,90% of total billed charges,306.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1596.93,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1514.61,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1481.69,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1152.42,70,,,percent of total billed charges,70% of total billed charges,1481.69,90,,,percent of total billed charges,90% of total billed charges,1564,95,,,percent of total billed charges,95% of total billed charges,1564,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1415.84,86,,,percent of total billed charges,86% of total billed charges,1317.06,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1596.93,97,,,percent of total billed charges,97% of total billed charges,1481.69,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1596.93,97,,,percent of total billed charges,97% of total billed charges,1531.08,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1596.93,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.5,32247.16,
28470- Clsd tx/metatarsal fx w/o manip,3435205,CDM,510,RC,28470,HCPCS,Outpatient,,,549.63,274.82,,494.67,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,439.7,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.67,90,,,Percent of total Billed charges,90% of total billed charges,92.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,533.14,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,505.66,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,494.67,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,384.74,70,,,percent of total billed charges,70% of total billed charges,494.67,90,,,percent of total billed charges,90% of total billed charges,522.15,95,,,percent of total billed charges,95% of total billed charges,522.15,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,472.68,86,,,percent of total billed charges,86% of total billed charges,439.7,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,533.14,97,,,percent of total billed charges,97% of total billed charges,494.67,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,533.14,97,,,percent of total billed charges,97% of total billed charges,511.16,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,533.14,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,84.5,1009.19,
28476- Perc skel fix/metatar fx/manip/ea,3435206,CDM,510,RC,28476,HCPCS,Outpatient,,,982.41,491.21,,884.17,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,785.93,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,884.17,90,,,Percent of total Billed charges,90% of total billed charges,304.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,952.94,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,903.82,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,884.17,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,687.69,70,,,percent of total billed charges,70% of total billed charges,884.17,90,,,percent of total billed charges,90% of total billed charges,933.29,95,,,percent of total billed charges,95% of total billed charges,933.29,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,844.87,86,,,percent of total billed charges,86% of total billed charges,785.93,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,952.94,97,,,percent of total billed charges,97% of total billed charges,884.17,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,952.94,97,,,percent of total billed charges,97% of total billed charges,913.64,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,277,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,952.94,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,277,14511.58,
28485- Open tx/metatarsal fx/int fix/each,3435207,CDM,510,RC,28485,HCPCS,Outpatient,,,1441.97,720.99,,1297.77,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1153.58,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1297.77,90,,,Percent of total Billed charges,90% of total billed charges,168.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1398.71,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1326.61,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1297.77,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1009.38,70,,,percent of total billed charges,70% of total billed charges,1297.77,90,,,percent of total billed charges,90% of total billed charges,1369.87,95,,,percent of total billed charges,95% of total billed charges,1369.87,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1240.09,86,,,percent of total billed charges,86% of total billed charges,1153.58,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1398.71,97,,,percent of total billed charges,97% of total billed charges,1297.77,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1398.71,97,,,percent of total billed charges,97% of total billed charges,1341.03,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1398.71,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,153.5,32247.16,
28490- Clsd tx/fx grt toe/phalanx/phalang,3435208,CDM,510,RC,28490,HCPCS,Outpatient,,,352.26,176.13,,317.03,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,281.81,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.03,90,,,Percent of total Billed charges,90% of total billed charges,60.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,341.69,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,324.08,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,317.03,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,246.58,70,,,percent of total billed charges,70% of total billed charges,317.03,90,,,percent of total billed charges,90% of total billed charges,334.65,95,,,percent of total billed charges,95% of total billed charges,334.65,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,302.94,86,,,percent of total billed charges,86% of total billed charges,281.81,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,341.69,97,,,percent of total billed charges,97% of total billed charges,317.03,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.69,97,,,percent of total billed charges,97% of total billed charges,327.6,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,341.69,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55,1009.19,
28495- Clsd tx/fx great toe/manipulation,3435209,CDM,510,RC,28495,HCPCS,Outpatient,,,447.48,223.74,,402.73,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,357.98,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,402.73,90,,,Percent of total Billed charges,90% of total billed charges,83.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,434.06,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,411.68,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,402.73,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,313.24,70,,,percent of total billed charges,70% of total billed charges,402.73,90,,,percent of total billed charges,90% of total billed charges,425.11,95,,,percent of total billed charges,95% of total billed charges,425.11,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,384.83,86,,,percent of total billed charges,86% of total billed charges,357.98,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,434.06,97,,,percent of total billed charges,97% of total billed charges,402.73,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,434.06,97,,,percent of total billed charges,97% of total billed charges,416.16,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,434.06,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.5,1009.19,
28505- Open tx/great toe/phalanx/phalange,3435210,CDM,510,RC,28505,HCPCS,Outpatient,,,1670.32,835.16,,1503.29,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.26,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1503.29,90,,,Percent of total Billed charges,90% of total billed charges,183.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1620.21,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.69,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1503.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1169.22,70,,,percent of total billed charges,70% of total billed charges,1503.29,90,,,percent of total billed charges,90% of total billed charges,1586.8,95,,,percent of total billed charges,95% of total billed charges,1586.8,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1436.48,86,,,percent of total billed charges,86% of total billed charges,1336.26,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1620.21,97,,,percent of total billed charges,97% of total billed charges,1503.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1620.21,97,,,percent of total billed charges,97% of total billed charges,1553.4,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1620.21,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,166.5,14511.58,
28510- Clsd tx/phalanges fx w/o manip,3435211,CDM,510,RC,28510,HCPCS,Outpatient,,,300.16,150.08,,270.14,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,240.13,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,291.16,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,276.15,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,270.14,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,210.11,70,,,percent of total billed charges,70% of total billed charges,270.14,90,,,percent of total billed charges,90% of total billed charges,285.15,95,,,percent of total billed charges,95% of total billed charges,285.15,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,258.14,86,,,percent of total billed charges,86% of total billed charges,240.13,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,291.16,97,,,percent of total billed charges,97% of total billed charges,270.14,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.16,97,,,percent of total billed charges,97% of total billed charges,279.15,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,291.16,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
28515- Clsd tx/fx/phalanx/phalang/manip,3435212,CDM,510,RC,28515,HCPCS,Outpatient,,,408.98,204.49,,368.08,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,327.18,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.08,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,396.71,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,376.26,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,368.08,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,286.29,70,,,percent of total billed charges,70% of total billed charges,368.08,90,,,percent of total billed charges,90% of total billed charges,388.53,95,,,percent of total billed charges,95% of total billed charges,388.53,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,351.72,86,,,percent of total billed charges,86% of total billed charges,327.18,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,396.71,97,,,percent of total billed charges,97% of total billed charges,368.08,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.71,97,,,percent of total billed charges,97% of total billed charges,380.35,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.71,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,1009.19,
28525- Opn tx/fx/phalanx/phalang/int fix,3435213,CDM,510,RC,28525,HCPCS,Outpatient,,,1426.62,713.31,,1283.96,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1141.3,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1283.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1383.82,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1312.49,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1283.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,998.63,70,,,percent of total billed charges,70% of total billed charges,1283.96,90,,,percent of total billed charges,90% of total billed charges,1355.29,95,,,percent of total billed charges,95% of total billed charges,1355.29,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1226.89,86,,,percent of total billed charges,86% of total billed charges,1141.3,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1383.82,97,,,percent of total billed charges,97% of total billed charges,1283.96,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1383.82,97,,,percent of total billed charges,97% of total billed charges,1326.76,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1383.82,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,998.63,14511.58,
28530- Clsd tx/sesamoid fracture,3435214,CDM,510,RC,28530,HCPCS,Outpatient,,,282.96,141.48,,254.66,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,226.37,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,274.47,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,260.32,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,254.66,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,198.07,70,,,percent of total billed charges,70% of total billed charges,254.66,90,,,percent of total billed charges,90% of total billed charges,268.81,95,,,percent of total billed charges,95% of total billed charges,268.81,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,243.35,86,,,percent of total billed charges,86% of total billed charges,226.37,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,274.47,97,,,percent of total billed charges,97% of total billed charges,254.66,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.47,97,,,percent of total billed charges,97% of total billed charges,263.15,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,274.47,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,159.8,1009.19,
28555- Open tx/tarsal bone dislocateate,3435216,CDM,510,RC,28555,HCPCS,Outpatient,,,2189.08,1094.54,,1970.17,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1751.26,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1970.17,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2123.41,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2013.95,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1970.17,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1532.36,70,,,percent of total billed charges,70% of total billed charges,1970.17,90,,,percent of total billed charges,90% of total billed charges,2079.63,95,,,percent of total billed charges,95% of total billed charges,2079.63,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1882.61,86,,,percent of total billed charges,86% of total billed charges,1751.26,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2123.41,97,,,percent of total billed charges,97% of total billed charges,1970.17,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2123.41,97,,,percent of total billed charges,97% of total billed charges,2035.84,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2123.41,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,32247.16,
28575- Clsd tx/talotarsal dislocat/anes,3435217,CDM,510,RC,28575,HCPCS,Outpatient,,,963.08,481.54,,866.77,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,770.46,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,866.77,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,934.19,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,886.03,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,866.77,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,674.16,70,,,percent of total billed charges,70% of total billed charges,866.77,90,,,percent of total billed charges,90% of total billed charges,914.93,95,,,percent of total billed charges,95% of total billed charges,914.93,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,828.25,86,,,percent of total billed charges,86% of total billed charges,770.46,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,934.19,97,,,percent of total billed charges,97% of total billed charges,866.77,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,934.19,97,,,percent of total billed charges,97% of total billed charges,895.66,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,934.19,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,14511.58,
28585- Open tx/talotarsal dislocateation,3435218,CDM,510,RC,28585,HCPCS,Outpatient,,,2255.99,1128.00,,2030.39,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1804.79,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2030.39,90,,,Percent of total Billed charges,90% of total billed charges,411.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2188.31,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2075.51,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2030.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1579.19,70,,,percent of total billed charges,70% of total billed charges,2030.39,90,,,percent of total billed charges,90% of total billed charges,2143.19,95,,,percent of total billed charges,95% of total billed charges,2143.19,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1940.15,86,,,percent of total billed charges,86% of total billed charges,1804.79,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2188.31,97,,,percent of total billed charges,97% of total billed charges,2030.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2188.31,97,,,percent of total billed charges,97% of total billed charges,2098.07,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,374.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2188.31,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,374.5,32247.16,
28615- Open tx/tarsometatar jnt dislocateate,3435219,CDM,510,RC,28615,HCPCS,Outpatient,,,2134.02,1067.01,,1920.62,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1707.22,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.62,90,,,Percent of total Billed charges,90% of total billed charges,246.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2070,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1963.3,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1920.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1493.81,70,,,percent of total billed charges,70% of total billed charges,1920.62,90,,,percent of total billed charges,90% of total billed charges,2027.32,95,,,percent of total billed charges,95% of total billed charges,2027.32,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1835.26,86,,,percent of total billed charges,86% of total billed charges,1707.22,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2070,97,,,percent of total billed charges,97% of total billed charges,1920.62,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2070,97,,,percent of total billed charges,97% of total billed charges,1984.64,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,224,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2070,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,224,32247.16,
28630- Clsd tx/interphalang jnt dislocate,3435220,CDM,510,RC,28630,HCPCS,Outpatient,,,389.96,194.98,,350.96,90,,,percent of total billed charges,90% of total Billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,311.97,80,,,Percent of total Billed charges,80% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.96,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,378.26,97,,,Percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,358.76,92,,,Percent of total billed charges,92% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,499.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,796.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1009.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,350.96,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,272.97,70,,,percent of total billed charges,70% of total billed charges,350.96,90,,,percent of total billed charges,90% of total billed charges,370.46,95,,,percent of total billed charges,95% of total billed charges,370.46,95,,,percent of total billed charges,95% of total billed charges,188.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,376.03,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,335.37,86,,,percent of total billed charges,86% of total billed charges,311.97,80,,,percent of total billed charges,80% of total billed charges,222.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,378.26,97,,,percent of total billed charges,97% of total billed charges,350.96,90,,,percent of total billed charges,90% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.26,97,,,percent of total billed charges,97% of total billed charges,362.66,93,,,percent of total billed charges,93% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,378.26,97,,,percent of total billed charges,97% of total billed charges,188.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.8,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,1009.19,
28645- Open tx/metatarsophalan jnt dislocate,3435221,CDM,510,RC,28645,HCPCS,Outpatient,,,1643.66,821.83,,1479.29,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1314.93,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1479.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1594.35,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1512.17,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1479.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1150.56,70,,,percent of total billed charges,70% of total billed charges,1479.29,90,,,percent of total billed charges,90% of total billed charges,1561.48,95,,,percent of total billed charges,95% of total billed charges,1561.48,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1413.55,86,,,percent of total billed charges,86% of total billed charges,1314.93,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1594.35,97,,,percent of total billed charges,97% of total billed charges,1479.29,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1594.35,97,,,percent of total billed charges,97% of total billed charges,1528.6,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1594.35,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1150.56,14511.58,
28665- Clsd tx/interphal jnt disloc/anest,3435222,CDM,510,RC,28665,HCPCS,Outpatient,,,383.37,191.69,,345.03,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,306.7,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,371.87,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,352.7,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,345.03,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,268.36,70,,,percent of total billed charges,70% of total billed charges,345.03,90,,,percent of total billed charges,90% of total billed charges,364.2,95,,,percent of total billed charges,95% of total billed charges,364.2,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,329.7,86,,,percent of total billed charges,86% of total billed charges,306.7,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,371.87,97,,,percent of total billed charges,97% of total billed charges,345.03,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,371.87,97,,,percent of total billed charges,97% of total billed charges,356.53,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.87,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,185.21,1169.58,
28675- Open tx/interphalang jnt dislocateat,3435223,CDM,510,RC,28675,HCPCS,Outpatient,,,1445.74,722.87,,1301.17,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1156.59,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1301.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1402.37,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1330.08,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1301.17,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1012.02,70,,,percent of total billed charges,70% of total billed charges,1301.17,90,,,percent of total billed charges,90% of total billed charges,1373.45,95,,,percent of total billed charges,95% of total billed charges,1373.45,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1243.34,86,,,percent of total billed charges,86% of total billed charges,1156.59,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1402.37,97,,,percent of total billed charges,97% of total billed charges,1301.17,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1402.37,97,,,percent of total billed charges,97% of total billed charges,1344.54,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1402.37,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1012.02,14511.58,
28715- Arthrodesis/pantalar/triple,3435224,CDM,510,RC,28715,HCPCS,Outpatient,,,2445.94,1222.97,,2201.35,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.75,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2201.35,90,,,Percent of total Billed charges,90% of total billed charges,669.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2372.56,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2250.26,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2201.35,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1712.16,70,,,percent of total billed charges,70% of total billed charges,2201.35,90,,,percent of total billed charges,90% of total billed charges,2323.64,95,,,percent of total billed charges,95% of total billed charges,2323.64,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2103.51,86,,,percent of total billed charges,86% of total billed charges,1956.75,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2372.56,97,,,percent of total billed charges,97% of total billed charges,2201.35,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2372.56,97,,,percent of total billed charges,97% of total billed charges,2274.72,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,609,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2372.56,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,609,63611.04,
28725- Arthrodesis/pantalar/subtalar,3435225,CDM,510,RC,28725,HCPCS,Outpatient,,,2021.09,1010.55,,1818.98,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1616.87,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1818.98,90,,,Percent of total Billed charges,90% of total billed charges,803.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1960.46,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1859.4,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1818.98,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1414.76,70,,,percent of total billed charges,70% of total billed charges,1818.98,90,,,percent of total billed charges,90% of total billed charges,1920.04,95,,,percent of total billed charges,95% of total billed charges,1920.04,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1738.14,86,,,percent of total billed charges,86% of total billed charges,1616.87,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1960.46,97,,,percent of total billed charges,97% of total billed charges,1818.98,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1960.46,97,,,percent of total billed charges,97% of total billed charges,1879.61,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1960.46,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,730.37,63611.04,
28730- Arthrodesis/mid/tarsometatarsal,3435226,CDM,510,RC,28730,HCPCS,Outpatient,,,1901.77,950.89,,1711.59,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1521.42,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1711.59,90,,,Percent of total Billed charges,90% of total billed charges,366.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1844.72,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1749.63,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1711.59,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1331.24,70,,,percent of total billed charges,70% of total billed charges,1711.59,90,,,percent of total billed charges,90% of total billed charges,1806.68,95,,,percent of total billed charges,95% of total billed charges,1806.68,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1635.52,86,,,percent of total billed charges,86% of total billed charges,1521.42,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1844.72,97,,,percent of total billed charges,97% of total billed charges,1711.59,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1844.72,97,,,percent of total billed charges,97% of total billed charges,1768.65,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,333,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1844.72,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,333,63611.04,
28735- Arthrodesis/mid/tarsometatarsal/mult/transv/osteotomy,3435227,CDM,510,RC,28735,HCPCS,Outpatient,,,2043.61,1021.81,,1839.25,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1634.89,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1839.25,90,,,Percent of total Billed charges,90% of total billed charges,425.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1982.3,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1880.12,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1839.25,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1430.53,70,,,percent of total billed charges,70% of total billed charges,1839.25,90,,,percent of total billed charges,90% of total billed charges,1941.43,95,,,percent of total billed charges,95% of total billed charges,1941.43,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1757.5,86,,,percent of total billed charges,86% of total billed charges,1634.89,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1982.3,97,,,percent of total billed charges,97% of total billed charges,1839.25,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,1982.3,97,,,percent of total billed charges,97% of total billed charges,1900.56,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,387,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1982.3,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,387,63611.04,
28740- Arthrodes/mid/tarsometatar/sng jnt,3435228,CDM,510,RC,28740,HCPCS,Outpatient,,,2099.78,1049.89,,1889.8,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1679.82,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1889.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2036.79,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1931.8,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1889.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1469.85,70,,,percent of total billed charges,70% of total billed charges,1889.8,90,,,percent of total billed charges,90% of total billed charges,1994.79,95,,,percent of total billed charges,95% of total billed charges,1994.79,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1805.81,86,,,percent of total billed charges,86% of total billed charges,1679.82,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2036.79,97,,,percent of total billed charges,97% of total billed charges,1889.8,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2036.79,97,,,percent of total billed charges,97% of total billed charges,1952.8,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2036.79,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1469.85,32247.16,
28750- Arthrodes/grt toe/metatarsophalan,3435229,CDM,510,RC,28750,HCPCS,Outpatient,,,1985.56,992.78,,1787,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1588.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1787,90,,,Percent of total Billed charges,90% of total billed charges,306.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1925.99,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1826.72,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1787,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1389.89,70,,,percent of total billed charges,70% of total billed charges,1787,90,,,percent of total billed charges,90% of total billed charges,1886.28,95,,,percent of total billed charges,95% of total billed charges,1886.28,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1707.58,86,,,percent of total billed charges,86% of total billed charges,1588.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1925.99,97,,,percent of total billed charges,97% of total billed charges,1787,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1925.99,97,,,percent of total billed charges,97% of total billed charges,1846.57,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1925.99,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.5,32247.16,
28755- Arthrodes/grt toe/interphalangeal,3435230,CDM,510,RC,28755,HCPCS,Outpatient,,,1267.6,633.80,,1140.84,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1014.08,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1140.84,90,,,Percent of total Billed charges,90% of total billed charges,234.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1229.57,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1166.19,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1140.84,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,887.32,70,,,percent of total billed charges,70% of total billed charges,1140.84,90,,,percent of total billed charges,90% of total billed charges,1204.22,95,,,percent of total billed charges,95% of total billed charges,1204.22,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1090.14,86,,,percent of total billed charges,86% of total billed charges,1014.08,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1229.57,97,,,percent of total billed charges,97% of total billed charges,1140.84,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1229.57,97,,,percent of total billed charges,97% of total billed charges,1178.87,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1229.57,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,213.5,32247.16,
28825- Amputation/toe/interphalangeal jnt,3435233,CDM,510,RC,28825,HCPCS,Outpatient,,,747.98,373.99,,673.18,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,598.38,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,725.54,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,688.14,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,673.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,523.59,70,,,percent of total billed charges,70% of total billed charges,673.18,90,,,percent of total billed charges,90% of total billed charges,710.58,95,,,percent of total billed charges,95% of total billed charges,710.58,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,643.26,86,,,percent of total billed charges,86% of total billed charges,598.38,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,725.54,97,,,percent of total billed charges,97% of total billed charges,673.18,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,725.54,97,,,percent of total billed charges,97% of total billed charges,695.62,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,725.54,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,523.59,14511.58,
29065- Apply figure 8 cast/shoulder/hand,3435235,CDM,510,RC,29065,HCPCS,Outpatient,,,240.45,120.23,,216.41,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,192.36,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.41,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.24,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,221.21,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.41,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,168.32,70,,,percent of total billed charges,70% of total billed charges,216.41,90,,,percent of total billed charges,90% of total billed charges,228.43,95,,,percent of total billed charges,95% of total billed charges,228.43,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.79,86,,,percent of total billed charges,86% of total billed charges,192.36,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.24,97,,,percent of total billed charges,97% of total billed charges,216.41,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.24,97,,,percent of total billed charges,97% of total billed charges,223.62,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.24,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1169.58,
29075- Apply figure 8 cast/elbow/finger,3435236,CDM,510,RC,29075,HCPCS,Outpatient,,,215,107.50,,193.5,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,172,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.5,90,,,Percent of total Billed charges,90% of total billed charges,50.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,208.55,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,197.8,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,193.5,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,150.5,70,,,percent of total billed charges,70% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.9,86,,,percent of total billed charges,86% of total billed charges,172,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,208.55,97,,,percent of total billed charges,97% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.55,97,,,percent of total billed charges,97% of total billed charges,199.95,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,208.55,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.5,1169.58,
29085- Apply fig 8 cast/hand/low forearm,3435237,CDM,510,RC,29085,HCPCS,Outpatient,,,237.77,118.89,,213.99,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,190.22,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.99,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,230.64,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,218.75,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,213.99,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,166.44,70,,,percent of total billed charges,70% of total billed charges,213.99,90,,,percent of total billed charges,90% of total billed charges,225.88,95,,,percent of total billed charges,95% of total billed charges,225.88,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.48,86,,,percent of total billed charges,86% of total billed charges,190.22,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,230.64,97,,,percent of total billed charges,97% of total billed charges,213.99,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.64,97,,,percent of total billed charges,97% of total billed charges,221.13,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.64,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,710.59,
29105- Application long arm splint,3435238,CDM,510,RC,29105,HCPCS,Outpatient,,,203.54,101.77,,183.19,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,162.83,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.19,90,,,Percent of total Billed charges,90% of total billed charges,36.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,197.43,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,187.26,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,183.19,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,142.48,70,,,percent of total billed charges,70% of total billed charges,183.19,90,,,percent of total billed charges,90% of total billed charges,193.36,95,,,percent of total billed charges,95% of total billed charges,193.36,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,175.04,86,,,percent of total billed charges,86% of total billed charges,162.83,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,197.43,97,,,percent of total billed charges,97% of total billed charges,183.19,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,197.43,97,,,percent of total billed charges,97% of total billed charges,189.29,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197.43,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33.5,710.59,
App Long Arm Splint,3428386,CDM,981,RC,29105,HCPCS,Outpatient,,,203.54,101.77,,183.19,90,,,percent of total billed charges,90% of total Billed charges,119.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,66.42,155,,,Fee Schedule,155% of CMS OPPS Rate,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,66.42,155,,,Fee Schedule,155% of CMS OPPS Rate,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.05,155,,,Fee Schedule,155% of CMS OPPS Rate,185.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,170,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,33.5,185.05,
29125- App of short arm splint/static,3435239,CDM,510,RC,29125,HCPCS,Outpatient,,,160.97,80.49,,144.87,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,128.78,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.87,90,,,Percent of total Billed charges,90% of total billed charges,28.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.14,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,148.09,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,144.87,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,112.68,70,,,percent of total billed charges,70% of total billed charges,144.87,90,,,percent of total billed charges,90% of total billed charges,152.92,95,,,percent of total billed charges,95% of total billed charges,152.92,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.43,86,,,percent of total billed charges,86% of total billed charges,128.78,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.14,97,,,percent of total billed charges,97% of total billed charges,144.87,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.14,97,,,percent of total billed charges,97% of total billed charges,149.7,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.14,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26,566.05,
App Short Arm Splnt;Statc,3428388,CDM,981,RC,29125,HCPCS,Outpatient,,,160.97,80.49,,144.87,90,,,percent of total billed charges,90% of total Billed charges,99.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.92,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,60.47,155,,,Fee Schedule,155% of CMS OPPS Rate,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,45.47,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,60.47,155,,,Fee Schedule,155% of CMS OPPS Rate,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.27,155,,,Fee Schedule,155% of CMS OPPS Rate,154.27,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,60.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,136.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,154.27,
29126- Apply short arm splint/dynamic,3435240,CDM,510,RC,29126,HCPCS,Outpatient,,,190.46,95.23,,171.41,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,152.37,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.41,90,,,Percent of total Billed charges,90% of total billed charges,28.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.75,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,175.22,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.41,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,133.32,70,,,percent of total billed charges,70% of total billed charges,171.41,90,,,percent of total billed charges,90% of total billed charges,180.94,95,,,percent of total billed charges,95% of total billed charges,180.94,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.8,86,,,percent of total billed charges,86% of total billed charges,152.37,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.75,97,,,percent of total billed charges,97% of total billed charges,171.41,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.75,97,,,percent of total billed charges,97% of total billed charges,177.13,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.75,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26,566.05,
29130- Application finger splint/static,3435241,CDM,510,RC,29130,HCPCS,Outpatient,,,104.89,52.45,,94.4,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,83.91,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,101.74,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,96.5,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,94.4,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,73.42,70,,,percent of total billed charges,70% of total billed charges,94.4,90,,,percent of total billed charges,90% of total billed charges,99.65,95,,,percent of total billed charges,95% of total billed charges,99.65,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,90.21,86,,,percent of total billed charges,86% of total billed charges,83.91,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,101.74,97,,,percent of total billed charges,97% of total billed charges,94.4,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.74,97,,,percent of total billed charges,97% of total billed charges,97.55,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.74,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,56.87,566.05,
APPLICATION SPLINT STATIC FINGER CUSTOM,3428390,CDM,981,RC,29130,HCPCS,Outpatient,,,104.89,52.45,,94.4,90,,,percent of total billed charges,90% of total Billed charges,68.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.55,155,,,Fee Schedule,155% of CMS OPPS Rate,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.34,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,36.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,45.55,155,,,Fee Schedule,155% of CMS OPPS Rate,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.69,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,80.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.6,106.69,
29260 Strapping Elbow/Wrist,4305638,CDM,761,RC,29260,HCPCS,Outpatient,,,317.28,158.64,,285.55,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,253.82,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.55,90,,,Percent of total Billed charges,90% of total billed charges,34.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,307.76,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,291.9,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,285.55,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,222.1,70,,,percent of total billed charges,70% of total billed charges,285.55,90,,,percent of total billed charges,90% of total billed charges,301.42,95,,,percent of total billed charges,95% of total billed charges,301.42,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,272.86,86,,,percent of total billed charges,86% of total billed charges,253.82,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,307.76,97,,,percent of total billed charges,97% of total billed charges,285.55,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.76,97,,,percent of total billed charges,97% of total billed charges,295.07,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,307.76,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.38,307.76,
29280 Strapping Hand/Finger,4305639,CDM,761,RC,29280,HCPCS,Outpatient,,,318.51,159.26,,286.66,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,254.81,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,308.95,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,293.03,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,286.66,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,222.96,70,,,percent of total billed charges,70% of total billed charges,286.66,90,,,percent of total billed charges,90% of total billed charges,302.58,95,,,percent of total billed charges,95% of total billed charges,302.58,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,273.92,86,,,percent of total billed charges,86% of total billed charges,254.81,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,308.95,97,,,percent of total billed charges,97% of total billed charges,286.66,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.95,97,,,percent of total billed charges,97% of total billed charges,296.21,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,308.95,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.56,308.95,
29280- Strapping/hand or finger,3435242,CDM,510,RC,29280,HCPCS,Outpatient,,,350.16,175.08,,315.14,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,280.13,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,339.66,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,322.15,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,315.14,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,245.11,70,,,percent of total billed charges,70% of total billed charges,315.14,90,,,percent of total billed charges,90% of total billed charges,332.65,95,,,percent of total billed charges,95% of total billed charges,332.65,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,301.14,86,,,percent of total billed charges,86% of total billed charges,280.13,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.66,97,,,percent of total billed charges,97% of total billed charges,315.14,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.66,97,,,percent of total billed charges,97% of total billed charges,325.65,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,339.66,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.56,339.66,
29305- Application hip spica cast/1 leg,3435243,CDM,510,RC,29305,HCPCS,Outpatient,,,608.66,304.33,,547.79,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,486.93,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,547.79,90,,,Percent of total Billed charges,90% of total billed charges,147.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,590.4,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,559.97,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,547.79,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,426.06,70,,,percent of total billed charges,70% of total billed charges,547.79,90,,,percent of total billed charges,90% of total billed charges,578.23,95,,,percent of total billed charges,95% of total billed charges,578.23,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,523.45,86,,,percent of total billed charges,86% of total billed charges,486.93,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,590.4,97,,,percent of total billed charges,97% of total billed charges,547.79,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,590.4,97,,,percent of total billed charges,97% of total billed charges,566.05,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,590.4,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.5,1169.58,
29325- Apply hip spica cast/both legs,3435244,CDM,510,RC,29325,HCPCS,Outpatient,,,674.35,337.18,,606.92,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,539.48,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,606.92,90,,,Percent of total Billed charges,90% of total billed charges,168.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,654.12,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,620.4,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,606.92,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,472.05,70,,,percent of total billed charges,70% of total billed charges,606.92,90,,,percent of total billed charges,90% of total billed charges,640.63,95,,,percent of total billed charges,95% of total billed charges,640.63,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,579.94,86,,,percent of total billed charges,86% of total billed charges,539.48,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,654.12,97,,,percent of total billed charges,97% of total billed charges,606.92,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,654.12,97,,,percent of total billed charges,97% of total billed charges,627.15,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,654.12,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,153.6,1169.58,
29345- Apply long leg cast/thigh/toes,3435245,CDM,510,RC,29345,HCPCS,Outpatient,,,340.21,170.11,,306.19,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,272.17,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,306.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,330,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,312.99,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,306.19,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,238.15,70,,,percent of total billed charges,70% of total billed charges,306.19,90,,,percent of total billed charges,90% of total billed charges,323.2,95,,,percent of total billed charges,95% of total billed charges,323.2,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,292.58,86,,,percent of total billed charges,86% of total billed charges,272.17,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,330,97,,,percent of total billed charges,97% of total billed charges,306.19,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,330,97,,,percent of total billed charges,97% of total billed charges,316.4,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,330,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,185.21,1169.58,
29355- Apply long leg cast/ambulatory,3435246,CDM,510,RC,29355,HCPCS,Outpatient,,,357.55,178.78,,321.8,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,286.04,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.8,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,346.82,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,328.95,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,321.8,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,250.29,70,,,percent of total billed charges,70% of total billed charges,321.8,90,,,percent of total billed charges,90% of total billed charges,339.67,95,,,percent of total billed charges,95% of total billed charges,339.67,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,307.49,86,,,percent of total billed charges,86% of total billed charges,286.04,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,346.82,97,,,percent of total billed charges,97% of total billed charges,321.8,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,346.82,97,,,percent of total billed charges,97% of total billed charges,332.52,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,346.82,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,1169.58,
29365- Apply cylinder cast/thigh/ankle,3435247,CDM,510,RC,29365,HCPCS,Outpatient,,,307.18,153.59,,276.46,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,245.74,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.46,90,,,Percent of total Billed charges,90% of total billed charges,66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,297.96,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,282.61,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,276.46,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,215.03,70,,,percent of total billed charges,70% of total billed charges,276.46,90,,,percent of total billed charges,90% of total billed charges,291.82,95,,,percent of total billed charges,95% of total billed charges,291.82,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,264.17,86,,,percent of total billed charges,86% of total billed charges,245.74,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,297.96,97,,,percent of total billed charges,97% of total billed charges,276.46,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.96,97,,,percent of total billed charges,97% of total billed charges,285.68,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.96,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60,1169.58,
29405 Application Short Leg Cast Below Knee-Toe,3436035,CDM,761,RC,29405,HCPCS,Outpatient,,,198.2,99.10,,178.38,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,158.56,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.38,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,192.25,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,182.34,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,178.38,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,138.74,70,,,percent of total billed charges,70% of total billed charges,178.38,90,,,percent of total billed charges,90% of total billed charges,188.29,95,,,percent of total billed charges,95% of total billed charges,188.29,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,170.45,86,,,percent of total billed charges,86% of total billed charges,158.56,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,192.25,97,,,percent of total billed charges,97% of total billed charges,178.38,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.25,97,,,percent of total billed charges,97% of total billed charges,184.33,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,192.25,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,1169.58,
29405- Apply short leg cast/below knee/to,3435248,CDM,510,RC,29405,HCPCS,Outpatient,,,1473.99,737.00,,1326.59,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1179.19,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1326.59,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1429.77,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.07,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1326.59,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1031.79,70,,,percent of total billed charges,70% of total billed charges,1326.59,90,,,percent of total billed charges,90% of total billed charges,1400.29,95,,,percent of total billed charges,95% of total billed charges,1400.29,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1267.63,86,,,percent of total billed charges,86% of total billed charges,1179.19,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1429.77,97,,,percent of total billed charges,97% of total billed charges,1326.59,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1429.77,97,,,percent of total billed charges,97% of total billed charges,1370.81,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1429.77,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,1429.77,
29425 Application Short Leg Cast Walking/Ambulatory,3549204,CDM,761,RC,29425,HCPCS,Outpatient,,,187.29,93.65,,168.56,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,149.83,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.56,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,181.67,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,172.31,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,168.56,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,131.1,70,,,percent of total billed charges,70% of total billed charges,168.56,90,,,percent of total billed charges,90% of total billed charges,177.93,95,,,percent of total billed charges,95% of total billed charges,177.93,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,161.07,86,,,percent of total billed charges,86% of total billed charges,149.83,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,181.67,97,,,percent of total billed charges,97% of total billed charges,168.56,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,181.67,97,,,percent of total billed charges,97% of total billed charges,174.18,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.67,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1169.58,
29425- Apply short leg cast/ambulatory,3435249,CDM,510,RC,29425,HCPCS,Outpatient,,,1464.62,732.31,,1318.16,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.7,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1318.16,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1420.68,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1347.45,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1318.16,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.23,70,,,percent of total billed charges,70% of total billed charges,1318.16,90,,,percent of total billed charges,90% of total billed charges,1391.39,95,,,percent of total billed charges,95% of total billed charges,1391.39,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1259.57,86,,,percent of total billed charges,86% of total billed charges,1171.7,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1420.68,97,,,percent of total billed charges,97% of total billed charges,1318.16,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1420.68,97,,,percent of total billed charges,97% of total billed charges,1362.1,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1420.68,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1420.68,
29445 Application Rigid Total Contact Leg Cast,3436037,CDM,761,RC,29445,HCPCS,Outpatient,,,327.2,163.60,,294.48,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,261.76,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.48,90,,,Percent of total Billed charges,90% of total billed charges,111.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,317.38,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,301.02,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,294.48,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,229.04,70,,,percent of total billed charges,70% of total billed charges,294.48,90,,,percent of total billed charges,90% of total billed charges,310.84,95,,,percent of total billed charges,95% of total billed charges,310.84,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,281.39,86,,,percent of total billed charges,86% of total billed charges,261.76,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,317.38,97,,,percent of total billed charges,97% of total billed charges,294.48,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.38,97,,,percent of total billed charges,97% of total billed charges,304.3,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,317.38,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,101.47,1169.58,
29450- Apply clubfoot cast/long or short,3435250,CDM,510,RC,29450,HCPCS,Outpatient,,,372.97,186.49,,335.67,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,298.38,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,361.78,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,343.13,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,335.67,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,261.08,70,,,percent of total billed charges,70% of total billed charges,335.67,90,,,percent of total billed charges,90% of total billed charges,354.32,95,,,percent of total billed charges,95% of total billed charges,354.32,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,320.75,86,,,percent of total billed charges,86% of total billed charges,298.38,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,361.78,97,,,percent of total billed charges,97% of total billed charges,335.67,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.78,97,,,percent of total billed charges,97% of total billed charges,346.86,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,361.78,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,710.59,
29505- Application long leg splint,3435251,CDM,510,RC,29505,HCPCS,Outpatient,,,213.81,106.91,,192.43,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,171.05,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.43,90,,,Percent of total Billed charges,90% of total billed charges,40.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,207.4,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,196.71,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,192.43,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,149.67,70,,,percent of total billed charges,70% of total billed charges,192.43,90,,,percent of total billed charges,90% of total billed charges,203.12,95,,,percent of total billed charges,95% of total billed charges,203.12,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,183.88,86,,,percent of total billed charges,86% of total billed charges,171.05,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,207.4,97,,,percent of total billed charges,97% of total billed charges,192.43,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.4,97,,,percent of total billed charges,97% of total billed charges,198.84,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,207.4,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37,710.59,
App Long Leg Splint,3428387,CDM,981,RC,29505,HCPCS,Outpatient,,,213.81,106.91,,192.43,90,,,percent of total billed charges,90% of total Billed charges,130.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,77.64,155,,,Fee Schedule,155% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,74.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.64,155,,,Fee Schedule,155% of CMS OPPS Rate,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.24,155,,,Fee Schedule,155% of CMS OPPS Rate,202.24,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,153.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,153.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37,202.24,
29515- Apply short leg splint/calf/foot,3435252,CDM,510,RC,29515,HCPCS,Outpatient,,,177.21,88.61,,159.49,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,141.77,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.49,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.89,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,163.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,159.49,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,124.05,70,,,percent of total billed charges,70% of total billed charges,159.49,90,,,percent of total billed charges,90% of total billed charges,168.35,95,,,percent of total billed charges,95% of total billed charges,168.35,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,152.4,86,,,percent of total billed charges,86% of total billed charges,141.77,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.89,97,,,percent of total billed charges,97% of total billed charges,159.49,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.89,97,,,percent of total billed charges,97% of total billed charges,164.81,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.89,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,710.59,
App Short Leg Splint,3428389,CDM,981,RC,29515,HCPCS,Outpatient,,,177.21,88.61,,159.49,90,,,percent of total billed charges,90% of total Billed charges,114.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.89,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.11,155,,,Fee Schedule,155% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,95.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,57.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,74.11,155,,,Fee Schedule,155% of CMS OPPS Rate,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.4,155,,,Fee Schedule,155% of CMS OPPS Rate,177.4,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,144.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,177.4,
29540 Strapping Ankle &/Foot,3436039,CDM,761,RC,29540,HCPCS,Outpatient,,,71.12,35.56,,64.01,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,56.9,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.01,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.99,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.01,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,49.78,70,,,percent of total billed charges,70% of total billed charges,64.01,90,,,percent of total billed charges,90% of total billed charges,67.56,95,,,percent of total billed charges,95% of total billed charges,67.56,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.16,86,,,percent of total billed charges,86% of total billed charges,56.9,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.99,97,,,percent of total billed charges,97% of total billed charges,64.01,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.99,97,,,percent of total billed charges,97% of total billed charges,66.14,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.99,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,710.59,
29540- Strapping/ankle and/or foot,3435253,CDM,510,RC,29540,HCPCS,Outpatient,,,830.92,415.46,,747.83,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,664.74,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,747.83,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,805.99,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,764.45,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,747.83,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,581.64,70,,,percent of total billed charges,70% of total billed charges,747.83,90,,,percent of total billed charges,90% of total billed charges,789.37,95,,,percent of total billed charges,95% of total billed charges,789.37,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,714.59,86,,,percent of total billed charges,86% of total billed charges,664.74,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,805.99,97,,,percent of total billed charges,97% of total billed charges,747.83,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,805.99,97,,,percent of total billed charges,97% of total billed charges,772.76,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,805.99,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,805.99,
29550- Strapping/toes,3435254,CDM,510,RC,29550,HCPCS,Outpatient,,,48.1,24.05,,43.29,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,38.48,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.29,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,46.66,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,43.29,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,33.67,70,,,percent of total billed charges,70% of total billed charges,43.29,90,,,percent of total billed charges,90% of total billed charges,45.7,95,,,percent of total billed charges,95% of total billed charges,45.7,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.37,86,,,percent of total billed charges,86% of total billed charges,38.48,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,46.66,97,,,percent of total billed charges,97% of total billed charges,43.29,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.66,97,,,percent of total billed charges,97% of total billed charges,44.73,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.66,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,280.22,
29580 Application of Paste Boot,3436042,CDM,761,RC,29580,HCPCS,Outpatient,,,159.71,79.86,,143.74,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,127.77,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,154.92,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,146.93,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.74,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,111.8,70,,,percent of total billed charges,70% of total billed charges,143.74,90,,,percent of total billed charges,90% of total billed charges,151.72,95,,,percent of total billed charges,95% of total billed charges,151.72,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,137.35,86,,,percent of total billed charges,86% of total billed charges,127.77,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,154.92,97,,,percent of total billed charges,97% of total billed charges,143.74,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.92,97,,,percent of total billed charges,97% of total billed charges,148.53,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.92,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111.8,710.59,
29580 Application of Paste Boot - Bilateral,3436041,CDM,761,RC,29580,HCPCS,Outpatient,,,319.43,159.72,,287.49,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,255.54,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,309.85,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,293.88,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,287.49,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,223.6,70,,,percent of total billed charges,70% of total billed charges,287.49,90,,,percent of total billed charges,90% of total billed charges,303.46,95,,,percent of total billed charges,95% of total billed charges,303.46,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,274.71,86,,,percent of total billed charges,86% of total billed charges,255.54,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,309.85,97,,,percent of total billed charges,97% of total billed charges,287.49,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.85,97,,,percent of total billed charges,97% of total billed charges,297.07,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,309.85,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,710.59,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,849.92,424.96,,764.93,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,679.94,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,764.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.42,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,781.93,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,764.93,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,594.94,70,,,percent of total billed charges,70% of total billed charges,764.93,90,,,percent of total billed charges,90% of total billed charges,807.42,95,,,percent of total billed charges,95% of total billed charges,807.42,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,730.93,86,,,percent of total billed charges,86% of total billed charges,679.94,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,824.42,97,,,percent of total billed charges,97% of total billed charges,764.93,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,824.42,97,,,percent of total billed charges,97% of total billed charges,790.43,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,824.42,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,824.42,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,3436046,CDM,761,RC,29581,HCPCS,Outpatient,,,757.44,378.72,,681.7,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,605.95,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,734.72,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,696.84,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,681.7,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,530.21,70,,,percent of total billed charges,70% of total billed charges,681.7,90,,,percent of total billed charges,90% of total billed charges,719.57,95,,,percent of total billed charges,95% of total billed charges,719.57,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,651.4,86,,,percent of total billed charges,86% of total billed charges,605.95,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,734.72,97,,,percent of total billed charges,97% of total billed charges,681.7,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.72,97,,,percent of total billed charges,97% of total billed charges,704.42,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,734.72,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,734.72,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bil,3436045,CDM,761,RC,29581,HCPCS,Outpatient,,,1136.17,568.09,,1022.55,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,908.94,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1022.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1102.08,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.28,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1022.55,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,795.32,70,,,percent of total billed charges,70% of total billed charges,1022.55,90,,,percent of total billed charges,90% of total billed charges,1079.36,95,,,percent of total billed charges,95% of total billed charges,1079.36,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,977.11,86,,,percent of total billed charges,86% of total billed charges,908.94,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1102.08,97,,,percent of total billed charges,97% of total billed charges,1022.55,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.08,97,,,percent of total billed charges,97% of total billed charges,1056.64,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1102.08,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,1102.08,
29581- Apply multi-lay compres/lower leg,3436044,CDM,761,RC,29581,HCPCS,Outpatient,,,757.44,378.72,,681.7,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,605.95,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,734.72,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,696.84,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,681.7,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,530.21,70,,,percent of total billed charges,70% of total billed charges,681.7,90,,,percent of total billed charges,90% of total billed charges,719.57,95,,,percent of total billed charges,95% of total billed charges,719.57,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,651.4,86,,,percent of total billed charges,86% of total billed charges,605.95,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,734.72,97,,,percent of total billed charges,97% of total billed charges,681.7,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,734.72,97,,,percent of total billed charges,97% of total billed charges,704.42,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,734.72,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,734.72,
29584 Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4305637,CDM,761,RC,29584,HCPCS,Outpatient,,,735.16,367.58,,661.64,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,588.13,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,713.11,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,676.35,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,661.64,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,514.61,70,,,percent of total billed charges,70% of total billed charges,661.64,90,,,percent of total billed charges,90% of total billed charges,698.4,95,,,percent of total billed charges,95% of total billed charges,698.4,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,632.24,86,,,percent of total billed charges,86% of total billed charges,588.13,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,713.11,97,,,percent of total billed charges,97% of total billed charges,661.64,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,713.11,97,,,percent of total billed charges,97% of total billed charges,683.7,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,713.11,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,713.11,
29705- Rmv/bivalve cast/full arm/full leg,3435255,CDM,510,RC,29705,HCPCS,Outpatient,,,159.46,79.73,,143.51,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,127.57,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,154.68,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,146.7,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.51,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,111.62,70,,,percent of total billed charges,70% of total billed charges,143.51,90,,,percent of total billed charges,90% of total billed charges,151.49,95,,,percent of total billed charges,95% of total billed charges,151.49,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,137.14,86,,,percent of total billed charges,86% of total billed charges,127.57,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,154.68,97,,,percent of total billed charges,97% of total billed charges,143.51,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.68,97,,,percent of total billed charges,97% of total billed charges,148.3,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.68,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,111.62,1169.58,
29805- Arthroscopy/shoulder/diagnostic,3435257,CDM,510,RC,29805,HCPCS,Outpatient,,,1218.02,609.01,,1096.22,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,974.42,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1096.22,90,,,Percent of total Billed charges,90% of total billed charges,204.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1181.48,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.58,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1096.22,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,852.61,70,,,percent of total billed charges,70% of total billed charges,1096.22,90,,,percent of total billed charges,90% of total billed charges,1157.12,95,,,percent of total billed charges,95% of total billed charges,1157.12,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1047.5,86,,,percent of total billed charges,86% of total billed charges,974.42,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1181.48,97,,,percent of total billed charges,97% of total billed charges,1096.22,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1181.48,97,,,percent of total billed charges,97% of total billed charges,1132.76,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,186,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1181.48,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,186,14511.58,
29806- Arthroscopy/shoulder/surgical,3435258,CDM,510,RC,29806,HCPCS,Outpatient,,,2774.88,1387.44,,2497.39,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2219.9,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2497.39,90,,,Percent of total Billed charges,90% of total billed charges,846.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2691.63,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2552.89,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2497.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1942.42,70,,,percent of total billed charges,70% of total billed charges,2497.39,90,,,percent of total billed charges,90% of total billed charges,2636.14,95,,,percent of total billed charges,95% of total billed charges,2636.14,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2386.4,86,,,percent of total billed charges,86% of total billed charges,2219.9,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2691.63,97,,,percent of total billed charges,97% of total billed charges,2497.39,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2691.63,97,,,percent of total billed charges,97% of total billed charges,2580.64,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,769.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2691.63,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,769.17,32247.16,
29807- Arthroscop/shoulder/rpr SLAP les,3435259,CDM,510,RC,29807,HCPCS,Outpatient,,,2704.8,1352.40,,2434.32,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2163.84,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2434.32,90,,,Percent of total Billed charges,90% of total billed charges,867.11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2623.66,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2488.42,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2434.32,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1893.36,70,,,percent of total billed charges,70% of total billed charges,2434.32,90,,,percent of total billed charges,90% of total billed charges,2569.56,95,,,percent of total billed charges,95% of total billed charges,2569.56,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2326.13,86,,,percent of total billed charges,86% of total billed charges,2163.84,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2623.66,97,,,percent of total billed charges,97% of total billed charges,2434.32,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2623.66,97,,,percent of total billed charges,97% of total billed charges,2515.46,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2623.66,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,788.28,32247.16,
29819- Arthroscopy/shoulder/rmv loose/FB,3435260,CDM,510,RC,29819,HCPCS,Outpatient,,,1530.23,765.12,,1377.21,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.18,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1377.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1484.32,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.81,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1377.21,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.16,70,,,percent of total billed charges,70% of total billed charges,1377.21,90,,,percent of total billed charges,90% of total billed charges,1453.72,95,,,percent of total billed charges,95% of total billed charges,1453.72,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1316,86,,,percent of total billed charges,86% of total billed charges,1224.18,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1484.32,97,,,percent of total billed charges,97% of total billed charges,1377.21,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1484.32,97,,,percent of total billed charges,97% of total billed charges,1423.11,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1484.32,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1071.16,14511.58,
29820-  Shoulder arthroscopy/surgery,3435261,CDM,510,RC,29820,HCPCS,Outpatient,,,1399.81,699.91,,1259.83,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1119.85,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1259.83,90,,,Percent of total Billed charges,90% of total billed charges,528.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1357.82,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.83,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1259.83,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,979.87,70,,,percent of total billed charges,70% of total billed charges,1259.83,90,,,percent of total billed charges,90% of total billed charges,1329.82,95,,,percent of total billed charges,95% of total billed charges,1329.82,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1203.84,86,,,percent of total billed charges,86% of total billed charges,1119.85,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1357.82,97,,,percent of total billed charges,97% of total billed charges,1259.83,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1357.82,97,,,percent of total billed charges,97% of total billed charges,1301.82,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1357.82,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,480.82,32247.16,
29821- Arthroscopy/shoulder/synovect/comp,3435262,CDM,510,RC,29821,HCPCS,Outpatient,,,1550.62,775.31,,1395.56,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1240.5,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.56,90,,,Percent of total Billed charges,90% of total billed charges,577.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1504.1,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1426.57,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1395.56,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.43,70,,,percent of total billed charges,70% of total billed charges,1395.56,90,,,percent of total billed charges,90% of total billed charges,1473.09,95,,,percent of total billed charges,95% of total billed charges,1473.09,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1333.53,86,,,percent of total billed charges,86% of total billed charges,1240.5,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1504.1,97,,,percent of total billed charges,97% of total billed charges,1395.56,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.1,97,,,percent of total billed charges,97% of total billed charges,1442.08,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1504.1,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,525.29,14511.58,
29822- Arthroscop/shoulder/debrid/ltd,3435263,CDM,510,RC,29822,HCPCS,Outpatient,,,1408.54,704.27,,1267.69,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.83,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1267.69,90,,,Percent of total Billed charges,90% of total billed charges,561.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1366.28,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1295.86,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1267.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,985.98,70,,,percent of total billed charges,70% of total billed charges,1267.69,90,,,percent of total billed charges,90% of total billed charges,1338.11,95,,,percent of total billed charges,95% of total billed charges,1338.11,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1211.34,86,,,percent of total billed charges,86% of total billed charges,1126.83,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1366.28,97,,,percent of total billed charges,97% of total billed charges,1267.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.28,97,,,percent of total billed charges,97% of total billed charges,1309.94,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1366.28,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,510.85,14511.58,
29823- Arthroscop/shoulder/debrid/ext,3435264,CDM,510,RC,29823,HCPCS,Outpatient,,,1546.3,773.15,,1391.67,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1237.04,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1391.67,90,,,Percent of total Billed charges,90% of total billed charges,597.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1499.91,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.6,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1391.67,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.41,70,,,percent of total billed charges,70% of total billed charges,1391.67,90,,,percent of total billed charges,90% of total billed charges,1468.99,95,,,percent of total billed charges,95% of total billed charges,1468.99,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1329.82,86,,,percent of total billed charges,86% of total billed charges,1237.04,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1499.91,97,,,percent of total billed charges,97% of total billed charges,1391.67,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1499.91,97,,,percent of total billed charges,97% of total billed charges,1438.06,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1499.91,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,543.5,14511.58,
29824- Arthro/shoulder/dis claviculectomy,3435265,CDM,510,RC,29824,HCPCS,Outpatient,,,1764.12,882.06,,1587.71,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1411.3,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1587.71,90,,,Percent of total Billed charges,90% of total billed charges,517.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1711.2,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1622.99,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1587.71,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1234.88,70,,,percent of total billed charges,70% of total billed charges,1587.71,90,,,percent of total billed charges,90% of total billed charges,1675.91,95,,,percent of total billed charges,95% of total billed charges,1675.91,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1517.14,86,,,percent of total billed charges,86% of total billed charges,1411.3,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1711.2,97,,,percent of total billed charges,97% of total billed charges,1587.71,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1711.2,97,,,percent of total billed charges,97% of total billed charges,1640.63,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,470.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1711.2,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,470.26,14511.58,
29825- Arthroscop/shoulder/resect adhes,3435266,CDM,510,RC,29825,HCPCS,Outpatient,,,1529.91,764.96,,1376.92,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1223.93,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1376.92,90,,,Percent of total Billed charges,90% of total billed charges,572.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1484.01,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1407.52,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1376.92,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1070.94,70,,,percent of total billed charges,70% of total billed charges,1376.92,90,,,percent of total billed charges,90% of total billed charges,1453.41,95,,,percent of total billed charges,95% of total billed charges,1453.41,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1315.72,86,,,percent of total billed charges,86% of total billed charges,1223.93,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1484.01,97,,,percent of total billed charges,97% of total billed charges,1376.92,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1484.01,97,,,percent of total billed charges,97% of total billed charges,1422.82,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,520.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1484.01,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,520.46,14511.58,
29826- Arthroscop/shoulder/decomp/subacro,3435267,CDM,510,RC,29826,HCPCS,Outpatient,,,460.68,230.34,,414.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,368.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,414.61,90,,,Percent of total Billed charges,90% of total billed charges,597.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,446.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,423.83,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,294.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,362.33,78.65,,,percent of total billed charges,78.65% of total billed charges,411.53,89.33,,,percent of total billed charges,89.33% of total billed charges,414.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,322.48,70,,,percent of total billed charges,70% of total billed charges,414.61,90,,,percent of total billed charges,90% of total billed charges,437.65,95,,,percent of total billed charges,95% of total billed charges,437.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,396.18,86,,,percent of total billed charges,86% of total billed charges,368.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,446.86,97,,,percent of total billed charges,97% of total billed charges,414.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,446.86,97,,,percent of total billed charges,97% of total billed charges,428.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,446.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.2,597.85,
29827- Arthroscop/shoulder/rotat cuff rpr,3435268,CDM,510,RC,29827,HCPCS,Outpatient,,,2803.34,1401.67,,2523.01,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2242.67,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2523.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2719.24,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2579.07,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2523.01,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1962.34,70,,,percent of total billed charges,70% of total billed charges,2523.01,90,,,percent of total billed charges,90% of total billed charges,2663.17,95,,,percent of total billed charges,95% of total billed charges,2663.17,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2410.87,86,,,percent of total billed charges,86% of total billed charges,2242.67,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2719.24,97,,,percent of total billed charges,97% of total billed charges,2523.01,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2719.24,97,,,percent of total billed charges,97% of total billed charges,2607.11,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2719.24,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1962.34,32247.16,
29828- Arthroscop/shoulder/biceps tenodes,3435269,CDM,510,RC,29828,HCPCS,Outpatient,,,2402.97,1201.49,,2162.67,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.38,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2162.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2330.88,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2210.73,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2162.67,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1682.08,70,,,percent of total billed charges,70% of total billed charges,2162.67,90,,,percent of total billed charges,90% of total billed charges,2282.82,95,,,percent of total billed charges,95% of total billed charges,2282.82,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2066.55,86,,,percent of total billed charges,86% of total billed charges,1922.38,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2330.88,97,,,percent of total billed charges,97% of total billed charges,2162.67,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2330.88,97,,,percent of total billed charges,97% of total billed charges,2234.76,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2330.88,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1682.08,32247.16,
29834- Arthroscopy/elbow/surg/remove FB,3435270,CDM,510,RC,29834,HCPCS,Outpatient,,,1280.28,640.14,,1152.25,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.22,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1152.25,90,,,Percent of total Billed charges,90% of total billed charges,480.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1241.87,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1177.86,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1152.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,896.2,70,,,percent of total billed charges,70% of total billed charges,1152.25,90,,,percent of total billed charges,90% of total billed charges,1216.27,95,,,percent of total billed charges,95% of total billed charges,1216.27,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1101.04,86,,,percent of total billed charges,86% of total billed charges,1024.22,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1241.87,97,,,percent of total billed charges,97% of total billed charges,1152.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1241.87,97,,,percent of total billed charges,97% of total billed charges,1190.66,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1241.87,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,436.97,14511.58,
29837- Arthroscopy/elbow/surg/debride/lmt,3435271,CDM,510,RC,29837,HCPCS,Outpatient,,,1379.37,689.69,,1241.43,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1103.5,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1241.43,90,,,Percent of total Billed charges,90% of total billed charges,516.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1337.99,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1269.02,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1241.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,965.56,70,,,percent of total billed charges,70% of total billed charges,1241.43,90,,,percent of total billed charges,90% of total billed charges,1310.4,95,,,percent of total billed charges,95% of total billed charges,1310.4,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1186.26,86,,,percent of total billed charges,86% of total billed charges,1103.5,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1337.99,97,,,percent of total billed charges,97% of total billed charges,1241.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1337.99,97,,,percent of total billed charges,97% of total billed charges,1282.81,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1337.99,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,469.41,14511.58,
29838- Arthroscopy/elbow/surg/debride/ext,3435272,CDM,510,RC,29838,HCPCS,Outpatient,,,1545.78,772.89,,1391.2,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1236.62,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1391.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1499.41,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1422.12,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1391.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1082.05,70,,,percent of total billed charges,70% of total billed charges,1391.2,90,,,percent of total billed charges,90% of total billed charges,1468.49,95,,,percent of total billed charges,95% of total billed charges,1468.49,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1329.37,86,,,percent of total billed charges,86% of total billed charges,1236.62,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1499.41,97,,,percent of total billed charges,97% of total billed charges,1391.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1499.41,97,,,percent of total billed charges,97% of total billed charges,1437.58,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1499.41,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1082.05,14511.58,
29840- Arthroscopy/wrist/diagnostic,3435273,CDM,510,RC,29840,HCPCS,Outpatient,,,1165.8,582.90,,1049.22,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,932.64,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.22,90,,,Percent of total Billed charges,90% of total billed charges,383.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1130.83,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1072.54,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1049.22,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,816.06,70,,,percent of total billed charges,70% of total billed charges,1049.22,90,,,percent of total billed charges,90% of total billed charges,1107.51,95,,,percent of total billed charges,95% of total billed charges,1107.51,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1002.59,86,,,percent of total billed charges,86% of total billed charges,932.64,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1130.83,97,,,percent of total billed charges,97% of total billed charges,1049.22,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1130.83,97,,,percent of total billed charges,97% of total billed charges,1084.19,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,349,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1130.83,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,349,14511.58,
29844- Arthrosc/wrist/surg/synovect/part,3435274,CDM,510,RC,29844,HCPCS,Outpatient,,,1295.35,647.68,,1165.82,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1036.28,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1165.82,90,,,Percent of total Billed charges,90% of total billed charges,482.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1256.49,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1191.72,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1165.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,906.75,70,,,percent of total billed charges,70% of total billed charges,1165.82,90,,,percent of total billed charges,90% of total billed charges,1230.58,95,,,percent of total billed charges,95% of total billed charges,1230.58,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1114,86,,,percent of total billed charges,86% of total billed charges,1036.28,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1256.49,97,,,percent of total billed charges,97% of total billed charges,1165.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1256.49,97,,,percent of total billed charges,97% of total billed charges,1204.68,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1256.49,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,438.59,14511.58,
29846- Arthrosc/wrist/surg/joint debrid,3435275,CDM,510,RC,29846,HCPCS,Outpatient,,,1357.14,678.57,,1221.43,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.71,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1221.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1316.43,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1248.57,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1221.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,950,70,,,percent of total billed charges,70% of total billed charges,1221.43,90,,,percent of total billed charges,90% of total billed charges,1289.28,95,,,percent of total billed charges,95% of total billed charges,1289.28,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1167.14,86,,,percent of total billed charges,86% of total billed charges,1085.71,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1316.43,97,,,percent of total billed charges,97% of total billed charges,1221.43,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1316.43,97,,,percent of total billed charges,97% of total billed charges,1262.14,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1316.43,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,950,14511.58,
29848- Endoscopy/wrist/surgical,3435276,CDM,510,RC,29848,HCPCS,Outpatient,,,1321.26,660.63,,1189.13,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1057.01,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1189.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1281.62,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1215.56,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1189.13,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,924.88,70,,,percent of total billed charges,70% of total billed charges,1189.13,90,,,percent of total billed charges,90% of total billed charges,1255.2,95,,,percent of total billed charges,95% of total billed charges,1255.2,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1136.28,86,,,percent of total billed charges,86% of total billed charges,1057.01,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1281.62,97,,,percent of total billed charges,97% of total billed charges,1189.13,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1281.62,97,,,percent of total billed charges,97% of total billed charges,1228.77,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1281.62,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,924.88,6993.46,
29850- Arthroscope/intercond spine w/o fi,3435277,CDM,510,RC,29850,HCPCS,Outpatient,,,1626.79,813.40,,1464.11,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1301.43,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1464.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1577.99,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1496.65,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1464.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.75,70,,,percent of total billed charges,70% of total billed charges,1464.11,90,,,percent of total billed charges,90% of total billed charges,1545.45,95,,,percent of total billed charges,95% of total billed charges,1545.45,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1399.04,86,,,percent of total billed charges,86% of total billed charges,1301.43,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1577.99,97,,,percent of total billed charges,97% of total billed charges,1464.11,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1577.99,97,,,percent of total billed charges,97% of total billed charges,1512.91,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1577.99,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1107.47,6993.46,
29851- Arthroscope/intercond spine w/fix,3435278,CDM,510,RC,29851,HCPCS,Outpatient,,,2436.13,1218.07,,2192.52,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1948.9,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2192.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2363.05,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,2241.24,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2192.52,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1705.29,70,,,percent of total billed charges,70% of total billed charges,2192.52,90,,,percent of total billed charges,90% of total billed charges,2314.32,95,,,percent of total billed charges,95% of total billed charges,2314.32,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2095.07,86,,,percent of total billed charges,86% of total billed charges,1948.9,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2363.05,97,,,percent of total billed charges,97% of total billed charges,2192.52,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,2363.05,97,,,percent of total billed charges,97% of total billed charges,2265.6,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2363.05,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1107.47,6993.46,
29855- Arthrosc/knee/surg/drill/bone gft,3435279,CDM,510,RC,29855,HCPCS,Outpatient,,,2041.99,1021.00,,1837.79,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1633.59,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1837.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1980.73,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1878.63,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1837.79,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1429.39,70,,,percent of total billed charges,70% of total billed charges,1837.79,90,,,percent of total billed charges,90% of total billed charges,1939.89,95,,,percent of total billed charges,95% of total billed charges,1939.89,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1756.11,86,,,percent of total billed charges,86% of total billed charges,1633.59,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1980.73,97,,,percent of total billed charges,97% of total billed charges,1837.79,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1980.73,97,,,percent of total billed charges,97% of total billed charges,1899.05,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1980.73,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1429.39,32247.16,
29856- Arthrosc/knee/surg/drill/lesion,3435280,CDM,510,RC,29856,HCPCS,Outpatient,,,2605.11,1302.56,,2344.6,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2084.09,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2344.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2526.96,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2396.7,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2344.6,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,1823.58,70,,,percent of total billed charges,70% of total billed charges,2344.6,90,,,percent of total billed charges,90% of total billed charges,2474.85,95,,,percent of total billed charges,95% of total billed charges,2474.85,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2240.39,86,,,percent of total billed charges,86% of total billed charges,2084.09,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2526.96,97,,,percent of total billed charges,97% of total billed charges,2344.6,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2526.96,97,,,percent of total billed charges,97% of total billed charges,2422.75,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2526.96,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1823.58,63611.04,
29862- Arthroscop/hip/debrid/chondroplast,3435281,CDM,510,RC,29862,HCPCS,Outpatient,,,2127.09,1063.55,,1914.38,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1701.67,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1914.38,90,,,Percent of total Billed charges,90% of total billed charges,665.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2063.28,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1956.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1914.38,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1488.96,70,,,percent of total billed charges,70% of total billed charges,1914.38,90,,,percent of total billed charges,90% of total billed charges,2020.74,95,,,percent of total billed charges,95% of total billed charges,2020.74,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1829.3,86,,,percent of total billed charges,86% of total billed charges,1701.67,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2063.28,97,,,percent of total billed charges,97% of total billed charges,1914.38,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2063.28,97,,,percent of total billed charges,97% of total billed charges,1978.19,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,605.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2063.28,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,605.18,32247.16,
29866- Arthroscop/knee/osteochon autogft,3435282,CDM,510,RC,29866,HCPCS,Outpatient,,,2752.16,1376.08,,2476.94,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2201.73,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2476.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2669.6,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2531.99,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2476.94,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1926.51,70,,,percent of total billed charges,70% of total billed charges,2476.94,90,,,percent of total billed charges,90% of total billed charges,2614.55,95,,,percent of total billed charges,95% of total billed charges,2614.55,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2366.86,86,,,percent of total billed charges,86% of total billed charges,2201.73,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2669.6,97,,,percent of total billed charges,97% of total billed charges,2476.94,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2669.6,97,,,percent of total billed charges,97% of total billed charges,2559.51,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2669.6,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1926.51,32247.16,
29867- Arthroscop/knee/osteochon allogft,3435283,CDM,510,RC,29867,HCPCS,Outpatient,,,3351.55,1675.78,,3016.4,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2681.24,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3016.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3251,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,3083.43,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3016.4,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.09,70,,,percent of total billed charges,70% of total billed charges,3016.4,90,,,percent of total billed charges,90% of total billed charges,3183.97,95,,,percent of total billed charges,95% of total billed charges,3183.97,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2882.33,86,,,percent of total billed charges,86% of total billed charges,2681.24,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3251,97,,,percent of total billed charges,97% of total billed charges,3016.4,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3251,97,,,percent of total billed charges,97% of total billed charges,3116.94,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3251,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2346.09,63611.04,
29870- Arthroscopy/knee w/w/o synovial bx,3435284,CDM,510,RC,29870,HCPCS,Outpatient,,,1402.45,701.23,,1262.21,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1121.96,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1262.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1360.38,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.25,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1262.21,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,981.72,70,,,percent of total billed charges,70% of total billed charges,1262.21,90,,,percent of total billed charges,90% of total billed charges,1332.33,95,,,percent of total billed charges,95% of total billed charges,1332.33,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1206.11,86,,,percent of total billed charges,86% of total billed charges,1121.96,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1360.38,97,,,percent of total billed charges,97% of total billed charges,1262.21,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1360.38,97,,,percent of total billed charges,97% of total billed charges,1304.28,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1360.38,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,981.72,14511.58,
29871- Arthroscopy/knee/surg/lavage/infec,3435285,CDM,510,RC,29871,HCPCS,Outpatient,,,1339.06,669.53,,1205.15,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1071.25,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.15,90,,,Percent of total Billed charges,90% of total billed charges,497.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1298.89,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1231.94,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1205.15,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,937.34,70,,,percent of total billed charges,70% of total billed charges,1205.15,90,,,percent of total billed charges,90% of total billed charges,1272.11,95,,,percent of total billed charges,95% of total billed charges,1272.11,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1151.59,86,,,percent of total billed charges,86% of total billed charges,1071.25,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1298.89,97,,,percent of total billed charges,97% of total billed charges,1205.15,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1298.89,97,,,percent of total billed charges,97% of total billed charges,1245.33,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,452.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1298.89,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,452.43,14511.58,
29873- Arthroscopy/knee/surg/lat release,3435286,CDM,510,RC,29873,HCPCS,Outpatient,,,1386.26,693.13,,1247.63,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.01,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.63,90,,,Percent of total Billed charges,90% of total billed charges,498.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1344.67,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1275.36,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1247.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,970.38,70,,,percent of total billed charges,70% of total billed charges,1247.63,90,,,percent of total billed charges,90% of total billed charges,1316.95,95,,,percent of total billed charges,95% of total billed charges,1316.95,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1192.18,86,,,percent of total billed charges,86% of total billed charges,1109.01,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1344.67,97,,,percent of total billed charges,97% of total billed charges,1247.63,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1344.67,97,,,percent of total billed charges,97% of total billed charges,1289.22,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1344.67,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,453.3,14511.58,
29874- Arthroscopy/knee/surg/rmv loose/FB,3435287,CDM,510,RC,29874,HCPCS,Outpatient,,,1398.62,699.31,,1258.76,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1118.9,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1258.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1356.66,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1286.73,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1258.76,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,979.03,70,,,percent of total billed charges,70% of total billed charges,1258.76,90,,,percent of total billed charges,90% of total billed charges,1328.69,95,,,percent of total billed charges,95% of total billed charges,1328.69,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1202.81,86,,,percent of total billed charges,86% of total billed charges,1118.9,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1356.66,97,,,percent of total billed charges,97% of total billed charges,1258.76,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1356.66,97,,,percent of total billed charges,97% of total billed charges,1300.72,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1356.66,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,979.03,14511.58,
29875- Arthroscopy/knee/surg/synovectomy,3435288,CDM,510,RC,29875,HCPCS,Outpatient,,,1291.68,645.84,,1162.51,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1033.34,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1162.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1252.93,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1188.35,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1162.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,904.18,70,,,percent of total billed charges,70% of total billed charges,1162.51,90,,,percent of total billed charges,90% of total billed charges,1227.1,95,,,percent of total billed charges,95% of total billed charges,1227.1,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1110.84,86,,,percent of total billed charges,86% of total billed charges,1033.34,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1252.93,97,,,percent of total billed charges,97% of total billed charges,1162.51,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1252.93,97,,,percent of total billed charges,97% of total billed charges,1201.26,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1252.93,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,904.18,14511.58,
29876- Knee artho/synovectomy/2or> comp,3431443,CDM,510,RC,29876,HCPCS,Outpatient,,,1705.83,852.92,,1535.25,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1364.66,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1535.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1654.66,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1569.36,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1535.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1194.08,70,,,percent of total billed charges,70% of total billed charges,1535.25,90,,,percent of total billed charges,90% of total billed charges,1620.54,95,,,percent of total billed charges,95% of total billed charges,1620.54,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1467.01,86,,,percent of total billed charges,86% of total billed charges,1364.66,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1654.66,97,,,percent of total billed charges,97% of total billed charges,1535.25,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1654.66,97,,,percent of total billed charges,97% of total billed charges,1586.42,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1654.66,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1194.08,14511.58,
29877- Arthroscopy/knee/chondroplasty,3435289,CDM,510,RC,29877,HCPCS,Outpatient,,,1621.02,810.51,,1458.92,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.82,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1458.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1572.39,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1491.34,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1458.92,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.71,70,,,percent of total billed charges,70% of total billed charges,1458.92,90,,,percent of total billed charges,90% of total billed charges,1539.97,95,,,percent of total billed charges,95% of total billed charges,1539.97,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1394.08,86,,,percent of total billed charges,86% of total billed charges,1296.82,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1572.39,97,,,percent of total billed charges,97% of total billed charges,1458.92,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1572.39,97,,,percent of total billed charges,97% of total billed charges,1507.55,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1572.39,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1134.71,14511.58,
29879- Arthroscopy/knee/abras arthroplast,3435290,CDM,510,RC,29879,HCPCS,Outpatient,,,1727.6,863.80,,1554.84,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.08,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1554.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1675.77,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1589.39,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1554.84,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.32,70,,,percent of total billed charges,70% of total billed charges,1554.84,90,,,percent of total billed charges,90% of total billed charges,1641.22,95,,,percent of total billed charges,95% of total billed charges,1641.22,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1485.74,86,,,percent of total billed charges,86% of total billed charges,1382.08,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1675.77,97,,,percent of total billed charges,97% of total billed charges,1554.84,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1675.77,97,,,percent of total billed charges,97% of total billed charges,1606.67,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1675.77,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1209.32,14511.58,
29880- Arthroscopy/knee/meniscect/med/lat,3435291,CDM,510,RC,29880,HCPCS,Outpatient,,,1463.91,731.96,,1317.52,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.13,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1317.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1419.99,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1346.8,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1317.52,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.74,70,,,percent of total billed charges,70% of total billed charges,1317.52,90,,,percent of total billed charges,90% of total billed charges,1390.71,95,,,percent of total billed charges,95% of total billed charges,1390.71,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1258.96,86,,,percent of total billed charges,86% of total billed charges,1171.13,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1419.99,97,,,percent of total billed charges,97% of total billed charges,1317.52,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1419.99,97,,,percent of total billed charges,97% of total billed charges,1361.44,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1419.99,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1024.74,14511.58,
29881- Arthroscopy/knee/menisc/med or lat,3435292,CDM,510,RC,29881,HCPCS,Outpatient,,,1408.82,704.41,,1267.94,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1127.06,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1267.94,90,,,Percent of total Billed charges,90% of total billed charges,597.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1366.56,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1296.11,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1267.94,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,986.17,70,,,percent of total billed charges,70% of total billed charges,1267.94,90,,,percent of total billed charges,90% of total billed charges,1338.38,95,,,percent of total billed charges,95% of total billed charges,1338.38,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1211.59,86,,,percent of total billed charges,86% of total billed charges,1127.06,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1366.56,97,,,percent of total billed charges,97% of total billed charges,1267.94,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1366.56,97,,,percent of total billed charges,97% of total billed charges,1310.2,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1366.56,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,543.5,14511.58,
29882- Arthroscopy/knee w/meniscus repair,3435293,CDM,510,RC,29882,HCPCS,Outpatient,,,1800.31,900.16,,1620.28,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1440.25,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1620.28,90,,,Percent of total Billed charges,90% of total billed charges,597.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1746.3,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1656.29,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1620.28,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.22,70,,,percent of total billed charges,70% of total billed charges,1620.28,90,,,percent of total billed charges,90% of total billed charges,1710.29,95,,,percent of total billed charges,95% of total billed charges,1710.29,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1548.27,86,,,percent of total billed charges,86% of total billed charges,1440.25,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1746.3,97,,,percent of total billed charges,97% of total billed charges,1620.28,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1746.3,97,,,percent of total billed charges,97% of total billed charges,1674.29,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1746.3,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,543.5,14511.58,
29883- Arthroscopy/knee/meniscus repair,3435294,CDM,510,RC,29883,HCPCS,Outpatient,,,2199.92,1099.96,,1979.93,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1759.94,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1979.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2133.92,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2023.93,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1979.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1539.94,70,,,percent of total billed charges,70% of total billed charges,1979.93,90,,,percent of total billed charges,90% of total billed charges,2089.92,95,,,percent of total billed charges,95% of total billed charges,2089.92,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1891.93,86,,,percent of total billed charges,86% of total billed charges,1759.94,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2133.92,97,,,percent of total billed charges,97% of total billed charges,1979.93,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2133.92,97,,,percent of total billed charges,97% of total billed charges,2045.93,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2133.92,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1539.94,14511.58,
29887- Arthroscopy/knee/surg/drill for intact osteochondritis dissecans les,3435295,CDM,510,RC,29887,HCPCS,Outpatient,,,1966.12,983.06,,1769.51,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1572.9,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1769.51,90,,,Percent of total Billed charges,90% of total billed charges,597.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1907.14,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1808.83,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1769.51,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1376.28,70,,,percent of total billed charges,70% of total billed charges,1769.51,90,,,percent of total billed charges,90% of total billed charges,1867.81,95,,,percent of total billed charges,95% of total billed charges,1867.81,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1690.86,86,,,percent of total billed charges,86% of total billed charges,1572.9,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1907.14,97,,,percent of total billed charges,97% of total billed charges,1769.51,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,1907.14,97,,,percent of total billed charges,97% of total billed charges,1828.49,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1907.14,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,543.5,32247.16,
29888- Arthroscope/ant cruciate lig rpr,3435296,CDM,510,RC,29888,HCPCS,Outpatient,,,2563.57,1281.79,,2307.21,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2050.86,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2307.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2486.66,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2358.48,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2307.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1794.5,70,,,percent of total billed charges,70% of total billed charges,2307.21,90,,,percent of total billed charges,90% of total billed charges,2435.39,95,,,percent of total billed charges,95% of total billed charges,2435.39,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2204.67,86,,,percent of total billed charges,86% of total billed charges,2050.86,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2486.66,97,,,percent of total billed charges,97% of total billed charges,2307.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2486.66,97,,,percent of total billed charges,97% of total billed charges,2384.12,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2486.66,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1794.5,32247.16,
29889- Arthroscope/post cruciate lig rpr,3435297,CDM,510,RC,29889,HCPCS,Outpatient,,,3207.23,1603.62,,2886.51,90,,,percent of total billed charges,90% of total Billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2565.78,80,,,Percent of total Billed charges,80% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2886.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3111.01,97,,,Percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2950.65,92,,,Percent of total billed charges,92% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,31501.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50219.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,63611.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2886.51,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2245.06,70,,,percent of total billed charges,70% of total billed charges,2886.51,90,,,percent of total billed charges,90% of total billed charges,3046.87,95,,,percent of total billed charges,95% of total billed charges,3046.87,95,,,percent of total billed charges,95% of total billed charges,11851.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23702.09,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2758.22,86,,,percent of total billed charges,86% of total billed charges,2565.78,80,,,percent of total billed charges,80% of total billed charges,12303.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3111.01,97,,,percent of total billed charges,97% of total billed charges,2886.51,90,,,percent of total billed charges,90% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,3111.01,97,,,percent of total billed charges,97% of total billed charges,2982.72,93,,,percent of total billed charges,93% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3111.01,97,,,percent of total billed charges,97% of total billed charges,11851.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,11851.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10073.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2245.06,63611.04,
29891- Arthros/ankle/exc osteochon defect,3435298,CDM,510,RC,29891,HCPCS,Outpatient,,,1743.83,871.92,,1569.45,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1395.06,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1569.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1691.52,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1604.32,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1569.45,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1220.68,70,,,percent of total billed charges,70% of total billed charges,1569.45,90,,,percent of total billed charges,90% of total billed charges,1656.64,95,,,percent of total billed charges,95% of total billed charges,1656.64,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1499.69,86,,,percent of total billed charges,86% of total billed charges,1395.06,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1691.52,97,,,percent of total billed charges,97% of total billed charges,1569.45,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1691.52,97,,,percent of total billed charges,97% of total billed charges,1621.76,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1691.52,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1220.68,14511.58,
29893- Endoscopic/plantar fasciotomy,3435299,CDM,510,RC,29893,HCPCS,Outpatient,,,1656.92,828.46,,1491.23,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.54,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1491.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1607.21,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.37,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1491.23,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1159.84,70,,,percent of total billed charges,70% of total billed charges,1491.23,90,,,percent of total billed charges,90% of total billed charges,1574.07,95,,,percent of total billed charges,95% of total billed charges,1574.07,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1424.95,86,,,percent of total billed charges,86% of total billed charges,1325.54,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1607.21,97,,,percent of total billed charges,97% of total billed charges,1491.23,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1607.21,97,,,percent of total billed charges,97% of total billed charges,1540.94,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1607.21,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1159.84,14511.58,
29894- Arthroscop/ankle/rmv loose/FB,3435300,CDM,510,RC,29894,HCPCS,Outpatient,,,1314.24,657.12,,1182.82,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.39,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1274.81,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.1,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,919.97,70,,,percent of total billed charges,70% of total billed charges,1182.82,90,,,percent of total billed charges,90% of total billed charges,1248.53,95,,,percent of total billed charges,95% of total billed charges,1248.53,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.25,86,,,percent of total billed charges,86% of total billed charges,1051.39,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.81,97,,,percent of total billed charges,97% of total billed charges,1182.82,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.81,97,,,percent of total billed charges,97% of total billed charges,1222.24,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1274.81,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,919.97,14511.58,
29897- Arthros/ankle/debridement/limited,3435301,CDM,510,RC,29897,HCPCS,Outpatient,,,1282.44,641.22,,1154.2,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1025.95,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1154.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1243.97,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1179.84,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1154.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,897.71,70,,,percent of total billed charges,70% of total billed charges,1154.2,90,,,percent of total billed charges,90% of total billed charges,1218.32,95,,,percent of total billed charges,95% of total billed charges,1218.32,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1102.9,86,,,percent of total billed charges,86% of total billed charges,1025.95,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1243.97,97,,,percent of total billed charges,97% of total billed charges,1154.2,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1243.97,97,,,percent of total billed charges,97% of total billed charges,1192.67,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1243.97,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,897.71,14511.58,
29898- Arthroscopy/ankle/debridement/ext,3435302,CDM,510,RC,29898,HCPCS,Outpatient,,,1463.51,731.76,,1317.16,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1170.81,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1317.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1419.6,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1346.43,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1317.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1024.46,70,,,percent of total billed charges,70% of total billed charges,1317.16,90,,,percent of total billed charges,90% of total billed charges,1390.33,95,,,percent of total billed charges,95% of total billed charges,1390.33,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1258.62,86,,,percent of total billed charges,86% of total billed charges,1170.81,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1419.6,97,,,percent of total billed charges,97% of total billed charges,1317.16,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1419.6,97,,,percent of total billed charges,97% of total billed charges,1361.06,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1419.6,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1024.46,14511.58,
29899- Arthroscopy/ankle w/arthrodesis,3435303,CDM,510,RC,29899,HCPCS,Outpatient,,,2666.19,1333.10,,2399.57,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2132.95,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2399.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2586.2,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2452.89,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2399.57,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1866.33,70,,,percent of total billed charges,70% of total billed charges,2399.57,90,,,percent of total billed charges,90% of total billed charges,2532.88,95,,,percent of total billed charges,95% of total billed charges,2532.88,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2292.92,86,,,percent of total billed charges,86% of total billed charges,2132.95,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2586.2,97,,,percent of total billed charges,97% of total billed charges,2399.57,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2586.2,97,,,percent of total billed charges,97% of total billed charges,2479.56,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2586.2,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1866.33,32247.16,
29902- Arthrosc/metacarpophalangeal joint,3435304,CDM,510,RC,29902,HCPCS,Outpatient,,,1487.45,743.73,,1338.71,90,,,percent of total billed charges,90% of total Billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.96,80,,,Percent of total Billed charges,80% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1338.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1442.83,97,,,Percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1368.45,92,,,Percent of total billed charges,92% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,3463.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5521.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6993.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1338.71,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1041.22,70,,,percent of total billed charges,70% of total billed charges,1338.71,90,,,percent of total billed charges,90% of total billed charges,1413.08,95,,,percent of total billed charges,95% of total billed charges,1413.08,95,,,percent of total billed charges,95% of total billed charges,1302.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2605.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1279.21,86,,,percent of total billed charges,86% of total billed charges,1189.96,80,,,percent of total billed charges,80% of total billed charges,1401.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1442.83,97,,,percent of total billed charges,97% of total billed charges,1338.71,90,,,percent of total billed charges,90% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1442.83,97,,,percent of total billed charges,97% of total billed charges,1383.33,93,,,percent of total billed charges,93% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1442.83,97,,,percent of total billed charges,97% of total billed charges,1302.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,1302.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1107.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1041.22,6993.46,
29906- Arthroscop/subtal jnt/surg/debrid,3435305,CDM,510,RC,29906,HCPCS,Outpatient,,,1701.88,850.94,,1531.69,90,,,percent of total billed charges,90% of total Billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.5,80,,,Percent of total Billed charges,80% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1531.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1650.82,97,,,Percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1565.73,92,,,Percent of total billed charges,92% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,7186.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11456.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14511.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1531.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,1191.32,70,,,percent of total billed charges,70% of total billed charges,1531.69,90,,,percent of total billed charges,90% of total billed charges,1616.79,95,,,percent of total billed charges,95% of total billed charges,1616.79,95,,,percent of total billed charges,95% of total billed charges,2703.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5407.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1463.62,86,,,percent of total billed charges,86% of total billed charges,1361.5,80,,,percent of total billed charges,80% of total billed charges,2830.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1650.82,97,,,percent of total billed charges,97% of total billed charges,1531.69,90,,,percent of total billed charges,90% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,1650.82,97,,,percent of total billed charges,97% of total billed charges,1582.75,93,,,percent of total billed charges,93% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1650.82,97,,,percent of total billed charges,97% of total billed charges,2703.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,2703.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2298.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1191.32,14511.58,
29914- Arthroscopy/hip/femoroplasty,3435306,CDM,510,RC,29914,HCPCS,Outpatient,,,2618.93,1309.47,,2357.04,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2095.14,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2357.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2540.36,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2409.42,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2357.04,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1833.25,70,,,percent of total billed charges,70% of total billed charges,2357.04,90,,,percent of total billed charges,90% of total billed charges,2487.98,95,,,percent of total billed charges,95% of total billed charges,2487.98,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2252.28,86,,,percent of total billed charges,86% of total billed charges,2095.14,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2540.36,97,,,percent of total billed charges,97% of total billed charges,2357.04,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2540.36,97,,,percent of total billed charges,97% of total billed charges,2435.6,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2540.36,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1833.25,32247.16,
29915- Arthroscopy/hip/acetabuloplasty,3435307,CDM,510,RC,29915,HCPCS,Outpatient,,,2696.45,1348.23,,2426.81,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2157.16,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2426.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2615.56,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2480.73,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2426.81,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1887.52,70,,,percent of total billed charges,70% of total billed charges,2426.81,90,,,percent of total billed charges,90% of total billed charges,2561.63,95,,,percent of total billed charges,95% of total billed charges,2561.63,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2318.95,86,,,percent of total billed charges,86% of total billed charges,2157.16,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2615.56,97,,,percent of total billed charges,97% of total billed charges,2426.81,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2615.56,97,,,percent of total billed charges,97% of total billed charges,2507.7,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2615.56,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1887.52,32247.16,
29916- Arthroscopy/hip/labral repair,3435308,CDM,510,RC,29916,HCPCS,Outpatient,,,2679.12,1339.56,,2411.21,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2143.3,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2411.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2598.75,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2464.79,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2411.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1875.38,70,,,percent of total billed charges,70% of total billed charges,2411.21,90,,,percent of total billed charges,90% of total billed charges,2545.16,95,,,percent of total billed charges,95% of total billed charges,2545.16,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2304.04,86,,,percent of total billed charges,86% of total billed charges,2143.3,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2598.75,97,,,percent of total billed charges,97% of total billed charges,2411.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2598.75,97,,,percent of total billed charges,97% of total billed charges,2491.58,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2598.75,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1875.38,32247.16,
30110- Excision/nasal polyps/simple,3435860,CDM,510,RC,30110,HCPCS,Outpatient,,,620.87,310.44,,558.78,90,,,percent of total billed charges,90% of total Billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,496.7,80,,,Percent of total Billed charges,80% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,558.78,90,,,Percent of total Billed charges,90% of total billed charges,49.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,602.24,97,,,Percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,571.2,92,,,Percent of total billed charges,92% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,3351.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5342.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6767.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,558.78,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,434.61,70,,,percent of total billed charges,70% of total billed charges,558.78,90,,,percent of total billed charges,90% of total billed charges,589.83,95,,,percent of total billed charges,95% of total billed charges,589.83,95,,,percent of total billed charges,95% of total billed charges,1260.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2521.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,533.95,86,,,percent of total billed charges,86% of total billed charges,496.7,80,,,percent of total billed charges,80% of total billed charges,1395.04,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,602.24,97,,,percent of total billed charges,97% of total billed charges,558.78,90,,,percent of total billed charges,90% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,602.24,97,,,percent of total billed charges,97% of total billed charges,577.41,93,,,percent of total billed charges,93% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,602.24,97,,,percent of total billed charges,97% of total billed charges,1260.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,1260.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1071.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45,6767.35,
30220 Insert nasal septal button,3584866,CDM,960,RC,30220,HCPCS,Outpatient,,,759.95,379.98,,683.96,90,,,percent of total billed charges,90% of total Billed charges,408.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,189.83,155,,,Fee Schedule,155% of CMS OPPS Rate,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,215.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,138.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,189.83,155,,,Fee Schedule,155% of CMS OPPS Rate,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,632.76,155,,,Fee Schedule,155% of CMS OPPS Rate,632.76,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,222.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,612.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,612.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,99,683.96,
30300- Rmv foreign body/nose/office proc,3435861,CDM,510,RC,30300,HCPCS,Outpatient,,,519.23,259.62,,467.31,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,415.38,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,467.31,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,503.65,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,477.69,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,467.31,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,363.46,70,,,percent of total billed charges,70% of total billed charges,467.31,90,,,percent of total billed charges,90% of total billed charges,493.27,95,,,percent of total billed charges,95% of total billed charges,493.27,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,446.54,86,,,percent of total billed charges,86% of total billed charges,415.38,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,503.65,97,,,percent of total billed charges,97% of total billed charges,467.31,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.65,97,,,percent of total billed charges,97% of total billed charges,482.88,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,503.65,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,566.05,
PHY-REMOVAL FOREIGN BODY INTRANASAL,3428511,CDM,981,RC,30300,HCPCS,Outpatient,,,519.23,259.62,,467.31,90,,,percent of total billed charges,90% of total Billed charges,312.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,181.02,155,,,Fee Schedule,155% of CMS OPPS Rate,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.3,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,161.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,161.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,190.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.57,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,181.02,155,,,Fee Schedule,155% of CMS OPPS Rate,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.66,155,,,Fee Schedule,155% of CMS OPPS Rate,483.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,195.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,116.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,458.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,483.66,
30310 Remove nasal foreign body,3584867,CDM,960,RC,30310,HCPCS,Outpatient,,,530.11,265.06,,477.1,90,,,percent of total billed charges,90% of total Billed charges,396.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,305.12,155,,,Fee Schedule,155% of CMS OPPS Rate,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,302.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,302.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,290.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,290.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,163.95,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,393.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,213.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,305.12,155,,,Fee Schedule,155% of CMS OPPS Rate,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,614.09,155,,,Fee Schedule,155% of CMS OPPS Rate,614.09,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,418.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,418.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,614.09,
30465- Repair/nasal vestibular stenosis,3435862,CDM,510,RC,30465,HCPCS,Outpatient,,,2657.92,1328.96,,2392.13,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2126.34,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2392.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2578.18,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2445.29,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2392.13,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1860.54,70,,,percent of total billed charges,70% of total billed charges,2392.13,90,,,percent of total billed charges,90% of total billed charges,2525.02,95,,,percent of total billed charges,95% of total billed charges,2525.02,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2285.81,86,,,percent of total billed charges,86% of total billed charges,2126.34,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2578.18,97,,,percent of total billed charges,97% of total billed charges,2392.13,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2578.18,97,,,percent of total billed charges,97% of total billed charges,2471.87,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2578.18,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1860.54,26031.56,
30901- Control nosebleed/anterior/simple,3435863,CDM,510,RC,30901,HCPCS,Outpatient,,,396.2,198.10,,356.58,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,316.96,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.58,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,384.31,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,364.5,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,356.58,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,277.34,70,,,percent of total billed charges,70% of total billed charges,356.58,90,,,percent of total billed charges,90% of total billed charges,376.39,95,,,percent of total billed charges,95% of total billed charges,376.39,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,340.73,86,,,percent of total billed charges,86% of total billed charges,316.96,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,384.31,97,,,percent of total billed charges,97% of total billed charges,356.58,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.31,97,,,percent of total billed charges,97% of total billed charges,368.47,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,384.31,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,566.05,
30903 Control of nosebleed,3584868,CDM,960,RC,30903,HCPCS,Outpatient,,,616.22,308.11,,554.6,90,,,percent of total billed charges,90% of total Billed charges,309.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,121.21,155,,,Fee Schedule,155% of CMS OPPS Rate,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,105.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,118.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,118.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,145.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,101.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,121.21,155,,,Fee Schedule,155% of CMS OPPS Rate,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.36,155,,,Fee Schedule,155% of CMS OPPS Rate,480.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,253.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,406.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,406.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.5,554.6,
PHY-CONTROL NASAL HEMORRHAGE POSTR W/PACK INITIAL,3428507,CDM,981,RC,30905,HCPCS,Outpatient,,,878.11,439.06,,790.3,90,,,percent of total billed charges,90% of total Billed charges,436.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,164.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,159.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,84.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,164.69,155,,,Fee Schedule,155% of CMS OPPS Rate,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,676.48,155,,,Fee Schedule,155% of CMS OPPS Rate,676.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,298.73,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,503.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,503.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,79.5,790.3,
30906- Control nosebleed/post/subsequent,3435864,CDM,510,RC,30906,HCPCS,Outpatient,,,927.79,463.90,,835.01,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,742.23,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,835.01,90,,,Percent of total Billed charges,90% of total billed charges,87.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,899.96,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,853.57,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,835.01,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,649.45,70,,,percent of total billed charges,70% of total billed charges,835.01,90,,,percent of total billed charges,90% of total billed charges,881.4,95,,,percent of total billed charges,95% of total billed charges,881.4,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,797.9,86,,,percent of total billed charges,86% of total billed charges,742.23,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,899.96,97,,,percent of total billed charges,97% of total billed charges,835.01,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.96,97,,,percent of total billed charges,97% of total billed charges,862.84,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,899.96,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79.5,1013.19,
31030 - Exporation Maxillary Sinus,4189303,CDM,960,RC,31030,HCPCS,Outpatient,,,1434.42,717.21,,1290.98,90,,,percent of total billed charges,90% of total Billed charges,1090.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,486.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,385.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,753.67,155,,,Fee Schedule,155% of CMS OPPS Rate,486.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,681.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,486.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,765.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,765.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,742.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,742.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,420.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,486.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,972.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,875.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,539.18,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,753.67,155,,,Fee Schedule,155% of CMS OPPS Rate,486.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1690.06,155,,,Fee Schedule,155% of CMS OPPS Rate,1690.06,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,486.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,486.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,1389.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1389.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,385.5,1690.06,
31087- Sinusotomy/nonob/osteo flp/cor inc,3435865,CDM,510,RC,31087,HCPCS,Outpatient,,,2908.75,1454.38,,2617.88,90,,,percent of total billed charges,90% of total Billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2327,80,,,Percent of total Billed charges,80% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2617.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2821.49,97,,,Percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2676.05,92,,,Percent of total billed charges,92% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,12891.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20551.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26031.56,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2617.88,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2036.13,70,,,percent of total billed charges,70% of total billed charges,2617.88,90,,,percent of total billed charges,90% of total billed charges,2763.31,95,,,percent of total billed charges,95% of total billed charges,2763.31,95,,,percent of total billed charges,95% of total billed charges,4849.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9699.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2501.53,86,,,percent of total billed charges,86% of total billed charges,2327,80,,,percent of total billed charges,80% of total billed charges,5014.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2821.49,97,,,percent of total billed charges,97% of total billed charges,2617.88,90,,,percent of total billed charges,90% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2821.49,97,,,percent of total billed charges,97% of total billed charges,2705.14,93,,,percent of total billed charges,93% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2821.49,97,,,percent of total billed charges,97% of total billed charges,4849.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4849.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4122.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2036.13,26031.56,
31231- Nasal endoscopy dx,3431300,CDM,510,RC,31231,HCPCS,Outpatient,,,1131.52,565.76,,1018.37,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,905.22,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1018.37,90,,,Percent of total Billed charges,90% of total billed charges,64.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1097.57,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1041,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1018.37,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,792.06,70,,,percent of total billed charges,70% of total billed charges,1018.37,90,,,percent of total billed charges,90% of total billed charges,1074.94,95,,,percent of total billed charges,95% of total billed charges,1074.94,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,973.11,86,,,percent of total billed charges,86% of total billed charges,905.22,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1097.57,97,,,percent of total billed charges,97% of total billed charges,1018.37,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1097.57,97,,,percent of total billed charges,97% of total billed charges,1052.31,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1097.57,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.86,1097.57,
31231-OCC Nasal endoscopy dx,3536973,CDM,510,RC,31231,HCPCS,Outpatient,,,1131.52,565.76,,1018.37,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,905.22,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1018.37,90,,,Percent of total Billed charges,90% of total billed charges,64.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1097.57,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1041,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1018.37,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,792.06,70,,,percent of total billed charges,70% of total billed charges,1018.37,90,,,percent of total billed charges,90% of total billed charges,1074.94,95,,,percent of total billed charges,95% of total billed charges,1074.94,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,973.11,86,,,percent of total billed charges,86% of total billed charges,905.22,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1097.57,97,,,percent of total billed charges,97% of total billed charges,1018.37,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1097.57,97,,,percent of total billed charges,97% of total billed charges,1052.31,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1097.57,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.86,1097.57,
Endoscopy,3428425,CDM,490,RC,31231,HCPCS,Outpatient,,,465.68,232.84,,419.11,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,372.54,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,419.11,90,,,Percent of total Billed charges,90% of total billed charges,64.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,451.71,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,428.43,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,419.11,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,325.98,70,,,percent of total billed charges,70% of total billed charges,419.11,90,,,percent of total billed charges,90% of total billed charges,442.4,95,,,percent of total billed charges,95% of total billed charges,442.4,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,400.48,86,,,percent of total billed charges,86% of total billed charges,372.54,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,451.71,97,,,percent of total billed charges,97% of total billed charges,419.11,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,451.71,97,,,percent of total billed charges,97% of total billed charges,433.08,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,451.71,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.86,871.42,
31237 - Nasal/Sinus Endoscopy Surg,4189304,CDM,960,RC,31237,HCPCS,Outpatient,,,578.59,289.30,,520.73,90,,,percent of total billed charges,90% of total Billed charges,399.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,156.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.02,155,,,Fee Schedule,155% of CMS OPPS Rate,156.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,156.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,238.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,238.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,135.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,312.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,281,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,183.7,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,242.02,155,,,Fee Schedule,155% of CMS OPPS Rate,156.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.72,155,,,Fee Schedule,155% of CMS OPPS Rate,619.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,156.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,355.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,156.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,661.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,661.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,135.98,661.64,
"Hemorrhage Repair ? Eyes, Ears, Nose, Throat (EENT)",3428461,CDM,981,RC,31238,HCPCS,Outpatient,,,636.27,318.14,,572.64,90,,,percent of total billed charges,90% of total Billed charges,402.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,252.74,155,,,Fee Schedule,155% of CMS OPPS Rate,163.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,240.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,250.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,250.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,326.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,295.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,194.16,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,252.74,155,,,Fee Schedule,155% of CMS OPPS Rate,163.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,623.58,155,,,Fee Schedule,155% of CMS OPPS Rate,623.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,163.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,367.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,163.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,680.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,147.68,680.68,
31239- Nasal/sinus endoscopy/surgical,3431301,CDM,510,RC,31239,HCPCS,Outpatient,,,1560.47,780.24,,1404.42,90,,,percent of total billed charges,90% of total Billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1248.38,80,,,Percent of total Billed charges,80% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1404.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1513.66,97,,,Percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1435.63,92,,,Percent of total billed charges,92% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,8048.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12830.66,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16251.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1404.42,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1092.33,70,,,percent of total billed charges,70% of total billed charges,1404.42,90,,,percent of total billed charges,90% of total billed charges,1482.45,95,,,percent of total billed charges,95% of total billed charges,1482.45,95,,,percent of total billed charges,95% of total billed charges,3027.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6055.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1342,86,,,percent of total billed charges,86% of total billed charges,1248.38,80,,,percent of total billed charges,80% of total billed charges,3036.4,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1513.66,97,,,percent of total billed charges,97% of total billed charges,1404.42,90,,,percent of total billed charges,90% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1513.66,97,,,percent of total billed charges,97% of total billed charges,1451.24,93,,,percent of total billed charges,93% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1513.66,97,,,percent of total billed charges,97% of total billed charges,3027.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,3027.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2573.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1092.33,16251.96,
INCISION OF WINDPIPE,3527827,CDM,981,RC,31605,HCPCS,Outpatient,,,900.37,450.19,,810.33,90,,,percent of total billed charges,90% of total Billed charges,673.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,168.69,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,519.65,155,,,Fee Schedule,155% of CMS OPPS Rate,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,335.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,489.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,489.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,526.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,526.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,147.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,670.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,620.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,441.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,519.65,155,,,Fee Schedule,155% of CMS OPPS Rate,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,1044.42,155,,,Fee Schedule,155% of CMS OPPS Rate,1044.42,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,335.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,376.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,147.22,1044.42,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,57.43,28.72,,51.69,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,10.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.59,155,,,Fee Schedule,155% of CMS OPPS Rate,39.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.43,51.69,
36415 Venipuncture,3435565,CDM,300,RC,36415,HCPCS,Outpatient,,,14.63,7.32,,13.17,90,,,percent of total billed charges,90% of total Billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11.7,80,,,Percent of total Billed charges,80% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.19,97,,,Percent of total billed charges,97% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,13.46,92,,,Percent of total billed charges,92% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.17,90,,,percent of total billed charges,90% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,10.24,70,,,percent of total billed charges,70% of total billed charges,13.17,90,,,percent of total billed charges,90% of total billed charges,13.9,95,,,percent of total billed charges,95% of total billed charges,13.9,95,,,percent of total billed charges,95% of total billed charges,8.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12.58,86,,,percent of total billed charges,86% of total billed charges,11.7,80,,,percent of total billed charges,80% of total billed charges,3.33,111,,,Fee Schedule,111% of CMS OPPS Rate,14.19,97,,,percent of total billed charges,97% of total billed charges,13.17,90,,,percent of total billed charges,90% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.19,97,,,percent of total billed charges,97% of total billed charges,13.61,93,,,percent of total billed charges,93% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14.19,97,,,percent of total billed charges,97% of total billed charges,8.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.33,42.35,
36416 - Collection of Capillary Blood Specimen,4315464,CDM,983,RC,36416,HCPCS,Outpatient,,,45.42,22.71,,40.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,3.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,3.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,3.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.63,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.6,40.88,
36460- Transfusion/intrauterine/fetal,3430713,CDM,510,RC,36460,HCPCS,Outpatient,,,920.12,460.06,,828.11,90,,,percent of total billed charges,90% of total Billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,736.1,80,,,Percent of total Billed charges,80% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,828.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,892.52,97,,,Percent of total billed charges,97% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,846.51,92,,,Percent of total billed charges,92% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,984.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1569.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1987.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,828.11,90,,,percent of total billed charges,90% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,644.08,70,,,percent of total billed charges,70% of total billed charges,828.11,90,,,percent of total billed charges,90% of total billed charges,874.11,95,,,percent of total billed charges,95% of total billed charges,874.11,95,,,percent of total billed charges,95% of total billed charges,370.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,740.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,791.3,86,,,percent of total billed charges,86% of total billed charges,736.1,80,,,percent of total billed charges,80% of total billed charges,401.18,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,892.52,97,,,percent of total billed charges,97% of total billed charges,828.11,90,,,percent of total billed charges,90% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,892.52,97,,,percent of total billed charges,97% of total billed charges,855.71,93,,,percent of total billed charges,93% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,892.52,97,,,percent of total billed charges,97% of total billed charges,370.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.34,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,314.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,314.77,1987.82,
36465 NJX Noncmpnd Sclerosant Single Incmptnt Vein,3436048,CDM,761,RC,36465,HCPCS,Outpatient,,,3257.89,1628.95,,2932.1,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2606.31,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,2932.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3160.15,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2997.26,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2932.1,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2280.52,70,,,percent of total billed charges,70% of total billed charges,2932.1,90,,,percent of total billed charges,90% of total billed charges,3095,95,,,percent of total billed charges,95% of total billed charges,3095,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2801.79,86,,,percent of total billed charges,86% of total billed charges,2606.31,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3160.15,97,,,percent of total billed charges,97% of total billed charges,2932.1,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,3160.15,97,,,percent of total billed charges,97% of total billed charges,3029.84,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3160.15,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8413.78,
36466 NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,3436049,CDM,761,RC,36466,HCPCS,Outpatient,,,3609.18,1804.59,,3248.26,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2887.34,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,3248.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3500.9,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,3320.45,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3248.26,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,2526.43,70,,,percent of total billed charges,70% of total billed charges,3248.26,90,,,percent of total billed charges,90% of total billed charges,3428.72,95,,,percent of total billed charges,95% of total billed charges,3428.72,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3103.89,86,,,percent of total billed charges,86% of total billed charges,2887.34,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3500.9,97,,,percent of total billed charges,97% of total billed charges,3248.26,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,3500.9,97,,,percent of total billed charges,97% of total billed charges,3356.54,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3500.9,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8413.78,
36468 Tx of symptomatic spider veins sclerotherapy,4117375,CDM,761,RC,36468,HCPCS,Outpatient,,,380.64,190.32,,342.58,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,304.51,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,369.22,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,350.19,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,342.58,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,266.45,70,,,percent of total billed charges,70% of total billed charges,342.58,90,,,percent of total billed charges,90% of total billed charges,361.61,95,,,percent of total billed charges,95% of total billed charges,361.61,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,327.35,86,,,percent of total billed charges,86% of total billed charges,304.51,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,369.22,97,,,percent of total billed charges,97% of total billed charges,342.58,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,369.22,97,,,percent of total billed charges,97% of total billed charges,354,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,369.22,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.64,1818.76,
36470 Injection Sclerosant Single Incmptnt Vein,3436050,CDM,761,RC,36470,HCPCS,Outpatient,,,285.8,142.90,,257.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,228.64,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.22,90,,,Percent of total Billed charges,90% of total billed charges,10.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,277.23,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,262.94,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,257.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,200.06,70,,,percent of total billed charges,70% of total billed charges,257.22,90,,,percent of total billed charges,90% of total billed charges,271.51,95,,,percent of total billed charges,95% of total billed charges,271.51,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,245.79,86,,,percent of total billed charges,86% of total billed charges,228.64,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,277.23,97,,,percent of total billed charges,97% of total billed charges,257.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.23,97,,,percent of total billed charges,97% of total billed charges,265.79,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.23,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.35,1818.76,
36471 Injection Sclerosant Multiple Incmptnt Veins,3436052,CDM,761,RC,36471,HCPCS,Outpatient,,,500.57,250.29,,450.51,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,400.46,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,450.51,90,,,Percent of total Billed charges,90% of total billed charges,100.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,485.55,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,460.52,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,450.51,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,350.4,70,,,percent of total billed charges,70% of total billed charges,450.51,90,,,percent of total billed charges,90% of total billed charges,475.54,95,,,percent of total billed charges,95% of total billed charges,475.54,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,430.49,86,,,percent of total billed charges,86% of total billed charges,400.46,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,485.55,97,,,percent of total billed charges,97% of total billed charges,450.51,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,485.55,97,,,percent of total billed charges,97% of total billed charges,465.53,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,485.55,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.12,1818.76,
36475 - Radiofrequency ablation vein,4023140,CDM,761,RC,36475,HCPCS,Outpatient,,,2739.73,1369.87,,2465.76,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2191.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2465.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2657.54,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2520.55,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2465.76,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1917.81,70,,,percent of total billed charges,70% of total billed charges,2465.76,90,,,percent of total billed charges,90% of total billed charges,2602.74,95,,,percent of total billed charges,95% of total billed charges,2602.74,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2356.17,86,,,percent of total billed charges,86% of total billed charges,2191.78,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2657.54,97,,,percent of total billed charges,97% of total billed charges,2465.76,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2657.54,97,,,percent of total billed charges,97% of total billed charges,2547.95,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2657.54,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1917.81,14522.85,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,16672.2,8336.10,,15004.98,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,13337.76,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15004.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16172.03,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,15338.42,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15004.98,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11670.54,70,,,percent of total billed charges,70% of total billed charges,15004.98,90,,,percent of total billed charges,90% of total billed charges,15838.59,95,,,percent of total billed charges,95% of total billed charges,15838.59,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14338.09,86,,,percent of total billed charges,86% of total billed charges,13337.76,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16172.03,97,,,percent of total billed charges,97% of total billed charges,15004.98,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,16172.03,97,,,percent of total billed charges,97% of total billed charges,15505.15,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16172.03,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,16172.03,
36478 Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,3436053,CDM,761,RC,36478,HCPCS,Outpatient,,,2505.7,1252.85,,2255.13,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2004.56,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2255.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2430.53,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2305.24,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2255.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1753.99,70,,,percent of total billed charges,70% of total billed charges,2255.13,90,,,percent of total billed charges,90% of total billed charges,2380.42,95,,,percent of total billed charges,95% of total billed charges,2380.42,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2154.9,86,,,percent of total billed charges,86% of total billed charges,2004.56,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2430.53,97,,,percent of total billed charges,97% of total billed charges,2255.13,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2430.53,97,,,percent of total billed charges,97% of total billed charges,2330.3,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2430.53,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1753.99,14522.85,
36482 Endoven Ablti Ther Chem Adhesive 1st Vein,3549208,CDM,761,RC,36482,HCPCS,Outpatient,,,4161.61,2080.81,,3745.45,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3329.29,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,3745.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4036.76,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,3828.68,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3745.45,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2913.13,70,,,percent of total billed charges,70% of total billed charges,3745.45,90,,,percent of total billed charges,90% of total billed charges,3953.53,95,,,percent of total billed charges,95% of total billed charges,3953.53,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3578.98,86,,,percent of total billed charges,86% of total billed charges,3329.29,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4036.76,97,,,percent of total billed charges,97% of total billed charges,3745.45,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4036.76,97,,,percent of total billed charges,97% of total billed charges,3870.3,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4036.76,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2913.13,25056.97,
36483 Endoven Ablti Ther Chem Adhesive Sbsq Vein,3549209,CDM,761,RC,36483,HCPCS,Outpatient,,,357.23,178.62,,321.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,285.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,321.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,346.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,328.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,228.13,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,280.97,78.65,,,percent of total billed charges,78.65% of total billed charges,319.12,89.33,,,percent of total billed charges,89.33% of total billed charges,321.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,250.06,70,,,percent of total billed charges,70% of total billed charges,321.51,90,,,percent of total billed charges,90% of total billed charges,339.37,95,,,percent of total billed charges,95% of total billed charges,339.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.22,86,,,percent of total billed charges,86% of total billed charges,285.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,346.51,97,,,percent of total billed charges,97% of total billed charges,321.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,346.51,97,,,percent of total billed charges,97% of total billed charges,332.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,346.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.13,346.51,
36558 - Hero Graft Placement- add-on,4233191,CDM,481,RC,36558,HCPCS,Outpatient,,,1613.4,806.70,,1452.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.72,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1452.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1565,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1484.33,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1452.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.38,70,,,percent of total billed charges,70% of total billed charges,1452.06,90,,,percent of total billed charges,90% of total billed charges,1532.73,95,,,percent of total billed charges,95% of total billed charges,1532.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1387.52,86,,,percent of total billed charges,86% of total billed charges,1290.72,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1565,97,,,percent of total billed charges,97% of total billed charges,1452.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565,97,,,percent of total billed charges,97% of total billed charges,1500.46,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1565,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1129.38,14522.85,
36558 - PF Hero Graft Placement- add-on,4233189,CDM,960,RC,36558,HCPCS,Outpatient,,,1613.4,806.70,,1452.06,90,,,percent of total billed charges,90% of total Billed charges,1050.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,434.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,434.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,398.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,507.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,470.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,308.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,393.17,155,,,Fee Schedule,155% of CMS OPPS Rate,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1627.56,155,,,Fee Schedule,155% of CMS OPPS Rate,1627.56,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1459.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,253.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,217.44,1627.56,
Hero Graft Placement- add-on,,,761,RC,36558,HCPCS,Outpatient,,,1613.4,806.70,,1452.06,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1290.72,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1452.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1565,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1484.33,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1452.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1129.38,70,,,percent of total billed charges,70% of total billed charges,1452.06,90,,,percent of total billed charges,90% of total billed charges,1532.73,95,,,percent of total billed charges,95% of total billed charges,1532.73,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1387.52,86,,,percent of total billed charges,86% of total billed charges,1290.72,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1565,97,,,percent of total billed charges,97% of total billed charges,1452.06,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565,97,,,percent of total billed charges,97% of total billed charges,1500.46,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1565,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1129.38,14522.85,
36591 Draw blood of venous device,3428321,CDM,301,RC,36591,HCPCS,Outpatient,,,62.69,31.35,,56.42,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,50.15,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,60.81,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,57.67,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,56.42,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,43.88,70,,,percent of total billed charges,70% of total billed charges,56.42,90,,,percent of total billed charges,90% of total billed charges,59.56,95,,,percent of total billed charges,95% of total billed charges,59.56,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,53.91,86,,,percent of total billed charges,86% of total billed charges,50.15,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,60.81,97,,,percent of total billed charges,97% of total billed charges,56.42,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.81,97,,,percent of total billed charges,97% of total billed charges,58.3,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.81,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.88,566.05,
"36592- Collect bld, cen/per cath vein NOS",3430726,CDM,300,RC,36592,HCPCS,Outpatient,,,69.81,34.91,,62.83,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,55.85,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.72,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,64.23,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,62.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,48.87,70,,,percent of total billed charges,70% of total billed charges,62.83,90,,,percent of total billed charges,90% of total billed charges,66.32,95,,,percent of total billed charges,95% of total billed charges,66.32,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.04,86,,,percent of total billed charges,86% of total billed charges,55.85,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,67.72,97,,,percent of total billed charges,97% of total billed charges,62.83,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.72,97,,,percent of total billed charges,97% of total billed charges,64.92,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.72,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.87,566.05,
36600- Arterial puncture/blood draw,3430727,CDM,300,RC,36600,HCPCS,Outpatient,,,72.55,36.28,,65.3,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,58.04,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.3,90,,,Percent of total Billed charges,90% of total billed charges,14.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,70.37,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,66.75,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,65.3,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,50.79,70,,,percent of total billed charges,70% of total billed charges,65.3,90,,,percent of total billed charges,90% of total billed charges,68.92,95,,,percent of total billed charges,95% of total billed charges,68.92,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.39,86,,,percent of total billed charges,86% of total billed charges,58.04,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70.37,97,,,percent of total billed charges,97% of total billed charges,65.3,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.37,97,,,percent of total billed charges,97% of total billed charges,67.47,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.37,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13,566.05,
36660- Umbilical artery cath/newborn,3430729,CDM,510,RC,36660,HCPCS,Outpatient,,,179.83,89.92,,161.85,90,,,percent of total billed charges,90% of total Billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,143.86,80,,,Percent of total Billed charges,80% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,161.85,90,,,Percent of total Billed charges,90% of total billed charges,54.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,174.44,97,,,Percent of total billed charges,97% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,165.44,92,,,Percent of total billed charges,92% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,161.85,90,,,percent of total billed charges,90% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,125.88,70,,,percent of total billed charges,70% of total billed charges,161.85,90,,,percent of total billed charges,90% of total billed charges,170.84,95,,,percent of total billed charges,95% of total billed charges,170.84,95,,,percent of total billed charges,95% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,154.65,86,,,percent of total billed charges,86% of total billed charges,143.86,80,,,percent of total billed charges,80% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,174.44,97,,,percent of total billed charges,97% of total billed charges,161.85,90,,,percent of total billed charges,90% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,174.44,97,,,percent of total billed charges,97% of total billed charges,167.24,93,,,percent of total billed charges,93% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,49.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,174.44,97,,,percent of total billed charges,97% of total billed charges,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,179.83,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,49.5,179.83,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,53259.29,26629.65,,47933.36,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,42607.43,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,47933.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51661.51,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,48998.55,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,47933.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,37281.5,70,,,percent of total billed charges,70% of total billed charges,47933.36,90,,,percent of total billed charges,90% of total billed charges,50596.33,95,,,percent of total billed charges,95% of total billed charges,50596.33,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45802.99,86,,,percent of total billed charges,86% of total billed charges,42607.43,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51661.51,97,,,percent of total billed charges,97% of total billed charges,47933.36,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,51661.51,97,,,percent of total billed charges,97% of total billed charges,49531.14,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51661.51,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,84934.9,42467.45,,76441.41,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,67947.92,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,76441.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82386.85,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,78140.11,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,76441.41,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,59454.43,70,,,percent of total billed charges,70% of total billed charges,76441.41,90,,,percent of total billed charges,90% of total billed charges,80688.16,95,,,percent of total billed charges,95% of total billed charges,80688.16,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,73044.01,86,,,percent of total billed charges,86% of total billed charges,67947.92,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,82386.85,97,,,percent of total billed charges,97% of total billed charges,76441.41,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,82386.85,97,,,percent of total billed charges,97% of total billed charges,78989.46,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,82386.85,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,510,RC,43999,HCPCS,Outpatient,,,4497.48,2248.74,,4047.73,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3597.98,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,4047.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4362.56,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,4137.68,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4047.73,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3148.24,70,,,percent of total billed charges,70% of total billed charges,4047.73,90,,,percent of total billed charges,90% of total billed charges,4272.61,95,,,percent of total billed charges,95% of total billed charges,4272.61,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3867.83,86,,,percent of total billed charges,86% of total billed charges,3597.98,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4362.56,97,,,percent of total billed charges,97% of total billed charges,4047.73,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,4362.56,97,,,percent of total billed charges,97% of total billed charges,4182.66,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4362.56,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4362.56,
44144- Colectomy/w colostomy or ileostomy,3431222,CDM,510,RC,44144,HCPCS,Outpatient,,,3743.67,1871.84,,3369.3,90,,,percent of total billed charges,90% of total Billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2994.94,80,,,Percent of total Billed charges,80% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3369.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3631.36,97,,,Percent of total billed charges,97% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3444.18,92,,,Percent of total billed charges,92% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3369.3,90,,,percent of total billed charges,90% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2620.57,70,,,percent of total billed charges,70% of total billed charges,3369.3,90,,,percent of total billed charges,90% of total billed charges,3556.49,95,,,percent of total billed charges,95% of total billed charges,3556.49,95,,,percent of total billed charges,95% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3219.56,86,,,percent of total billed charges,86% of total billed charges,2994.94,80,,,percent of total billed charges,80% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.36,97,,,percent of total billed charges,97% of total billed charges,3369.3,90,,,percent of total billed charges,90% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3631.36,97,,,percent of total billed charges,97% of total billed charges,3481.61,93,,,percent of total billed charges,93% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,3631.36,97,,,percent of total billed charges,97% of total billed charges,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3743.67,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2620.57,3743.67,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,1384.71,692.36,,1246.24,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1107.77,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1246.24,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1343.17,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.93,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1246.24,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,969.3,70,,,percent of total billed charges,70% of total billed charges,1246.24,90,,,percent of total billed charges,90% of total billed charges,1315.47,95,,,percent of total billed charges,95% of total billed charges,1315.47,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1190.85,86,,,percent of total billed charges,86% of total billed charges,1107.77,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1343.17,97,,,percent of total billed charges,97% of total billed charges,1246.24,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1343.17,97,,,percent of total billed charges,97% of total billed charges,1287.78,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1343.17,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,1343.17,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,4803.77,2401.89,,4323.39,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3843.02,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,4323.39,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4659.66,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4419.47,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4323.39,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3362.64,70,,,percent of total billed charges,70% of total billed charges,4323.39,90,,,percent of total billed charges,90% of total billed charges,4563.58,95,,,percent of total billed charges,95% of total billed charges,4563.58,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4131.24,86,,,percent of total billed charges,86% of total billed charges,3843.02,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4659.66,97,,,percent of total billed charges,97% of total billed charges,4323.39,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,4659.66,97,,,percent of total billed charges,97% of total billed charges,4467.51,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4659.66,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,5279.31,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,1292.57,646.29,,1163.31,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1034.06,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1163.31,90,,,Percent of total Billed charges,90% of total billed charges,128.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1253.79,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1189.16,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1163.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,904.8,70,,,percent of total billed charges,70% of total billed charges,1163.31,90,,,percent of total billed charges,90% of total billed charges,1227.94,95,,,percent of total billed charges,95% of total billed charges,1227.94,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1111.61,86,,,percent of total billed charges,86% of total billed charges,1034.06,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1253.79,97,,,percent of total billed charges,97% of total billed charges,1163.31,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1253.79,97,,,percent of total billed charges,97% of total billed charges,1202.09,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1253.79,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.03,1253.79,
"49329-MA UNLISTED LAP ABD, PERIT, OMENT",3430022,CDM,510,RC,49329,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,25409.89,
51700- Bladder irrigate/lavage/instill,3435948,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,1107.42,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,984.38,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.42,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1193.56,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.03,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,861.33,70,,,percent of total billed charges,70% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1058.2,86,,,percent of total billed charges,86% of total billed charges,984.38,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1193.56,97,,,percent of total billed charges,97% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1193.56,97,,,percent of total billed charges,97% of total billed charges,1144.34,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1193.56,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1193.56,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,1107.42,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,984.38,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.42,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1193.56,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.03,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,861.33,70,,,percent of total billed charges,70% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1058.2,86,,,percent of total billed charges,86% of total billed charges,984.38,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1193.56,97,,,percent of total billed charges,97% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1193.56,97,,,percent of total billed charges,97% of total billed charges,1144.34,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1193.56,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1193.56,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,1230.47,615.24,,1107.42,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,984.38,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1107.42,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1193.56,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1132.03,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,861.33,70,,,percent of total billed charges,70% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,1168.95,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1058.2,86,,,percent of total billed charges,86% of total billed charges,984.38,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1193.56,97,,,percent of total billed charges,97% of total billed charges,1107.42,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1193.56,97,,,percent of total billed charges,97% of total billed charges,1144.34,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1193.56,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1193.56,
51701- Insert/non-indwelling bladder cath,3435949,CDM,510,RC,51701,HCPCS,Outpatient,,,686.4,343.20,,617.76,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,549.12,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,617.76,90,,,Percent of total Billed charges,90% of total billed charges,28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,665.81,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,631.49,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,617.76,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,480.48,70,,,percent of total billed charges,70% of total billed charges,617.76,90,,,percent of total billed charges,90% of total billed charges,652.08,95,,,percent of total billed charges,95% of total billed charges,652.08,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,590.3,86,,,percent of total billed charges,86% of total billed charges,549.12,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,665.81,97,,,percent of total billed charges,97% of total billed charges,617.76,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,665.81,97,,,percent of total billed charges,97% of total billed charges,638.35,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,665.81,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.45,665.81,
CATH INSERT STRAIGHT,3428402,CDM,981,RC,51701,HCPCS,Outpatient,,,59.82,29.91,,53.84,90,,,percent of total billed charges,90% of total Billed charges,68.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,32.84,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,39.04,155,,,Fee Schedule,155% of CMS OPPS Rate,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.51,155,,,Fee Schedule,155% of CMS OPPS Rate,105.51,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,105.51,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,510,RC,51720,HCPCS,Outpatient,,,3477.25,1738.63,,3129.53,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2781.8,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3129.53,90,,,Percent of total Billed charges,90% of total billed charges,73.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3372.93,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3199.07,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3129.53,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2434.08,70,,,percent of total billed charges,70% of total billed charges,3129.53,90,,,percent of total billed charges,90% of total billed charges,3303.39,95,,,percent of total billed charges,95% of total billed charges,3303.39,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2990.44,86,,,percent of total billed charges,86% of total billed charges,2781.8,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3372.93,97,,,percent of total billed charges,97% of total billed charges,3129.53,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3372.93,97,,,percent of total billed charges,97% of total billed charges,3233.84,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3372.93,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.94,3372.93,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,1657.45,828.73,,1491.71,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1325.96,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1491.71,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1607.73,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.85,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1491.71,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1160.22,70,,,percent of total billed charges,70% of total billed charges,1491.71,90,,,percent of total billed charges,90% of total billed charges,1574.58,95,,,percent of total billed charges,95% of total billed charges,1574.58,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1425.41,86,,,percent of total billed charges,86% of total billed charges,1325.96,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1607.73,97,,,percent of total billed charges,97% of total billed charges,1491.71,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1607.73,97,,,percent of total billed charges,97% of total billed charges,1541.43,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1607.73,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1607.73,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,1810.53,905.27,,1629.48,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1448.42,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1629.48,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1756.21,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.69,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1629.48,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1267.37,70,,,percent of total billed charges,70% of total billed charges,1629.48,90,,,percent of total billed charges,90% of total billed charges,1720,95,,,percent of total billed charges,95% of total billed charges,1720,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1557.06,86,,,percent of total billed charges,86% of total billed charges,1448.42,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1756.21,97,,,percent of total billed charges,97% of total billed charges,1629.48,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1756.21,97,,,percent of total billed charges,97% of total billed charges,1683.79,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1756.21,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1756.21,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,510,RC,51728,HCPCS,Outpatient,,,3227.64,1613.82,,2904.88,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.11,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2904.88,90,,,Percent of total Billed charges,90% of total billed charges,154.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3130.81,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2969.43,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2904.88,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2259.35,70,,,percent of total billed charges,70% of total billed charges,2904.88,90,,,percent of total billed charges,90% of total billed charges,3066.26,95,,,percent of total billed charges,95% of total billed charges,3066.26,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2775.77,86,,,percent of total billed charges,86% of total billed charges,2582.11,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3130.81,97,,,percent of total billed charges,97% of total billed charges,2904.88,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3130.81,97,,,percent of total billed charges,97% of total billed charges,3001.71,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3130.81,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,140.4,3130.81,
Clinic Complex Uroflometry - 51741,4305355,CDM,510,RC,51741,HCPCS,Outpatient,,,718.46,359.23,,646.61,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,574.77,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,646.61,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,696.91,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,660.98,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,646.61,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,502.92,70,,,percent of total billed charges,70% of total billed charges,646.61,90,,,percent of total billed charges,90% of total billed charges,682.54,95,,,percent of total billed charges,95% of total billed charges,682.54,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,617.88,86,,,percent of total billed charges,86% of total billed charges,574.77,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,696.91,97,,,percent of total billed charges,97% of total billed charges,646.61,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.91,97,,,percent of total billed charges,97% of total billed charges,668.17,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,696.91,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,708.98,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,510,RC,51784,HCPCS,Outpatient,,,777.65,388.83,,699.89,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,622.12,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,699.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,754.32,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,715.44,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,699.89,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,544.36,70,,,percent of total billed charges,70% of total billed charges,699.89,90,,,percent of total billed charges,90% of total billed charges,738.77,95,,,percent of total billed charges,95% of total billed charges,738.77,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,668.78,86,,,percent of total billed charges,86% of total billed charges,622.12,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,754.32,97,,,percent of total billed charges,97% of total billed charges,699.89,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.32,97,,,percent of total billed charges,97% of total billed charges,723.21,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,754.32,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,754.32,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,3561.37,1780.69,,3205.23,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2849.1,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3205.23,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3454.53,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3276.46,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3205.23,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2492.96,70,,,percent of total billed charges,70% of total billed charges,3205.23,90,,,percent of total billed charges,90% of total billed charges,3383.3,95,,,percent of total billed charges,95% of total billed charges,3383.3,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3062.78,86,,,percent of total billed charges,86% of total billed charges,2849.1,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3454.53,97,,,percent of total billed charges,97% of total billed charges,3205.23,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3454.53,97,,,percent of total billed charges,97% of total billed charges,3312.07,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3454.53,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,3454.53,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,10359.33,5179.67,,9323.4,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8287.46,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9323.4,90,,,Percent of total Billed charges,90% of total billed charges,141.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10048.55,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9530.58,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9323.4,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7251.53,70,,,percent of total billed charges,70% of total billed charges,9323.4,90,,,percent of total billed charges,90% of total billed charges,9841.36,95,,,percent of total billed charges,95% of total billed charges,9841.36,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8909.02,86,,,percent of total billed charges,86% of total billed charges,8287.46,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10048.55,97,,,percent of total billed charges,97% of total billed charges,9323.4,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,10048.55,97,,,percent of total billed charges,97% of total billed charges,9634.18,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10048.55,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129,10048.55,
54056- Cryosurgery/penis lesion(s),3431644,CDM,510,RC,54056,HCPCS,Outpatient,,,1154.1,577.05,,1038.69,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,923.28,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1038.69,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1119.48,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.77,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1038.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,807.87,70,,,percent of total billed charges,70% of total billed charges,1038.69,90,,,percent of total billed charges,90% of total billed charges,1096.4,95,,,percent of total billed charges,95% of total billed charges,1096.4,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,992.53,86,,,percent of total billed charges,86% of total billed charges,923.28,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1119.48,97,,,percent of total billed charges,97% of total billed charges,1038.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1119.48,97,,,percent of total billed charges,97% of total billed charges,1073.31,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1119.48,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,1119.48,
Clinic Vasectomy,3550629,CDM,510,RC,55250,HCPCS,Outpatient,,,9402.54,4701.27,,8462.29,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7522.03,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,8462.29,90,,,Percent of total Billed charges,90% of total billed charges,163.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9120.46,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8650.34,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8462.29,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6581.78,70,,,percent of total billed charges,70% of total billed charges,8462.29,90,,,percent of total billed charges,90% of total billed charges,8932.41,95,,,percent of total billed charges,95% of total billed charges,8932.41,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8086.18,86,,,percent of total billed charges,86% of total billed charges,7522.03,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9120.46,97,,,percent of total billed charges,97% of total billed charges,8462.29,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9120.46,97,,,percent of total billed charges,97% of total billed charges,8744.36,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9120.46,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.5,9120.46,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,1217.47,608.74,,1095.72,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,973.98,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1095.72,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1180.95,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1120.07,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1095.72,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,852.23,70,,,percent of total billed charges,70% of total billed charges,1095.72,90,,,percent of total billed charges,90% of total billed charges,1156.6,95,,,percent of total billed charges,95% of total billed charges,1156.6,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1047.02,86,,,percent of total billed charges,86% of total billed charges,973.98,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1180.95,97,,,percent of total billed charges,97% of total billed charges,1095.72,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1180.95,97,,,percent of total billed charges,97% of total billed charges,1132.25,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1180.95,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,1180.95,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,9474.23,4737.12,,8526.81,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7579.38,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8526.81,90,,,Percent of total Billed charges,90% of total billed charges,69.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9190,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8716.29,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8526.81,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6631.96,70,,,percent of total billed charges,70% of total billed charges,8526.81,90,,,percent of total billed charges,90% of total billed charges,9000.52,95,,,percent of total billed charges,95% of total billed charges,9000.52,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8147.84,86,,,percent of total billed charges,86% of total billed charges,7579.38,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9190,97,,,percent of total billed charges,97% of total billed charges,8526.81,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9190,97,,,percent of total billed charges,97% of total billed charges,8811.03,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9190,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.5,9190,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,16016.57,8008.29,,14414.91,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12813.26,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,14414.91,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15536.07,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14735.24,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14414.91,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11211.6,70,,,percent of total billed charges,70% of total billed charges,14414.91,90,,,percent of total billed charges,90% of total billed charges,15215.74,95,,,percent of total billed charges,95% of total billed charges,15215.74,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13774.25,86,,,percent of total billed charges,86% of total billed charges,12813.26,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15536.07,97,,,percent of total billed charges,97% of total billed charges,14414.91,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,15536.07,97,,,percent of total billed charges,97% of total billed charges,14895.41,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15536.07,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,15536.07,
57100 - Bx vaginal mucosa; simple,3431363,CDM,360,RC,57100,HCPCS,Outpatient,,,266.73,133.37,,240.06,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,213.38,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.06,90,,,Percent of total Billed charges,90% of total billed charges,65.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,258.73,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,245.39,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,240.06,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,186.71,70,,,percent of total billed charges,70% of total billed charges,240.06,90,,,percent of total billed charges,90% of total billed charges,253.39,95,,,percent of total billed charges,95% of total billed charges,253.39,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,229.39,86,,,percent of total billed charges,86% of total billed charges,213.38,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,258.73,97,,,percent of total billed charges,97% of total billed charges,240.06,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.73,97,,,percent of total billed charges,97% of total billed charges,248.06,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,258.73,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.99,3429.49,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,1887.88,943.94,,1699.09,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1510.3,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1699.09,90,,,Percent of total Billed charges,90% of total billed charges,116.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1831.24,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1736.85,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1699.09,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1321.52,70,,,percent of total billed charges,70% of total billed charges,1699.09,90,,,percent of total billed charges,90% of total billed charges,1793.49,95,,,percent of total billed charges,95% of total billed charges,1793.49,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1623.58,86,,,percent of total billed charges,86% of total billed charges,1510.3,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1831.24,97,,,percent of total billed charges,97% of total billed charges,1699.09,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1831.24,97,,,percent of total billed charges,97% of total billed charges,1755.73,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1831.24,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.94,1831.24,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,3563.5,1781.75,,3207.15,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2850.8,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,3207.15,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3456.6,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3278.42,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3207.15,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2494.45,70,,,percent of total billed charges,70% of total billed charges,3207.15,90,,,percent of total billed charges,90% of total billed charges,3385.33,95,,,percent of total billed charges,95% of total billed charges,3385.33,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3064.61,86,,,percent of total billed charges,86% of total billed charges,2850.8,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3456.6,97,,,percent of total billed charges,97% of total billed charges,3207.15,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,3456.6,97,,,percent of total billed charges,97% of total billed charges,3314.06,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3456.6,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.12,3456.6,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,370.53,185.27,,333.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,296.42,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,333.48,90,,,Percent of total Billed charges,90% of total billed charges,35.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,359.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,340.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,236.63,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,291.43,78.65,,,percent of total billed charges,78.65% of total billed charges,331,89.33,,,percent of total billed charges,89.33% of total billed charges,333.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,259.37,70,,,percent of total billed charges,70% of total billed charges,333.48,90,,,percent of total billed charges,90% of total billed charges,352,95,,,percent of total billed charges,95% of total billed charges,352,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,318.66,86,,,percent of total billed charges,86% of total billed charges,296.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,359.41,97,,,percent of total billed charges,97% of total billed charges,333.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,359.41,97,,,percent of total billed charges,97% of total billed charges,344.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,359.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,359.41,
Clinic Artificial Insemination/Intrauterine-58322,4311235,CDM,983,RC,58322,HCPCS,Outpatient,,,981.16,490.58,,883.04,90,,,percent of total billed charges,90% of total Billed charges,146.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.82,155,,,Fee Schedule,155% of CMS OPPS Rate,57.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,294.35,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,73.62,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,89.82,155,,,Fee Schedule,155% of CMS OPPS Rate,57.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.84,155,,,Fee Schedule,155% of CMS OPPS Rate,226.84,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,57.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,171.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.95,883.04,
58340- Cath/saline/contrast/SIS/hysteosal,3431413,CDM,510,RC,58340,HCPCS,Outpatient,,,304.09,152.05,,273.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,243.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,273.68,90,,,Percent of total Billed charges,90% of total billed charges,57.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,294.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,279.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,194.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,239.17,78.65,,,percent of total billed charges,78.65% of total billed charges,271.65,89.33,,,percent of total billed charges,89.33% of total billed charges,273.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,212.86,70,,,percent of total billed charges,70% of total billed charges,273.68,90,,,percent of total billed charges,90% of total billed charges,288.89,95,,,percent of total billed charges,95% of total billed charges,288.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.52,86,,,percent of total billed charges,86% of total billed charges,243.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,294.97,97,,,percent of total billed charges,97% of total billed charges,273.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,294.97,97,,,percent of total billed charges,97% of total billed charges,282.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,294.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,294.97,
58679-MA AST LAPARO PROC OVIDUCT-OVARY,3430266,CDM,510,RC,58679,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,12583.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20060.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25409.89,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9467.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,4997.45,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4733.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4023.88,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,25409.89,
Lapt Stg/Restg Ovarian Tubal/Prim Mal 2nd Look PF,4223273,CDM,983,RC,58960,HCPCS,Outpatient,,,2089.45,1044.73,,1880.51,90,,,percent of total billed charges,90% of total Billed charges,1964.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,979.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,827.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1518.09,155,,,Fee Schedule,155% of CMS OPPS Rate,979.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1287.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,979.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1447.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1447.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1476.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1476.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,878.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,979.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1958.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1741.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1173.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1518.09,155,,,Fee Schedule,155% of CMS OPPS Rate,979.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3045.73,155,,,Fee Schedule,155% of CMS OPPS Rate,3045.73,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,979.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,827.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1096.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,979.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1907.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1907.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,827.01,3045.73,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,1014.63,507.32,,913.17,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,811.7,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,913.17,90,,,Percent of total Billed charges,90% of total billed charges,5.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,984.19,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,933.46,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,913.17,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,710.24,70,,,percent of total billed charges,70% of total billed charges,913.17,90,,,percent of total billed charges,90% of total billed charges,963.9,95,,,percent of total billed charges,95% of total billed charges,963.9,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,872.58,86,,,percent of total billed charges,86% of total billed charges,811.7,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,984.19,97,,,percent of total billed charges,97% of total billed charges,913.17,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,984.19,97,,,percent of total billed charges,97% of total billed charges,943.61,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,984.19,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.72,984.19,
"HEPARIN ASSAY, POC",3430586,CDM,300,RC,59051,HCPCS,Outpatient,,,113.37,56.69,,102.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,90.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,102.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,104.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,72.4,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,89.17,78.65,,,percent of total billed charges,78.65% of total billed charges,101.28,89.33,,,percent of total billed charges,89.33% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.36,70,,,percent of total billed charges,70% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,107.7,95,,,percent of total billed charges,95% of total billed charges,107.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.5,86,,,percent of total billed charges,86% of total billed charges,90.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,102.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,105.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.4,109.97,
59412 - Antepartum Manipulation,4189312,CDM,960,RC,59412,HCPCS,Outpatient,,,221.75,110.88,,199.58,90,,,percent of total billed charges,90% of total Billed charges,208.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.11,155,,,Fee Schedule,155% of CMS OPPS Rate,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,155.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,155.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,209.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,179.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,162.11,155,,,Fee Schedule,155% of CMS OPPS Rate,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.7,155,,,Fee Schedule,155% of CMS OPPS Rate,323.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,140,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,104.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,102.16,323.7,
62272- Spinal puncture/CSF drainage,3435332,CDM,510,RC,62272,HCPCS,Outpatient,,,438.7,219.35,,394.83,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,350.96,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.83,90,,,Percent of total Billed charges,90% of total billed charges,40.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,425.54,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,403.6,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,394.83,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,307.09,70,,,percent of total billed charges,70% of total billed charges,394.83,90,,,percent of total billed charges,90% of total billed charges,416.77,95,,,percent of total billed charges,95% of total billed charges,416.77,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,377.28,86,,,percent of total billed charges,86% of total billed charges,350.96,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,425.54,97,,,percent of total billed charges,97% of total billed charges,394.83,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.54,97,,,percent of total billed charges,97% of total billed charges,407.99,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,425.54,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37,3141.23,
62284- Inj/myelography/CT/lumbar,3435333,CDM,320,RC,62284,HCPCS,Outpatient,,,486.09,243.05,,437.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,388.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,437.48,90,,,Percent of total Billed charges,90% of total billed charges,87.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,471.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,447.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,310.43,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,382.32,78.65,,,percent of total billed charges,78.65% of total billed charges,434.23,89.33,,,percent of total billed charges,89.33% of total billed charges,437.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,340.26,70,,,percent of total billed charges,70% of total billed charges,437.48,90,,,percent of total billed charges,90% of total billed charges,461.79,95,,,percent of total billed charges,95% of total billed charges,461.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.04,86,,,percent of total billed charges,86% of total billed charges,388.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,471.51,97,,,percent of total billed charges,97% of total billed charges,437.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,471.51,97,,,percent of total billed charges,97% of total billed charges,452.06,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,471.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.54,471.51,
62290- Inj/discography/ea lev/lumbar,3435334,CDM,510,RC,62290,HCPCS,Outpatient,,,902.82,451.41,,812.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,722.26,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,812.54,90,,,Percent of total Billed charges,90% of total billed charges,167.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,875.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,830.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,576.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,710.09,78.65,,,percent of total billed charges,78.65% of total billed charges,806.5,89.33,,,percent of total billed charges,89.33% of total billed charges,812.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,631.97,70,,,percent of total billed charges,70% of total billed charges,812.54,90,,,percent of total billed charges,90% of total billed charges,857.68,95,,,percent of total billed charges,95% of total billed charges,857.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,776.43,86,,,percent of total billed charges,86% of total billed charges,722.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,875.74,97,,,percent of total billed charges,97% of total billed charges,812.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,875.74,97,,,percent of total billed charges,97% of total billed charges,839.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,875.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.63,875.74,
62350- Implant intrathe/epi cath w/o lami,3435337,CDM,510,RC,62350,HCPCS,Outpatient,,,1045.35,522.68,,940.82,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,836.28,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,940.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1013.99,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,961.72,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.69,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,940.82,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,731.75,70,,,percent of total billed charges,70% of total billed charges,940.82,90,,,percent of total billed charges,90% of total billed charges,993.08,95,,,percent of total billed charges,95% of total billed charges,993.08,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,899,86,,,percent of total billed charges,86% of total billed charges,836.28,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1013.99,97,,,percent of total billed charges,97% of total billed charges,940.82,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1013.99,97,,,percent of total billed charges,97% of total billed charges,972.18,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1013.99,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,731.75,30121.69,
62351- Implant intrathe/epi cath/laminec,3435338,CDM,510,RC,62351,HCPCS,Outpatient,,,2414.56,1207.28,,2173.1,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1931.65,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2173.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2342.12,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2221.4,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2173.1,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1690.19,70,,,percent of total billed charges,70% of total billed charges,2173.1,90,,,percent of total billed charges,90% of total billed charges,2293.83,95,,,percent of total billed charges,95% of total billed charges,2293.83,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2076.52,86,,,percent of total billed charges,86% of total billed charges,1931.65,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2342.12,97,,,percent of total billed charges,97% of total billed charges,2173.1,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2342.12,97,,,percent of total billed charges,97% of total billed charges,2245.54,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2342.12,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1690.19,32247.16,
62355- Rmv prev implt intrathecal/epi cat,3435339,CDM,510,RC,62355,HCPCS,Outpatient,,,707.7,353.85,,636.93,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,566.16,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,686.47,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,651.08,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.13,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.93,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,495.39,70,,,percent of total billed charges,70% of total billed charges,636.93,90,,,percent of total billed charges,90% of total billed charges,672.32,95,,,percent of total billed charges,95% of total billed charges,672.32,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.62,86,,,percent of total billed charges,86% of total billed charges,566.16,80,,,percent of total billed charges,80% of total billed charges,1777.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.47,97,,,percent of total billed charges,97% of total billed charges,636.93,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.47,97,,,percent of total billed charges,97% of total billed charges,658.16,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,686.47,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,495.39,8763.13,
62362- Implant program pump/intrathe/epi,3435340,CDM,510,RC,62362,HCPCS,Outpatient,,,1011.98,505.99,,910.78,90,,,percent of total billed charges,90% of total Billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate,809.58,80,,,Percent of total Billed charges,80% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,910.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,981.62,97,,,Percent of total billed charges,97% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate,931.02,92,,,Percent of total billed charges,92% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate,40893.9,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15384.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65193.3,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,82577.14,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,910.78,90,,,percent of total billed charges,90% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate,708.39,70,,,percent of total billed charges,70% of total billed charges,910.78,90,,,percent of total billed charges,90% of total billed charges,961.38,95,,,percent of total billed charges,95% of total billed charges,961.38,95,,,percent of total billed charges,95% of total billed charges,15384.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30769.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,870.3,86,,,percent of total billed charges,86% of total billed charges,809.58,80,,,percent of total billed charges,80% of total billed charges,17075.94,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,981.62,97,,,percent of total billed charges,97% of total billed charges,910.78,90,,,percent of total billed charges,90% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,981.62,97,,,percent of total billed charges,97% of total billed charges,941.14,93,,,percent of total billed charges,93% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,981.62,97,,,percent of total billed charges,97% of total billed charges,15384.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,15384.52,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13076.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,708.39,82577.14,
62365- Remove/SQ infusion reservoir/pump,3435341,CDM,510,RC,62365,HCPCS,Outpatient,,,773.57,386.79,,696.21,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,618.86,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,696.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,750.36,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,711.68,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,696.21,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,541.5,70,,,percent of total billed charges,70% of total billed charges,696.21,90,,,percent of total billed charges,90% of total billed charges,734.89,95,,,percent of total billed charges,95% of total billed charges,734.89,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,665.27,86,,,percent of total billed charges,86% of total billed charges,618.86,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,750.36,97,,,percent of total billed charges,97% of total billed charges,696.21,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.36,97,,,percent of total billed charges,97% of total billed charges,719.42,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,750.36,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,541.5,30121.7,
62367- Analysis/implant pump/intrathe/epi,3435342,CDM,510,RC,62367,HCPCS,Outpatient,,,82.68,41.34,,74.41,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,66.14,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.2,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,76.07,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.41,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,57.88,70,,,percent of total billed charges,70% of total billed charges,74.41,90,,,percent of total billed charges,90% of total billed charges,78.55,95,,,percent of total billed charges,95% of total billed charges,78.55,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.1,86,,,percent of total billed charges,86% of total billed charges,66.14,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.2,97,,,percent of total billed charges,97% of total billed charges,74.41,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.2,97,,,percent of total billed charges,97% of total billed charges,76.89,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.2,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.88,1348.7,
62368- Reprogram/implant pump/intrath/epi,3435343,CDM,510,RC,62368,HCPCS,Outpatient,,,115.02,57.51,,103.52,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,92.02,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.52,90,,,Percent of total Billed charges,90% of total billed charges,36.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,111.57,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,105.82,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,103.52,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,80.51,70,,,percent of total billed charges,70% of total billed charges,103.52,90,,,percent of total billed charges,90% of total billed charges,109.27,95,,,percent of total billed charges,95% of total billed charges,109.27,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,98.92,86,,,percent of total billed charges,86% of total billed charges,92.02,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,111.57,97,,,percent of total billed charges,97% of total billed charges,103.52,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.57,97,,,percent of total billed charges,97% of total billed charges,106.97,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.57,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33.02,1348.7,
62370- Refill/implant pump/intrathe/epi,3435344,CDM,510,RC,62370,HCPCS,Outpatient,,,234.39,117.20,,210.95,90,,,percent of total billed charges,90% of total Billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,187.51,80,,,Percent of total Billed charges,80% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.95,90,,,Percent of total Billed charges,90% of total billed charges,40.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,227.36,97,,,Percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,215.64,92,,,Percent of total billed charges,92% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,667.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1064.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1348.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,210.95,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,164.07,70,,,percent of total billed charges,70% of total billed charges,210.95,90,,,percent of total billed charges,90% of total billed charges,222.67,95,,,percent of total billed charges,95% of total billed charges,222.67,95,,,percent of total billed charges,95% of total billed charges,251.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,502.53,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,201.58,86,,,percent of total billed charges,86% of total billed charges,187.51,80,,,percent of total billed charges,80% of total billed charges,280.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,227.36,97,,,percent of total billed charges,97% of total billed charges,210.95,90,,,percent of total billed charges,90% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.36,97,,,percent of total billed charges,97% of total billed charges,217.98,93,,,percent of total billed charges,93% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.36,97,,,percent of total billed charges,97% of total billed charges,251.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,213.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.78,1348.7,
63012- Laminectomy/remove abnormal facets,3435345,CDM,510,RC,63012,HCPCS,Outpatient,,,3195.29,1597.65,,2875.76,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2556.23,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2875.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3099.43,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2939.67,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2875.76,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2236.7,70,,,percent of total billed charges,70% of total billed charges,2875.76,90,,,percent of total billed charges,90% of total billed charges,3035.53,95,,,percent of total billed charges,95% of total billed charges,3035.53,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2747.95,86,,,percent of total billed charges,86% of total billed charges,2556.23,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3099.43,97,,,percent of total billed charges,97% of total billed charges,2875.76,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3099.43,97,,,percent of total billed charges,97% of total billed charges,2971.62,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3099.43,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2236.7,32247.16,
63015 - PF Laminectomy w/o FFD > 2 Vert Seg Cervical,4363325,CDM,960,RC,63015,HCPCS,Outpatient,,,3028.86,1514.43,,2725.97,90,,,percent of total billed charges,90% of total Billed charges,2999.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1506.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2334.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1506.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2118.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1506.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2382.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2382.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,2294.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,2294.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1368.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1506.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3012.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2707.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,2053.88,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2334.72,155,,,Fee Schedule,155% of CMS OPPS Rate,1506.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,4649.74,155,,,Fee Schedule,155% of CMS OPPS Rate,4649.74,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1506.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1753.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1506.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3010.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,3010.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4649.74,
63016- Laminectomy/explor/>2vert seg/cerv,3435346,CDM,510,RC,63016,HCPCS,Outpatient,,,4100.47,2050.24,,3690.42,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3280.38,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3690.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3977.46,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3772.43,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3690.42,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2870.33,70,,,percent of total billed charges,70% of total billed charges,3690.42,90,,,percent of total billed charges,90% of total billed charges,3895.45,95,,,percent of total billed charges,95% of total billed charges,3895.45,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3526.4,86,,,percent of total billed charges,86% of total billed charges,3280.38,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3977.46,97,,,percent of total billed charges,97% of total billed charges,3690.42,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3977.46,97,,,percent of total billed charges,97% of total billed charges,3813.44,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3977.46,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2870.33,32247.16,
63020- Laminotomy/1 interspace/cervical,3435347,CDM,510,RC,63020,HCPCS,Outpatient,,,3088.03,1544.02,,2779.23,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2470.42,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2779.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2995.39,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2840.99,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2779.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2161.62,70,,,percent of total billed charges,70% of total billed charges,2779.23,90,,,percent of total billed charges,90% of total billed charges,2933.63,95,,,percent of total billed charges,95% of total billed charges,2933.63,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2655.71,86,,,percent of total billed charges,86% of total billed charges,2470.42,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2995.39,97,,,percent of total billed charges,97% of total billed charges,2779.23,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2995.39,97,,,percent of total billed charges,97% of total billed charges,2871.87,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2995.39,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2161.62,32247.16,
63030- Laminotomy/sng interspace/lumbar,3435348,CDM,510,RC,63030,HCPCS,Outpatient,,,2589.16,1294.58,,2330.24,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2071.33,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2330.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2511.49,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2382.03,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2330.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,1812.41,70,,,percent of total billed charges,70% of total billed charges,2330.24,90,,,percent of total billed charges,90% of total billed charges,2459.7,95,,,percent of total billed charges,95% of total billed charges,2459.7,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2226.68,86,,,percent of total billed charges,86% of total billed charges,2071.33,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2511.49,97,,,percent of total billed charges,97% of total billed charges,2330.24,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2511.49,97,,,percent of total billed charges,97% of total billed charges,2407.92,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2511.49,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1812.41,32247.16,
63035- Laminotomy/add interspace/cerv/lum,3435349,CDM,510,RC,63035,HCPCS,Outpatient,,,516.23,258.12,,464.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,412.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,464.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,500.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,474.93,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,329.68,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,406.03,78.65,,,percent of total billed charges,78.65% of total billed charges,461.16,89.33,,,percent of total billed charges,89.33% of total billed charges,464.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,361.36,70,,,percent of total billed charges,70% of total billed charges,464.61,90,,,percent of total billed charges,90% of total billed charges,490.42,95,,,percent of total billed charges,95% of total billed charges,490.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.96,86,,,percent of total billed charges,86% of total billed charges,412.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,500.74,97,,,percent of total billed charges,97% of total billed charges,464.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,500.74,97,,,percent of total billed charges,97% of total billed charges,480.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,500.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,329.68,500.74,
63040- Laminotomy/hemi/reexplor/sng/cerv,3435350,CDM,510,RC,63040,HCPCS,Outpatient,,,3694.98,1847.49,,3325.48,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2955.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3325.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3584.13,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3399.38,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3325.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2586.49,70,,,percent of total billed charges,70% of total billed charges,3325.48,90,,,percent of total billed charges,90% of total billed charges,3510.23,95,,,percent of total billed charges,95% of total billed charges,3510.23,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3177.68,86,,,percent of total billed charges,86% of total billed charges,2955.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3584.13,97,,,percent of total billed charges,97% of total billed charges,3325.48,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3584.13,97,,,percent of total billed charges,97% of total billed charges,3436.33,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3584.13,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2586.49,32247.16,
63042- Laminotomy/re-explore/sng/lumbar,3435351,CDM,510,RC,63042,HCPCS,Outpatient,,,3446.9,1723.45,,3102.21,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2757.52,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3102.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3343.49,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3171.15,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3102.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2412.83,70,,,percent of total billed charges,70% of total billed charges,3102.21,90,,,percent of total billed charges,90% of total billed charges,3274.56,95,,,percent of total billed charges,95% of total billed charges,3274.56,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2964.33,86,,,percent of total billed charges,86% of total billed charges,2757.52,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3343.49,97,,,percent of total billed charges,97% of total billed charges,3102.21,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3343.49,97,,,percent of total billed charges,97% of total billed charges,3205.62,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3343.49,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2412.83,32247.16,
63043- Laminotomy/hemi/reexplor/add cerv,3435352,CDM,510,RC,63043,HCPCS,Outpatient,,,726.43,363.22,,653.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,581.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,653.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,668.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,571.35,78.65,,,percent of total billed charges,78.65% of total billed charges,648.93,89.33,,,percent of total billed charges,89.33% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,508.5,70,,,percent of total billed charges,70% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,690.11,95,,,percent of total billed charges,95% of total billed charges,690.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.73,86,,,percent of total billed charges,86% of total billed charges,581.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,675.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.91,704.64,
63044- Laminotomy/addl lumbar interspace,3435353,CDM,510,RC,63044,HCPCS,Outpatient,,,726.43,363.22,,653.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,581.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,653.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,668.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,571.35,78.65,,,percent of total billed charges,78.65% of total billed charges,648.93,89.33,,,percent of total billed charges,89.33% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,508.5,70,,,percent of total billed charges,70% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,690.11,95,,,percent of total billed charges,95% of total billed charges,690.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,624.73,86,,,percent of total billed charges,86% of total billed charges,581.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,653.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,675.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,704.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.91,704.64,
63045 - PF Lam Facetectomy & Foramotomy 1 Crt Sgm Cervical,4363326,CDM,960,RC,63045,HCPCS,Outpatient,,,2615.82,1307.91,,2354.24,90,,,percent of total billed charges,90% of total Billed charges,2598.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1303.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1000,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,2019.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1303.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1841.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2071.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,2071.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1987.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1987.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1179.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1303.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2606.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,2345.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1757.94,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2019.94,155,,,Fee Schedule,155% of CMS OPPS Rate,1303.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,4028.2,155,,,Fee Schedule,155% of CMS OPPS Rate,4028.2,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1303.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1593.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1303.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,2581.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2581.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,1000,4028.2,
63045- Lamin/facetectomy/foraminotomy/cer,3435354,CDM,510,RC,63045,HCPCS,Outpatient,,,3445.56,1722.78,,3101,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2756.45,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3101,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3342.19,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3169.92,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3101,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2411.89,70,,,percent of total billed charges,70% of total billed charges,3101,90,,,percent of total billed charges,90% of total billed charges,3273.28,95,,,percent of total billed charges,95% of total billed charges,3273.28,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2963.18,86,,,percent of total billed charges,86% of total billed charges,2756.45,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3342.19,97,,,percent of total billed charges,97% of total billed charges,3101,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3342.19,97,,,percent of total billed charges,97% of total billed charges,3204.37,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3342.19,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2411.89,32247.16,
63046- Lamin/facetectomy/foraminotomy/tho,3435355,CDM,510,RC,63046,HCPCS,Outpatient,,,3275.85,1637.93,,2948.27,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2620.68,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2948.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3177.57,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3013.78,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2948.27,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2293.1,70,,,percent of total billed charges,70% of total billed charges,2948.27,90,,,percent of total billed charges,90% of total billed charges,3112.06,95,,,percent of total billed charges,95% of total billed charges,3112.06,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2817.23,86,,,percent of total billed charges,86% of total billed charges,2620.68,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3177.57,97,,,percent of total billed charges,97% of total billed charges,2948.27,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3177.57,97,,,percent of total billed charges,97% of total billed charges,3046.54,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3177.57,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2293.1,32247.16,
63047 - PF Lam Facetectomy & Foramotomy 1 Vrt Sgm Lumbar,4363327,CDM,960,RC,63047,HCPCS,Outpatient,,,2224.28,1112.14,,2001.85,90,,,percent of total billed charges,90% of total Billed charges,2215.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1110.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,951.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,1720.7,155,,,Fee Schedule,155% of CMS OPPS Rate,1110.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1579.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1110.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1776.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1776.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1694.15,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1694.15,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,1032.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1110.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2220.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1999.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1463.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1720.7,155,,,Fee Schedule,155% of CMS OPPS Rate,1110.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,3434.13,155,,,Fee Schedule,155% of CMS OPPS Rate,3434.13,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,1110.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,951.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1408.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1110.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2231.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,2231.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,951.59,3434.13,
63047- Laminectomy/lumbar,3435311,CDM,510,RC,63047,HCPCS,Outpatient,,,2939.76,1469.88,,2645.78,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2351.81,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2645.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2851.57,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2704.58,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2645.78,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.83,70,,,percent of total billed charges,70% of total billed charges,2645.78,90,,,percent of total billed charges,90% of total billed charges,2792.77,95,,,percent of total billed charges,95% of total billed charges,2792.77,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2528.19,86,,,percent of total billed charges,86% of total billed charges,2351.81,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2851.57,97,,,percent of total billed charges,97% of total billed charges,2645.78,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,2851.57,97,,,percent of total billed charges,97% of total billed charges,2733.98,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2851.57,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2057.83,32247.16,
63048 - PF Lam Facetectomy&Foramot 1 Vrt Sgm Ea Addl Sgm,4363328,CDM,960,RC,63048,HCPCS,Outpatient,,,428.22,214.11,,385.4,90,,,percent of total billed charges,90% of total Billed charges,427.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,213.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,194.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,330.89,155,,,Fee Schedule,155% of CMS OPPS Rate,213.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,213.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,341.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,332.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,332.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,206.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,426.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,392.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,295.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,330.89,155,,,Fee Schedule,155% of CMS OPPS Rate,213.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,662.08,155,,,Fee Schedule,155% of CMS OPPS Rate,662.08,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,213.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,194.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,345.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,213.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,438.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,438.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,194.01,662.08,
63048- Laminectomy/addl seg/cerv/thor/lum,3435356,CDM,510,RC,63048,HCPCS,Outpatient,,,568.24,284.12,,511.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,454.59,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,511.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,551.19,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,522.78,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,362.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,446.93,78.65,,,percent of total billed charges,78.65% of total billed charges,507.62,89.33,,,percent of total billed charges,89.33% of total billed charges,511.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,397.77,70,,,percent of total billed charges,70% of total billed charges,511.42,90,,,percent of total billed charges,90% of total billed charges,539.83,95,,,percent of total billed charges,95% of total billed charges,539.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,488.69,86,,,percent of total billed charges,86% of total billed charges,454.59,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,551.19,97,,,percent of total billed charges,97% of total billed charges,511.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,551.19,97,,,percent of total billed charges,97% of total billed charges,528.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.19,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,362.89,551.19,
63052- PF Lam Facetec/Foramot Drg Arthrd Lumbar 1 Vrt Sgm,4363329,CDM,960,RC,63052,HCPCS,Outpatient,,,524.72,262.36,,472.25,90,,,percent of total billed charges,90% of total Billed charges,524.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,262.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.77,155,,,Fee Schedule,155% of CMS OPPS Rate,262.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.42,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,524.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,406.77,155,,,Fee Schedule,155% of CMS OPPS Rate,262.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,813.35,155,,,Fee Schedule,155% of CMS OPPS Rate,813.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,262.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.42,813.35,
63053 - PF Lam Facetec/Foramot Drg Arthrd Lmbr Ea Addl Sgm,4363330,CDM,960,RC,63053,HCPCS,Outpatient,,,466.36,233.18,,419.72,90,,,percent of total billed charges,90% of total Billed charges,428.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,232.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.93,155,,,Fee Schedule,155% of CMS OPPS Rate,232.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.91,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,464.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.93,155,,,Fee Schedule,155% of CMS OPPS Rate,232.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,663.87,155,,,Fee Schedule,155% of CMS OPPS Rate,663.87,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,232.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.91,663.87,
63055- Decompress spinal cord/thoracic,3435357,CDM,510,RC,63055,HCPCS,Outpatient,,,4371.25,2185.63,,3934.13,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3497,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3934.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4240.11,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,4021.55,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3934.13,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3059.88,70,,,percent of total billed charges,70% of total billed charges,3934.13,90,,,percent of total billed charges,90% of total billed charges,4152.69,95,,,percent of total billed charges,95% of total billed charges,4152.69,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3759.28,86,,,percent of total billed charges,86% of total billed charges,3497,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4240.11,97,,,percent of total billed charges,97% of total billed charges,3934.13,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,4240.11,97,,,percent of total billed charges,97% of total billed charges,4065.26,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4240.11,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3059.88,32247.16,
63056- Decompress spinal cord/lumbar,3435358,CDM,510,RC,63056,HCPCS,Outpatient,,,3999.87,1999.94,,3599.88,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3199.9,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3599.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3879.87,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3679.88,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3599.88,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2799.91,70,,,percent of total billed charges,70% of total billed charges,3599.88,90,,,percent of total billed charges,90% of total billed charges,3799.88,95,,,percent of total billed charges,95% of total billed charges,3799.88,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3439.89,86,,,percent of total billed charges,86% of total billed charges,3199.9,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3879.87,97,,,percent of total billed charges,97% of total billed charges,3599.88,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3879.87,97,,,percent of total billed charges,97% of total billed charges,3719.88,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3879.87,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2799.91,32247.16,
63057- Decomp spinal cord/transped/ad seg,3435359,CDM,510,RC,63057,HCPCS,Outpatient,,,868.01,434.01,,781.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,694.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,781.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,841.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,798.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,554.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,682.71,78.65,,,percent of total billed charges,78.65% of total billed charges,775.41,89.33,,,percent of total billed charges,89.33% of total billed charges,781.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,607.61,70,,,percent of total billed charges,70% of total billed charges,781.21,90,,,percent of total billed charges,90% of total billed charges,824.61,95,,,percent of total billed charges,95% of total billed charges,824.61,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.49,86,,,percent of total billed charges,86% of total billed charges,694.41,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,841.97,97,,,percent of total billed charges,97% of total billed charges,781.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,841.97,97,,,percent of total billed charges,97% of total billed charges,807.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,841.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,554.33,841.97,
63075- Discectomy/ant/cerv/sng interspace,3435360,CDM,510,RC,63075,HCPCS,Outpatient,,,3633.73,1816.87,,3270.36,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2906.98,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3270.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3524.72,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3343.03,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3270.36,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2543.61,70,,,percent of total billed charges,70% of total billed charges,3270.36,90,,,percent of total billed charges,90% of total billed charges,3452.04,95,,,percent of total billed charges,95% of total billed charges,3452.04,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3125.01,86,,,percent of total billed charges,86% of total billed charges,2906.98,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3524.72,97,,,percent of total billed charges,97% of total billed charges,3270.36,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3524.72,97,,,percent of total billed charges,97% of total billed charges,3379.37,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3524.72,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2543.61,32247.16,
63076- Discectomy/ant/cerv/addl interspac,3435361,CDM,510,RC,63076,HCPCS,Outpatient,,,656.03,328.02,,590.43,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,524.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,590.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,603.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,418.96,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,515.98,78.65,,,percent of total billed charges,78.65% of total billed charges,586.04,89.33,,,percent of total billed charges,89.33% of total billed charges,590.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.22,70,,,percent of total billed charges,70% of total billed charges,590.43,90,,,percent of total billed charges,90% of total billed charges,623.23,95,,,percent of total billed charges,95% of total billed charges,623.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.19,86,,,percent of total billed charges,86% of total billed charges,524.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,636.35,97,,,percent of total billed charges,97% of total billed charges,590.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.35,97,,,percent of total billed charges,97% of total billed charges,610.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,636.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,418.96,636.35,
63081- Vertebral corpectomy/cervical,3435362,CDM,510,RC,63081,HCPCS,Outpatient,,,4713.31,2356.66,,4241.98,90,,,percent of total billed charges,90% of total Billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3770.65,80,,,Percent of total Billed charges,80% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4241.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4571.91,97,,,Percent of total billed charges,97% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4336.25,92,,,Percent of total billed charges,92% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4241.98,90,,,percent of total billed charges,90% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3299.32,70,,,percent of total billed charges,70% of total billed charges,4241.98,90,,,percent of total billed charges,90% of total billed charges,4477.64,95,,,percent of total billed charges,95% of total billed charges,4477.64,95,,,percent of total billed charges,95% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4053.45,86,,,percent of total billed charges,86% of total billed charges,3770.65,80,,,percent of total billed charges,80% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4571.91,97,,,percent of total billed charges,97% of total billed charges,4241.98,90,,,percent of total billed charges,90% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4571.91,97,,,percent of total billed charges,97% of total billed charges,4383.38,93,,,percent of total billed charges,93% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,4571.91,97,,,percent of total billed charges,97% of total billed charges,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4713.31,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3299.32,4713.31,
63082- Verteb resect/anterior/cerv/ad seg,3435363,CDM,510,RC,63082,HCPCS,Outpatient,,,714.96,357.48,,643.46,90,,,percent of total billed charges,90% of total Billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,571.97,80,,,Percent of total Billed charges,80% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,643.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,693.51,97,,,Percent of total billed charges,97% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,657.76,92,,,Percent of total billed charges,92% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,643.46,90,,,percent of total billed charges,90% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,500.47,70,,,percent of total billed charges,70% of total billed charges,643.46,90,,,percent of total billed charges,90% of total billed charges,679.21,95,,,percent of total billed charges,95% of total billed charges,679.21,95,,,percent of total billed charges,95% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,614.87,86,,,percent of total billed charges,86% of total billed charges,571.97,80,,,percent of total billed charges,80% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,693.51,97,,,percent of total billed charges,97% of total billed charges,643.46,90,,,percent of total billed charges,90% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,693.51,97,,,percent of total billed charges,97% of total billed charges,664.91,93,,,percent of total billed charges,93% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,693.51,97,,,percent of total billed charges,97% of total billed charges,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,714.96,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,500.47,714.96,
63085- Vertebral corpectomy/thoracic,3435364,CDM,510,RC,63085,HCPCS,Outpatient,,,5178.43,2589.22,,4660.59,90,,,percent of total billed charges,90% of total Billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4142.74,80,,,Percent of total Billed charges,80% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4660.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5023.08,97,,,Percent of total billed charges,97% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4764.16,92,,,Percent of total billed charges,92% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4660.59,90,,,percent of total billed charges,90% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3624.9,70,,,percent of total billed charges,70% of total billed charges,4660.59,90,,,percent of total billed charges,90% of total billed charges,4919.51,95,,,percent of total billed charges,95% of total billed charges,4919.51,95,,,percent of total billed charges,95% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4453.45,86,,,percent of total billed charges,86% of total billed charges,4142.74,80,,,percent of total billed charges,80% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5023.08,97,,,percent of total billed charges,97% of total billed charges,4660.59,90,,,percent of total billed charges,90% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5023.08,97,,,percent of total billed charges,97% of total billed charges,4815.94,93,,,percent of total billed charges,93% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5023.08,97,,,percent of total billed charges,97% of total billed charges,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5178.43,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3624.9,5178.43,
63086- Vertebral corpectomy/thoracic/addl,3435365,CDM,510,RC,63086,HCPCS,Outpatient,,,514.56,257.28,,463.1,90,,,percent of total billed charges,90% of total Billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,411.65,80,,,Percent of total Billed charges,80% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,463.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,499.12,97,,,Percent of total billed charges,97% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,473.4,92,,,Percent of total billed charges,92% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,463.1,90,,,percent of total billed charges,90% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,360.19,70,,,percent of total billed charges,70% of total billed charges,463.1,90,,,percent of total billed charges,90% of total billed charges,488.83,95,,,percent of total billed charges,95% of total billed charges,488.83,95,,,percent of total billed charges,95% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,442.52,86,,,percent of total billed charges,86% of total billed charges,411.65,80,,,percent of total billed charges,80% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,499.12,97,,,percent of total billed charges,97% of total billed charges,463.1,90,,,percent of total billed charges,90% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,499.12,97,,,percent of total billed charges,97% of total billed charges,478.54,93,,,percent of total billed charges,93% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,499.12,97,,,percent of total billed charges,97% of total billed charges,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,514.56,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,360.19,514.56,
63087- Verteb corpect/low thoracic/lumbar,3435366,CDM,510,RC,63087,HCPCS,Outpatient,,,6463.48,3231.74,,5817.13,90,,,percent of total billed charges,90% of total Billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5170.78,80,,,Percent of total Billed charges,80% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5817.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6269.58,97,,,Percent of total billed charges,97% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5946.4,92,,,Percent of total billed charges,92% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5817.13,90,,,percent of total billed charges,90% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4524.44,70,,,percent of total billed charges,70% of total billed charges,5817.13,90,,,percent of total billed charges,90% of total billed charges,6140.31,95,,,percent of total billed charges,95% of total billed charges,6140.31,95,,,percent of total billed charges,95% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5558.59,86,,,percent of total billed charges,86% of total billed charges,5170.78,80,,,percent of total billed charges,80% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6269.58,97,,,percent of total billed charges,97% of total billed charges,5817.13,90,,,percent of total billed charges,90% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6269.58,97,,,percent of total billed charges,97% of total billed charges,6011.04,93,,,percent of total billed charges,93% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,6269.58,97,,,percent of total billed charges,97% of total billed charges,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6463.48,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4524.44,6463.48,
63090- Verteb corpect/low thor/lumbar/sac,3435367,CDM,510,RC,63090,HCPCS,Outpatient,,,5246.19,2623.10,,4721.57,90,,,percent of total billed charges,90% of total Billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4196.95,80,,,Percent of total Billed charges,80% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4721.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5088.8,97,,,Percent of total billed charges,97% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4826.49,92,,,Percent of total billed charges,92% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4721.57,90,,,percent of total billed charges,90% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3672.33,70,,,percent of total billed charges,70% of total billed charges,4721.57,90,,,percent of total billed charges,90% of total billed charges,4983.88,95,,,percent of total billed charges,95% of total billed charges,4983.88,95,,,percent of total billed charges,95% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4511.72,86,,,percent of total billed charges,86% of total billed charges,4196.95,80,,,percent of total billed charges,80% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5088.8,97,,,percent of total billed charges,97% of total billed charges,4721.57,90,,,percent of total billed charges,90% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5088.8,97,,,percent of total billed charges,97% of total billed charges,4878.96,93,,,percent of total billed charges,93% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5088.8,97,,,percent of total billed charges,97% of total billed charges,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5246.19,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,3672.33,5246.19,
63091- Vertebral corpect/trans peri/addl,3435368,CDM,510,RC,63091,HCPCS,Outpatient,,,477.3,238.65,,429.57,90,,,percent of total billed charges,90% of total Billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,381.84,80,,,Percent of total Billed charges,80% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,429.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,462.98,97,,,Percent of total billed charges,97% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,439.12,92,,,Percent of total billed charges,92% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,429.57,90,,,percent of total billed charges,90% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,334.11,70,,,percent of total billed charges,70% of total billed charges,429.57,90,,,percent of total billed charges,90% of total billed charges,453.44,95,,,percent of total billed charges,95% of total billed charges,453.44,95,,,percent of total billed charges,95% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,410.48,86,,,percent of total billed charges,86% of total billed charges,381.84,80,,,percent of total billed charges,80% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,462.98,97,,,percent of total billed charges,97% of total billed charges,429.57,90,,,percent of total billed charges,90% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,462.98,97,,,percent of total billed charges,97% of total billed charges,443.89,93,,,percent of total billed charges,93% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,462.98,97,,,percent of total billed charges,97% of total billed charges,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,477.3,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,334.11,477.3,
"63199- Laminectomy w/cordotomy, thoracic",3435369,CDM,510,RC,63199,HCPCS,Outpatient,,,6285.11,3142.56,,5656.6,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5028.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5656.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6096.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5782.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,4013.81,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4943.38,78.65,,,percent of total billed charges,78.65% of total billed charges,5614.59,89.33,,,percent of total billed charges,89.33% of total billed charges,5656.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4399.58,70,,,percent of total billed charges,70% of total billed charges,5656.6,90,,,percent of total billed charges,90% of total billed charges,5970.85,95,,,percent of total billed charges,95% of total billed charges,5970.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5405.19,86,,,percent of total billed charges,86% of total billed charges,5028.09,80,,,percent of total billed charges,80% of total billed charges,6285.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,6096.56,97,,,percent of total billed charges,97% of total billed charges,5656.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6096.56,97,,,percent of total billed charges,97% of total billed charges,5845.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6096.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4013.81,6285.11,
63267- Laminectomy/AV malformation/lumbar,3435370,CDM,510,RC,63267,HCPCS,Outpatient,,,3675.75,1837.88,,3308.18,90,,,percent of total billed charges,90% of total Billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2940.6,80,,,Percent of total Billed charges,80% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3308.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3565.48,97,,,Percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,3381.69,92,,,Percent of total billed charges,92% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15969.46,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25458.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32247.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3308.18,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2573.03,70,,,percent of total billed charges,70% of total billed charges,3308.18,90,,,percent of total billed charges,90% of total billed charges,3491.96,95,,,percent of total billed charges,95% of total billed charges,3491.96,95,,,percent of total billed charges,95% of total billed charges,6007.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12015.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3161.15,86,,,percent of total billed charges,86% of total billed charges,2940.6,80,,,percent of total billed charges,80% of total billed charges,6184.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3565.48,97,,,percent of total billed charges,97% of total billed charges,3308.18,90,,,percent of total billed charges,90% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,3565.48,97,,,percent of total billed charges,97% of total billed charges,3418.45,93,,,percent of total billed charges,93% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3565.48,97,,,percent of total billed charges,97% of total billed charges,6007.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,6007.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5106.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2573.03,32247.16,
63301- Vertebral corpect/extradural/thor,3435371,CDM,510,RC,63301,HCPCS,Outpatient,,,5969.74,2984.87,,5372.77,90,,,percent of total billed charges,90% of total Billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4775.79,80,,,Percent of total Billed charges,80% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5372.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5790.65,97,,,Percent of total billed charges,97% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5492.16,92,,,Percent of total billed charges,92% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5372.77,90,,,percent of total billed charges,90% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4178.82,70,,,percent of total billed charges,70% of total billed charges,5372.77,90,,,percent of total billed charges,90% of total billed charges,5671.25,95,,,percent of total billed charges,95% of total billed charges,5671.25,95,,,percent of total billed charges,95% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5133.98,86,,,percent of total billed charges,86% of total billed charges,4775.79,80,,,percent of total billed charges,80% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5790.65,97,,,percent of total billed charges,97% of total billed charges,5372.77,90,,,percent of total billed charges,90% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5790.65,97,,,percent of total billed charges,97% of total billed charges,5551.86,93,,,percent of total billed charges,93% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,5790.65,97,,,percent of total billed charges,97% of total billed charges,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,5969.74,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,4178.82,5969.74,
63308- Verteb corpect/ intraspin les/addl,3435372,CDM,510,RC,63308,HCPCS,Outpatient,,,861.54,430.77,,775.39,90,,,percent of total billed charges,90% of total Billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,689.23,80,,,Percent of total Billed charges,80% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,775.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,835.69,97,,,Percent of total billed charges,97% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,792.62,92,,,Percent of total billed charges,92% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,775.39,90,,,percent of total billed charges,90% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,603.08,70,,,percent of total billed charges,70% of total billed charges,775.39,90,,,percent of total billed charges,90% of total billed charges,818.46,95,,,percent of total billed charges,95% of total billed charges,818.46,95,,,percent of total billed charges,95% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,740.92,86,,,percent of total billed charges,86% of total billed charges,689.23,80,,,percent of total billed charges,80% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,835.69,97,,,percent of total billed charges,97% of total billed charges,775.39,90,,,percent of total billed charges,90% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,835.69,97,,,percent of total billed charges,97% of total billed charges,801.23,93,,,percent of total billed charges,93% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,835.69,97,,,percent of total billed charges,97% of total billed charges,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,861.54,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,603.08,861.54,
63650- Implant neurostim electrode/epidur,3435373,CDM,510,RC,63650,HCPCS,Outpatient,,,5707.03,2853.52,,5136.33,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4565.62,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5136.33,90,,,Percent of total Billed charges,90% of total billed charges,410.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5535.82,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5250.47,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5136.33,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,3994.92,70,,,percent of total billed charges,70% of total billed charges,5136.33,90,,,percent of total billed charges,90% of total billed charges,5421.68,95,,,percent of total billed charges,95% of total billed charges,5421.68,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4908.05,86,,,percent of total billed charges,86% of total billed charges,4565.62,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5535.82,97,,,percent of total billed charges,97% of total billed charges,5136.33,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5535.82,97,,,percent of total billed charges,97% of total billed charges,5307.54,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5535.82,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,372.95,32194.6,
63655- Laminect/implt neurostim elec/epid,3435374,CDM,510,RC,63655,HCPCS,Outpatient,,,2221.65,1110.83,,1999.49,90,,,percent of total billed charges,90% of total Billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1777.32,80,,,Percent of total Billed charges,80% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,1999.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2155,97,,,Percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,2043.92,92,,,Percent of total billed charges,92% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,51943.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82809.03,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,104890.11,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1999.49,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.16,70,,,percent of total billed charges,70% of total billed charges,1999.49,90,,,percent of total billed charges,90% of total billed charges,2110.57,95,,,percent of total billed charges,95% of total billed charges,2110.57,95,,,percent of total billed charges,95% of total billed charges,19541.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39083.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1910.62,86,,,percent of total billed charges,86% of total billed charges,1777.32,80,,,percent of total billed charges,80% of total billed charges,19932.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2155,97,,,percent of total billed charges,97% of total billed charges,1999.49,90,,,percent of total billed charges,90% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,2155,97,,,percent of total billed charges,97% of total billed charges,2066.13,93,,,percent of total billed charges,93% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2155,97,,,percent of total billed charges,97% of total billed charges,19541.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,19541.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,16610.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1555.16,104890.11,
63661- Remove spinal neurostim electrode,3435312,CDM,510,RC,63661,HCPCS,Outpatient,,,1722.71,861.36,,1550.44,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1378.17,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1550.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1671.03,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1584.89,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.13,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1550.44,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.9,70,,,percent of total billed charges,70% of total billed charges,1550.44,90,,,percent of total billed charges,90% of total billed charges,1636.57,95,,,percent of total billed charges,95% of total billed charges,1636.57,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1481.53,86,,,percent of total billed charges,86% of total billed charges,1378.17,80,,,percent of total billed charges,80% of total billed charges,1777.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1671.03,97,,,percent of total billed charges,97% of total billed charges,1550.44,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1671.03,97,,,percent of total billed charges,97% of total billed charges,1602.12,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1671.03,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1205.9,8763.13,
63662- Rmv spinal neurostim/plate/paddle,3435375,CDM,510,RC,63662,HCPCS,Outpatient,,,2250.14,1125.07,,2025.13,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1800.11,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2025.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2182.64,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2070.13,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2025.13,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,1575.1,70,,,percent of total billed charges,70% of total billed charges,2025.13,90,,,percent of total billed charges,90% of total billed charges,2137.63,95,,,percent of total billed charges,95% of total billed charges,2137.63,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1935.12,86,,,percent of total billed charges,86% of total billed charges,1800.11,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2182.64,97,,,percent of total billed charges,97% of total billed charges,2025.13,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2182.64,97,,,percent of total billed charges,97% of total billed charges,2092.63,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2182.64,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1575.1,15832.85,
63663- Revise spinal neurostim electrode,3435376,CDM,510,RC,63663,HCPCS,Outpatient,,,2271.92,1135.96,,2044.73,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1817.54,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2044.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2203.76,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,2090.17,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2044.73,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1590.34,70,,,percent of total billed charges,70% of total billed charges,2044.73,90,,,percent of total billed charges,90% of total billed charges,2158.32,95,,,percent of total billed charges,95% of total billed charges,2158.32,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1953.85,86,,,percent of total billed charges,86% of total billed charges,1817.54,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2203.76,97,,,percent of total billed charges,97% of total billed charges,2044.73,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,2203.76,97,,,percent of total billed charges,97% of total billed charges,2112.89,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2203.76,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1590.34,32194.6,
63664- Revise/spinal neurostim plate/pad,3435377,CDM,510,RC,63664,HCPCS,Outpatient,,,2343.74,1171.87,,2109.37,90,,,percent of total billed charges,90% of total Billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1874.99,80,,,Percent of total Billed charges,80% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,2109.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2273.43,97,,,Percent of total billed charges,97% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate,2156.24,92,,,Percent of total billed charges,92% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate,28856.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,10856.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46003.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,58270.39,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2109.37,90,,,percent of total billed charges,90% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate,1640.62,70,,,percent of total billed charges,70% of total billed charges,2109.37,90,,,percent of total billed charges,90% of total billed charges,2226.55,95,,,percent of total billed charges,95% of total billed charges,2226.55,95,,,percent of total billed charges,95% of total billed charges,10856.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21712.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2015.62,86,,,percent of total billed charges,86% of total billed charges,1874.99,80,,,percent of total billed charges,80% of total billed charges,19932.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2273.43,97,,,percent of total billed charges,97% of total billed charges,2109.37,90,,,percent of total billed charges,90% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,2273.43,97,,,percent of total billed charges,97% of total billed charges,2179.68,93,,,percent of total billed charges,93% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2273.43,97,,,percent of total billed charges,97% of total billed charges,10856.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,10856.06,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,9227.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1640.62,58270.39,
63685- Ins/rplcmt spi npgr pocket,3435378,CDM,510,RC,63685,HCPCS,Outpatient,,,947.6,473.80,,852.84,90,,,percent of total billed charges,90% of total Billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate,758.08,80,,,Percent of total Billed charges,80% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,852.84,90,,,Percent of total Billed charges,90% of total billed charges,331.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,919.17,97,,,Percent of total billed charges,97% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate,871.79,92,,,Percent of total billed charges,92% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate,70879.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26665.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112995.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,143126.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,852.84,90,,,percent of total billed charges,90% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate,663.32,70,,,percent of total billed charges,70% of total billed charges,852.84,90,,,percent of total billed charges,90% of total billed charges,900.22,95,,,percent of total billed charges,95% of total billed charges,900.22,95,,,percent of total billed charges,95% of total billed charges,26665.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53330.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,814.94,86,,,percent of total billed charges,86% of total billed charges,758.08,80,,,percent of total billed charges,80% of total billed charges,30105.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,919.17,97,,,percent of total billed charges,97% of total billed charges,852.84,90,,,percent of total billed charges,90% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,919.17,97,,,percent of total billed charges,97% of total billed charges,881.27,93,,,percent of total billed charges,93% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,301,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,919.17,97,,,percent of total billed charges,97% of total billed charges,26665.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,26665.13,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22665.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301,143126.32,
63688- Rev/rmv imp spi npgr dtch cn,3435379,CDM,510,RC,63688,HCPCS,Outpatient,,,976.5,488.25,,878.85,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,781.2,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,878.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,947.21,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,898.38,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,878.85,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,683.55,70,,,percent of total billed charges,70% of total billed charges,878.85,90,,,percent of total billed charges,90% of total billed charges,927.68,95,,,percent of total billed charges,95% of total billed charges,927.68,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,839.79,86,,,percent of total billed charges,86% of total billed charges,781.2,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,947.21,97,,,percent of total billed charges,97% of total billed charges,878.85,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,947.21,97,,,percent of total billed charges,97% of total billed charges,908.15,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,947.21,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,683.55,15832.85,
63709- Rpr/dural/CSF leak/laminectomy,3435380,CDM,510,RC,63709,HCPCS,Outpatient,,,2977.93,1488.97,,2680.14,90,,,percent of total billed charges,90% of total Billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2382.34,80,,,Percent of total Billed charges,80% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2680.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2888.59,97,,,Percent of total billed charges,97% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2739.7,92,,,Percent of total billed charges,92% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2680.14,90,,,percent of total billed charges,90% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2084.55,70,,,percent of total billed charges,70% of total billed charges,2680.14,90,,,percent of total billed charges,90% of total billed charges,2829.03,95,,,percent of total billed charges,95% of total billed charges,2829.03,95,,,percent of total billed charges,95% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2561.02,86,,,percent of total billed charges,86% of total billed charges,2382.34,80,,,percent of total billed charges,80% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2888.59,97,,,percent of total billed charges,97% of total billed charges,2680.14,90,,,percent of total billed charges,90% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2888.59,97,,,percent of total billed charges,97% of total billed charges,2769.47,93,,,percent of total billed charges,93% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2888.59,97,,,percent of total billed charges,97% of total billed charges,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2977.93,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2084.55,2977.93,
63710- Dural graft/spinal,3435381,CDM,510,RC,63710,HCPCS,Outpatient,,,2885.11,1442.56,,2596.6,90,,,percent of total billed charges,90% of total Billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2308.09,80,,,Percent of total Billed charges,80% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2596.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2798.56,97,,,Percent of total billed charges,97% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2654.3,92,,,Percent of total billed charges,92% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2596.6,90,,,percent of total billed charges,90% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2019.58,70,,,percent of total billed charges,70% of total billed charges,2596.6,90,,,percent of total billed charges,90% of total billed charges,2740.85,95,,,percent of total billed charges,95% of total billed charges,2740.85,95,,,percent of total billed charges,95% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2481.19,86,,,percent of total billed charges,86% of total billed charges,2308.09,80,,,percent of total billed charges,80% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2798.56,97,,,percent of total billed charges,97% of total billed charges,2596.6,90,,,percent of total billed charges,90% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2798.56,97,,,percent of total billed charges,97% of total billed charges,2683.15,93,,,percent of total billed charges,93% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,2798.56,97,,,percent of total billed charges,97% of total billed charges,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2885.11,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,2019.58,2885.11,
64400- Inj/anest/trigeminal nerve,3435382,CDM,510,RC,64400,HCPCS,Outpatient,,,283.75,141.88,,255.38,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,227,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.38,90,,,Percent of total Billed charges,90% of total billed charges,14.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,275.24,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,261.05,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,255.38,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,198.63,70,,,percent of total billed charges,70% of total billed charges,255.38,90,,,percent of total billed charges,90% of total billed charges,269.56,95,,,percent of total billed charges,95% of total billed charges,269.56,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,244.03,86,,,percent of total billed charges,86% of total billed charges,227,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,275.24,97,,,percent of total billed charges,97% of total billed charges,255.38,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.24,97,,,percent of total billed charges,97% of total billed charges,263.89,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,275.24,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13,1325.49,
64402- Inj/anest/facial nerve,3435383,CDM,510,RC,64402,HCPCS,Outpatient,,,384.64,192.32,,346.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,307.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,346.18,90,,,Percent of total Billed charges,90% of total billed charges,14.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,373.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,353.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,245.64,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,302.53,78.65,,,percent of total billed charges,78.65% of total billed charges,343.61,89.33,,,percent of total billed charges,89.33% of total billed charges,346.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,269.25,70,,,percent of total billed charges,70% of total billed charges,346.18,90,,,percent of total billed charges,90% of total billed charges,365.41,95,,,percent of total billed charges,95% of total billed charges,365.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.79,86,,,percent of total billed charges,86% of total billed charges,307.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,373.1,97,,,percent of total billed charges,97% of total billed charges,346.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,373.1,97,,,percent of total billed charges,97% of total billed charges,357.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,373.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13,373.1,
64418- Inj/anest/suprascapular nerve,3435385,CDM,510,RC,64418,HCPCS,Outpatient,,,225.01,112.51,,202.51,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,180.01,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.51,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.26,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,207.01,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,202.51,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,157.51,70,,,percent of total billed charges,70% of total billed charges,202.51,90,,,percent of total billed charges,90% of total billed charges,213.76,95,,,percent of total billed charges,95% of total billed charges,213.76,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,193.51,86,,,percent of total billed charges,86% of total billed charges,180.01,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.26,97,,,percent of total billed charges,97% of total billed charges,202.51,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.26,97,,,percent of total billed charges,97% of total billed charges,209.26,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.26,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,3141.23,
64420 N block inj intercost sng,3428325,CDM,983,RC,64420,HCPCS,Outpatient,,,246.55,123.28,,221.9,90,,,percent of total billed charges,90% of total Billed charges,149.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.21,155,,,Fee Schedule,155% of CMS OPPS Rate,56.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,90.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,90.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,60.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,67.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.21,155,,,Fee Schedule,155% of CMS OPPS Rate,56.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.9,155,,,Fee Schedule,155% of CMS OPPS Rate,231.9,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,56.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,56.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,224.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.5,266.3,
64421- Inj/anesth/intercostal nerves/mult,3435386,CDM,510,RC,64421,HCPCS,Outpatient,,,85.47,42.74,,76.92,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,68.38,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.92,90,,,Percent of total Billed charges,90% of total billed charges,47.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,82.91,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,78.63,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,76.92,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,59.83,70,,,percent of total billed charges,70% of total billed charges,76.92,90,,,percent of total billed charges,90% of total billed charges,81.2,95,,,percent of total billed charges,95% of total billed charges,81.2,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,73.5,86,,,percent of total billed charges,86% of total billed charges,68.38,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,82.91,97,,,percent of total billed charges,97% of total billed charges,76.92,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.91,97,,,percent of total billed charges,97% of total billed charges,79.49,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.91,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.5,4154.47,
64430- Pudendal nerve block,3435388,CDM,510,RC,64430,HCPCS,Outpatient,,,248.64,124.32,,223.78,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,198.91,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.78,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,241.18,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,228.75,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,223.78,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,174.05,70,,,percent of total billed charges,70% of total billed charges,223.78,90,,,percent of total billed charges,90% of total billed charges,236.21,95,,,percent of total billed charges,95% of total billed charges,236.21,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,213.83,86,,,percent of total billed charges,86% of total billed charges,198.91,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,241.18,97,,,percent of total billed charges,97% of total billed charges,223.78,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.18,97,,,percent of total billed charges,97% of total billed charges,231.24,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,241.18,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,4154.47,
64435- Inj/anest/paracervical nerve,3435389,CDM,510,RC,64435,HCPCS,Outpatient,,,204.32,102.16,,183.89,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,163.46,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.89,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,198.19,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,187.97,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,183.89,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,143.02,70,,,percent of total billed charges,70% of total billed charges,183.89,90,,,percent of total billed charges,90% of total billed charges,194.1,95,,,percent of total billed charges,95% of total billed charges,194.1,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,175.72,86,,,percent of total billed charges,86% of total billed charges,163.46,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,198.19,97,,,percent of total billed charges,97% of total billed charges,183.89,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.19,97,,,percent of total billed charges,97% of total billed charges,190.02,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.19,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,3141.23,
64445 N block inj sciatic sng,3428326,CDM,983,RC,64445,HCPCS,Outpatient,,,313.09,156.55,,281.78,90,,,percent of total billed charges,90% of total Billed charges,189.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,111.86,155,,,Fee Schedule,155% of CMS OPPS Rate,72.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,60.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,111.86,155,,,Fee Schedule,155% of CMS OPPS Rate,72.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,294.35,155,,,Fee Schedule,155% of CMS OPPS Rate,294.35,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,152.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,267.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.5,294.35,
64449- Inj/anesth/lumbar plex/cont infuse,3435390,CDM,510,RC,64449,HCPCS,Outpatient,,,162.17,81.09,,145.95,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.3,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,149.2,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.95,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,113.52,70,,,percent of total billed charges,70% of total billed charges,145.95,90,,,percent of total billed charges,90% of total billed charges,154.06,95,,,percent of total billed charges,95% of total billed charges,154.06,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,139.47,86,,,percent of total billed charges,86% of total billed charges,129.74,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,157.3,97,,,percent of total billed charges,97% of total billed charges,145.95,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.3,97,,,percent of total billed charges,97% of total billed charges,150.82,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,157.3,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.52,4154.47,
64455- Inj/plantar common digital nerve,3435392,CDM,510,RC,64455,HCPCS,Outpatient,,,128.08,64.04,,115.27,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,102.46,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,124.24,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,117.83,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,115.27,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,89.66,70,,,percent of total billed charges,70% of total billed charges,115.27,90,,,percent of total billed charges,90% of total billed charges,121.68,95,,,percent of total billed charges,95% of total billed charges,121.68,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,110.15,86,,,percent of total billed charges,86% of total billed charges,102.46,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,124.24,97,,,percent of total billed charges,97% of total billed charges,115.27,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.24,97,,,percent of total billed charges,97% of total billed charges,119.11,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,124.24,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.66,1325.49,
64479- Epidural/cervical/thoracic w/image,3435393,CDM,510,RC,64479,HCPCS,Outpatient,,,668.5,334.25,,601.65,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,534.8,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,601.65,90,,,Percent of total Billed charges,90% of total billed charges,118.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,648.45,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,615.02,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,601.65,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,467.95,70,,,percent of total billed charges,70% of total billed charges,601.65,90,,,percent of total billed charges,90% of total billed charges,635.08,95,,,percent of total billed charges,95% of total billed charges,635.08,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,574.91,86,,,percent of total billed charges,86% of total billed charges,534.8,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,648.45,97,,,percent of total billed charges,97% of total billed charges,601.65,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,648.45,97,,,percent of total billed charges,97% of total billed charges,621.71,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,648.45,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,107.77,4154.47,
64480- Transforamin epi/cer/thor/ad level,3435394,CDM,510,RC,64480,HCPCS,Outpatient,,,339.71,169.86,,305.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,271.77,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,305.74,90,,,Percent of total Billed charges,90% of total billed charges,77.37,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,329.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,312.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,216.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,267.19,78.65,,,percent of total billed charges,78.65% of total billed charges,303.47,89.33,,,percent of total billed charges,89.33% of total billed charges,305.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.8,70,,,percent of total billed charges,70% of total billed charges,305.74,90,,,percent of total billed charges,90% of total billed charges,322.72,95,,,percent of total billed charges,95% of total billed charges,322.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.15,86,,,percent of total billed charges,86% of total billed charges,271.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,329.52,97,,,percent of total billed charges,97% of total billed charges,305.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,329.52,97,,,percent of total billed charges,97% of total billed charges,315.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,329.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.34,329.52,
64483- Inj/anes/steroid/lumbar/sacral/sng,3435313,CDM,360,RC,64483,HCPCS,Outpatient,,,618.25,309.13,,556.43,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,494.6,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.43,90,,,Percent of total Billed charges,90% of total billed charges,104.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,599.7,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,568.79,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,556.43,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,432.78,70,,,percent of total billed charges,70% of total billed charges,556.43,90,,,percent of total billed charges,90% of total billed charges,587.34,95,,,percent of total billed charges,95% of total billed charges,587.34,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,531.7,86,,,percent of total billed charges,86% of total billed charges,494.6,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,599.7,97,,,percent of total billed charges,97% of total billed charges,556.43,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,599.7,97,,,percent of total billed charges,97% of total billed charges,574.97,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,599.7,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,95.04,4154.47,
64484- Epidural/lumbar/sacral/ea add leve,3435395,CDM,360,RC,64484,HCPCS,Outpatient,,,282.29,141.15,,254.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,225.83,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,254.06,90,,,Percent of total Billed charges,90% of total billed charges,65.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,273.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,259.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,180.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,222.03,78.65,,,percent of total billed charges,78.65% of total billed charges,252.17,89.33,,,percent of total billed charges,89.33% of total billed charges,254.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,197.6,70,,,percent of total billed charges,70% of total billed charges,254.06,90,,,percent of total billed charges,90% of total billed charges,268.18,95,,,percent of total billed charges,95% of total billed charges,268.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.77,86,,,percent of total billed charges,86% of total billed charges,225.83,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,273.82,97,,,percent of total billed charges,97% of total billed charges,254.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,273.82,97,,,percent of total billed charges,97% of total billed charges,262.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.6,273.82,
64490- Inj/PV facet joint/cerv/thor/1 lev,3435396,CDM,360,RC,64490,HCPCS,Outpatient,,,480.12,240.06,,432.11,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,384.1,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,465.72,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,441.71,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,432.11,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,336.08,70,,,percent of total billed charges,70% of total billed charges,432.11,90,,,percent of total billed charges,90% of total billed charges,456.11,95,,,percent of total billed charges,95% of total billed charges,456.11,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,412.9,86,,,percent of total billed charges,86% of total billed charges,384.1,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,465.72,97,,,percent of total billed charges,97% of total billed charges,432.11,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,465.72,97,,,percent of total billed charges,97% of total billed charges,446.51,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,465.72,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,336.08,4154.47,
64491- Inj/PV facet joint/cerv/thor/2 lev,3435397,CDM,360,RC,64491,HCPCS,Outpatient,,,245.22,122.61,,220.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,196.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,220.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,225.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,156.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,192.87,78.65,,,percent of total billed charges,78.65% of total billed charges,219.06,89.33,,,percent of total billed charges,89.33% of total billed charges,220.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,171.65,70,,,percent of total billed charges,70% of total billed charges,220.7,90,,,percent of total billed charges,90% of total billed charges,232.96,95,,,percent of total billed charges,95% of total billed charges,232.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.89,86,,,percent of total billed charges,86% of total billed charges,196.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,237.86,97,,,percent of total billed charges,97% of total billed charges,220.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.86,97,,,percent of total billed charges,97% of total billed charges,228.05,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156.6,237.86,
64492- Inj/PV facet joint/cerv/thor/3 lev,3435398,CDM,360,RC,64492,HCPCS,Outpatient,,,246.02,123.01,,221.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,196.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,221.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,238.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,226.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,157.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,193.5,78.65,,,percent of total billed charges,78.65% of total billed charges,219.77,89.33,,,percent of total billed charges,89.33% of total billed charges,221.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,172.21,70,,,percent of total billed charges,70% of total billed charges,221.42,90,,,percent of total billed charges,90% of total billed charges,233.72,95,,,percent of total billed charges,95% of total billed charges,233.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.58,86,,,percent of total billed charges,86% of total billed charges,196.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,238.64,97,,,percent of total billed charges,97% of total billed charges,221.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,238.64,97,,,percent of total billed charges,97% of total billed charges,228.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.11,238.64,
64493- Inj/paravert facet/lumb/sacr/1 lev,3435399,CDM,360,RC,64493,HCPCS,Outpatient,,,436.42,218.21,,392.78,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,349.14,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,392.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,423.33,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,401.51,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,392.78,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,305.49,70,,,percent of total billed charges,70% of total billed charges,392.78,90,,,percent of total billed charges,90% of total billed charges,414.6,95,,,percent of total billed charges,95% of total billed charges,414.6,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,375.32,86,,,percent of total billed charges,86% of total billed charges,349.14,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,423.33,97,,,percent of total billed charges,97% of total billed charges,392.78,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,423.33,97,,,percent of total billed charges,97% of total billed charges,405.87,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,423.33,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,305.49,4154.47,
64494- Inj/paravert facet/lumb/sacr/2 lev,3435400,CDM,360,RC,64494,HCPCS,Outpatient,,,229.39,114.70,,206.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,183.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,206.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,222.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,146.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,180.42,78.65,,,percent of total billed charges,78.65% of total billed charges,204.92,89.33,,,percent of total billed charges,89.33% of total billed charges,206.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,160.57,70,,,percent of total billed charges,70% of total billed charges,206.45,90,,,percent of total billed charges,90% of total billed charges,217.92,95,,,percent of total billed charges,95% of total billed charges,217.92,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.28,86,,,percent of total billed charges,86% of total billed charges,183.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.51,97,,,percent of total billed charges,97% of total billed charges,206.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,222.51,97,,,percent of total billed charges,97% of total billed charges,213.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.49,222.51,
64495- Inj/paravert facet/lumb/sacr/3 lev,3435401,CDM,360,RC,64495,HCPCS,Outpatient,,,228.6,114.30,,205.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,182.88,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,205.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,221.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,210.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,145.99,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,179.8,78.65,,,percent of total billed charges,78.65% of total billed charges,204.21,89.33,,,percent of total billed charges,89.33% of total billed charges,205.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,160.02,70,,,percent of total billed charges,70% of total billed charges,205.74,90,,,percent of total billed charges,90% of total billed charges,217.17,95,,,percent of total billed charges,95% of total billed charges,217.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.6,86,,,percent of total billed charges,86% of total billed charges,182.88,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,221.74,97,,,percent of total billed charges,97% of total billed charges,205.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,221.74,97,,,percent of total billed charges,97% of total billed charges,212.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.99,221.74,
64505- Inj/anest/sphenopalatine ganglion,3435402,CDM,510,RC,64505,HCPCS,Outpatient,,,364,182.00,,327.6,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,291.2,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.6,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.08,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,334.88,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.6,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,254.8,70,,,percent of total billed charges,70% of total billed charges,327.6,90,,,percent of total billed charges,90% of total billed charges,345.8,95,,,percent of total billed charges,95% of total billed charges,345.8,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.04,86,,,percent of total billed charges,86% of total billed charges,291.2,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.08,97,,,percent of total billed charges,97% of total billed charges,327.6,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.08,97,,,percent of total billed charges,97% of total billed charges,338.52,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.08,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,1325.49,
64510- Inj/anest/stellate ganglion,3435403,CDM,510,RC,64510,HCPCS,Outpatient,,,366.83,183.42,,330.15,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,293.46,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,330.15,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,355.83,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,337.48,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,330.15,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,256.78,70,,,percent of total billed charges,70% of total billed charges,330.15,90,,,percent of total billed charges,90% of total billed charges,348.49,95,,,percent of total billed charges,95% of total billed charges,348.49,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,315.47,86,,,percent of total billed charges,86% of total billed charges,293.46,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,355.83,97,,,percent of total billed charges,97% of total billed charges,330.15,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.83,97,,,percent of total billed charges,97% of total billed charges,341.15,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,355.83,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,4154.47,
64561(50) Percutaneous neurostimulator,3623710,CDM,510,RC,64561,HCPCS,Outpatient,,,706.19,353.10,,635.57,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,564.95,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,635.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,685,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,649.69,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,635.57,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,494.33,70,,,percent of total billed charges,70% of total billed charges,635.57,90,,,percent of total billed charges,90% of total billed charges,670.88,95,,,percent of total billed charges,95% of total billed charges,670.88,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,607.32,86,,,percent of total billed charges,86% of total billed charges,564.95,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,685,97,,,percent of total billed charges,97% of total billed charges,635.57,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,685,97,,,percent of total billed charges,97% of total billed charges,656.76,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,685,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,494.33,32194.6,
Clinic PNE,3550634,CDM,510,RC,64561,HCPCS,Outpatient,,,32716.57,16358.29,,29444.91,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,26173.26,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,29444.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31735.07,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,30099.24,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,29444.91,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22901.6,70,,,percent of total billed charges,70% of total billed charges,29444.91,90,,,percent of total billed charges,90% of total billed charges,31080.74,95,,,percent of total billed charges,95% of total billed charges,31080.74,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28136.25,86,,,percent of total billed charges,86% of total billed charges,26173.26,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31735.07,97,,,percent of total billed charges,97% of total billed charges,29444.91,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31735.07,97,,,percent of total billed charges,97% of total billed charges,30426.41,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31735.07,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5098.3,32194.6,
64566- Post tib/neurostim/needle electrod,3435404,CDM,510,RC,64566,HCPCS,Outpatient,,,293.34,146.67,,264.01,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,234.67,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,284.54,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,269.87,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,264.01,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,205.34,70,,,percent of total billed charges,70% of total billed charges,264.01,90,,,percent of total billed charges,90% of total billed charges,278.67,95,,,percent of total billed charges,95% of total billed charges,278.67,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,252.27,86,,,percent of total billed charges,86% of total billed charges,234.67,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,284.54,97,,,percent of total billed charges,97% of total billed charges,264.01,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.54,97,,,percent of total billed charges,97% of total billed charges,272.81,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,284.54,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,205.34,1325.49,
"64568 - Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array",3572814,CDM,960,RC,64568,HCPCS,Outpatient,,,1615.07,807.54,,1453.56,90,,,percent of total billed charges,90% of total Billed charges,1199.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,592.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917.86,155,,,Fee Schedule,155% of CMS OPPS Rate,592.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,778.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,592.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,956.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,956.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,678.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,592.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1184.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1128.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,809.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,917.86,155,,,Fee Schedule,155% of CMS OPPS Rate,592.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1859.19,155,,,Fee Schedule,155% of CMS OPPS Rate,1859.19,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,592.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,683.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,592.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1284.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1284.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,592.17,1859.19,
64569 - Revise/Replcmt Neurostimulato Elctrd Cranial NRV,3899070,CDM,983,RC,64569,HCPCS,Outpatient,,,2055.51,1027.76,,1849.96,90,,,percent of total billed charges,90% of total Billed charges,1548.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,775.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1201.93,155,,,Fee Schedule,155% of CMS OPPS Rate,775.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,944.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,775.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1062.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1062.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1169.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1169.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,669.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,775.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1550.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1380.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,1020.63,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,1201.93,155,,,Fee Schedule,155% of CMS OPPS Rate,775.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,2399.97,155,,,Fee Schedule,155% of CMS OPPS Rate,2399.97,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,775.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,687.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,775.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,1268.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1268.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,669.36,2399.97,
64600- Destruct/trigem nerv/inf alveolar,3435408,CDM,510,RC,64600,HCPCS,Outpatient,,,1166.52,583.26,,1049.87,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,933.22,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.87,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1131.52,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,1073.2,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1049.87,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,816.56,70,,,percent of total billed charges,70% of total billed charges,1049.87,90,,,percent of total billed charges,90% of total billed charges,1108.19,95,,,percent of total billed charges,95% of total billed charges,1108.19,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1003.21,86,,,percent of total billed charges,86% of total billed charges,933.22,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1131.52,97,,,percent of total billed charges,97% of total billed charges,1049.87,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,1131.52,97,,,percent of total billed charges,97% of total billed charges,1084.86,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1131.52,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,4154.47,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,510,RC,64612,HCPCS,Outpatient,,,1734.39,867.20,,1560.95,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1387.51,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1682.36,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1595.64,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1560.95,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.07,70,,,percent of total billed charges,70% of total billed charges,1560.95,90,,,percent of total billed charges,90% of total billed charges,1647.67,95,,,percent of total billed charges,95% of total billed charges,1647.67,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1491.58,86,,,percent of total billed charges,86% of total billed charges,1387.51,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1682.36,97,,,percent of total billed charges,97% of total billed charges,1560.95,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1682.36,97,,,percent of total billed charges,97% of total billed charges,1612.98,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1682.36,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,209.89,1682.36,
64612-OCC Chemodenerv/facial nerv musc/uni,3536974,CDM,983,RC,64612,HCPCS,Outpatient,,,1734.39,867.20,,1560.95,90,,,percent of total billed charges,90% of total Billed charges,243.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,172.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,172.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,202.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,134.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,176.45,155,,,Fee Schedule,155% of CMS OPPS Rate,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,377.77,155,,,Fee Schedule,155% of CMS OPPS Rate,377.77,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,113.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,351.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.84,1560.95,
64615- Chemodenerv/fac/trigem/cerv spine,3435412,CDM,510,RC,64615,HCPCS,Outpatient,,,405.4,202.70,,364.86,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,324.32,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,364.86,90,,,Percent of total Billed charges,90% of total billed charges,112.74,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,393.24,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,372.97,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,364.86,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,283.78,70,,,percent of total billed charges,70% of total billed charges,364.86,90,,,percent of total billed charges,90% of total billed charges,385.13,95,,,percent of total billed charges,95% of total billed charges,385.13,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,348.64,86,,,percent of total billed charges,86% of total billed charges,324.32,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,393.24,97,,,percent of total billed charges,97% of total billed charges,364.86,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,393.24,97,,,percent of total billed charges,97% of total billed charges,377.02,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,393.24,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.49,1325.49,
64616- Chemodenerv/neck/unilateral,3435413,CDM,510,RC,64616,HCPCS,Outpatient,,,359.38,179.69,,323.44,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,287.5,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.6,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,330.63,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,323.44,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,251.57,70,,,percent of total billed charges,70% of total billed charges,323.44,90,,,percent of total billed charges,90% of total billed charges,341.41,95,,,percent of total billed charges,95% of total billed charges,341.41,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,309.07,86,,,percent of total billed charges,86% of total billed charges,287.5,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,348.6,97,,,percent of total billed charges,97% of total billed charges,323.44,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.6,97,,,percent of total billed charges,97% of total billed charges,334.22,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,348.6,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,209.89,1325.49,
64632- Inj neurolytic/plantar com dig ner,3435416,CDM,510,RC,64632,HCPCS,Outpatient,,,229.24,114.62,,206.32,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,183.39,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,222.36,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,210.9,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.32,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,160.47,70,,,percent of total billed charges,70% of total billed charges,206.32,90,,,percent of total billed charges,90% of total billed charges,217.78,95,,,percent of total billed charges,95% of total billed charges,217.78,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.15,86,,,percent of total billed charges,86% of total billed charges,183.39,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.36,97,,,percent of total billed charges,97% of total billed charges,206.32,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.36,97,,,percent of total billed charges,97% of total billed charges,213.19,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,222.36,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,160.47,1325.49,
64633- Neurolytic agent/cerv/thor sng jt,3435417,CDM,510,RC,64633,HCPCS,Outpatient,,,1100.75,550.38,,990.68,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,880.6,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,990.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1067.73,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1012.69,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,990.68,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,770.53,70,,,percent of total billed charges,70% of total billed charges,990.68,90,,,percent of total billed charges,90% of total billed charges,1045.71,95,,,percent of total billed charges,95% of total billed charges,1045.71,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,946.65,86,,,percent of total billed charges,86% of total billed charges,880.6,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1067.73,97,,,percent of total billed charges,97% of total billed charges,990.68,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1067.73,97,,,percent of total billed charges,97% of total billed charges,1023.7,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1067.73,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,770.53,8763.12,
64634- Destruct/cerv/thor/addl facet jnt,3435418,CDM,510,RC,64634,HCPCS,Outpatient,,,640.85,320.43,,576.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,512.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,576.77,90,,,Percent of total Billed charges,90% of total billed charges,60.74,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,621.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,589.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,409.26,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,504.04,78.65,,,percent of total billed charges,78.65% of total billed charges,572.48,89.33,,,percent of total billed charges,89.33% of total billed charges,576.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,448.6,70,,,percent of total billed charges,70% of total billed charges,576.77,90,,,percent of total billed charges,90% of total billed charges,608.81,95,,,percent of total billed charges,95% of total billed charges,608.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.13,86,,,percent of total billed charges,86% of total billed charges,512.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,621.62,97,,,percent of total billed charges,97% of total billed charges,576.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,621.62,97,,,percent of total billed charges,97% of total billed charges,595.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,621.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.22,621.62,
64635- Destruct/lum/sacral/sng facet jnt,3435419,CDM,360,RC,64635,HCPCS,Outpatient,,,1109.9,554.95,,998.91,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,887.92,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,998.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1076.6,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1021.11,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,998.91,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,776.93,70,,,percent of total billed charges,70% of total billed charges,998.91,90,,,percent of total billed charges,90% of total billed charges,1054.41,95,,,percent of total billed charges,95% of total billed charges,1054.41,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,954.51,86,,,percent of total billed charges,86% of total billed charges,887.92,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1076.6,97,,,percent of total billed charges,97% of total billed charges,998.91,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1076.6,97,,,percent of total billed charges,97% of total billed charges,1032.21,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1076.6,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,776.93,8763.12,
64636- Neurolyt agent/lumb/sac/ea add jt,3435420,CDM,360,RC,64636,HCPCS,Outpatient,,,603.69,301.85,,543.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,482.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,543.32,90,,,Percent of total Billed charges,90% of total billed charges,52.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,555.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,385.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,474.82,78.65,,,percent of total billed charges,78.65% of total billed charges,539.29,89.33,,,percent of total billed charges,89.33% of total billed charges,543.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,422.58,70,,,percent of total billed charges,70% of total billed charges,543.32,90,,,percent of total billed charges,90% of total billed charges,573.51,95,,,percent of total billed charges,95% of total billed charges,573.51,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.17,86,,,percent of total billed charges,86% of total billed charges,482.95,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,585.58,97,,,percent of total billed charges,97% of total billed charges,543.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,585.58,97,,,percent of total billed charges,97% of total billed charges,561.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.02,585.58,
64640- Destruct/other periph nerve/branch,3435421,CDM,360,RC,64640,HCPCS,Outpatient,,,618.83,309.42,,556.95,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,495.06,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.95,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,600.27,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,569.32,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,556.95,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,433.18,70,,,percent of total billed charges,70% of total billed charges,556.95,90,,,percent of total billed charges,90% of total billed charges,587.89,95,,,percent of total billed charges,95% of total billed charges,587.89,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.19,86,,,percent of total billed charges,86% of total billed charges,495.06,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,600.27,97,,,percent of total billed charges,97% of total billed charges,556.95,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.27,97,,,percent of total billed charges,97% of total billed charges,575.51,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,600.27,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,4154.47,
64642- Chemodenerv/1 extrem/1-4 musc,3435422,CDM,510,RC,64642,HCPCS,Outpatient,,,390.68,195.34,,351.61,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,312.54,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.61,90,,,Percent of total Billed charges,90% of total billed charges,94.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,378.96,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,359.43,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,351.61,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,273.48,70,,,percent of total billed charges,70% of total billed charges,351.61,90,,,percent of total billed charges,90% of total billed charges,371.15,95,,,percent of total billed charges,95% of total billed charges,371.15,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,335.98,86,,,percent of total billed charges,86% of total billed charges,312.54,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,378.96,97,,,percent of total billed charges,97% of total billed charges,351.61,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.96,97,,,percent of total billed charges,97% of total billed charges,363.33,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,378.96,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.7,3141.23,
64643- Chemodenerv/addl extrem/1-4 musc,3435423,CDM,510,RC,64643,HCPCS,Outpatient,,,242.96,121.48,,218.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,194.37,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,218.66,90,,,Percent of total Billed charges,90% of total billed charges,63.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,235.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,223.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,155.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,191.09,78.65,,,percent of total billed charges,78.65% of total billed charges,217.04,89.33,,,percent of total billed charges,89.33% of total billed charges,218.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,170.07,70,,,percent of total billed charges,70% of total billed charges,218.66,90,,,percent of total billed charges,90% of total billed charges,230.81,95,,,percent of total billed charges,95% of total billed charges,230.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.95,86,,,percent of total billed charges,86% of total billed charges,194.37,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,235.67,97,,,percent of total billed charges,97% of total billed charges,218.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,235.67,97,,,percent of total billed charges,97% of total billed charges,225.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,235.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.71,235.67,
64644- Chemodenerv/1 extrem/5/> musc,3435424,CDM,510,RC,64644,HCPCS,Outpatient,,,455.6,227.80,,410.04,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,364.48,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.04,90,,,Percent of total Billed charges,90% of total billed charges,102.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,441.93,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,419.15,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,410.04,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,318.92,70,,,percent of total billed charges,70% of total billed charges,410.04,90,,,percent of total billed charges,90% of total billed charges,432.82,95,,,percent of total billed charges,95% of total billed charges,432.82,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,391.82,86,,,percent of total billed charges,86% of total billed charges,364.48,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,441.93,97,,,percent of total billed charges,97% of total billed charges,410.04,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,441.93,97,,,percent of total billed charges,97% of total billed charges,423.71,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,441.93,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.54,3141.23,
64645- Chemodenerv/addl extrem/5/> musc,3435425,CDM,510,RC,64645,HCPCS,Outpatient,,,313.22,156.61,,281.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,250.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,281.9,90,,,Percent of total Billed charges,90% of total billed charges,72.79,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,303.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,288.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,200.03,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,246.35,78.65,,,percent of total billed charges,78.65% of total billed charges,279.8,89.33,,,percent of total billed charges,89.33% of total billed charges,281.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,219.25,70,,,percent of total billed charges,70% of total billed charges,281.9,90,,,percent of total billed charges,90% of total billed charges,297.56,95,,,percent of total billed charges,95% of total billed charges,297.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.37,86,,,percent of total billed charges,86% of total billed charges,250.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,303.82,97,,,percent of total billed charges,97% of total billed charges,281.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,303.82,97,,,percent of total billed charges,97% of total billed charges,291.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,303.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.17,303.82,
64646- Chemodenerv/trunk muscles/1-5,3435426,CDM,510,RC,64646,HCPCS,Outpatient,,,408.9,204.45,,368.01,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,327.12,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.01,90,,,Percent of total Billed charges,90% of total billed charges,101.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,396.63,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,376.19,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,368.01,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,286.23,70,,,percent of total billed charges,70% of total billed charges,368.01,90,,,percent of total billed charges,90% of total billed charges,388.46,95,,,percent of total billed charges,95% of total billed charges,388.46,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,351.65,86,,,percent of total billed charges,86% of total billed charges,327.12,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,396.63,97,,,percent of total billed charges,97% of total billed charges,368.01,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.63,97,,,percent of total billed charges,97% of total billed charges,380.28,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.63,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92.7,3141.23,
64647- Chemodenerv/trunk muscles/6/>,3435427,CDM,510,RC,64647,HCPCS,Outpatient,,,471.8,235.90,,424.62,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,377.44,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.62,90,,,Percent of total Billed charges,90% of total billed charges,117.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,457.65,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,434.06,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,424.62,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,330.26,70,,,percent of total billed charges,70% of total billed charges,424.62,90,,,percent of total billed charges,90% of total billed charges,448.21,95,,,percent of total billed charges,95% of total billed charges,448.21,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,405.75,86,,,percent of total billed charges,86% of total billed charges,377.44,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.65,97,,,percent of total billed charges,97% of total billed charges,424.62,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,457.65,97,,,percent of total billed charges,97% of total billed charges,438.77,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,457.65,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,107.06,3141.23,
64650- Chemodenerv/eccrine gland/both ax,3435428,CDM,510,RC,64650,HCPCS,Outpatient,,,221.04,110.52,,198.94,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,176.83,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,214.41,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,203.36,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,198.94,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,154.73,70,,,percent of total billed charges,70% of total billed charges,198.94,90,,,percent of total billed charges,90% of total billed charges,209.99,95,,,percent of total billed charges,95% of total billed charges,209.99,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,190.09,86,,,percent of total billed charges,86% of total billed charges,176.83,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,214.41,97,,,percent of total billed charges,97% of total billed charges,198.94,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.41,97,,,percent of total billed charges,97% of total billed charges,205.57,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,214.41,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.73,1325.49,
64680- Inj neurolytic/celiac plexus,3435429,CDM,510,RC,64680,HCPCS,Outpatient,,,876.55,438.28,,788.9,90,,,percent of total billed charges,90% of total Billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,701.24,80,,,Percent of total Billed charges,80% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.9,90,,,Percent of total Billed charges,90% of total billed charges,80.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,850.25,97,,,Percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,806.43,92,,,Percent of total billed charges,92% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,2057.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3279.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4154.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,788.9,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,613.59,70,,,percent of total billed charges,70% of total billed charges,788.9,90,,,percent of total billed charges,90% of total billed charges,832.72,95,,,percent of total billed charges,95% of total billed charges,832.72,95,,,percent of total billed charges,95% of total billed charges,774,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1548,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,753.83,86,,,percent of total billed charges,86% of total billed charges,701.24,80,,,percent of total billed charges,80% of total billed charges,839.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,850.25,97,,,percent of total billed charges,97% of total billed charges,788.9,90,,,percent of total billed charges,90% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,850.25,97,,,percent of total billed charges,97% of total billed charges,815.19,93,,,percent of total billed charges,93% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,850.25,97,,,percent of total billed charges,97% of total billed charges,774,100,,,Fee Schedule,100% of CMS OPPS Rate ,774,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,657.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.5,4154.47,
64704- Neuroplasty/hand/foot nerve,3435430,CDM,510,RC,64704,HCPCS,Outpatient,,,835.27,417.64,,751.74,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,668.22,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,751.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,810.21,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,768.45,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,751.74,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,584.69,70,,,percent of total billed charges,70% of total billed charges,751.74,90,,,percent of total billed charges,90% of total billed charges,793.51,95,,,percent of total billed charges,95% of total billed charges,793.51,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,718.33,86,,,percent of total billed charges,86% of total billed charges,668.22,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,810.21,97,,,percent of total billed charges,97% of total billed charges,751.74,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,810.21,97,,,percent of total billed charges,97% of total billed charges,776.8,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,810.21,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,584.69,8763.12,
64718- Neuroplasty/ulnar nerve/elbow,3435431,CDM,510,RC,64718,HCPCS,Outpatient,,,1550.18,775.09,,1395.16,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1240.14,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1395.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1503.67,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1426.17,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1395.16,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1085.13,70,,,percent of total billed charges,70% of total billed charges,1395.16,90,,,percent of total billed charges,90% of total billed charges,1472.67,95,,,percent of total billed charges,95% of total billed charges,1472.67,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1333.15,86,,,percent of total billed charges,86% of total billed charges,1240.14,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1503.67,97,,,percent of total billed charges,97% of total billed charges,1395.16,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1503.67,97,,,percent of total billed charges,97% of total billed charges,1441.67,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1503.67,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1085.13,8763.12,
64719- Neuroplasty/ulnar nerve at wrist,3435432,CDM,510,RC,64719,HCPCS,Outpatient,,,1051.68,525.84,,946.51,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,841.34,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,946.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1020.13,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,967.55,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,946.51,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,736.18,70,,,percent of total billed charges,70% of total billed charges,946.51,90,,,percent of total billed charges,90% of total billed charges,999.1,95,,,percent of total billed charges,95% of total billed charges,999.1,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,904.44,86,,,percent of total billed charges,86% of total billed charges,841.34,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1020.13,97,,,percent of total billed charges,97% of total billed charges,946.51,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.13,97,,,percent of total billed charges,97% of total billed charges,978.06,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1020.13,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,736.18,8763.12,
64721- Carpal tunnel surgery,3435433,CDM,510,RC,64721,HCPCS,Outpatient,,,1139.79,569.90,,1025.81,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,911.83,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1025.81,90,,,Percent of total Billed charges,90% of total billed charges,330,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1105.6,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1048.61,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1025.81,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,797.85,70,,,percent of total billed charges,70% of total billed charges,1025.81,90,,,percent of total billed charges,90% of total billed charges,1082.8,95,,,percent of total billed charges,95% of total billed charges,1082.8,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,980.22,86,,,percent of total billed charges,86% of total billed charges,911.83,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1105.6,97,,,percent of total billed charges,97% of total billed charges,1025.81,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1105.6,97,,,percent of total billed charges,97% of total billed charges,1060,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,300,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1105.6,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,300,8763.12,
64726- Decompression/plantar dig nerve,3435434,CDM,510,RC,64726,HCPCS,Outpatient,,,694.49,347.25,,625.04,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,555.59,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.04,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,673.66,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,638.93,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,625.04,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,486.14,70,,,percent of total billed charges,70% of total billed charges,625.04,90,,,percent of total billed charges,90% of total billed charges,659.77,95,,,percent of total billed charges,95% of total billed charges,659.77,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,597.26,86,,,percent of total billed charges,86% of total billed charges,555.59,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,673.66,97,,,percent of total billed charges,97% of total billed charges,625.04,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,673.66,97,,,percent of total billed charges,97% of total billed charges,645.88,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,673.66,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,486.14,8763.12,
64772- Transect/spinal nerve/extradural,3435435,CDM,510,RC,64772,HCPCS,Outpatient,,,1465.98,732.99,,1319.38,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1172.78,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1319.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1422,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1348.7,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1319.38,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1026.19,70,,,percent of total billed charges,70% of total billed charges,1319.38,90,,,percent of total billed charges,90% of total billed charges,1392.68,95,,,percent of total billed charges,95% of total billed charges,1392.68,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1260.74,86,,,percent of total billed charges,86% of total billed charges,1172.78,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1422,97,,,percent of total billed charges,97% of total billed charges,1319.38,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1422,97,,,percent of total billed charges,97% of total billed charges,1363.36,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1422,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1026.19,8763.12,
64774- Exc neuroma/cutaneous nerve,3435436,CDM,510,RC,64774,HCPCS,Outpatient,,,1086.66,543.33,,977.99,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,869.33,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,977.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1054.06,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,999.73,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,977.99,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,760.66,70,,,percent of total billed charges,70% of total billed charges,977.99,90,,,percent of total billed charges,90% of total billed charges,1032.33,95,,,percent of total billed charges,95% of total billed charges,1032.33,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,934.53,86,,,percent of total billed charges,86% of total billed charges,869.33,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1054.06,97,,,percent of total billed charges,97% of total billed charges,977.99,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.06,97,,,percent of total billed charges,97% of total billed charges,1010.59,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1054.06,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,760.66,8763.12,
64782- Exc neuroma/hand/foot/exc dig nerv,3435437,CDM,510,RC,64782,HCPCS,Outpatient,,,1184.86,592.43,,1066.37,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,947.89,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1066.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1149.31,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1090.07,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1066.37,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,829.4,70,,,percent of total billed charges,70% of total billed charges,1066.37,90,,,percent of total billed charges,90% of total billed charges,1125.62,95,,,percent of total billed charges,95% of total billed charges,1125.62,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1018.98,86,,,percent of total billed charges,86% of total billed charges,947.89,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1149.31,97,,,percent of total billed charges,97% of total billed charges,1066.37,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1149.31,97,,,percent of total billed charges,97% of total billed charges,1101.92,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1149.31,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,829.4,8763.12,
64784- Exc neuroma/major peripheral nerve,3435438,CDM,510,RC,64784,HCPCS,Outpatient,,,1905.65,952.83,,1715.09,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.52,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1715.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1848.48,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1753.2,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1715.09,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1333.96,70,,,percent of total billed charges,70% of total billed charges,1715.09,90,,,percent of total billed charges,90% of total billed charges,1810.37,95,,,percent of total billed charges,95% of total billed charges,1810.37,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1638.86,86,,,percent of total billed charges,86% of total billed charges,1524.52,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1848.48,97,,,percent of total billed charges,97% of total billed charges,1715.09,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1848.48,97,,,percent of total billed charges,97% of total billed charges,1772.25,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1848.48,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1333.96,8763.12,
64787- Implant nerve end into bone/muscle,3435439,CDM,510,RC,64787,HCPCS,Outpatient,,,632.41,316.21,,569.17,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,505.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,569.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,613.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,581.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,403.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,497.4,78.65,,,percent of total billed charges,78.65% of total billed charges,564.94,89.33,,,percent of total billed charges,89.33% of total billed charges,569.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,442.69,70,,,percent of total billed charges,70% of total billed charges,569.17,90,,,percent of total billed charges,90% of total billed charges,600.79,95,,,percent of total billed charges,95% of total billed charges,600.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,543.87,86,,,percent of total billed charges,86% of total billed charges,505.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,613.44,97,,,percent of total billed charges,97% of total billed charges,569.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,613.44,97,,,percent of total billed charges,97% of total billed charges,588.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,613.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,403.87,613.44,
64831- Suture/1 digital nerve/hand/foot,3435440,CDM,510,RC,64831,HCPCS,Outpatient,,,1796.03,898.02,,1616.43,90,,,percent of total billed charges,90% of total Billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1436.82,80,,,Percent of total Billed charges,80% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1616.43,90,,,Percent of total Billed charges,90% of total billed charges,453.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1742.15,97,,,Percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1652.35,92,,,Percent of total billed charges,92% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4339.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6918.35,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8763.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1616.43,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1257.22,70,,,percent of total billed charges,70% of total billed charges,1616.43,90,,,percent of total billed charges,90% of total billed charges,1706.23,95,,,percent of total billed charges,95% of total billed charges,1706.23,95,,,percent of total billed charges,95% of total billed charges,1632.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3265.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1544.59,86,,,percent of total billed charges,86% of total billed charges,1436.82,80,,,percent of total billed charges,80% of total billed charges,1777.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1742.15,97,,,percent of total billed charges,97% of total billed charges,1616.43,90,,,percent of total billed charges,90% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1742.15,97,,,percent of total billed charges,97% of total billed charges,1670.31,93,,,percent of total billed charges,93% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,412,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1742.15,97,,,percent of total billed charges,97% of total billed charges,1632.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1632.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1387.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,412,8763.12,
64832- Suture/digital nerve/hand/foot/add,3435441,CDM,510,RC,64832,HCPCS,Outpatient,,,877.82,438.91,,790.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,702.26,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,790.04,90,,,Percent of total Billed charges,90% of total billed charges,342.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,851.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,807.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,560.6,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,690.42,78.65,,,percent of total billed charges,78.65% of total billed charges,784.17,89.33,,,percent of total billed charges,89.33% of total billed charges,790.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,614.47,70,,,percent of total billed charges,70% of total billed charges,790.04,90,,,percent of total billed charges,90% of total billed charges,833.93,95,,,percent of total billed charges,95% of total billed charges,833.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,754.93,86,,,percent of total billed charges,86% of total billed charges,702.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,851.49,97,,,percent of total billed charges,97% of total billed charges,790.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.49,97,,,percent of total billed charges,97% of total billed charges,816.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,851.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.25,851.49,
64835- Suture 1 nerve/median motor thenar,3435442,CDM,510,RC,64835,HCPCS,Outpatient,,,2141.61,1070.81,,1927.45,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1713.29,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1927.45,90,,,Percent of total Billed charges,90% of total billed charges,362.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2077.36,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1970.28,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.69,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1927.45,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1499.13,70,,,percent of total billed charges,70% of total billed charges,1927.45,90,,,percent of total billed charges,90% of total billed charges,2034.53,95,,,percent of total billed charges,95% of total billed charges,2034.53,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1841.78,86,,,percent of total billed charges,86% of total billed charges,1713.29,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2077.36,97,,,percent of total billed charges,97% of total billed charges,1927.45,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2077.36,97,,,percent of total billed charges,97% of total billed charges,1991.7,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2077.36,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,329.5,30121.69,
64857- Suture/maj perpheral nerve/arm/leg,3435443,CDM,510,RC,64857,HCPCS,Outpatient,,,2770.01,1385.01,,2493.01,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2216.01,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2493.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2686.91,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2548.41,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.69,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2493.01,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1939.01,70,,,percent of total billed charges,70% of total billed charges,2493.01,90,,,percent of total billed charges,90% of total billed charges,2631.51,95,,,percent of total billed charges,95% of total billed charges,2631.51,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2382.21,86,,,percent of total billed charges,86% of total billed charges,2216.01,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2686.91,97,,,percent of total billed charges,97% of total billed charges,2493.01,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2686.91,97,,,percent of total billed charges,97% of total billed charges,2576.11,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2686.91,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1939.01,30121.69,
64893- Nerve graft/arm/leg/> 4 cm,3435444,CDM,510,RC,64893,HCPCS,Outpatient,,,2948.49,1474.25,,2653.64,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2358.79,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2653.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2860.04,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2712.61,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.69,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2653.64,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,2063.94,70,,,percent of total billed charges,70% of total billed charges,2653.64,90,,,percent of total billed charges,90% of total billed charges,2801.07,95,,,percent of total billed charges,95% of total billed charges,2801.07,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2535.7,86,,,percent of total billed charges,86% of total billed charges,2358.79,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2860.04,97,,,percent of total billed charges,97% of total billed charges,2653.64,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,2860.04,97,,,percent of total billed charges,97% of total billed charges,2742.1,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2860.04,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2063.94,30121.69,
64910- Nerve rpr/synthetic/vein/ea nerve,3435445,CDM,510,RC,64910,HCPCS,Outpatient,,,1995.69,997.85,,1796.12,90,,,percent of total billed charges,90% of total Billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1596.55,80,,,Percent of total Billed charges,80% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1796.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1935.82,97,,,Percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1836.03,92,,,Percent of total billed charges,92% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14916.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23780.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,30121.69,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1796.12,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.98,70,,,percent of total billed charges,70% of total billed charges,1796.12,90,,,percent of total billed charges,90% of total billed charges,1895.91,95,,,percent of total billed charges,95% of total billed charges,1895.91,95,,,percent of total billed charges,95% of total billed charges,5611.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11223.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1716.29,86,,,percent of total billed charges,86% of total billed charges,1596.55,80,,,percent of total billed charges,80% of total billed charges,5695.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1935.82,97,,,percent of total billed charges,97% of total billed charges,1796.12,90,,,percent of total billed charges,90% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1935.82,97,,,percent of total billed charges,97% of total billed charges,1855.99,93,,,percent of total billed charges,93% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1935.82,97,,,percent of total billed charges,97% of total billed charges,5611.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5611.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4770.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1396.98,30121.69,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,3095.38,1547.69,,2785.84,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2476.3,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2785.84,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3002.52,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2847.75,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2785.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2166.77,70,,,percent of total billed charges,70% of total billed charges,2785.84,90,,,percent of total billed charges,90% of total billed charges,2940.61,95,,,percent of total billed charges,95% of total billed charges,2940.61,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2662.03,86,,,percent of total billed charges,86% of total billed charges,2476.3,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3002.52,97,,,percent of total billed charges,97% of total billed charges,2785.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3002.52,97,,,percent of total billed charges,97% of total billed charges,2878.7,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3002.52,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,3002.52,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,743.9,371.95,,669.51,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,595.12,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,669.51,90,,,Percent of total Billed charges,90% of total billed charges,28.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,721.58,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,684.39,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,669.51,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,520.73,70,,,percent of total billed charges,70% of total billed charges,669.51,90,,,percent of total billed charges,90% of total billed charges,706.71,95,,,percent of total billed charges,95% of total billed charges,706.71,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,639.75,86,,,percent of total billed charges,86% of total billed charges,595.12,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,721.58,97,,,percent of total billed charges,97% of total billed charges,669.51,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,721.58,97,,,percent of total billed charges,97% of total billed charges,691.83,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,721.58,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26,721.58,
67700- Drainage of eyelid abscess,3431315,CDM,510,RC,67700,HCPCS,Outpatient,,,1695.72,847.86,,1526.15,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.58,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1526.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1644.85,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1560.06,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1526.15,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1187,70,,,percent of total billed charges,70% of total billed charges,1526.15,90,,,percent of total billed charges,90% of total billed charges,1610.93,95,,,percent of total billed charges,95% of total billed charges,1610.93,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1458.32,86,,,percent of total billed charges,86% of total billed charges,1356.58,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1644.85,97,,,percent of total billed charges,97% of total billed charges,1526.15,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1644.85,97,,,percent of total billed charges,97% of total billed charges,1577.02,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1644.85,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1644.85,
67700-OCC Drainage of eyelid abscess,3536975,CDM,983,RC,67700,HCPCS,Outpatient,,,1695.72,847.86,,1526.15,90,,,percent of total billed charges,90% of total Billed charges,370.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,195.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,117.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.57,155,,,Fee Schedule,155% of CMS OPPS Rate,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.65,155,,,Fee Schedule,155% of CMS OPPS Rate,574.65,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,323.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,507.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,507.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.81,1526.15,
67800- Excision of chalazion/single,3431316,CDM,510,RC,67800,HCPCS,Outpatient,,,1670.07,835.04,,1503.06,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1336.06,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1503.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1619.97,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1536.46,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1503.06,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1169.05,70,,,percent of total billed charges,70% of total billed charges,1503.06,90,,,percent of total billed charges,90% of total billed charges,1586.57,95,,,percent of total billed charges,95% of total billed charges,1586.57,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1436.26,86,,,percent of total billed charges,86% of total billed charges,1336.06,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1619.97,97,,,percent of total billed charges,97% of total billed charges,1503.06,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1619.97,97,,,percent of total billed charges,97% of total billed charges,1553.17,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1619.97,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1619.97,
67800-OCC Excision of chalazion/single,3536976,CDM,983,RC,67800,HCPCS,Outpatient,,,1670.07,835.04,,1503.06,90,,,percent of total billed charges,90% of total Billed charges,215.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,81.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,106.1,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,148.68,155,,,Fee Schedule,155% of CMS OPPS Rate,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.46,155,,,Fee Schedule,155% of CMS OPPS Rate,334.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.49,1503.06,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,5369.15,2684.58,,4832.24,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4295.32,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4832.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5208.08,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4939.62,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4832.24,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3758.41,70,,,percent of total billed charges,70% of total billed charges,4832.24,90,,,percent of total billed charges,90% of total billed charges,5100.69,95,,,percent of total billed charges,95% of total billed charges,5100.69,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4617.47,86,,,percent of total billed charges,86% of total billed charges,4295.32,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5208.08,97,,,percent of total billed charges,97% of total billed charges,4832.24,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,5208.08,97,,,percent of total billed charges,97% of total billed charges,4993.31,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5208.08,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,5208.08,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,510,RC,67805,HCPCS,Outpatient,,,1788.92,894.46,,1610.03,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1431.14,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1610.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1735.25,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1645.81,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1610.03,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1252.24,70,,,percent of total billed charges,70% of total billed charges,1610.03,90,,,percent of total billed charges,90% of total billed charges,1699.47,95,,,percent of total billed charges,95% of total billed charges,1699.47,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1538.47,86,,,percent of total billed charges,86% of total billed charges,1431.14,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1735.25,97,,,percent of total billed charges,97% of total billed charges,1610.03,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1735.25,97,,,percent of total billed charges,97% of total billed charges,1663.7,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1735.25,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1735.25,
67805 OCC EXCIS CHALAZION MULT BOTH,3686902,CDM,983,RC,67805,HCPCS,Outpatient,,,1788.92,894.46,,1610.03,90,,,percent of total billed charges,90% of total Billed charges,343.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,238.25,155,,,Fee Schedule,155% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,235.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,235.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,278.18,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,167.82,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,238.25,155,,,Fee Schedule,155% of CMS OPPS Rate,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,532.38,155,,,Fee Schedule,155% of CMS OPPS Rate,532.38,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,378.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,153.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,412.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,412.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.42,1610.03,
"67808- Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or m",3569414,CDM,983,RC,67808,HCPCS,Outpatient,,,712.32,356.16,,641.09,90,,,percent of total billed charges,90% of total Billed charges,685.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.7,155,,,Fee Schedule,155% of CMS OPPS Rate,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,635.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,635.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,527.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,527.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,290.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,684.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,621.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,377.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.7,155,,,Fee Schedule,155% of CMS OPPS Rate,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,1062.17,155,,,Fee Schedule,155% of CMS OPPS Rate,1062.17,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,363.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,762.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,762.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,290.19,1062.17,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,1606.24,803.12,,1445.62,90,,,percent of total billed charges,90% of total Billed charges,237.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.22,155,,,Fee Schedule,155% of CMS OPPS Rate,368.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.01,1445.62,
67820- Revise eyelashes,3431319,CDM,510,RC,67820,HCPCS,Outpatient,,,688.27,344.14,,619.44,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,550.62,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,667.62,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,633.21,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,619.44,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,481.79,70,,,percent of total billed charges,70% of total billed charges,619.44,90,,,percent of total billed charges,90% of total billed charges,653.86,95,,,percent of total billed charges,95% of total billed charges,653.86,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,591.91,86,,,percent of total billed charges,86% of total billed charges,550.62,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,667.62,97,,,percent of total billed charges,97% of total billed charges,619.44,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,667.62,97,,,percent of total billed charges,97% of total billed charges,640.09,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,667.62,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,667.62,
67820-OCC Revise eyelashes,3536977,CDM,983,RC,67820,HCPCS,Outpatient,,,688.27,344.14,,619.44,90,,,percent of total billed charges,90% of total Billed charges,39.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,40.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.15,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,32.13,155,,,Fee Schedule,155% of CMS OPPS Rate,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.7,155,,,Fee Schedule,155% of CMS OPPS Rate,60.7,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,103.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.73,619.44,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,5417.62,2708.81,,4875.86,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4334.1,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4875.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5255.09,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4984.21,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4875.86,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3792.33,70,,,percent of total billed charges,70% of total billed charges,4875.86,90,,,percent of total billed charges,90% of total billed charges,5146.74,95,,,percent of total billed charges,95% of total billed charges,5146.74,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4659.15,86,,,percent of total billed charges,86% of total billed charges,4334.1,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5255.09,97,,,percent of total billed charges,97% of total billed charges,4875.86,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,5255.09,97,,,percent of total billed charges,97% of total billed charges,5038.39,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5255.09,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,5255.09,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,5417.62,2708.81,,4875.86,90,,,percent of total billed charges,90% of total Billed charges,409.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,267.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.12,155,,,Fee Schedule,155% of CMS OPPS Rate,634.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.6,4875.86,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,510,RC,67850,HCPCS,Outpatient,,,5368.45,2684.23,,4831.61,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4294.76,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4831.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5207.4,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4938.97,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4831.61,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3757.92,70,,,percent of total billed charges,70% of total billed charges,4831.61,90,,,percent of total billed charges,90% of total billed charges,5100.03,95,,,percent of total billed charges,95% of total billed charges,5100.03,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4616.87,86,,,percent of total billed charges,86% of total billed charges,4294.76,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5207.4,97,,,percent of total billed charges,97% of total billed charges,4831.61,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,5207.4,97,,,percent of total billed charges,97% of total billed charges,4992.66,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5207.4,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,5207.4,
67850 -OCC Destruction/lid/lesion/up to 1 cm,3548666,CDM,983,RC,67850,HCPCS,Outpatient,,,5368.45,2684.23,,4831.61,90,,,percent of total billed charges,90% of total Billed charges,324.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,190.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,107.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,224.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,135.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,192.14,155,,,Fee Schedule,155% of CMS OPPS Rate,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,502.57,155,,,Fee Schedule,155% of CMS OPPS Rate,502.57,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,371.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,107.71,4831.61,
67875 -OCC Temp eyelid closure/suture,3548667,CDM,983,RC,67875,HCPCS,Outpatient,,,5299.39,2649.70,,4769.45,90,,,percent of total billed charges,90% of total Billed charges,258.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,165.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,163.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.97,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.96,155,,,Fee Schedule,155% of CMS OPPS Rate,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.14,155,,,Fee Schedule,155% of CMS OPPS Rate,401.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,454,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,335.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.79,4769.45,
67875- Temp eyelid closure/suture,3431322,CDM,510,RC,67875,HCPCS,Outpatient,,,5299.39,2649.70,,4769.45,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4239.51,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4769.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5140.41,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4875.44,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4769.45,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3709.57,70,,,percent of total billed charges,70% of total billed charges,4769.45,90,,,percent of total billed charges,90% of total billed charges,5034.42,95,,,percent of total billed charges,95% of total billed charges,5034.42,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4557.48,86,,,percent of total billed charges,86% of total billed charges,4239.51,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5140.41,97,,,percent of total billed charges,97% of total billed charges,4769.45,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,5140.41,97,,,percent of total billed charges,97% of total billed charges,4928.43,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5140.41,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,5140.41,
67880 -OCC Revision of eyelid,3548668,CDM,983,RC,67880,HCPCS,Outpatient,,,12512.66,6256.33,,11261.39,90,,,percent of total billed charges,90% of total Billed charges,778.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,563.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,633.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,633.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,525.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,290.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,619.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,373.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,530.92,155,,,Fee Schedule,155% of CMS OPPS Rate,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.98,155,,,Fee Schedule,155% of CMS OPPS Rate,1205.98,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,587.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,342.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,918.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,918.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,290.41,11261.39,
67880- Revision of eyelid,3431323,CDM,510,RC,67880,HCPCS,Outpatient,,,12512.66,6256.33,,11261.39,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10010.13,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11261.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12137.28,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11511.65,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11261.39,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8758.86,70,,,percent of total billed charges,70% of total billed charges,11261.39,90,,,percent of total billed charges,90% of total billed charges,11887.03,95,,,percent of total billed charges,95% of total billed charges,11887.03,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10760.89,86,,,percent of total billed charges,86% of total billed charges,10010.13,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12137.28,97,,,percent of total billed charges,97% of total billed charges,11261.39,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12137.28,97,,,percent of total billed charges,97% of total billed charges,11636.77,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12137.28,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,12137.28,
67900 -OCC Repair brow prosis,3548669,CDM,983,RC,67900,HCPCS,Outpatient,,,984.38,492.19,,885.94,90,,,percent of total billed charges,90% of total Billed charges,1082.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,779.6,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,876.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,876.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,732.6,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,401.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,947.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,864.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,529.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,734.64,155,,,Fee Schedule,155% of CMS OPPS Rate,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1677.66,155,,,Fee Schedule,155% of CMS OPPS Rate,1677.66,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,631.77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,473.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,1292,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1292,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,401.67,1677.66,
67901- OCC EYE Repair of blepharoptosis; frontalis muscle technique with suture or other material,3569420,CDM,983,RC,67901,HCPCS,Outpatient,,,1141.66,570.83,,1027.49,90,,,percent of total billed charges,90% of total Billed charges,1294.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,855,155,,,Fee Schedule,155% of CMS OPPS Rate,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,896.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,551.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1008.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1008.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,839.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,839.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,454.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1103.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,990.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,601.26,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,855,155,,,Fee Schedule,155% of CMS OPPS Rate,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,2006.1,155,,,Fee Schedule,155% of CMS OPPS Rate,2006.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,551.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1521.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1521.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,454.39,2006.1,
67904 -OCC Blepharoptosis/levator resct/ext,3548671,CDM,983,RC,67904,HCPCS,Outpatient,,,1157.12,578.56,,1041.41,90,,,percent of total billed charges,90% of total Billed charges,1250.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1029.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1029.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,858.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,470.57,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1113.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1012.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,614.61,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,863.18,155,,,Fee Schedule,155% of CMS OPPS Rate,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1938.29,155,,,Fee Schedule,155% of CMS OPPS Rate,1938.29,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,756.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,556.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1485.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1485.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,470.57,1938.29,
67909 -OCC Revise eyelid defect,3548672,CDM,983,RC,67909,HCPCS,Outpatient,,,12647.24,6323.62,,11382.52,90,,,percent of total billed charges,90% of total Billed charges,923.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,672.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,756.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,756.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,629,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,345.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,818.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,742.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,452.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,634.57,155,,,Fee Schedule,155% of CMS OPPS Rate,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1431.67,155,,,Fee Schedule,155% of CMS OPPS Rate,1431.67,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,559.65,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,409.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1082.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1082.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,345.97,11382.52,
67909- Revise eyelid defect,3431327,CDM,510,RC,67909,HCPCS,Outpatient,,,12647.24,6323.62,,11382.52,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10117.79,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11382.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12267.82,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11635.46,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11382.52,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8853.07,70,,,percent of total billed charges,70% of total billed charges,11382.52,90,,,percent of total billed charges,90% of total billed charges,12014.88,95,,,percent of total billed charges,95% of total billed charges,12014.88,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10876.63,86,,,percent of total billed charges,86% of total billed charges,10117.79,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12267.82,97,,,percent of total billed charges,97% of total billed charges,11382.52,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12267.82,97,,,percent of total billed charges,97% of total billed charges,11761.93,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12267.82,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,12267.82,
67912 -OCC Lagophthalmos/implt/up eyelid load,3548673,CDM,983,RC,67912,HCPCS,Outpatient,,,948.74,474.37,,853.87,90,,,percent of total billed charges,90% of total Billed charges,1302.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,709.05,155,,,Fee Schedule,155% of CMS OPPS Rate,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,747.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,457.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,840.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,840.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,701.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,701.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,386.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,914.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,827.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,510.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,709.05,155,,,Fee Schedule,155% of CMS OPPS Rate,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,2019.5,155,,,Fee Schedule,155% of CMS OPPS Rate,2019.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,969.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,457.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,1717.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1717.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,386.72,2019.5,
67917 -OCC Repair etropion/extensive,3548675,CDM,983,RC,67917,HCPCS,Outpatient,,,884.23,442.12,,795.81,90,,,percent of total billed charges,90% of total Billed charges,1010,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,660.25,155,,,Fee Schedule,155% of CMS OPPS Rate,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.96,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,851.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.96,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,469.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,660.25,155,,,Fee Schedule,155% of CMS OPPS Rate,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1565.5,155,,,Fee Schedule,155% of CMS OPPS Rate,1565.5,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,597.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,425.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1183.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1183.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.96,1565.5,
67923 -OCC Rpr entropion/excise tarsal wedge,3548676,CDM,983,RC,67923,HCPCS,Outpatient,,,832.21,416.11,,748.99,90,,,percent of total billed charges,90% of total Billed charges,969.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,620.64,155,,,Fee Schedule,155% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,400.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,742.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,742.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,616.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,616.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,339.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,800.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,727,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,439.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,620.64,155,,,Fee Schedule,155% of CMS OPPS Rate,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1502.59,155,,,Fee Schedule,155% of CMS OPPS Rate,1502.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,791.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,400.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1147.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1147.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,339.38,1502.59,
67924 -OCC Repair entropion/extensive,3548677,CDM,983,RC,67924,HCPCS,Outpatient,,,883.91,441.96,,795.52,90,,,percent of total billed charges,90% of total Billed charges,1031.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,700.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,788.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,788.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,655.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,360.9,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,850.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,773.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,468.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,659.37,155,,,Fee Schedule,155% of CMS OPPS Rate,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1599.04,155,,,Fee Schedule,155% of CMS OPPS Rate,1599.04,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,579.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,425.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,1179.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1179.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,360.9,1599.04,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,510,RC,67935,HCPCS,Outpatient,,,12658.14,6329.07,,11392.33,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10126.51,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11392.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12278.4,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11645.49,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11392.33,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8860.7,70,,,percent of total billed charges,70% of total billed charges,11392.33,90,,,percent of total billed charges,90% of total billed charges,12025.23,95,,,percent of total billed charges,95% of total billed charges,12025.23,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10886,86,,,percent of total billed charges,86% of total billed charges,10126.51,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12278.4,97,,,percent of total billed charges,97% of total billed charges,11392.33,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12278.4,97,,,percent of total billed charges,97% of total billed charges,11772.07,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12278.4,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,12278.4,
67935 -OCC Eyelid/recent wound sut/full thick,3548678,CDM,983,RC,67935,HCPCS,Outpatient,,,12658.14,6329.07,,11392.33,90,,,percent of total billed charges,90% of total Billed charges,976.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,641.87,155,,,Fee Schedule,155% of CMS OPPS Rate,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,678.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,414.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,763.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,763.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,641.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,641.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,348.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,828.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,756.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,464.48,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,641.87,155,,,Fee Schedule,155% of CMS OPPS Rate,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1513,155,,,Fee Schedule,155% of CMS OPPS Rate,1513,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,801.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,414.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,1207,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1207,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,348.29,11392.33,
67938 -OCC Removal of embedded FB/eyelid,3548679,CDM,983,RC,67938,HCPCS,Outpatient,,,1697.27,848.64,,1527.54,90,,,percent of total billed charges,90% of total Billed charges,360.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.93,155,,,Fee Schedule,155% of CMS OPPS Rate,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,200,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,200,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.76,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.76,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,194.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.85,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,169.93,155,,,Fee Schedule,155% of CMS OPPS Rate,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.46,155,,,Fee Schedule,155% of CMS OPPS Rate,559.46,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,811.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,109.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,464.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,464.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.77,1527.54,
67938- Removal of embedded FB/eyelid,3431333,CDM,510,RC,67938,HCPCS,Outpatient,,,1697.27,848.64,,1527.54,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1357.82,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1527.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1646.35,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1561.49,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1527.54,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1188.09,70,,,percent of total billed charges,70% of total billed charges,1527.54,90,,,percent of total billed charges,90% of total billed charges,1612.41,95,,,percent of total billed charges,95% of total billed charges,1612.41,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1459.65,86,,,percent of total billed charges,86% of total billed charges,1357.82,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1646.35,97,,,percent of total billed charges,97% of total billed charges,1527.54,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1646.35,97,,,percent of total billed charges,97% of total billed charges,1578.46,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1646.35,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1646.35,
67950 -OCC Canthoplasty/reconstruct canthus,3548680,CDM,983,RC,67950,HCPCS,Outpatient,,,896.57,448.29,,806.91,90,,,percent of total billed charges,90% of total Billed charges,980.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,670.13,155,,,Fee Schedule,155% of CMS OPPS Rate,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,710.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,432.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,798.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,798.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,664.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,664.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,365.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,864.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,784.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,477.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,670.13,155,,,Fee Schedule,155% of CMS OPPS Rate,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1519.48,155,,,Fee Schedule,155% of CMS OPPS Rate,1519.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,552.16,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,432.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1155.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1155.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,365.55,1519.48,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,12680,6340.00,,11412,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10144,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11412,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12299.6,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11665.6,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11412,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8876,70,,,percent of total billed charges,70% of total billed charges,11412,90,,,percent of total billed charges,90% of total billed charges,12046,95,,,percent of total billed charges,95% of total billed charges,12046,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10904.8,86,,,percent of total billed charges,86% of total billed charges,10144,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12299.6,97,,,percent of total billed charges,97% of total billed charges,11412,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12299.6,97,,,percent of total billed charges,97% of total billed charges,11792.4,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12299.6,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,12299.6,
67961 -OCC Exc/rpr eyelid/to 1/4 lid margin,3548681,CDM,983,RC,67961,HCPCS,Outpatient,,,12680,6340.00,,11412,90,,,percent of total billed charges,90% of total Billed charges,970.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,697.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,784.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,784.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,651.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,358.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,845.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,769.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,466.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,655.48,155,,,Fee Schedule,155% of CMS OPPS Rate,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1504.88,155,,,Fee Schedule,155% of CMS OPPS Rate,1504.88,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,542.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,422.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1158.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,358.5,11412,
"67966- OCC EYE Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus,",3569424,CDM,983,RC,67966,HCPCS,Outpatient,,,13071.64,6535.82,,11764.48,90,,,percent of total billed charges,90% of total Billed charges,1342.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,949.27,155,,,Fee Schedule,155% of CMS OPPS Rate,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1006.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,612.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1132.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1132.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,946.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,946.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,517.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1224.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1116.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,679.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,949.27,155,,,Fee Schedule,155% of CMS OPPS Rate,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,2081.14,155,,,Fee Schedule,155% of CMS OPPS Rate,2081.14,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,611.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,612.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,1572.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,1572.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,517.37,11764.48,
"68110- OCC EYE Excision of lesion, conj up to 1 cm",3569429,CDM,983,RC,68110,HCPCS,Outpatient,,,286.5,143.25,,257.85,90,,,percent of total billed charges,90% of total Billed charges,355.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.31,155,,,Fee Schedule,155% of CMS OPPS Rate,137.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,137.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,254.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,254.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,210.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,210.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,275.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,248.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,149.05,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,213.31,155,,,Fee Schedule,155% of CMS OPPS Rate,137.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,551.52,155,,,Fee Schedule,155% of CMS OPPS Rate,551.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,380.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,137.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,444.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,444.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.02,551.52,
68440- OCC EYE Snip incision of lacrimal punctum,3569422,CDM,983,RC,68440,HCPCS,Outpatient,,,1662.67,831.34,,1496.4,90,,,percent of total billed charges,90% of total Billed charges,187.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.23,155,,,Fee Schedule,155% of CMS OPPS Rate,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,139.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,139.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,99.25,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.23,155,,,Fee Schedule,155% of CMS OPPS Rate,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.31,155,,,Fee Schedule,155% of CMS OPPS Rate,291.31,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,310.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,206.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.18,1496.4,
"68705 - Correction of everted punctum, cautery",3572818,CDM,983,RC,68705,HCPCS,Outpatient,,,1791.85,895.93,,1612.67,90,,,percent of total billed charges,90% of total Billed charges,399.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.79,155,,,Fee Schedule,155% of CMS OPPS Rate,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,154.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,285.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,236.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,236.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,309.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,279.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,168.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,239.79,155,,,Fee Schedule,155% of CMS OPPS Rate,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,619.02,155,,,Fee Schedule,155% of CMS OPPS Rate,619.02,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,368.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,154.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,469.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,469.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,131.11,1612.67,
"68760 -Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery PF",4333262,CDM,983,RC,68760,HCPCS,Outpatient,,,1752.99,876.50,,1577.69,90,,,percent of total billed charges,90% of total Billed charges,339.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.85,155,,,Fee Schedule,155% of CMS OPPS Rate,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,250.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,250.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,207.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,207.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,115.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,270.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,244.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,209.85,155,,,Fee Schedule,155% of CMS OPPS Rate,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,526.58,155,,,Fee Schedule,155% of CMS OPPS Rate,526.58,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,301.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,135.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,398.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,115.09,1577.69,
68761- Close lacrimal punctum/plug/each,3431340,CDM,510,RC,68761,HCPCS,Outpatient,,,1696.02,848.01,,1526.42,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.82,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1526.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1645.14,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1560.34,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1526.42,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1187.21,70,,,percent of total billed charges,70% of total billed charges,1526.42,90,,,percent of total billed charges,90% of total billed charges,1611.22,95,,,percent of total billed charges,95% of total billed charges,1611.22,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1458.58,86,,,percent of total billed charges,86% of total billed charges,1356.82,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1645.14,97,,,percent of total billed charges,97% of total billed charges,1526.42,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1645.14,97,,,percent of total billed charges,97% of total billed charges,1577.3,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1645.14,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1645.14,
68761-OCC Close lacrimal punctum/plug/each,3536979,CDM,983,RC,68761,HCPCS,Outpatient,,,1696.02,848.01,,1526.42,90,,,percent of total billed charges,90% of total Billed charges,245.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,202.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,202.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,116.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,168.36,155,,,Fee Schedule,155% of CMS OPPS Rate,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.48,155,,,Fee Schedule,155% of CMS OPPS Rate,380.48,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,204.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,291.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,93.71,1526.42,
68801- Dilation of lacrimal punctum,3431341,CDM,510,RC,68801,HCPCS,Outpatient,,,2163.94,1081.97,,1947.55,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.15,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1947.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2099.02,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1990.82,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1947.55,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1514.76,70,,,percent of total billed charges,70% of total billed charges,1947.55,90,,,percent of total billed charges,90% of total billed charges,2055.74,95,,,percent of total billed charges,95% of total billed charges,2055.74,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1860.99,86,,,percent of total billed charges,86% of total billed charges,1731.15,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2099.02,97,,,percent of total billed charges,97% of total billed charges,1947.55,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2099.02,97,,,percent of total billed charges,97% of total billed charges,2012.46,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2099.02,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.49,2099.02,
68801-OCC Dilation of lacrimal punctum,3536980,CDM,983,RC,68801,HCPCS,Outpatient,,,2163.94,1081.97,,1947.55,90,,,percent of total billed charges,90% of total Billed charges,160.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,132.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,132.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,108.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,75.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,112.13,155,,,Fee Schedule,155% of CMS OPPS Rate,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.52,155,,,Fee Schedule,155% of CMS OPPS Rate,249.52,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,136.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,244.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,68.54,1947.55,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,12062.46,6031.23,,10856.21,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9649.97,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10856.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11700.59,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11097.46,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10856.21,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8443.72,70,,,percent of total billed charges,70% of total billed charges,10856.21,90,,,percent of total billed charges,90% of total billed charges,11459.34,95,,,percent of total billed charges,95% of total billed charges,11459.34,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10373.72,86,,,percent of total billed charges,86% of total billed charges,9649.97,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11700.59,97,,,percent of total billed charges,97% of total billed charges,10856.21,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11700.59,97,,,percent of total billed charges,97% of total billed charges,11218.09,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11700.59,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11700.59,
68815 -OCC Probe/nasolacrimal/tube/stent,3548684,CDM,983,RC,68815,HCPCS,Outpatient,,,12229.54,6114.77,,11006.59,90,,,percent of total billed charges,90% of total Billed charges,555.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,382.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,382.32,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,316.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,174.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,412.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,373.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,225.92,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,319.97,155,,,Fee Schedule,155% of CMS OPPS Rate,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,860.92,155,,,Fee Schedule,155% of CMS OPPS Rate,860.92,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,723.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,206.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,874.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,874.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,174.94,11006.59,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,510,RC,68815,HCPCS,Outpatient,,,12229.54,6114.77,,11006.59,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9783.63,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11006.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11862.65,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11251.18,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11006.59,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8560.68,70,,,percent of total billed charges,70% of total billed charges,11006.59,90,,,percent of total billed charges,90% of total billed charges,11618.06,95,,,percent of total billed charges,95% of total billed charges,11618.06,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10517.4,86,,,percent of total billed charges,86% of total billed charges,9783.63,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11862.65,97,,,percent of total billed charges,97% of total billed charges,11006.59,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11862.65,97,,,percent of total billed charges,97% of total billed charges,11373.47,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11862.65,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11862.65,
68840 -OCC Probe lacrimal canaliculi,3548685,CDM,983,RC,68840,HCPCS,Outpatient,,,1696.23,848.12,,1526.61,90,,,percent of total billed charges,90% of total Billed charges,231.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,216.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,193.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,167.97,155,,,Fee Schedule,155% of CMS OPPS Rate,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.18,155,,,Fee Schedule,155% of CMS OPPS Rate,359.18,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,154.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,108.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,257.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.92,1526.61,
68840- Probe lacrimal canaliculi,3431343,CDM,510,RC,68840,HCPCS,Outpatient,,,1696.23,848.12,,1526.61,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1356.98,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1526.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1645.34,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1560.53,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1526.61,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1187.36,70,,,percent of total billed charges,70% of total billed charges,1526.61,90,,,percent of total billed charges,90% of total billed charges,1611.42,95,,,percent of total billed charges,95% of total billed charges,1611.42,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1458.76,86,,,percent of total billed charges,86% of total billed charges,1356.98,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1645.34,97,,,percent of total billed charges,97% of total billed charges,1526.61,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1645.34,97,,,percent of total billed charges,97% of total billed charges,1577.49,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1645.34,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1645.34,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,1326.75,663.38,,1194.08,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1061.4,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1194.08,90,,,Percent of total Billed charges,90% of total billed charges,45.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1286.95,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1220.61,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1194.08,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,928.73,70,,,percent of total billed charges,70% of total billed charges,1194.08,90,,,percent of total billed charges,90% of total billed charges,1260.41,95,,,percent of total billed charges,95% of total billed charges,1260.41,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1141.01,86,,,percent of total billed charges,86% of total billed charges,1061.4,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1286.95,97,,,percent of total billed charges,97% of total billed charges,1194.08,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1286.95,97,,,percent of total billed charges,97% of total billed charges,1233.88,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1286.95,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.69,1286.95,
EAR REM IMPACT CERUMEN,3428422,CDM,360,RC,69210,HCPCS,Outpatient,,,121.35,60.68,,109.22,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,97.08,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.71,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,111.64,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,109.22,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,84.95,70,,,percent of total billed charges,70% of total billed charges,109.22,90,,,percent of total billed charges,90% of total billed charges,115.28,95,,,percent of total billed charges,95% of total billed charges,115.28,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,104.36,86,,,percent of total billed charges,86% of total billed charges,97.08,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,117.71,97,,,percent of total billed charges,97% of total billed charges,109.22,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.71,97,,,percent of total billed charges,97% of total billed charges,112.86,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.71,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
"69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning)",3584875,CDM,960,RC,69220,HCPCS,Outpatient,,,195.11,97.56,,175.6,90,,,percent of total billed charges,90% of total Billed charges,123.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.76,155,,,Fee Schedule,155% of CMS OPPS Rate,50.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.24,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,58.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,77.76,155,,,Fee Schedule,155% of CMS OPPS Rate,50.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.47,155,,,Fee Schedule,155% of CMS OPPS Rate,191.47,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,50.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131.83,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,280.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.17,280.16,
Orbits for Foreign Body,602189,CDM,320,RC,70030,HCPCS,Outpatient,,,79.56,39.78,,71.6,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,44.58,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.6,90,,,Percent of total Billed charges,90% of total billed charges,16.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.17,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,73.2,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,71.6,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,70,,,percent of total billed charges,70% of total billed charges,71.6,90,,,percent of total billed charges,90% of total billed charges,75.58,95,,,percent of total billed charges,95% of total billed charges,75.58,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.42,86,,,percent of total billed charges,86% of total billed charges,63.65,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,77.17,97,,,percent of total billed charges,97% of total billed charges,71.6,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.17,97,,,percent of total billed charges,97% of total billed charges,73.99,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.17,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.97,423.55,
Mandible Less than 4 views,602136,CDM,320,RC,70100,HCPCS,Outpatient,,,93.77,46.89,,84.39,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,53.55,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.39,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.96,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,86.27,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.39,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,65.64,70,,,percent of total billed charges,70% of total billed charges,84.39,90,,,percent of total billed charges,90% of total billed charges,89.08,95,,,percent of total billed charges,95% of total billed charges,89.08,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.64,86,,,percent of total billed charges,86% of total billed charges,75.02,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.96,97,,,percent of total billed charges,97% of total billed charges,84.39,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.96,97,,,percent of total billed charges,97% of total billed charges,87.21,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.96,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
Mandible Routine min 4 views,602134,CDM,320,RC,70110,HCPCS,Outpatient,,,107.34,53.67,,96.61,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,58.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.61,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,104.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,98.75,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,96.61,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,75.14,70,,,percent of total billed charges,70% of total billed charges,96.61,90,,,percent of total billed charges,90% of total billed charges,101.97,95,,,percent of total billed charges,95% of total billed charges,101.97,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.31,86,,,percent of total billed charges,86% of total billed charges,85.87,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,104.12,97,,,percent of total billed charges,97% of total billed charges,96.61,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.12,97,,,percent of total billed charges,97% of total billed charges,99.83,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,521.05,
WW Mandible Less than 4 views,3373266,CDM,972,RC,70110,HCPCS,Outpatient,,,107.34,53.67,,96.61,90,,,percent of total billed charges,90% of total Billed charges,56.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,79.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,96.61,
Mastoids min 3 views per side,602132,CDM,320,RC,70130,HCPCS,Outpatient,,,153.82,76.91,,138.44,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,84.28,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.44,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,149.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,138.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,107.67,70,,,percent of total billed charges,70% of total billed charges,138.44,90,,,percent of total billed charges,90% of total billed charges,146.13,95,,,percent of total billed charges,95% of total billed charges,146.13,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,132.29,86,,,percent of total billed charges,86% of total billed charges,123.06,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,149.21,97,,,percent of total billed charges,97% of total billed charges,138.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.21,97,,,percent of total billed charges,97% of total billed charges,143.05,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,521.05,
WW Mastoids min 3 views per side,3373268,CDM,972,RC,70130,HCPCS,Outpatient,,,153.82,76.91,,138.44,90,,,percent of total billed charges,90% of total Billed charges,82.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,155,,,Fee Schedule,155% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,114.83,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,107.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.64,138.44,
IAM,602096,CDM,320,RC,70134,HCPCS,Outpatient,,,150.36,75.18,,135.32,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,76.03,250,,,Fee Schedule,250% of Fee Schedule Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.85,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,138.33,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.46,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.32,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,70,,,percent of total billed charges,70% of total billed charges,135.32,90,,,percent of total billed charges,90% of total billed charges,142.84,95,,,percent of total billed charges,95% of total billed charges,142.84,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.31,86,,,percent of total billed charges,86% of total billed charges,120.29,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.85,97,,,percent of total billed charges,97% of total billed charges,135.32,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.85,97,,,percent of total billed charges,97% of total billed charges,139.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.85,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,2452.82,
Facial Bones,602068,CDM,320,RC,70150,HCPCS,Outpatient,,,116.13,58.07,,104.52,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.52,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,112.65,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,106.84,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,104.52,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,81.29,70,,,percent of total billed charges,70% of total billed charges,104.52,90,,,percent of total billed charges,90% of total billed charges,110.32,95,,,percent of total billed charges,95% of total billed charges,110.32,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,99.87,86,,,percent of total billed charges,86% of total billed charges,92.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,112.65,97,,,percent of total billed charges,97% of total billed charges,104.52,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.65,97,,,percent of total billed charges,97% of total billed charges,108,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112.65,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,521.05,
WW Facial Bones,3373186,CDM,972,RC,70150,HCPCS,Outpatient,,,116.13,58.07,,104.52,90,,,percent of total billed charges,90% of total Billed charges,61.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.62,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.48,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,86.42,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.96,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,79.96,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.44,104.52,
Nasal Bones,602181,CDM,320,RC,70160,HCPCS,Outpatient,,,92.87,46.44,,83.58,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.3,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.58,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.08,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,85.44,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,83.58,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,65.01,70,,,percent of total billed charges,70% of total billed charges,83.58,90,,,percent of total billed charges,90% of total billed charges,88.23,95,,,percent of total billed charges,95% of total billed charges,88.23,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,79.87,86,,,percent of total billed charges,86% of total billed charges,74.3,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.08,97,,,percent of total billed charges,97% of total billed charges,83.58,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.08,97,,,percent of total billed charges,97% of total billed charges,86.37,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.08,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
WW Nasal Bones,3373270,CDM,972,RC,70160,HCPCS,Outpatient,,,92.87,46.44,,83.58,90,,,percent of total billed charges,90% of total Billed charges,52.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.9,155,,,Fee Schedule,155% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,140,,,Fee Schedule,140% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.9,140,,,Fee Schedule,140% of CMS OPPS Rate,74.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,83.58,
Optic Foramina,602191,CDM,320,RC,70190,HCPCS,Outpatient,,,93.4,46.70,,84.06,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.3,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.06,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,90.6,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,85.93,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.06,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,65.38,70,,,percent of total billed charges,70% of total billed charges,84.06,90,,,percent of total billed charges,90% of total billed charges,88.73,95,,,percent of total billed charges,95% of total billed charges,88.73,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.32,86,,,percent of total billed charges,86% of total billed charges,74.72,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,90.6,97,,,percent of total billed charges,97% of total billed charges,84.06,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.6,97,,,percent of total billed charges,97% of total billed charges,86.86,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.6,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,423.55,
Orbits min 4 views,604260,CDM,320,RC,70200,HCPCS,Outpatient,,,118.76,59.38,,106.88,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.88,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,115.2,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,109.26,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,106.88,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.13,70,,,percent of total billed charges,70% of total billed charges,106.88,90,,,percent of total billed charges,90% of total billed charges,112.82,95,,,percent of total billed charges,95% of total billed charges,112.82,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.13,86,,,percent of total billed charges,86% of total billed charges,95.01,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,115.2,97,,,percent of total billed charges,97% of total billed charges,106.88,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.2,97,,,percent of total billed charges,97% of total billed charges,110.45,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,115.2,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,521.05,
WW Orbits min 4 views,3373272,CDM,972,RC,70200,HCPCS,Outpatient,,,118.76,59.38,,106.88,90,,,percent of total billed charges,90% of total Billed charges,61.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.86,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.62,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,63.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,63.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,86.42,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,81.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.44,106.88,
Sinuses Less than 3 views,602257,CDM,320,RC,70210,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,48.33,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.51,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.08,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,73.1,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,71.51,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.62,70,,,percent of total billed charges,70% of total billed charges,71.51,90,,,percent of total billed charges,90% of total billed charges,75.49,95,,,percent of total billed charges,95% of total billed charges,75.49,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.34,86,,,percent of total billed charges,86% of total billed charges,63.57,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,77.08,97,,,percent of total billed charges,97% of total billed charges,71.51,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.08,97,,,percent of total billed charges,97% of total billed charges,73.9,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.08,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
WW Sinuses Less than 3 views,3373312,CDM,972,RC,70210,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,42.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,71.51,
Sinus Series,602259,CDM,320,RC,70220,HCPCS,Outpatient,,,92.73,46.37,,83.46,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.46,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,89.95,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,85.31,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,83.46,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,64.91,70,,,percent of total billed charges,70% of total billed charges,83.46,90,,,percent of total billed charges,90% of total billed charges,88.09,95,,,percent of total billed charges,95% of total billed charges,88.09,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,79.75,86,,,percent of total billed charges,86% of total billed charges,74.18,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,89.95,97,,,percent of total billed charges,97% of total billed charges,83.46,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.95,97,,,percent of total billed charges,97% of total billed charges,86.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,89.95,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,423.55,
WW Sinus Series,3373310,CDM,972,RC,70220,HCPCS,Outpatient,,,92.73,46.37,,83.46,90,,,percent of total billed charges,90% of total Billed charges,48.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.64,155,,,Fee Schedule,155% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.64,140,,,Fee Schedule,140% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.64,140,,,Fee Schedule,140% of CMS OPPS Rate,67.89,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.88,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.03,83.46,
Sella Turcica,602281,CDM,320,RC,70240,HCPCS,Outpatient,,,81.3,40.65,,73.17,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.08,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.17,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.86,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,74.8,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,56.91,70,,,percent of total billed charges,70% of total billed charges,73.17,90,,,percent of total billed charges,90% of total billed charges,77.24,95,,,percent of total billed charges,95% of total billed charges,77.24,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.92,86,,,percent of total billed charges,86% of total billed charges,65.04,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.86,97,,,percent of total billed charges,97% of total billed charges,73.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.86,97,,,percent of total billed charges,97% of total billed charges,75.61,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.86,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
Skull AP and Lat,602255,CDM,320,RC,70250,HCPCS,Outpatient,,,87.46,43.73,,78.71,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,53.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.71,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,84.84,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,80.46,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,78.71,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,61.22,70,,,percent of total billed charges,70% of total billed charges,78.71,90,,,percent of total billed charges,90% of total billed charges,83.09,95,,,percent of total billed charges,95% of total billed charges,83.09,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,75.22,86,,,percent of total billed charges,86% of total billed charges,69.97,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,84.84,97,,,percent of total billed charges,97% of total billed charges,78.71,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.84,97,,,percent of total billed charges,97% of total billed charges,81.34,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.84,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,521.05,
WW Skull AP and Lat,3373314,CDM,972,RC,70250,HCPCS,Outpatient,,,87.46,43.73,,78.71,90,,,percent of total billed charges,90% of total Billed charges,48.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.79,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,33.64,155,,,Fee Schedule,155% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.64,140,,,Fee Schedule,140% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.64,140,,,Fee Schedule,140% of CMS OPPS Rate,67.47,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.13,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.13,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.03,78.71,
Skull Series,602251,CDM,320,RC,70260,HCPCS,Outpatient,,,110.1,55.05,,99.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.09,90,,,Percent of total Billed charges,90% of total billed charges,30.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,106.8,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,101.29,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,99.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,77.07,70,,,percent of total billed charges,70% of total billed charges,99.09,90,,,percent of total billed charges,90% of total billed charges,104.6,95,,,percent of total billed charges,95% of total billed charges,104.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,94.69,86,,,percent of total billed charges,86% of total billed charges,88.08,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,106.8,97,,,percent of total billed charges,97% of total billed charges,99.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.8,97,,,percent of total billed charges,97% of total billed charges,102.39,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,106.8,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.49,521.05,
WW Skull Series,3373316,CDM,972,RC,70260,HCPCS,Outpatient,,,110.1,55.05,,99.09,90,,,percent of total billed charges,90% of total Billed charges,55.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.54,155,,,Fee Schedule,155% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,85.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,60.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,60.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,77.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.48,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,88.48,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.53,99.09,
WW TMJ Open & Closed,3373338,CDM,972,RC,70328,HCPCS,Outpatient,,,85.1,42.55,,76.59,90,,,percent of total billed charges,90% of total Billed charges,46.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.92,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32,155,,,Fee Schedule,155% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,140,,,Fee Schedule,140% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,140,,,Fee Schedule,140% of CMS OPPS Rate,64.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.86,76.59,
Temporomandibular Jts open and closed,630441,CDM,320,RC,70330,HCPCS,Outpatient,,,130.09,65.05,,117.08,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.28,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.08,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.19,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,119.68,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.08,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,91.06,70,,,percent of total billed charges,70% of total billed charges,117.08,90,,,percent of total billed charges,90% of total billed charges,123.59,95,,,percent of total billed charges,95% of total billed charges,123.59,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,111.88,86,,,percent of total billed charges,86% of total billed charges,104.07,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.19,97,,,percent of total billed charges,97% of total billed charges,117.08,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.19,97,,,percent of total billed charges,97% of total billed charges,120.98,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.19,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
WW Temporomandibular Jts open and closed,3373326,CDM,972,RC,70330,HCPCS,Outpatient,,,130.09,65.05,,117.08,90,,,percent of total billed charges,90% of total Billed charges,74.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,99.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,38.38,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,56.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,90.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,117.08,
MRI TMJ,597371,CDM,614,RC,70336,HCPCS,Outpatient,,,687.3,343.65,,618.57,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,480.1,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,618.57,90,,,Percent of total Billed charges,90% of total billed charges,291.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,666.68,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,632.32,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,618.57,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,481.11,70,,,percent of total billed charges,70% of total billed charges,618.57,90,,,percent of total billed charges,90% of total billed charges,652.94,95,,,percent of total billed charges,95% of total billed charges,652.94,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,591.08,86,,,percent of total billed charges,86% of total billed charges,549.84,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,666.68,97,,,percent of total billed charges,97% of total billed charges,618.57,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,666.68,97,,,percent of total billed charges,97% of total billed charges,639.19,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,666.68,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.28,1138.43,
Soft Tissue Neck,602247,CDM,320,RC,70360,HCPCS,Outpatient,,,77.2,38.60,,69.48,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.08,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.48,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,74.88,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,71.02,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.48,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.04,70,,,percent of total billed charges,70% of total billed charges,69.48,90,,,percent of total billed charges,90% of total billed charges,73.34,95,,,percent of total billed charges,95% of total billed charges,73.34,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.39,86,,,percent of total billed charges,86% of total billed charges,61.76,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,74.88,97,,,percent of total billed charges,97% of total billed charges,69.48,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.88,97,,,percent of total billed charges,97% of total billed charges,71.8,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.88,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,423.55,
WW Soft Tissue Neck,3373318,CDM,972,RC,70360,HCPCS,Outpatient,,,77.2,38.60,,69.48,90,,,percent of total billed charges,90% of total Billed charges,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.34,155,,,Fee Schedule,155% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,56.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.5,69.48,
DOL Chest PA,3325655,CDM,324,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,57.4,90,,,percent of total billed charges,90% of total Billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,250,,,Fee Schedule,250% of Fee Schedule Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.4,90,,,Percent of total Billed charges,90% of total billed charges,8.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,61.87,97,,,Percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,58.68,92,,,Percent of total billed charges,92% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,209.74,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,57.4,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.65,70,,,percent of total billed charges,70% of total billed charges,57.4,90,,,percent of total billed charges,90% of total billed charges,60.59,95,,,percent of total billed charges,95% of total billed charges,60.59,95,,,percent of total billed charges,95% of total billed charges,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,54.85,86,,,percent of total billed charges,86% of total billed charges,51.02,80,,,percent of total billed charges,80% of total billed charges,82.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,61.87,97,,,percent of total billed charges,97% of total billed charges,57.4,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.87,97,,,percent of total billed charges,97% of total billed charges,59.32,93,,,percent of total billed charges,93% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.87,97,,,percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.11,423.55,
DOL Chest PA:Read,3325656,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,57.4,90,,,percent of total billed charges,90% of total Billed charges,30.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21.41,155,,,Fee Schedule,155% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,42.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,57.4,
Portable Chest,602311,CDM,324,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,57.4,90,,,percent of total billed charges,90% of total Billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,250,,,Fee Schedule,250% of Fee Schedule Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.4,90,,,Percent of total Billed charges,90% of total billed charges,8.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,61.87,97,,,Percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,58.68,92,,,Percent of total billed charges,92% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,209.74,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,57.4,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,44.65,70,,,percent of total billed charges,70% of total billed charges,57.4,90,,,percent of total billed charges,90% of total billed charges,60.59,95,,,percent of total billed charges,95% of total billed charges,60.59,95,,,percent of total billed charges,95% of total billed charges,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,54.85,86,,,percent of total billed charges,86% of total billed charges,51.02,80,,,percent of total billed charges,80% of total billed charges,82.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,61.87,97,,,percent of total billed charges,97% of total billed charges,57.4,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.87,97,,,percent of total billed charges,97% of total billed charges,59.32,93,,,percent of total billed charges,93% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.87,97,,,percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.11,423.55,
Read,3529345,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,57.4,90,,,percent of total billed charges,90% of total Billed charges,30.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21.41,155,,,Fee Schedule,155% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,42.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,57.4,
WW Chest single view AP or PA,3373170,CDM,972,RC,71045,HCPCS,Outpatient,,,63.78,31.89,,57.4,90,,,percent of total billed charges,90% of total Billed charges,30.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21.41,155,,,Fee Schedule,155% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,42.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,57.4,
Chest PA and Lat: Read,602000,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,74.22,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,74.22,
DOL Chest PA & Lat:Read,3325658,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,74.22,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,74.22,
WW Chest PA and Lat:WW DR Exam,3373168,CDM,972,RC,71046,HCPCS,Outpatient,,,82.47,41.24,,74.22,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,74.22,
WW Chest with apical Lordotic view,3373172,CDM,972,RC,71047,HCPCS,Outpatient,,,103.67,51.84,,93.3,90,,,percent of total billed charges,90% of total Billed charges,52.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.09,155,,,Fee Schedule,155% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,56.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,56.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,72.83,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,93.3,
WW Rib Lt 2 views with No Chest,3373276,CDM,972,RC,71100,HCPCS,Outpatient,,,90.37,45.19,,81.33,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,60.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,81.33,
WW Rib Rt 2 views with No Chest:WW DR Exam,3552736,CDM,972,RC,71100,HCPCS,Outpatient,,,90.37,45.19,,81.33,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,60.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,81.33,
Rib Rt with PA Chest Routine min 3 views,602299,CDM,320,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,93.3,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,54.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.3,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,100.56,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,95.38,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,93.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,72.57,70,,,percent of total billed charges,70% of total billed charges,93.3,90,,,percent of total billed charges,90% of total billed charges,98.49,95,,,percent of total billed charges,95% of total billed charges,98.49,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,89.16,86,,,percent of total billed charges,86% of total billed charges,82.94,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,100.56,97,,,percent of total billed charges,97% of total billed charges,93.3,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.56,97,,,percent of total billed charges,97% of total billed charges,96.41,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,100.56,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,521.05,
WW DR Exam,3552738,CDM,972,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,93.3,90,,,percent of total billed charges,90% of total Billed charges,52.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.5,155,,,Fee Schedule,155% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.5,140,,,Fee Schedule,140% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,140,,,Fee Schedule,140% of CMS OPPS Rate,73.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,74.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.07,93.3,
WW Rib Lt with PA Chest Rout min 3 views,3373278,CDM,972,RC,71101,HCPCS,Outpatient,,,103.67,51.84,,93.3,90,,,percent of total billed charges,90% of total Billed charges,52.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.5,155,,,Fee Schedule,155% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.5,140,,,Fee Schedule,140% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,140,,,Fee Schedule,140% of CMS OPPS Rate,73.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,74.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.07,93.3,
Ribs Bilat 3 views No Chest,602297,CDM,320,RC,71110,HCPCS,Outpatient,,,107.86,53.93,,97.07,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,104.62,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,99.23,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,97.07,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,75.5,70,,,percent of total billed charges,70% of total billed charges,97.07,90,,,percent of total billed charges,90% of total billed charges,102.47,95,,,percent of total billed charges,95% of total billed charges,102.47,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.76,86,,,percent of total billed charges,86% of total billed charges,86.29,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,104.62,97,,,percent of total billed charges,97% of total billed charges,97.07,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.62,97,,,percent of total billed charges,97% of total billed charges,100.31,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.62,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,521.05,
WW Ribs Bilat 3 views No Chest,3373280,CDM,972,RC,71110,HCPCS,Outpatient,,,107.86,53.93,,97.07,90,,,percent of total billed charges,90% of total Billed charges,53.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.31,155,,,Fee Schedule,155% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,32.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,74.89,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,76.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.65,97.07,
Ribs Bilat min 4 with PA Chest,602295,CDM,320,RC,71111,HCPCS,Outpatient,,,128.77,64.39,,115.89,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,68.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.89,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,124.91,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,118.47,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,115.89,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,90.14,70,,,percent of total billed charges,70% of total billed charges,115.89,90,,,percent of total billed charges,90% of total billed charges,122.33,95,,,percent of total billed charges,95% of total billed charges,122.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,110.74,86,,,percent of total billed charges,86% of total billed charges,103.02,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,124.91,97,,,percent of total billed charges,97% of total billed charges,115.89,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.91,97,,,percent of total billed charges,97% of total billed charges,119.76,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124.91,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,521.05,
WW Ribs Bilat min 4 with PA Chest,3373282,CDM,972,RC,71111,HCPCS,Outpatient,,,128.77,64.39,,115.89,90,,,percent of total billed charges,90% of total Billed charges,66.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.88,155,,,Fee Schedule,155% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,92.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,98.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,115.89,
Sternum min 2 views,602241,CDM,320,RC,71120,HCPCS,Outpatient,,,82.98,41.49,,74.68,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,44.58,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.68,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.49,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,76.34,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.68,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,58.09,70,,,percent of total billed charges,70% of total billed charges,74.68,90,,,percent of total billed charges,90% of total billed charges,78.83,95,,,percent of total billed charges,95% of total billed charges,78.83,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.36,86,,,percent of total billed charges,86% of total billed charges,66.38,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.49,97,,,percent of total billed charges,97% of total billed charges,74.68,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.49,97,,,percent of total billed charges,97% of total billed charges,77.17,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.49,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
WW Sternum min 2 views,3373324,CDM,972,RC,71120,HCPCS,Outpatient,,,82.98,41.49,,74.68,90,,,percent of total billed charges,90% of total Billed charges,43.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.73,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,35.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,74.68,
Sternoclavicular Joints min 3 views,602243,CDM,320,RC,71130,HCPCS,Outpatient,,,101.4,50.70,,91.26,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.8,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.26,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,98.36,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,93.29,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,91.26,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,70.98,70,,,percent of total billed charges,70% of total billed charges,91.26,90,,,percent of total billed charges,90% of total billed charges,96.33,95,,,percent of total billed charges,95% of total billed charges,96.33,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,87.2,86,,,percent of total billed charges,86% of total billed charges,81.12,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,98.36,97,,,percent of total billed charges,97% of total billed charges,91.26,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.36,97,,,percent of total billed charges,97% of total billed charges,94.3,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,98.36,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
WW Sternoclavicular Joints min 3 views,3373322,CDM,972,RC,71130,HCPCS,Outpatient,,,101.4,50.70,,91.26,90,,,percent of total billed charges,90% of total Billed charges,54.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.14,155,,,Fee Schedule,155% of CMS OPPS Rate,27.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.14,140,,,Fee Schedule,140% of CMS OPPS Rate,27.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.14,140,,,Fee Schedule,140% of CMS OPPS Rate,76.96,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,68.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19,91.26,
WW Spine single view,3373320,CDM,972,RC,72020,HCPCS,Outpatient,,,60.35,30.18,,54.32,90,,,percent of total billed charges,90% of total Billed charges,29.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21,155,,,Fee Schedule,155% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,33.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,33.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,140,,,Fee Schedule,140% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,140,,,Fee Schedule,140% of CMS OPPS Rate,41.94,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,24.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,43.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15,54.32,
Cervical Spine AP Lat and Odontoid,602010,CDM,320,RC,72040,HCPCS,Outpatient,,,96.66,48.33,,86.99,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,53.55,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.99,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93.76,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,88.93,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.99,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.66,70,,,percent of total billed charges,70% of total billed charges,86.99,90,,,percent of total billed charges,90% of total billed charges,91.83,95,,,percent of total billed charges,95% of total billed charges,91.83,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,83.13,86,,,percent of total billed charges,86% of total billed charges,77.33,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,93.76,97,,,percent of total billed charges,97% of total billed charges,86.99,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.76,97,,,percent of total billed charges,97% of total billed charges,89.89,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.76,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
WW Cervical Spine AP Lat and Odontoid,3373162,CDM,972,RC,72040,HCPCS,Outpatient,,,96.66,48.33,,86.99,90,,,percent of total billed charges,90% of total Billed charges,51.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.69,155,,,Fee Schedule,155% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.69,140,,,Fee Schedule,140% of CMS OPPS Rate,25.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.69,140,,,Fee Schedule,140% of CMS OPPS Rate,71.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,36.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.37,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,75.37,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.49,86.99,
Cervical Spine Series,602008,CDM,320,RC,72050,HCPCS,Outpatient,,,129.69,64.85,,116.72,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,73.03,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.72,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,125.8,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,119.31,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,116.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,90.78,70,,,percent of total billed charges,70% of total billed charges,116.72,90,,,percent of total billed charges,90% of total billed charges,123.21,95,,,percent of total billed charges,95% of total billed charges,123.21,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,111.53,86,,,percent of total billed charges,86% of total billed charges,103.75,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,125.8,97,,,percent of total billed charges,97% of total billed charges,116.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.8,97,,,percent of total billed charges,97% of total billed charges,120.61,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.8,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,521.05,
WW Cervical Spine Series,3373164,CDM,972,RC,72050,HCPCS,Outpatient,,,129.69,64.85,,116.72,90,,,percent of total billed charges,90% of total Billed charges,71.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,49.56,155,,,Fee Schedule,155% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.56,140,,,Fee Schedule,140% of CMS OPPS Rate,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.56,140,,,Fee Schedule,140% of CMS OPPS Rate,99.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.4,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,98.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.4,116.72,
Cervical Spine Series with Flex and Ext,602006,CDM,320,RC,72052,HCPCS,Outpatient,,,150.62,75.31,,135.56,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,88.03,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.56,90,,,Percent of total Billed charges,90% of total billed charges,35.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,146.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,138.57,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.56,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,105.43,70,,,percent of total billed charges,70% of total billed charges,135.56,90,,,percent of total billed charges,90% of total billed charges,143.09,95,,,percent of total billed charges,95% of total billed charges,143.09,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.53,86,,,percent of total billed charges,86% of total billed charges,120.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,146.1,97,,,percent of total billed charges,97% of total billed charges,135.56,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.1,97,,,percent of total billed charges,97% of total billed charges,140.08,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.5,521.05,
WW Cervical Spine Series w Flex and Ext,3373166,CDM,972,RC,72052,HCPCS,Outpatient,,,150.62,75.31,,135.56,90,,,percent of total billed charges,90% of total Billed charges,84.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49.34,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.94,155,,,Fee Schedule,155% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,50.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,118.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.1,135.56,
Thoracic Spine AP Lat with no swimmers,602225,CDM,320,RC,72070,HCPCS,Outpatient,,,80.63,40.32,,72.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,48.33,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.57,90,,,Percent of total Billed charges,90% of total billed charges,22.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,74.18,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,56.44,70,,,percent of total billed charges,70% of total billed charges,72.57,90,,,percent of total billed charges,90% of total billed charges,76.6,95,,,percent of total billed charges,95% of total billed charges,76.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.34,86,,,percent of total billed charges,86% of total billed charges,64.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.21,97,,,percent of total billed charges,97% of total billed charges,72.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.21,97,,,percent of total billed charges,97% of total billed charges,74.99,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.19,521.05,
WW Thoracic Spine AP Lat w no swimmers,3373328,CDM,972,RC,72070,HCPCS,Outpatient,,,80.63,40.32,,72.57,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.53,72.57,
Thoracic Spine Routine AP Lat and Swim,602231,CDM,320,RC,72072,HCPCS,Outpatient,,,96.04,48.02,,86.44,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,53.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.44,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,88.36,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,70,,,percent of total billed charges,70% of total billed charges,86.44,90,,,percent of total billed charges,90% of total billed charges,91.24,95,,,percent of total billed charges,95% of total billed charges,91.24,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,82.59,86,,,percent of total billed charges,86% of total billed charges,76.83,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,93.16,97,,,percent of total billed charges,97% of total billed charges,86.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.16,97,,,percent of total billed charges,97% of total billed charges,89.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,521.05,
WW Thoracic Spine Routine 3 views,3373330,CDM,972,RC,72072,HCPCS,Outpatient,,,96.04,48.02,,86.44,90,,,percent of total billed charges,90% of total Billed charges,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,68.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.2,86.44,
WW Thoracolumbar AP and Lat,3373332,CDM,972,RC,72080,HCPCS,Outpatient,,,85.5,42.75,,76.95,90,,,percent of total billed charges,90% of total Billed charges,43.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.38,155,,,Fee Schedule,155% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,61.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,69.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.7,76.95,
Scoliosis Standing AP or PA Spine,602283,CDM,320,RC,72081,HCPCS,Outpatient,,,104.29,52.15,,93.86,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,56.55,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.86,90,,,Percent of total Billed charges,90% of total billed charges,20.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,101.16,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,95.95,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,93.86,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,73,70,,,percent of total billed charges,70% of total billed charges,93.86,90,,,percent of total billed charges,90% of total billed charges,99.08,95,,,percent of total billed charges,95% of total billed charges,99.08,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,89.69,86,,,percent of total billed charges,86% of total billed charges,83.43,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,101.16,97,,,percent of total billed charges,97% of total billed charges,93.86,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.16,97,,,percent of total billed charges,97% of total billed charges,96.99,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.16,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.91,423.55,
WW Scoliosis Standing AP and PA Spine,3373300,CDM,972,RC,72081,HCPCS,Outpatient,,,104.29,52.15,,93.86,90,,,percent of total billed charges,90% of total Billed charges,53.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.58,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.31,155,,,Fee Schedule,155% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,56.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,56.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,74.89,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,93.86,
WW Scoliosis 2-3 views,3373294,CDM,972,RC,72082,HCPCS,Outpatient,,,170.82,85.41,,153.74,90,,,percent of total billed charges,90% of total Billed charges,97.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.91,155,,,Fee Schedule,155% of CMS OPPS Rate,48.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,91.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,91.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.91,140,,,Fee Schedule,140% of CMS OPPS Rate,48.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.91,140,,,Fee Schedule,140% of CMS OPPS Rate,136.65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.24,153.74,
WW Scoliosis 4-5 views,3373296,CDM,972,RC,72083,HCPCS,Outpatient,,,190.76,95.38,,171.68,90,,,percent of total billed charges,90% of total Billed charges,109.09,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,54.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,76.08,155,,,Fee Schedule,155% of CMS OPPS Rate,54.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,105.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,58.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.08,140,,,Fee Schedule,140% of CMS OPPS Rate,54.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.08,140,,,Fee Schedule,140% of CMS OPPS Rate,152.73,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,54.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.32,171.68,
WW Scoliosis 6 view minimun,3373298,CDM,972,RC,72084,HCPCS,Outpatient,,,239.23,119.62,,215.31,90,,,percent of total billed charges,90% of total Billed charges,139.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,97.48,155,,,Fee Schedule,155% of CMS OPPS Rate,69.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,179.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,125.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,125.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,69.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,139.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.48,140,,,Fee Schedule,140% of CMS OPPS Rate,69.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.48,140,,,Fee Schedule,140% of CMS OPPS Rate,195.33,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,83.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,215.31,
WW Lumbar Spine AP Lat and Spot,3373258,CDM,972,RC,72100,HCPCS,Outpatient,,,97.47,48.74,,87.72,90,,,percent of total billed charges,90% of total Billed charges,51.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.09,155,,,Fee Schedule,155% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.09,140,,,Fee Schedule,140% of CMS OPPS Rate,72.41,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,78.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.78,87.72,
Lumbar Spine Series,602140,CDM,320,RC,72110,HCPCS,Outpatient,,,124.84,62.42,,112.36,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,74.53,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.36,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.09,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,114.85,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.36,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,87.39,70,,,percent of total billed charges,70% of total billed charges,112.36,90,,,percent of total billed charges,90% of total billed charges,118.6,95,,,percent of total billed charges,95% of total billed charges,118.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.36,86,,,percent of total billed charges,86% of total billed charges,99.87,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.09,97,,,percent of total billed charges,97% of total billed charges,112.36,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.09,97,,,percent of total billed charges,97% of total billed charges,116.1,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.09,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,521.05,
WW Lumbar Spine Series,3373264,CDM,972,RC,72110,HCPCS,Outpatient,,,124.84,62.42,,112.36,90,,,percent of total billed charges,90% of total Billed charges,68.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,47.92,155,,,Fee Schedule,155% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.92,140,,,Fee Schedule,140% of CMS OPPS Rate,34.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.92,140,,,Fee Schedule,140% of CMS OPPS Rate,96.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.23,112.36,
WW Lumbar Spine Complete w Bending Views,3373262,CDM,972,RC,72114,HCPCS,Outpatient,,,150.62,75.31,,135.56,90,,,percent of total billed charges,90% of total Billed charges,83.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.13,155,,,Fee Schedule,155% of CMS OPPS Rate,41.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.13,140,,,Fee Schedule,140% of CMS OPPS Rate,41.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.13,140,,,Fee Schedule,140% of CMS OPPS Rate,117.32,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,142.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,142.88,
WW Lumbar Spine Bending Views,3373260,CDM,972,RC,72120,HCPCS,Outpatient,,,99.83,49.92,,89.85,90,,,percent of total billed charges,90% of total Billed charges,53.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,36.9,155,,,Fee Schedule,155% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.9,140,,,Fee Schedule,140% of CMS OPPS Rate,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.9,140,,,Fee Schedule,140% of CMS OPPS Rate,74.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,100.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.36,100.93,
Pelvis AP,602185,CDM,320,RC,72170,HCPCS,Outpatient,,,68.39,34.20,,61.55,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,51.33,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.55,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.34,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.92,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.55,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,47.87,70,,,percent of total billed charges,70% of total billed charges,61.55,90,,,percent of total billed charges,90% of total billed charges,64.97,95,,,percent of total billed charges,95% of total billed charges,64.97,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.82,86,,,percent of total billed charges,86% of total billed charges,54.71,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,66.34,97,,,percent of total billed charges,97% of total billed charges,61.55,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.34,97,,,percent of total billed charges,97% of total billed charges,63.6,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.34,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,521.05,
WW Pelvis AP,3373274,CDM,972,RC,72170,HCPCS,Outpatient,,,68.39,34.20,,61.55,90,,,percent of total billed charges,90% of total Billed charges,34.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,24.26,155,,,Fee Schedule,155% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,48.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.12,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.12,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.33,61.55,
Pelvis with Judet Views,602183,CDM,320,RC,72190,HCPCS,Outpatient,,,103.39,51.70,,93.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,61.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.05,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,100.29,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,95.12,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,93.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,72.37,70,,,percent of total billed charges,70% of total billed charges,93.05,90,,,percent of total billed charges,90% of total billed charges,98.22,95,,,percent of total billed charges,95% of total billed charges,98.22,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,88.92,86,,,percent of total billed charges,86% of total billed charges,82.71,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,100.29,97,,,percent of total billed charges,97% of total billed charges,93.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.29,97,,,percent of total billed charges,97% of total billed charges,96.15,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,100.29,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,521.05,
WW Sacroiliac Jts 3 views,3373286,CDM,972,RC,72200,HCPCS,Outpatient,,,80.23,40.12,,72.21,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.79,155,,,Fee Schedule,155% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.99,72.21,
Sacroiliac Joints 3 or more views,602292,CDM,320,RC,72202,HCPCS,Outpatient,,,96.04,48.02,,86.44,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,53.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.44,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,88.36,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,67.23,70,,,percent of total billed charges,70% of total billed charges,86.44,90,,,percent of total billed charges,90% of total billed charges,91.24,95,,,percent of total billed charges,95% of total billed charges,91.24,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,82.59,86,,,percent of total billed charges,86% of total billed charges,76.83,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,93.16,97,,,percent of total billed charges,97% of total billed charges,86.44,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.16,97,,,percent of total billed charges,97% of total billed charges,89.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,521.05,
WW Sacroiliac Joints 3 or more views,3373284,CDM,972,RC,72202,HCPCS,Outpatient,,,96.04,48.02,,86.44,90,,,percent of total billed charges,90% of total Billed charges,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.3,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,51.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,51.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.2,86.44,
Sacrum and Coccyx,601972,CDM,320,RC,72220,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.08,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.51,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.08,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,73.1,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,71.51,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.62,70,,,percent of total billed charges,70% of total billed charges,71.51,90,,,percent of total billed charges,90% of total billed charges,75.49,95,,,percent of total billed charges,95% of total billed charges,75.49,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.34,86,,,percent of total billed charges,86% of total billed charges,63.57,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,77.08,97,,,percent of total billed charges,97% of total billed charges,71.51,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.08,97,,,percent of total billed charges,97% of total billed charges,73.9,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.08,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
WW Sacrum and Coccyx,3373288,CDM,972,RC,72220,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,71.51,
WW Clavicle Lt,3373174,CDM,972,RC,73000,HCPCS,Outpatient,,,78.54,39.27,,70.69,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,70.69,
WW Clavicle Rt,3373176,CDM,972,RC,73000,HCPCS,Outpatient,,,78.54,39.27,,70.69,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,70.69,
WW Scapula Lt,3373290,CDM,972,RC,73010,HCPCS,Outpatient,,,58.9,29.45,,53.01,90,,,percent of total billed charges,90% of total Billed charges,26.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,155,,,Fee Schedule,155% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,140,,,Fee Schedule,140% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.55,140,,,Fee Schedule,140% of CMS OPPS Rate,37.41,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.25,59.64,
WW Scapula Rt,3373292,CDM,972,RC,73010,HCPCS,Outpatient,,,58.9,29.45,,53.01,90,,,percent of total billed charges,90% of total Billed charges,26.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,155,,,Fee Schedule,155% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.55,140,,,Fee Schedule,140% of CMS OPPS Rate,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.55,140,,,Fee Schedule,140% of CMS OPPS Rate,37.41,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.25,59.64,
Shoulder Rt one view,602265,CDM,320,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,47.83,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,33.35,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.83,90,,,Percent of total Billed charges,90% of total billed charges,15.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,51.55,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,48.89,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,47.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,37.2,70,,,percent of total billed charges,70% of total billed charges,47.83,90,,,percent of total billed charges,90% of total billed charges,50.48,95,,,percent of total billed charges,95% of total billed charges,50.48,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45.7,86,,,percent of total billed charges,86% of total billed charges,42.51,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.55,97,,,percent of total billed charges,97% of total billed charges,47.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.55,97,,,percent of total billed charges,97% of total billed charges,49.42,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.55,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.51,423.55,
WW Shoulder Lt 1 view,3373302,CDM,972,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,47.83,90,,,percent of total billed charges,90% of total Billed charges,25.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,155,,,Fee Schedule,155% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,35.34,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,45.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.66,47.83,
WW Shoulder Rt 1 view,3373306,CDM,972,RC,73020,HCPCS,Outpatient,,,53.14,26.57,,47.83,90,,,percent of total billed charges,90% of total Billed charges,25.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,155,,,Fee Schedule,155% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.8,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.72,140,,,Fee Schedule,140% of CMS OPPS Rate,35.34,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,45.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.66,47.83,
WW Shoulder Lt Rout 2 views,3373304,CDM,972,RC,73030,HCPCS,Outpatient,,,84.3,42.15,,75.87,90,,,percent of total billed charges,90% of total Billed charges,45.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.6,155,,,Fee Schedule,155% of CMS OPPS Rate,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.6,140,,,Fee Schedule,140% of CMS OPPS Rate,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.6,140,,,Fee Schedule,140% of CMS OPPS Rate,63.35,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.57,75.87,
WW Shoulder Rt Rout 2 views,3373308,CDM,972,RC,73030,HCPCS,Outpatient,,,84.3,42.15,,75.87,90,,,percent of total billed charges,90% of total Billed charges,45.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.6,155,,,Fee Schedule,155% of CMS OPPS Rate,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.6,140,,,Fee Schedule,140% of CMS OPPS Rate,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.6,140,,,Fee Schedule,140% of CMS OPPS Rate,63.35,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.57,75.87,
Acromioclavicular Joints Bilat,601905,CDM,320,RC,73050,HCPCS,Outpatient,,,70.11,35.06,,63.1,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,56.55,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.1,90,,,Percent of total Billed charges,90% of total billed charges,20.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.01,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,64.5,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.1,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.08,70,,,percent of total billed charges,70% of total billed charges,63.1,90,,,percent of total billed charges,90% of total billed charges,66.6,95,,,percent of total billed charges,95% of total billed charges,66.6,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.29,86,,,percent of total billed charges,86% of total billed charges,56.09,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.01,97,,,percent of total billed charges,97% of total billed charges,63.1,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.01,97,,,percent of total billed charges,97% of total billed charges,65.2,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.01,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19,423.55,
WW Acromioclavicular Joints Bilat,3373146,CDM,972,RC,73050,HCPCS,Outpatient,,,70.11,35.06,,63.1,90,,,percent of total billed charges,90% of total Billed charges,34.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,24.26,155,,,Fee Schedule,155% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.26,140,,,Fee Schedule,140% of CMS OPPS Rate,48.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,36.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.37,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,75.37,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.33,75.37,
WW Humerus Lt,3373240,CDM,972,RC,73060,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,69.97,
WW Humerus Rt,3373238,CDM,972,RC,73060,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,69.97,
WW Elbow Lt AP and Lat,3373178,CDM,972,RC,73070,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,37.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,52.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,64.26,
WW Elbow Rt AP & Lat,3373182,CDM,972,RC,73070,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,37.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,52.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,64.26,
WW Elbow Lt Rout AP Lat & Oblique,3373180,CDM,972,RC,73080,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,71.51,
WW Elbow Rt Rout AP Lat & Oblique,3373184,CDM,972,RC,73080,HCPCS,Outpatient,,,79.46,39.73,,71.51,90,,,percent of total billed charges,90% of total Billed charges,42.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,155,,,Fee Schedule,155% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.97,140,,,Fee Schedule,140% of CMS OPPS Rate,60.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.71,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.41,71.51,
WW Forearm Lt,3373208,CDM,972,RC,73090,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,38.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,155,,,Fee Schedule,155% of CMS OPPS Rate,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,140,,,Fee Schedule,140% of CMS OPPS Rate,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.71,140,,,Fee Schedule,140% of CMS OPPS Rate,53.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.08,64.26,
WW Forearm Rt,3373210,CDM,972,RC,73090,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,38.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,155,,,Fee Schedule,155% of CMS OPPS Rate,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.71,140,,,Fee Schedule,140% of CMS OPPS Rate,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.71,140,,,Fee Schedule,140% of CMS OPPS Rate,53.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,19.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.08,64.26,
Upper Extremity Rt Infant min 2 views,602199,CDM,320,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,43.83,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.97,90,,,Percent of total Billed charges,90% of total billed charges,12.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,75.41,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.97,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,54.42,70,,,percent of total billed charges,70% of total billed charges,69.97,90,,,percent of total billed charges,90% of total billed charges,73.85,95,,,percent of total billed charges,95% of total billed charges,73.85,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.86,86,,,percent of total billed charges,86% of total billed charges,62.19,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,75.41,97,,,percent of total billed charges,97% of total billed charges,69.97,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.41,97,,,percent of total billed charges,97% of total billed charges,72.3,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.41,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11,521.05,
WW Upper Extrem Lt Infant 2 views,3373344,CDM,972,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,42.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,69.97,
WW Upper Extrem Rt Infant 2 views,3373346,CDM,972,RC,73092,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,42.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,69.97,
WW Wrist Lt AP & Lat,3373348,CDM,972,RC,73100,HCPCS,Outpatient,,,82.47,41.24,,74.22,90,,,percent of total billed charges,90% of total Billed charges,45.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,155,,,Fee Schedule,155% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,140,,,Fee Schedule,140% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,140,,,Fee Schedule,140% of CMS OPPS Rate,64.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.95,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,60.95,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.86,74.22,
WW Wrist Rt AP & Lat,3373352,CDM,972,RC,73100,HCPCS,Outpatient,,,82.47,41.24,,74.22,90,,,percent of total billed charges,90% of total Billed charges,45.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,155,,,Fee Schedule,155% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,140,,,Fee Schedule,140% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,140,,,Fee Schedule,140% of CMS OPPS Rate,64.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.95,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,60.95,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.86,74.22,
WW Wrist Lt Rout AP Lat & Oblique,3373350,CDM,972,RC,73110,HCPCS,Outpatient,,,99.19,49.60,,89.27,90,,,percent of total billed charges,90% of total Billed charges,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.17,155,,,Fee Schedule,155% of CMS OPPS Rate,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.17,140,,,Fee Schedule,140% of CMS OPPS Rate,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.17,140,,,Fee Schedule,140% of CMS OPPS Rate,80.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.25,89.27,
WW Wrist Rt Rout AP Lat & Oblique,3373354,CDM,972,RC,73110,HCPCS,Outpatient,,,99.19,49.60,,89.27,90,,,percent of total billed charges,90% of total Billed charges,57.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.17,155,,,Fee Schedule,155% of CMS OPPS Rate,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.17,140,,,Fee Schedule,140% of CMS OPPS Rate,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.17,140,,,Fee Schedule,140% of CMS OPPS Rate,80.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,70.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,28.25,89.27,
WW Hand Lt AP & Lat,3373212,CDM,972,RC,73120,HCPCS,Outpatient,,,76.16,38.08,,68.54,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.53,68.54,
WW Hand Rt AP & Lat,3373216,CDM,972,RC,73120,HCPCS,Outpatient,,,76.16,38.08,,68.54,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,52.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.53,68.54,
WW Hand Lt AP Lat & Oblique,3373214,CDM,972,RC,73130,HCPCS,Outpatient,,,88.93,44.47,,80.04,90,,,percent of total billed charges,90% of total Billed charges,50.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.35,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.55,80.04,
WW Hand Rt AP Lat & Oblique,3373218,CDM,972,RC,73130,HCPCS,Outpatient,,,88.93,44.47,,80.04,90,,,percent of total billed charges,90% of total Billed charges,50.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.35,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.55,80.04,
Finger Rt,602058,CDM,320,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,81.68,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,56.55,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.68,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.04,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,83.5,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.68,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,63.53,70,,,percent of total billed charges,70% of total billed charges,81.68,90,,,percent of total billed charges,90% of total billed charges,86.22,95,,,percent of total billed charges,95% of total billed charges,86.22,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.05,86,,,percent of total billed charges,86% of total billed charges,72.61,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.04,97,,,percent of total billed charges,97% of total billed charges,81.68,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.04,97,,,percent of total billed charges,97% of total billed charges,84.41,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.04,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,423.55,
WW Fingers Lt,3373198,CDM,972,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,81.68,90,,,percent of total billed charges,90% of total Billed charges,54.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.54,155,,,Fee Schedule,155% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,76.94,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,81.68,
WW Fingers Rt,3373196,CDM,972,RC,73140,HCPCS,Outpatient,,,90.76,45.38,,81.68,90,,,percent of total billed charges,90% of total Billed charges,54.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.54,155,,,Fee Schedule,155% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.54,140,,,Fee Schedule,140% of CMS OPPS Rate,76.94,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.19,81.68,
"73206(26)- Computed tomographic angiography, upper extremity, with contrast material(s), including n",3621200,CDM,510,RC,73206,HCPCS,Outpatient,,,764.43,382.22,,687.99,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,420.2,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,687.99,90,,,Percent of total Billed charges,90% of total billed charges,207.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,741.5,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,703.28,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,687.99,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,535.1,70,,,percent of total billed charges,70% of total billed charges,687.99,90,,,percent of total billed charges,90% of total billed charges,726.21,95,,,percent of total billed charges,95% of total billed charges,726.21,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,657.41,86,,,percent of total billed charges,86% of total billed charges,611.54,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,741.5,97,,,percent of total billed charges,97% of total billed charges,687.99,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,741.5,97,,,percent of total billed charges,97% of total billed charges,710.92,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,741.5,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
Hip Rt 1 view,602110,CDM,320,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,71.6,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,45.33,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.6,90,,,Percent of total Billed charges,90% of total billed charges,16.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,77.17,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,73.2,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,71.6,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,55.69,70,,,percent of total billed charges,70% of total billed charges,71.6,90,,,percent of total billed charges,90% of total billed charges,75.58,95,,,percent of total billed charges,95% of total billed charges,75.58,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.42,86,,,percent of total billed charges,86% of total billed charges,63.65,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,77.17,97,,,percent of total billed charges,97% of total billed charges,71.6,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.17,97,,,percent of total billed charges,97% of total billed charges,73.99,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.17,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.92,423.55,
WW Hip Lt 1 view,3373220,CDM,972,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,71.6,90,,,percent of total billed charges,90% of total Billed charges,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,58.83,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,71.6,
WW Hip Rt 1 view,3373226,CDM,972,RC,73501,HCPCS,Outpatient,,,79.56,39.78,,71.6,90,,,percent of total billed charges,90% of total Billed charges,42.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,43.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.92,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,58.83,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,71.6,
C Arm Rt Hip,602024,CDM,320,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.65,90,,,Percent of total Billed charges,90% of total billed charges,24.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,110.64,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,104.94,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,102.65,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,79.84,70,,,percent of total billed charges,70% of total billed charges,102.65,90,,,percent of total billed charges,90% of total billed charges,108.36,95,,,percent of total billed charges,95% of total billed charges,108.36,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,98.09,86,,,percent of total billed charges,86% of total billed charges,91.25,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,110.64,97,,,percent of total billed charges,97% of total billed charges,102.65,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.64,97,,,percent of total billed charges,97% of total billed charges,106.08,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.64,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.36,423.55,
WW Hip Lt Rout include Pelvis,3373224,CDM,972,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,64.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,155,,,Fee Schedule,155% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,61.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,61.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,35.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,140,,,Fee Schedule,140% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.66,140,,,Fee Schedule,140% of CMS OPPS Rate,89.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.9,102.65,
WW Hip Rt Rout include Pelvis,3373230,CDM,972,RC,73502,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,64.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,155,,,Fee Schedule,155% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,61.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,61.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,35.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.66,140,,,Fee Schedule,140% of CMS OPPS Rate,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.66,140,,,Fee Schedule,140% of CMS OPPS Rate,89.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.9,102.65,
WW Hip Lt 4 views with Pelvis,3373222,CDM,972,RC,73503,HCPCS,Outpatient,,,143.13,71.57,,128.82,90,,,percent of total billed charges,90% of total Billed charges,81.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,155,,,Fee Schedule,155% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,114,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,128.82,
WW Hip Rt 4 views with Pelvis,3373228,CDM,972,RC,73503,HCPCS,Outpatient,,,143.13,71.57,,128.82,90,,,percent of total billed charges,90% of total Billed charges,81.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,155,,,Fee Schedule,155% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.9,140,,,Fee Schedule,140% of CMS OPPS Rate,114,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.64,128.82,
Hips Bilat,602106,CDM,320,RC,73521,HCPCS,Outpatient,,,100.63,50.32,,90.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,57.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.57,90,,,Percent of total Billed charges,90% of total billed charges,22.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,97.61,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,92.58,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,90.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,70.44,70,,,percent of total billed charges,70% of total billed charges,90.57,90,,,percent of total billed charges,90% of total billed charges,95.6,95,,,percent of total billed charges,95% of total billed charges,95.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,86.54,86,,,percent of total billed charges,86% of total billed charges,80.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,97.61,97,,,percent of total billed charges,97% of total billed charges,90.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.61,97,,,percent of total billed charges,97% of total billed charges,93.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,97.61,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.77,521.05,
WW Hips Bilat,3373232,CDM,972,RC,73521,HCPCS,Outpatient,,,100.63,50.32,,90.57,90,,,percent of total billed charges,90% of total Billed charges,54.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.02,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.72,155,,,Fee Schedule,155% of CMS OPPS Rate,26.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.72,140,,,Fee Schedule,140% of CMS OPPS Rate,26.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.72,140,,,Fee Schedule,140% of CMS OPPS Rate,75.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.94,90.57,
WW Hips Bilat 3-4 views w Pelvis,3373234,CDM,972,RC,73522,HCPCS,Outpatient,,,130.73,65.37,,117.66,90,,,percent of total billed charges,90% of total Billed charges,69.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,48.73,155,,,Fee Schedule,155% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.27,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.73,140,,,Fee Schedule,140% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.73,140,,,Fee Schedule,140% of CMS OPPS Rate,97.94,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.81,117.66,
WW Hips Bilat 5 views w Pelvis,3373236,CDM,972,RC,73523,HCPCS,Outpatient,,,149.18,74.59,,134.26,90,,,percent of total billed charges,90% of total Billed charges,82.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.99,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.71,155,,,Fee Schedule,155% of CMS OPPS Rate,41.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,113.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,113.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.71,140,,,Fee Schedule,140% of CMS OPPS Rate,41.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.71,140,,,Fee Schedule,140% of CMS OPPS Rate,115.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.15,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,41.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.22,134.26,
WW Femur Lt 1 view,3373190,CDM,972,RC,73551,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,37.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,52.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,64.26,
WW Femur Rt 1 view,3373194,CDM,972,RC,73551,HCPCS,Outpatient,,,71.4,35.70,,64.26,90,,,percent of total billed charges,90% of total Billed charges,37.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.08,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.01,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,52.64,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.05,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,64.26,
WW Femur Lt,3373188,CDM,972,RC,73552,HCPCS,Outpatient,,,85.87,42.94,,77.28,90,,,percent of total billed charges,90% of total Billed charges,47.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,155,,,Fee Schedule,155% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,66.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,77.28,
WW Femur Rt,3373192,CDM,972,RC,73552,HCPCS,Outpatient,,,85.87,42.94,,77.28,90,,,percent of total billed charges,90% of total Billed charges,47.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,155,,,Fee Schedule,155% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.24,140,,,Fee Schedule,140% of CMS OPPS Rate,66.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.74,77.28,
WW Knee Lt AP & Lat,3373244,CDM,972,RC,73560,HCPCS,Outpatient,,,83.26,41.63,,74.93,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,74.93,
WW Knee Rt AP & Lat,3373250,CDM,972,RC,73560,HCPCS,Outpatient,,,83.26,41.63,,74.93,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,45.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,45.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.17,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,74.93,
WW Knee Lt 3 views,3373242,CDM,972,RC,73562,HCPCS,Outpatient,,,99.32,49.66,,89.39,90,,,percent of total billed charges,90% of total Billed charges,56.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,78.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,71.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,89.39,
WW Knee Rt 3 views,3373248,CDM,972,RC,73562,HCPCS,Outpatient,,,99.32,49.66,,89.39,90,,,percent of total billed charges,90% of total Billed charges,56.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.52,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,78.6,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,71.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,89.39,
WW Knee Lt Series,3373246,CDM,972,RC,73564,HCPCS,Outpatient,,,112.47,56.24,,101.22,90,,,percent of total billed charges,90% of total Billed charges,62.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,88.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.32,101.22,
WW Knee Rt Series,3373252,CDM,972,RC,73564,HCPCS,Outpatient,,,112.47,56.24,,101.22,90,,,percent of total billed charges,90% of total Billed charges,62.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,88.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.32,101.22,
Knees Bilat Standing AP,602157,CDM,320,RC,73565,HCPCS,Outpatient,,,98.26,49.13,,88.43,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.43,90,,,Percent of total Billed charges,90% of total billed charges,19.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,95.31,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,90.4,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,88.43,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,68.78,70,,,percent of total billed charges,70% of total billed charges,88.43,90,,,percent of total billed charges,90% of total billed charges,93.35,95,,,percent of total billed charges,95% of total billed charges,93.35,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,84.5,86,,,percent of total billed charges,86% of total billed charges,78.61,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,95.31,97,,,percent of total billed charges,97% of total billed charges,88.43,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.31,97,,,percent of total billed charges,97% of total billed charges,91.38,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.31,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.36,423.55,
WW Knees Bilat Standing AP,3373254,CDM,972,RC,73565,HCPCS,Outpatient,,,98.26,49.13,,88.43,90,,,percent of total billed charges,90% of total Billed charges,56.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,79.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.39,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,68.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.4,88.43,
WW Tibia Fibula Lt,3373334,CDM,972,RC,73590,HCPCS,Outpatient,,,76.93,38.47,,69.24,90,,,percent of total billed charges,90% of total Billed charges,42.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,69.24,
WW Tibia Fibula Rt,3373336,CDM,972,RC,73590,HCPCS,Outpatient,,,76.93,38.47,,69.24,90,,,percent of total billed charges,90% of total Billed charges,42.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.57,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.57,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,69.24,
Lower Extremity Rt Infant min 2 views,602148,CDM,320,RC,73592,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,43.83,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.97,90,,,Percent of total Billed charges,90% of total billed charges,18.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,75.41,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,71.52,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,69.97,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,54.42,70,,,percent of total billed charges,70% of total billed charges,69.97,90,,,percent of total billed charges,90% of total billed charges,73.85,95,,,percent of total billed charges,95% of total billed charges,73.85,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,66.86,86,,,percent of total billed charges,86% of total billed charges,62.19,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,75.41,97,,,percent of total billed charges,97% of total billed charges,69.97,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.41,97,,,percent of total billed charges,97% of total billed charges,72.3,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.41,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.5,423.55,
WW Lower Extremity Bilat Infant,3373256,CDM,972,RC,73592,HCPCS,Outpatient,,,77.74,38.87,,69.97,90,,,percent of total billed charges,90% of total Billed charges,42.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,155,,,Fee Schedule,155% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.06,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.57,140,,,Fee Schedule,140% of CMS OPPS Rate,59.65,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.12,69.97,
WW Ankle Lt AP & Lat,3373148,CDM,972,RC,73600,HCPCS,Outpatient,,,78.49,39.25,,70.64,90,,,percent of total billed charges,90% of total Billed charges,43.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,155,,,Fee Schedule,155% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,60.89,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.7,70.64,
WW Ankle Rt AP & Lat,3373152,CDM,972,RC,73600,HCPCS,Outpatient,,,78.49,39.25,,70.64,90,,,percent of total billed charges,90% of total Billed charges,43.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,155,,,Fee Schedule,155% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.38,140,,,Fee Schedule,140% of CMS OPPS Rate,60.89,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21.7,70.64,
WW Ankle Lt AP Lat & Oblique,3373150,CDM,972,RC,73610,HCPCS,Outpatient,,,89.73,44.87,,80.76,90,,,percent of total billed charges,90% of total Billed charges,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.11,80.76,
WW Ankle Rt AP Lat & Oblique,3373154,CDM,972,RC,73610,HCPCS,Outpatient,,,89.73,44.87,,80.76,90,,,percent of total billed charges,90% of total Billed charges,50.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.11,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,63.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.11,80.76,
WW Foot Lt AP & Lat,3373200,CDM,972,RC,73620,HCPCS,Outpatient,,,69.06,34.53,,62.15,90,,,percent of total billed charges,90% of total Billed charges,37.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,155,,,Fee Schedule,155% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,51.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.49,62.15,
WW Foot Rt AP & Lat,3373204,CDM,972,RC,73620,HCPCS,Outpatient,,,69.06,34.53,,62.15,90,,,percent of total billed charges,90% of total Billed charges,37.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,155,,,Fee Schedule,155% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,51.81,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.49,62.15,
Foot Rt AP Lat and Oblique,602042,CDM,320,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,75.75,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,48.33,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.75,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,81.64,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,77.44,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,75.75,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,58.92,70,,,percent of total billed charges,70% of total billed charges,75.75,90,,,percent of total billed charges,90% of total billed charges,79.96,95,,,percent of total billed charges,95% of total billed charges,79.96,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,72.39,86,,,percent of total billed charges,86% of total billed charges,67.34,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,81.64,97,,,percent of total billed charges,97% of total billed charges,75.75,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.64,97,,,percent of total billed charges,97% of total billed charges,78.28,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,81.64,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
WW Foot Lt AP Lat & Oblique,3373202,CDM,972,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,75.75,90,,,percent of total billed charges,90% of total Billed charges,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65.42,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,75.75,
WW Foot Rt AP Lat & Oblique,3373206,CDM,972,RC,73630,HCPCS,Outpatient,,,84.17,42.09,,75.75,90,,,percent of total billed charges,90% of total Billed charges,46.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,155,,,Fee Schedule,155% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.84,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.42,140,,,Fee Schedule,140% of CMS OPPS Rate,65.42,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,59.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.16,75.75,
Calcaneus Rt,602018,CDM,320,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,63.55,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,40.08,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.55,90,,,Percent of total Billed charges,90% of total billed charges,12.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.49,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,64.96,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.55,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.43,70,,,percent of total billed charges,70% of total billed charges,63.55,90,,,percent of total billed charges,90% of total billed charges,67.08,95,,,percent of total billed charges,95% of total billed charges,67.08,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.72,86,,,percent of total billed charges,86% of total billed charges,56.49,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.49,97,,,percent of total billed charges,97% of total billed charges,63.55,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.49,97,,,percent of total billed charges,97% of total billed charges,65.67,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.49,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.5,423.55,
WW Calcaneus Lt,3373158,CDM,972,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,63.55,90,,,percent of total billed charges,90% of total Billed charges,37.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,155,,,Fee Schedule,155% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,52.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.49,63.55,
WW Calcaneus Rt,3373160,CDM,972,RC,73650,HCPCS,Outpatient,,,70.61,35.31,,63.55,90,,,percent of total billed charges,90% of total Billed charges,37.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,155,,,Fee Schedule,155% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.89,140,,,Fee Schedule,140% of CMS OPPS Rate,52.23,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,54.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.49,63.55,
Toes Rt,602213,CDM,320,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,63.93,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,46.83,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.93,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.9,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,65.35,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.93,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,49.72,70,,,percent of total billed charges,70% of total billed charges,63.93,90,,,percent of total billed charges,90% of total billed charges,67.48,95,,,percent of total billed charges,95% of total billed charges,67.48,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.09,86,,,percent of total billed charges,86% of total billed charges,56.82,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.9,97,,,percent of total billed charges,97% of total billed charges,63.93,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.9,97,,,percent of total billed charges,97% of total billed charges,66.06,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.9,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,423.55,
WW Toes Lt,3373340,CDM,972,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,63.93,90,,,percent of total billed charges,90% of total Billed charges,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,155,,,Fee Schedule,155% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,56.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.24,63.93,
WW Toes Rt,3373342,CDM,972,RC,73660,HCPCS,Outpatient,,,71.03,35.52,,63.93,90,,,percent of total billed charges,90% of total Billed charges,40.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,155,,,Fee Schedule,155% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,22.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,56.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.47,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.24,63.93,
WW Abdomen AP,3373136,CDM,972,RC,74018,HCPCS,Outpatient,,,74.03,37.02,,66.63,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.87,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,66.63,
WW Abdomen Flat and Uprt No Chest,3373140,CDM,972,RC,74019,HCPCS,Outpatient,,,90.5,45.25,,81.45,90,,,percent of total billed charges,90% of total Billed charges,45.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.82,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32,155,,,Fee Schedule,155% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32,140,,,Fee Schedule,140% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,140,,,Fee Schedule,140% of CMS OPPS Rate,64.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,35.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,81.45,
WW Abdomen Rout Flat & Uprt w PA Chest,3373142,CDM,972,RC,74021,HCPCS,Outpatient,,,106.03,53.02,,95.43,90,,,percent of total billed charges,90% of total Billed charges,53.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.23,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.31,155,,,Fee Schedule,155% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,56.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,56.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,34.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.79,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,140,,,Fee Schedule,140% of CMS OPPS Rate,75.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.46,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,95.43,
Abdomen Routine Flat and Uprt w PA Chest,601903,CDM,320,RC,74022,HCPCS,Outpatient,,,122.46,61.23,,110.21,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.21,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,118.79,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,112.66,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,110.21,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,85.72,70,,,percent of total billed charges,70% of total billed charges,110.21,90,,,percent of total billed charges,90% of total billed charges,116.34,95,,,percent of total billed charges,95% of total billed charges,116.34,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,105.32,86,,,percent of total billed charges,86% of total billed charges,97.97,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,118.79,97,,,percent of total billed charges,97% of total billed charges,110.21,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.79,97,,,percent of total billed charges,97% of total billed charges,113.89,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,118.79,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,521.05,
WW Abdomen W/S/E/D views w Chest,3373144,CDM,972,RC,74022,HCPCS,Outpatient,,,122.46,61.23,,110.21,90,,,percent of total billed charges,90% of total Billed charges,61.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.62,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,93.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.62,140,,,Fee Schedule,140% of CMS OPPS Rate,86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.13,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,89.13,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.44,110.21,
Esophageal Dilatation:Read,3334677,CDM,972,RC,74360,HCPCS,Outpatient,,,142.96,71.48,,128.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,137.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,117.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.29,228.66,
"74740 - PF - Hysterosalpingography, radiological supervision and interpretation",3640903,CDM,510,RC,74740,HCPCS,Outpatient,,,238.05,119.03,,214.25,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,133.7,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.25,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,230.91,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,219.01,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.25,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,166.64,70,,,percent of total billed charges,70% of total billed charges,214.25,90,,,percent of total billed charges,90% of total billed charges,226.15,95,,,percent of total billed charges,95% of total billed charges,226.15,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.72,86,,,percent of total billed charges,86% of total billed charges,190.44,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,230.91,97,,,percent of total billed charges,97% of total billed charges,214.25,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.91,97,,,percent of total billed charges,97% of total billed charges,221.39,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,230.91,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,1138.43,
75557 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635232,CDM,510,RC,75557,HCPCS,Outpatient,,,731.08,365.54,,657.97,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,440.03,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.97,90,,,Percent of total Billed charges,90% of total billed charges,276.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,709.15,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,672.59,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,657.97,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,511.76,70,,,percent of total billed charges,70% of total billed charges,657.97,90,,,percent of total billed charges,90% of total billed charges,694.53,95,,,percent of total billed charges,95% of total billed charges,694.53,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,628.73,86,,,percent of total billed charges,86% of total billed charges,584.86,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,709.15,97,,,percent of total billed charges,97% of total billed charges,657.97,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.15,97,,,percent of total billed charges,97% of total billed charges,679.9,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,709.15,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.28,1138.43,
75559 - (PF) Cardiac magnetic resonance imaging for morphology and function without contrast mat,3635233,CDM,510,RC,75559,HCPCS,Outpatient,,,982.73,491.37,,884.46,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,653.88,250,,,Fee Schedule,250% of Fee Schedule Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,884.46,90,,,Percent of total Billed charges,90% of total billed charges,276.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,953.25,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,904.11,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,884.46,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,687.91,70,,,percent of total billed charges,70% of total billed charges,884.46,90,,,percent of total billed charges,90% of total billed charges,933.59,95,,,percent of total billed charges,95% of total billed charges,933.59,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,845.15,86,,,percent of total billed charges,86% of total billed charges,786.18,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,953.25,97,,,percent of total billed charges,97% of total billed charges,884.46,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,953.25,97,,,percent of total billed charges,97% of total billed charges,913.94,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,953.25,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,251.54,2452.82,
75561(26)- Cardiac magnetic resonance imaging for morphology and function without contrast material(,3621301,CDM,510,RC,75561,HCPCS,Outpatient,,,952.9,476.45,,857.61,90,,,percent of total billed charges,90% of total Billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,629.9,250,,,Fee Schedule,250% of Fee Schedule Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,857.61,90,,,Percent of total Billed charges,90% of total billed charges,423.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,924.31,97,,,Percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,876.67,92,,,Percent of total billed charges,92% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,889.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1796.13,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,857.61,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,667.03,70,,,percent of total billed charges,70% of total billed charges,857.61,90,,,percent of total billed charges,90% of total billed charges,905.26,95,,,percent of total billed charges,95% of total billed charges,905.26,95,,,percent of total billed charges,95% of total billed charges,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,819.49,86,,,percent of total billed charges,86% of total billed charges,762.32,80,,,percent of total billed charges,80% of total billed charges,394.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,924.31,97,,,percent of total billed charges,97% of total billed charges,857.61,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,924.31,97,,,percent of total billed charges,97% of total billed charges,886.2,93,,,percent of total billed charges,93% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,384.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,924.31,97,,,percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,284.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,284.43,1796.13,
75565 (26) Cardiac MRI for velocity flow mapping,3620978,CDM,510,RC,75565,HCPCS,Outpatient,,,118.88,59.44,,106.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,86.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,109.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,75.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,93.5,78.65,,,percent of total billed charges,78.65% of total billed charges,106.2,89.33,,,percent of total billed charges,89.33% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.22,70,,,percent of total billed charges,70% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,112.94,95,,,percent of total billed charges,95% of total billed charges,112.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.24,86,,,percent of total billed charges,86% of total billed charges,95.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,110.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.92,115.31,
75565- Cardiac MRI for velocity flow mapping,3569427,CDM,510,RC,75565,HCPCS,Outpatient,,,118.88,59.44,,106.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,86.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,109.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,75.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,93.5,78.65,,,percent of total billed charges,78.65% of total billed charges,106.2,89.33,,,percent of total billed charges,89.33% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.22,70,,,percent of total billed charges,70% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,112.94,95,,,percent of total billed charges,95% of total billed charges,112.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.24,86,,,percent of total billed charges,86% of total billed charges,95.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,106.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,110.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.92,115.31,
"75572 - (PF) Computed tomography, heart, with contrast mater",3635236,CDM,510,RC,75572,HCPCS,Outpatient,,,582.52,291.26,,524.27,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,379,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.27,90,,,Percent of total Billed charges,90% of total billed charges,185.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,565.04,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,535.92,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,524.27,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,407.76,70,,,percent of total billed charges,70% of total billed charges,524.27,90,,,percent of total billed charges,90% of total billed charges,553.39,95,,,percent of total billed charges,95% of total billed charges,553.39,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,500.97,86,,,percent of total billed charges,86% of total billed charges,466.02,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,565.04,97,,,percent of total billed charges,97% of total billed charges,524.27,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.04,97,,,percent of total billed charges,97% of total billed charges,541.74,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,565.04,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
"75574(26)- Computed tomographic angiography, heart, coronary arteries and bypass grafts (when presen",3621300,CDM,510,RC,75574,HCPCS,Outpatient,,,829.3,414.65,,746.37,90,,,percent of total billed charges,90% of total Billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,420.2,250,,,Fee Schedule,250% of Fee Schedule Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,746.37,90,,,Percent of total Billed charges,90% of total billed charges,227.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,804.42,97,,,Percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,762.96,92,,,Percent of total billed charges,92% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,435.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,694.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,879.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,746.37,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,580.51,70,,,percent of total billed charges,70% of total billed charges,746.37,90,,,percent of total billed charges,90% of total billed charges,787.84,95,,,percent of total billed charges,95% of total billed charges,787.84,95,,,percent of total billed charges,95% of total billed charges,163.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,327.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,713.2,86,,,percent of total billed charges,86% of total billed charges,663.44,80,,,percent of total billed charges,80% of total billed charges,188.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,804.42,97,,,percent of total billed charges,97% of total billed charges,746.37,90,,,percent of total billed charges,90% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,804.42,97,,,percent of total billed charges,97% of total billed charges,771.25,93,,,percent of total billed charges,93% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,804.42,97,,,percent of total billed charges,97% of total billed charges,163.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.79,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.21,879.17,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,16287.33,8143.67,,14658.6,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14658.6,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15798.71,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14984.34,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14658.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11401.13,70,,,percent of total billed charges,70% of total billed charges,14658.6,90,,,percent of total billed charges,90% of total billed charges,15472.96,95,,,percent of total billed charges,95% of total billed charges,15472.96,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14007.1,86,,,percent of total billed charges,86% of total billed charges,13029.86,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15798.71,97,,,percent of total billed charges,97% of total billed charges,14658.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15798.71,97,,,percent of total billed charges,97% of total billed charges,15147.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15798.71,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.98,15798.71,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,16287.33,8143.67,,14658.6,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14658.6,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15798.71,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14984.34,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14658.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11401.13,70,,,percent of total billed charges,70% of total billed charges,14658.6,90,,,percent of total billed charges,90% of total billed charges,15472.96,95,,,percent of total billed charges,95% of total billed charges,15472.96,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14007.1,86,,,percent of total billed charges,86% of total billed charges,13029.86,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15798.71,97,,,percent of total billed charges,97% of total billed charges,14658.6,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15798.71,97,,,percent of total billed charges,97% of total billed charges,15147.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15798.71,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.98,15798.71,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,14639.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14639.25,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15777.86,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11386.08,70,,,percent of total billed charges,70% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13988.61,86,,,percent of total billed charges,86% of total billed charges,13012.66,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15777.86,97,,,percent of total billed charges,97% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15777.86,97,,,percent of total billed charges,97% of total billed charges,15127.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15777.86,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15777.86,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,14639.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14639.25,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15777.86,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11386.08,70,,,percent of total billed charges,70% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13988.61,86,,,percent of total billed charges,86% of total billed charges,13012.66,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15777.86,97,,,percent of total billed charges,97% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15777.86,97,,,percent of total billed charges,97% of total billed charges,15127.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15777.86,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15777.86,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,14639.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14639.25,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15777.86,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11386.08,70,,,percent of total billed charges,70% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13988.61,86,,,percent of total billed charges,86% of total billed charges,13012.66,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15777.86,97,,,percent of total billed charges,97% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15777.86,97,,,percent of total billed charges,97% of total billed charges,15127.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15777.86,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15777.86,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,16265.83,8132.92,,14639.25,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14639.25,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15777.86,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14964.56,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11386.08,70,,,percent of total billed charges,70% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,15452.54,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13988.61,86,,,percent of total billed charges,86% of total billed charges,13012.66,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15777.86,97,,,percent of total billed charges,97% of total billed charges,14639.25,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15777.86,97,,,percent of total billed charges,97% of total billed charges,15127.22,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15777.86,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15777.86,
"75716 - PF - Angiography, extremity, bilateral, radiological supervision and interpretation",3640906,CDM,510,RC,75716,HCPCS,Outpatient,,,418.27,209.14,,376.44,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.44,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,405.72,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,384.81,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,376.44,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,292.79,70,,,percent of total billed charges,70% of total billed charges,376.44,90,,,percent of total billed charges,90% of total billed charges,397.36,95,,,percent of total billed charges,95% of total billed charges,397.36,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,359.71,86,,,percent of total billed charges,86% of total billed charges,334.62,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,405.72,97,,,percent of total billed charges,97% of total billed charges,376.44,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.72,97,,,percent of total billed charges,97% of total billed charges,388.99,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,405.72,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75894 XR Transcatheter Embolization Any Meth RS&I,3436057,CDM,761,RC,75894,HCPCS,Outpatient,,,376.14,188.07,,338.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2102.5,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,338.53,90,,,Percent of total Billed charges,90% of total billed charges,103.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,364.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,346.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,240.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,295.84,78.65,,,percent of total billed charges,78.65% of total billed charges,336.01,89.33,,,percent of total billed charges,89.33% of total billed charges,338.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,263.3,70,,,percent of total billed charges,70% of total billed charges,338.53,90,,,percent of total billed charges,90% of total billed charges,357.33,95,,,percent of total billed charges,95% of total billed charges,357.33,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.48,86,,,percent of total billed charges,86% of total billed charges,300.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,364.86,97,,,percent of total billed charges,97% of total billed charges,338.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,364.86,97,,,percent of total billed charges,97% of total billed charges,349.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,364.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.04,2102.5,
Foreign Body Nose to Rectum Child,602034,CDM,320,RC,76010,HCPCS,Outpatient,,,73.24,36.62,,65.92,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,38.58,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.92,90,,,Percent of total Billed charges,90% of total billed charges,9.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,71.04,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,67.38,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,65.92,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,51.27,70,,,percent of total billed charges,70% of total billed charges,65.92,90,,,percent of total billed charges,90% of total billed charges,69.58,95,,,percent of total billed charges,95% of total billed charges,69.58,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.99,86,,,percent of total billed charges,86% of total billed charges,58.59,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,71.04,97,,,percent of total billed charges,97% of total billed charges,65.92,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.04,97,,,percent of total billed charges,97% of total billed charges,68.11,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.04,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.7,423.55,
3D TEE Imaging,3569848,CDM,350,RC,76376,HCPCS,Outpatient,,,50.84,25.42,,45.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,45.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,49.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,46.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,32.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,39.99,78.65,,,percent of total billed charges,78.65% of total billed charges,45.42,89.33,,,percent of total billed charges,89.33% of total billed charges,45.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.59,70,,,percent of total billed charges,70% of total billed charges,45.76,90,,,percent of total billed charges,90% of total billed charges,48.3,95,,,percent of total billed charges,95% of total billed charges,48.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.72,86,,,percent of total billed charges,86% of total billed charges,40.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,49.31,97,,,percent of total billed charges,97% of total billed charges,45.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,49.31,97,,,percent of total billed charges,97% of total billed charges,47.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.1,49.31,
"76376(26)- 3D rendering with interpretation and reporting of computed tomography, magnetic resonance",3620958,CDM,510,RC,76376,HCPCS,Outpatient,,,56.94,28.47,,51.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,51.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,52.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,36.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,44.78,78.65,,,percent of total billed charges,78.65% of total billed charges,50.87,89.33,,,percent of total billed charges,89.33% of total billed charges,51.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.86,70,,,percent of total billed charges,70% of total billed charges,51.25,90,,,percent of total billed charges,90% of total billed charges,54.09,95,,,percent of total billed charges,95% of total billed charges,54.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.97,86,,,percent of total billed charges,86% of total billed charges,45.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,55.23,97,,,percent of total billed charges,97% of total billed charges,51.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.23,97,,,percent of total billed charges,97% of total billed charges,52.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.1,55.23,
76536- US head and neck,3430613,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.47,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,266.72,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,252.97,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.48,70,,,percent of total billed charges,70% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,236.47,86,,,percent of total billed charges,86% of total billed charges,219.98,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,266.72,97,,,percent of total billed charges,97% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.72,97,,,percent of total billed charges,97% of total billed charges,255.72,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.72,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
SCMP US Guided Fine Needle Asp. Thyroid,3370908,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,247.47,
SCMP US Guided Fine Needle Asp. Thyroid,3575239,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,247.47,
SCMP US Guided Fine Needle Asp. Thyroid,3575240,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,247.47,
SCMP US Thyroid,3575246,CDM,972,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,247.47,
SCMP US Thyroid,3370915,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.47,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,266.72,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,252.97,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.48,70,,,percent of total billed charges,70% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,236.47,86,,,percent of total billed charges,86% of total billed charges,219.98,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,266.72,97,,,percent of total billed charges,97% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.72,97,,,percent of total billed charges,97% of total billed charges,255.72,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.72,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
SCSN US Thyroid,3370964,CDM,402,RC,76536,HCPCS,Outpatient,,,274.97,137.49,,247.47,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.47,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,266.72,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,252.97,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.48,70,,,percent of total billed charges,70% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,261.22,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,236.47,86,,,percent of total billed charges,86% of total billed charges,219.98,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,266.72,97,,,percent of total billed charges,97% of total billed charges,247.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.72,97,,,percent of total billed charges,97% of total billed charges,255.72,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,266.72,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
US Chest Marking Rt,3351913,CDM,402,RC,76604,HCPCS,Outpatient,,,146.66,73.33,,131.99,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,130.7,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.99,90,,,Percent of total Billed charges,90% of total billed charges,51.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,142.26,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.93,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,131.99,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.66,70,,,percent of total billed charges,70% of total billed charges,131.99,90,,,percent of total billed charges,90% of total billed charges,139.33,95,,,percent of total billed charges,95% of total billed charges,139.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,126.13,86,,,percent of total billed charges,86% of total billed charges,117.33,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,142.26,97,,,percent of total billed charges,97% of total billed charges,131.99,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.26,97,,,percent of total billed charges,97% of total billed charges,136.39,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.26,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.92,521.05,
76641 - (26) US Breast Complete,3896985,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
76641 - (TC) US Breast Complete,3896992,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
76641 - US Breast Complete,3896999,CDM,960,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
76641- US  breast complete,3430614,CDM,402,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.28,90,,,Percent of total Billed charges,90% of total billed charges,58.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,248.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,235.4,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,179.11,70,,,percent of total billed charges,70% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,243.08,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,220.05,86,,,percent of total billed charges,86% of total billed charges,204.7,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,248.19,97,,,percent of total billed charges,97% of total billed charges,230.28,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.19,97,,,percent of total billed charges,97% of total billed charges,237.96,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,248.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.43,521.05,
Read,3575229,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast L,3370898,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast L,3575230,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast L,3575232,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast L:Read,4119871,CDM,983,RC,76641,HCPCS,Outpatient,,,228.46,114.23,,205.61,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
SCMP US Breast R,3370900,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast R:Read,3575231,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
SCMP US Breast R:Read,4119897,CDM,983,RC,76641,HCPCS,Outpatient,,,228.46,114.23,,205.61,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,217.06,
US Breast Left:Read,3317746,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
US HKBT Breast Bilateral:Read,3317823,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
US HKBT Breast Left:Read,3317809,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
US HKBT Breast Right:Read,3317816,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
WHFMT US Breast Complete Bilateral,4165499,CDM,972,RC,76641,HCPCS,Outpatient,,,511.76,255.88,,460.58,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,460.58,
WHFMT US Exam,4165501,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
WHFMT US Exam,4165503,CDM,972,RC,76641,HCPCS,Outpatient,,,255.87,127.94,,230.28,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,230.28,
76642 - (26) US Breast Limited,3897005,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
76642 - (TC) US Breast Limited,3897012,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
76642 - US Breast Limited,3897019,CDM,960,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
76642- US  breast limited,3430615,CDM,402,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
Read,3569766,CDM,510,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
Read,3575277,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast Limite Bilat Interp,3575275,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast Limited Bilat,3569759,CDM,401,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,379.83,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,379.83,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,409.37,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,388.27,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,379.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,295.42,70,,,percent of total billed charges,70% of total billed charges,379.83,90,,,percent of total billed charges,90% of total billed charges,400.93,95,,,percent of total billed charges,95% of total billed charges,400.93,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,362.95,86,,,percent of total billed charges,86% of total billed charges,337.62,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,409.37,97,,,percent of total billed charges,97% of total billed charges,379.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.37,97,,,percent of total billed charges,97% of total billed charges,392.49,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,409.37,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited LT,3569761,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited RT,3569763,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited RT Interp,3575279,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast w Axilla Bilat,3569765,CDM,401,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,379.83,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,379.83,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,409.37,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,388.27,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,379.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,295.42,70,,,percent of total billed charges,70% of total billed charges,379.83,90,,,percent of total billed charges,90% of total billed charges,400.93,95,,,percent of total billed charges,95% of total billed charges,400.93,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,362.95,86,,,percent of total billed charges,86% of total billed charges,337.62,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,409.37,97,,,percent of total billed charges,97% of total billed charges,379.83,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,409.37,97,,,percent of total billed charges,97% of total billed charges,392.49,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,409.37,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w axilla Bilat Interp,3575281,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast w Axilla LT,3575283,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast w Axilla LT,3575285,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
SCSN US Breast w Axilla LT,3569767,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w Axilla RT,3569769,CDM,401,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.91,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,204.68,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,194.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,147.71,70,,,percent of total billed charges,70% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,200.46,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.47,86,,,percent of total billed charges,86% of total billed charges,168.81,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,204.68,97,,,percent of total billed charges,97% of total billed charges,189.91,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.68,97,,,percent of total billed charges,97% of total billed charges,196.24,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,204.68,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
US Breast Bilateral Limited:Read,3318563,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
US Breast Rt Limited,3318871,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,359.17,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.17,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,387.11,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,367.15,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,279.36,70,,,percent of total billed charges,70% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,343.21,86,,,percent of total billed charges,86% of total billed charges,319.26,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,387.11,97,,,percent of total billed charges,97% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.11,97,,,percent of total billed charges,97% of total billed charges,371.14,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.11,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
WHFMT US Exam,3610982,CDM,972,RC,76642,HCPCS,Outpatient,,,422.03,211.02,,379.83,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,379.83,
WHFMT US Exam,3610984,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
WHFMT US Exam,3610986,CDM,972,RC,76642,HCPCS,Outpatient,,,211.01,105.51,,189.91,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,189.91,
"76700 (26) Ultrasound, abdominal, real time with image documentation; complete",3621069,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.78,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.14,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,267.6,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,203.61,70,,,percent of total billed charges,70% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.15,86,,,percent of total billed charges,86% of total billed charges,232.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.14,97,,,percent of total billed charges,97% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.14,97,,,percent of total billed charges,97% of total billed charges,270.51,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.14,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
"76700 (TC) Ultrasound, abdominal, real time with image documentation; complete",3621070,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.78,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.14,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,267.6,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,203.61,70,,,percent of total billed charges,70% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.15,86,,,percent of total billed charges,86% of total billed charges,232.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.14,97,,,percent of total billed charges,97% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.14,97,,,percent of total billed charges,97% of total billed charges,270.51,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.14,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
76700- US abdommen complete,3430616,CDM,402,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.78,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.14,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,267.6,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,203.61,70,,,percent of total billed charges,70% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.15,86,,,percent of total billed charges,86% of total billed charges,232.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.14,97,,,percent of total billed charges,97% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.14,97,,,percent of total billed charges,97% of total billed charges,270.51,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.14,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
Read,3575253,CDM,983,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
SCSN US Abdomen Complete PR:SCSN US Exam,3575254,CDM,510,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.78,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.14,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,267.6,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,203.61,70,,,percent of total billed charges,70% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.15,86,,,percent of total billed charges,86% of total billed charges,232.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.14,97,,,percent of total billed charges,97% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.14,97,,,percent of total billed charges,97% of total billed charges,270.51,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.14,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
SCSN US Abdomen Complete:SCSN US Exam,3555174,CDM,402,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.78,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,282.14,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,267.6,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,203.61,70,,,percent of total billed charges,70% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,276.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,250.15,86,,,percent of total billed charges,86% of total billed charges,232.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,282.14,97,,,percent of total billed charges,97% of total billed charges,261.78,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.14,97,,,percent of total billed charges,97% of total billed charges,270.51,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,282.14,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
US HKBT Abdomen  Complete,3317829,CDM,402,RC,76700,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,554.06,
US HKBT Abdomen  Complete:Read,3317830,CDM,983,RC,76700,HCPCS,Outpatient,,,290.87,145.44,,261.78,90,,,percent of total billed charges,90% of total Billed charges,140.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,95.27,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,96.88,155,,,Fee Schedule,155% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,102.56,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,118.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.88,140,,,Fee Schedule,140% of CMS OPPS Rate,196.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,69.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,263.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,69.2,263.47,
76705 - (TC) Echo Exam of Abdomen -Limited,3897025,CDM,960,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
"76705 (26) Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3621066,CDM,510,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.95,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,211.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.3,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,152.4,70,,,percent of total billed charges,70% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,187.24,86,,,percent of total billed charges,86% of total billed charges,174.18,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,211.19,97,,,percent of total billed charges,97% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.19,97,,,percent of total billed charges,97% of total billed charges,202.48,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,510,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.95,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,211.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.3,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,152.4,70,,,percent of total billed charges,70% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,187.24,86,,,percent of total billed charges,86% of total billed charges,174.18,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,211.19,97,,,percent of total billed charges,97% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.19,97,,,percent of total billed charges,97% of total billed charges,202.48,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
Read,,,972,RC,76705,HCPCS,Outpatient,,,69.19,34.60,,62.27,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3575225,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
Read,3575309,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
SCMP US Abdomen,3370896,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
SCMP US Abdomen,3575226,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
SCSN US Exam,3575310,CDM,402,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.95,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,211.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.3,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,152.4,70,,,percent of total billed charges,70% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,187.24,86,,,percent of total billed charges,86% of total billed charges,174.18,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,211.19,97,,,percent of total billed charges,97% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.19,97,,,percent of total billed charges,97% of total billed charges,202.48,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
SCSN US RUQ/GB Ultrasound,3370960,CDM,402,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.95,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,211.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.3,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,152.4,70,,,percent of total billed charges,70% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,206.83,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,187.24,86,,,percent of total billed charges,86% of total billed charges,174.18,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,211.19,97,,,percent of total billed charges,97% of total billed charges,195.95,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,211.19,97,,,percent of total billed charges,97% of total billed charges,202.48,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,211.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
URMC US Abdomen,3358605,CDM,402,RC,76705,HCPCS,Outpatient,,,534.4,267.20,,480.96,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.96,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,518.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,491.65,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,374.08,70,,,percent of total billed charges,70% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.58,86,,,percent of total billed charges,86% of total billed charges,427.52,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,518.37,97,,,percent of total billed charges,97% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.37,97,,,percent of total billed charges,97% of total billed charges,496.99,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,518.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
US Abdomen Limited,596617,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,554.06,
US Biliary Tree,3351907,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,554.06,
US Biliary Tree:Read,3351906,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
US Gallbladder,3351919,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,554.06,
US HKBT Abdomen Limited,3317838,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,554.06,
US HKBT Abdomen Limited:Read,3317839,CDM,972,RC,76705,HCPCS,Outpatient,,,217.72,108.86,,195.95,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
US Liver,3351923,CDM,402,RC,76705,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,554.06,
76770- US abdomen back wall complete,3430617,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
Read,3569770,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3575227,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
Read,3575257,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
SCMP US Aorta/ Retro,3563000,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
SCMP US Exam,3575228,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Aorta/ Retro Complete,3575258,CDM,320,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Aorta/ Retro Complete,3370930,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Renal BILAT,3569771,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Renal Bilat Interp,3575303,CDM,972,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,247.74,
SCSN US Renal Bilat Interp,3575304,CDM,402,RC,76770,HCPCS,Outpatient,,,269.45,134.73,,242.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.51,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,261.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,188.62,70,,,percent of total billed charges,70% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,255.98,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,231.73,86,,,percent of total billed charges,86% of total billed charges,215.56,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.37,97,,,percent of total billed charges,97% of total billed charges,242.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.37,97,,,percent of total billed charges,97% of total billed charges,250.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,261.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
76775- Us exam abdo back wall lim,3430507,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
CL Renal Artery Ultrasound LT,3427573,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
CL Renal Artery Ultrasound RT,3427574,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
SCSN US Aorta Stent,3370926,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
SCSN US Renal Artery,3370956,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
SCSN US Renal LT,3569773,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.57,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.71,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,91.44,70,,,percent of total billed charges,70% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.34,86,,,percent of total billed charges,86% of total billed charges,104.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.71,97,,,percent of total billed charges,97% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.71,97,,,percent of total billed charges,97% of total billed charges,121.49,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.71,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.05,
SCSN US Renal RT,3569775,CDM,402,RC,76775,HCPCS,Outpatient,,,130.63,65.32,,117.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.57,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,126.71,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.18,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,91.44,70,,,percent of total billed charges,70% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,124.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.34,86,,,percent of total billed charges,86% of total billed charges,104.5,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,126.71,97,,,percent of total billed charges,97% of total billed charges,117.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,126.71,97,,,percent of total billed charges,97% of total billed charges,121.49,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.71,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.05,
URMC US Kidney,3370978,CDM,402,RC,76775,HCPCS,Outpatient,,,707.38,353.69,,636.64,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.64,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,686.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,650.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,495.17,70,,,percent of total billed charges,70% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,672.01,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.35,86,,,percent of total billed charges,86% of total billed charges,565.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,686.16,97,,,percent of total billed charges,97% of total billed charges,636.64,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.16,97,,,percent of total billed charges,97% of total billed charges,657.86,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,686.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,686.16,
US Transplanted Kidney Lt:Read,596511,CDM,972,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,329.72,90,,,percent of total billed charges,90% of total Billed charges,200.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.68,155,,,Fee Schedule,155% of CMS OPPS Rate,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.68,140,,,Fee Schedule,140% of CMS OPPS Rate,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.68,140,,,Fee Schedule,140% of CMS OPPS Rate,281.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,285.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.13,329.72,
US Transplanted Kidney Rt,596507,CDM,402,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,329.72,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,247.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.72,90,,,Percent of total Billed charges,90% of total billed charges,69.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,355.36,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,337.04,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,329.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,256.45,70,,,percent of total billed charges,70% of total billed charges,329.72,90,,,percent of total billed charges,90% of total billed charges,348.03,95,,,percent of total billed charges,95% of total billed charges,348.03,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,315.06,86,,,percent of total billed charges,86% of total billed charges,293.08,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,355.36,97,,,percent of total billed charges,97% of total billed charges,329.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.36,97,,,percent of total billed charges,97% of total billed charges,340.71,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,355.36,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.49,521.04,
US Transplanted Kidney Rt:Read,596508,CDM,972,RC,76776,HCPCS,Outpatient,,,366.35,183.18,,329.72,90,,,percent of total billed charges,90% of total Billed charges,200.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,91.13,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.68,155,,,Fee Schedule,155% of CMS OPPS Rate,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,316.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,316.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,125.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,198.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.68,140,,,Fee Schedule,140% of CMS OPPS Rate,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.68,140,,,Fee Schedule,140% of CMS OPPS Rate,281.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.13,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,119,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,99.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,285.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,91.13,329.72,
US Pilonidal Dimple,1587103,CDM,402,RC,76800,HCPCS,Outpatient,,,366.24,183.12,,329.62,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,177.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,329.62,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,355.25,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,336.94,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,329.62,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,256.37,70,,,percent of total billed charges,70% of total billed charges,329.62,90,,,percent of total billed charges,90% of total billed charges,347.93,95,,,percent of total billed charges,95% of total billed charges,347.93,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,314.97,86,,,percent of total billed charges,86% of total billed charges,292.99,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,355.25,97,,,percent of total billed charges,97% of total billed charges,329.62,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,355.25,97,,,percent of total billed charges,97% of total billed charges,340.6,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,355.25,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
76801 Ob us < 14 wks single fetus,3428328,CDM,983,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,263.2,90,,,percent of total billed charges,90% of total Billed charges,125.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.5,155,,,Fee Schedule,155% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,176.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.5,263.2,
WHFMT US OB less than 14 wks,3561674,CDM,972,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,263.2,90,,,percent of total billed charges,90% of total Billed charges,125.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.5,155,,,Fee Schedule,155% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,176.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.5,263.2,
WHMP US OB less than 14 weeks,3372937,CDM,972,RC,76801,HCPCS,Outpatient,,,292.44,146.22,,263.2,90,,,percent of total billed charges,90% of total Billed charges,125.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.5,155,,,Fee Schedule,155% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,176.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.5,263.2,
76802 Ob us < 14 wks addl fetus,3428329,CDM,983,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,37.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.11,155,,,Fee Schedule,155% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,52.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.65,140.23,
WHFMT US OB < 14 wk Addtl fetus,3563035,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,37.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.11,155,,,Fee Schedule,155% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,52.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.65,140.23,
WHMP US OB < 14 wk Addtl fetus,3548737,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,37.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.11,155,,,Fee Schedule,155% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,52.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.65,140.23,
WHMP US OB less than 14 wks additional fetus,3372939,CDM,972,RC,76802,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,37.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.11,155,,,Fee Schedule,155% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,52.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.65,140.23,
76805 Ob us >/= 14 wks sngl fetus,3428330,CDM,983,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,300.87,90,,,percent of total billed charges,90% of total Billed charges,156.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.31,155,,,Fee Schedule,155% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,219.63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,279.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.5,300.87,
WHFMT US OB > 14 wks Fetal Anat Scan,3561670,CDM,972,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,300.87,90,,,percent of total billed charges,90% of total Billed charges,156.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.31,155,,,Fee Schedule,155% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,219.63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,279.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.5,300.87,
WHMP US OB >14 wks Fetal Anatomy Scan,3372931,CDM,972,RC,76805,HCPCS,Outpatient,,,334.3,167.15,,300.87,90,,,percent of total billed charges,90% of total Billed charges,156.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.31,155,,,Fee Schedule,155% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,219.63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,279.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.5,300.87,
76810 Ob us >/= 14 wks addl fetus,3428331,CDM,983,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,199.83,90,,,percent of total billed charges,90% of total Billed charges,73.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.56,244.04,
WHFMT US OB > 14 wk addtl fetus,3563037,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,199.83,90,,,percent of total billed charges,90% of total Billed charges,73.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.56,244.04,
WHMP US OB > 14 wk addtl fetus,3548739,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,199.83,90,,,percent of total billed charges,90% of total Billed charges,73.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.56,244.04,
WHMP US OB >14 wk gest Fetal Anat add'l fetus,3372929,CDM,972,RC,76810,HCPCS,Outpatient,,,222.03,111.02,,199.83,90,,,percent of total billed charges,90% of total Billed charges,73.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.56,244.04,
"76811 OB US, DETAILED SINGL FETUS",3430508,CDM,960,RC,76811,HCPCS,Outpatient,,,438.08,219.04,,394.27,90,,,percent of total billed charges,90% of total Billed charges,150.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,106.44,155,,,Fee Schedule,155% of CMS OPPS Rate,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.44,140,,,Fee Schedule,140% of CMS OPPS Rate,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.44,140,,,Fee Schedule,140% of CMS OPPS Rate,211.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,292,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.03,394.27,
76813 -  US Fetal Nuchal Meas 1 Gest,4327193,CDM,983,RC,76813,HCPCS,Outpatient,,,523.7,261.85,,471.33,90,,,percent of total billed charges,90% of total Billed charges,109.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.26,155,,,Fee Schedule,155% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,152.74,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53.76,471.33,
WHFMT US OB Nuchal Translucency,3561678,CDM,972,RC,76813,HCPCS,Outpatient,,,295.74,147.87,,266.17,90,,,percent of total billed charges,90% of total Billed charges,109.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.26,155,,,Fee Schedule,155% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,152.74,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53.76,266.17,
WHMP US OB Nuchal Translucency,3372943,CDM,972,RC,76813,HCPCS,Outpatient,,,295.74,147.87,,266.17,90,,,percent of total billed charges,90% of total Billed charges,109.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.16,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,75.26,155,,,Fee Schedule,155% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,169.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,100.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,90.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.26,140,,,Fee Schedule,140% of CMS OPPS Rate,152.74,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,53.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,237.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,53.76,266.17,
76815 Ob us limited fetus(s),3428332,CDM,983,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
WHFMT US OB Limited,3561676,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
WHFMT US OB Limited,3563043,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
WHMP US OB Limited,3372941,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
WHMP US OB Limited,3548745,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
WHMPLimited OB,3548724,CDM,972,RC,76815,HCPCS,Outpatient,,,202.73,101.37,,182.46,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,182.46,
76816 Ob us follow-up per fetus,3428333,CDM,983,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,245.22,90,,,percent of total billed charges,90% of total Billed charges,122.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,85.46,155,,,Fee Schedule,155% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,172.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.04,245.22,
US Pelvis OB follow up with Transvag,3351982,CDM,402,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,245.22,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,149.43,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,245.22,90,,,Percent of total Billed charges,90% of total billed charges,43.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,264.3,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,250.67,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,245.22,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,190.73,70,,,percent of total billed charges,70% of total billed charges,245.22,90,,,percent of total billed charges,90% of total billed charges,258.85,95,,,percent of total billed charges,95% of total billed charges,258.85,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,234.32,86,,,percent of total billed charges,86% of total billed charges,217.98,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,264.3,97,,,percent of total billed charges,97% of total billed charges,245.22,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.3,97,,,percent of total billed charges,97% of total billed charges,253.4,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,264.3,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.78,521.05,
WHFMT US OB Follow Up,3561672,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,245.22,90,,,percent of total billed charges,90% of total Billed charges,122.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,85.46,155,,,Fee Schedule,155% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,172.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.04,245.22,
WHMP Follow Up OB,3548722,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,245.22,90,,,percent of total billed charges,90% of total Billed charges,122.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,85.46,155,,,Fee Schedule,155% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,172.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.04,245.22,
WHMP US Exam,3372949,CDM,972,RC,76816,HCPCS,Outpatient,,,272.47,136.24,,245.22,90,,,percent of total billed charges,90% of total Billed charges,122.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,85.46,155,,,Fee Schedule,155% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,219.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,155.42,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.46,140,,,Fee Schedule,140% of CMS OPPS Rate,172.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,225.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.04,245.22,
"76817(TC)- Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart",3621067,CDM,510,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,208.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.98,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.51,90,,,Percent of total Billed charges,90% of total billed charges,58.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,224.73,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,213.15,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,208.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.18,70,,,percent of total billed charges,70% of total billed charges,208.51,90,,,percent of total billed charges,90% of total billed charges,220.1,95,,,percent of total billed charges,95% of total billed charges,220.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,199.24,86,,,percent of total billed charges,86% of total billed charges,185.34,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,224.73,97,,,percent of total billed charges,97% of total billed charges,208.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.73,97,,,percent of total billed charges,97% of total billed charges,215.46,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.73,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.03,521.05,
WHFMT US OB Transvaginal,3561682,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,208.51,90,,,percent of total billed charges,90% of total Billed charges,101.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.36,155,,,Fee Schedule,155% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,142.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.26,208.51,
WHFMT US OB Transvaginal,3563047,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,208.51,90,,,percent of total billed charges,90% of total Billed charges,101.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.36,155,,,Fee Schedule,155% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,142.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.26,208.51,
WHMP US OB Transvaginal,3548749,CDM,972,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,208.51,90,,,percent of total billed charges,90% of total Billed charges,101.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,87.59,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,70.36,155,,,Fee Schedule,155% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,185.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,185.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,84.43,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.36,140,,,Fee Schedule,140% of CMS OPPS Rate,142.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.69,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,192.69,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,50.26,208.51,
WHMP US OB Tranvaginal,3372947,CDM,402,RC,76817,HCPCS,Outpatient,,,231.68,115.84,,208.51,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.98,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.51,90,,,Percent of total Billed charges,90% of total billed charges,58.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,224.73,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,213.15,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,208.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.18,70,,,percent of total billed charges,70% of total billed charges,208.51,90,,,percent of total billed charges,90% of total billed charges,220.1,95,,,percent of total billed charges,95% of total billed charges,220.1,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,199.24,86,,,percent of total billed charges,86% of total billed charges,185.34,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,224.73,97,,,percent of total billed charges,97% of total billed charges,208.51,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.73,97,,,percent of total billed charges,97% of total billed charges,215.46,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.73,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.03,521.05,
76818- Fetal biophys profile/non-stress,3431737,CDM,402,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,257.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,143.08,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.08,90,,,Percent of total Billed charges,90% of total billed charges,63.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,277.07,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,262.79,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,257.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,199.95,70,,,percent of total billed charges,70% of total billed charges,257.08,90,,,percent of total billed charges,90% of total billed charges,271.36,95,,,percent of total billed charges,95% of total billed charges,271.36,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,245.65,86,,,percent of total billed charges,86% of total billed charges,228.51,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,277.07,97,,,percent of total billed charges,97% of total billed charges,257.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.07,97,,,percent of total billed charges,97% of total billed charges,265.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,277.07,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.09,521.04,
WHFMT US Biophysical Profile,3561658,CDM,972,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,257.08,90,,,percent of total billed charges,90% of total Billed charges,116.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,107.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.98,155,,,Fee Schedule,155% of CMS OPPS Rate,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.98,140,,,Fee Schedule,140% of CMS OPPS Rate,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.98,140,,,Fee Schedule,140% of CMS OPPS Rate,162.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.56,257.08,
WHMP Biophysicial Profile,3548720,CDM,972,RC,76818,HCPCS,Outpatient,,,285.64,142.82,,257.08,90,,,percent of total billed charges,90% of total Billed charges,116.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,107.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,81.98,155,,,Fee Schedule,155% of CMS OPPS Rate,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,228.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,228.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,117.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.44,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.98,140,,,Fee Schedule,140% of CMS OPPS Rate,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.98,140,,,Fee Schedule,140% of CMS OPPS Rate,162.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,124,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,58.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,58.56,257.08,
76819- Fetal biophy profile w/o non-stres,3431738,CDM,402,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,188.15,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.15,90,,,Percent of total Billed charges,90% of total billed charges,53.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,202.78,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.33,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,188.15,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,146.34,70,,,percent of total billed charges,70% of total billed charges,188.15,90,,,percent of total billed charges,90% of total billed charges,198.6,95,,,percent of total billed charges,95% of total billed charges,198.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,179.78,86,,,percent of total billed charges,86% of total billed charges,167.24,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,202.78,97,,,percent of total billed charges,97% of total billed charges,188.15,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.78,97,,,percent of total billed charges,97% of total billed charges,194.42,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,202.78,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.68,521.04,
WHFMT US OB Biophysical Profile,3563039,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,188.15,90,,,percent of total billed charges,90% of total Billed charges,83.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.94,155,,,Fee Schedule,155% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,117.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,94.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,168.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.1,188.15,
WHMP US OB Biophysical Profile,3372933,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,188.15,90,,,percent of total billed charges,90% of total Billed charges,83.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.94,155,,,Fee Schedule,155% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,117.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,94.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,168.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.1,188.15,
WHMP US OB Biophysicial Profile,3548741,CDM,972,RC,76819,HCPCS,Outpatient,,,209.05,104.53,,188.15,90,,,percent of total billed charges,90% of total Billed charges,83.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,85.52,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.94,155,,,Fee Schedule,155% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,168.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,168.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,78.35,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,70.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.94,140,,,Fee Schedule,140% of CMS OPPS Rate,117.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,94.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,168.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.1,188.15,
76820 Umbilical artery echo,3428335,CDM,983,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
WHFMT US Fetal Doppler,3561660,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
WHFMT US OB Fetal Doppler,3563041,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
WHMP Umbilical Cord Doppler,3548729,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
WHMP US OB Fetal Doppler,3372935,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
WHMP US OB Fetal Doppler,3548743,CDM,972,RC,76820,HCPCS,Outpatient,,,114.06,57.03,,102.65,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,102.65,
76821 Middle cerebral artery echo,3430509,CDM,960,RC,76821,HCPCS,Outpatient,,,219.35,109.68,,197.42,90,,,percent of total billed charges,90% of total Billed charges,98.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.32,155,,,Fee Schedule,155% of CMS OPPS Rate,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,140,,,Fee Schedule,140% of CMS OPPS Rate,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.32,140,,,Fee Schedule,140% of CMS OPPS Rate,137.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.8,197.42,
76825 Echo exam of fetal heart,3430510,CDM,960,RC,76825,HCPCS,Outpatient,,,649.99,325.00,,584.99,90,,,percent of total billed charges,90% of total Billed charges,327.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,226.39,155,,,Fee Schedule,155% of CMS OPPS Rate,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,372.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,372.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.39,140,,,Fee Schedule,140% of CMS OPPS Rate,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.39,140,,,Fee Schedule,140% of CMS OPPS Rate,459,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,416.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,584.99,
76826 Echo exam of fetal heart,3430511,CDM,960,RC,76826,HCPCS,Outpatient,,,389.38,194.69,,350.44,90,,,percent of total billed charges,90% of total Billed charges,210.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,145.22,155,,,Fee Schedule,155% of CMS OPPS Rate,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.22,140,,,Fee Schedule,140% of CMS OPPS Rate,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.22,140,,,Fee Schedule,140% of CMS OPPS Rate,294.78,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.8,350.44,
76827 Echo exam of fetal heart,3430512,CDM,960,RC,76827,HCPCS,Outpatient,,,175.14,87.57,,157.63,90,,,percent of total billed charges,90% of total Billed charges,75.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,52,155,,,Fee Schedule,155% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,140,,,Fee Schedule,140% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,52,140,,,Fee Schedule,140% of CMS OPPS Rate,106.19,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,116.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.14,157.63,
76828 Echo exam of fetal heart,3430513,CDM,960,RC,76828,HCPCS,Outpatient,,,125.12,62.56,,112.61,90,,,percent of total billed charges,90% of total Billed charges,40.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.34,155,,,Fee Schedule,155% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,57.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.24,112.61,
"76830- US Transvaginal, non-ob",3430618,CDM,402,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.07,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,286.76,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,271.98,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,266.07,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,206.94,70,,,percent of total billed charges,70% of total billed charges,266.07,90,,,percent of total billed charges,90% of total billed charges,280.85,95,,,percent of total billed charges,95% of total billed charges,280.85,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,254.24,86,,,percent of total billed charges,86% of total billed charges,236.5,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,286.76,97,,,percent of total billed charges,97% of total billed charges,266.07,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.76,97,,,percent of total billed charges,97% of total billed charges,274.94,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,286.76,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,521.04,
Read,3372926,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHFMT US Non OB Transvaginal,3561668,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHFMT US NON OB Transvaginal,3563033,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHMP TV OB,3548726,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHMP US Exam,3372927,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHMP US NON OB Transvagina,3548733,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
WHMP US NON OB Transvaginal,3548735,CDM,972,RC,76830,HCPCS,Outpatient,,,295.63,147.82,,266.07,90,,,percent of total billed charges,90% of total Billed charges,154.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,249.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,249.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,167.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.57,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,236.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.49,266.07,
"76831 - PF - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640911,CDM,510,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1376.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1483.22,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.76,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1376.18,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1070.36,70,,,percent of total billed charges,70% of total billed charges,1376.18,90,,,percent of total billed charges,90% of total billed charges,1452.64,95,,,percent of total billed charges,95% of total billed charges,1452.64,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1315.02,86,,,percent of total billed charges,86% of total billed charges,1223.27,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1483.22,97,,,percent of total billed charges,97% of total billed charges,1376.18,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1483.22,97,,,percent of total billed charges,97% of total billed charges,1422.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1483.22,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.4,1483.22,
"76831 - Saline infusion sonohysterography (SIS), including color flow Doppler, when performed",3640909,CDM,510,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1376.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1483.22,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1406.76,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1376.18,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1070.36,70,,,percent of total billed charges,70% of total billed charges,1376.18,90,,,percent of total billed charges,90% of total billed charges,1452.64,95,,,percent of total billed charges,95% of total billed charges,1452.64,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1315.02,86,,,percent of total billed charges,86% of total billed charges,1223.27,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1483.22,97,,,percent of total billed charges,97% of total billed charges,1376.18,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1483.22,97,,,percent of total billed charges,97% of total billed charges,1422.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1483.22,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.4,1483.22,
WHFMT US OB Sonohysterography,3561680,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,146.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,155,,,Fee Schedule,155% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,204.62,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.41,1376.18,
WHFMT US OB Sonohysterography,3563045,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,146.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,155,,,Fee Schedule,155% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,204.62,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.41,1376.18,
WHMP US OB Sonohysterography,3372945,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,146.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,155,,,Fee Schedule,155% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,204.62,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.41,1376.18,
WHMP US OB Sonohysterography,3548747,CDM,972,RC,76831,HCPCS,Outpatient,,,1529.09,764.55,,1376.18,90,,,percent of total billed charges,90% of total Billed charges,146.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,155,,,Fee Schedule,155% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,241.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,162.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.05,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.37,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.37,140,,,Fee Schedule,140% of CMS OPPS Rate,204.62,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,72.41,1376.18,
76856- US pelvic complete,3430619,CDM,402,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,236.23,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,158.43,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.23,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,254.61,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,241.48,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,236.23,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.74,70,,,percent of total billed charges,70% of total billed charges,236.23,90,,,percent of total billed charges,90% of total billed charges,249.36,95,,,percent of total billed charges,95% of total billed charges,249.36,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.73,86,,,percent of total billed charges,86% of total billed charges,209.98,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.61,97,,,percent of total billed charges,97% of total billed charges,236.23,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.61,97,,,percent of total billed charges,97% of total billed charges,244.11,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.61,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,521.04,
US HKBT Pelvis Complete:Read,3317848,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,236.23,90,,,percent of total billed charges,90% of total Billed charges,129.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.95,155,,,Fee Schedule,155% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,181.97,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.25,236.23,
WHFMT US Non OB Pelvic Transabdominal,3561664,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,236.23,90,,,percent of total billed charges,90% of total Billed charges,129.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.95,155,,,Fee Schedule,155% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,181.97,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.25,236.23,
WHMP US Non OB Pelvic Transabdominal,3372925,CDM,972,RC,76856,HCPCS,Outpatient,,,262.48,131.24,,236.23,90,,,percent of total billed charges,90% of total Billed charges,129.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,89.95,155,,,Fee Schedule,155% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,222.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,149.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.95,140,,,Fee Schedule,140% of CMS OPPS Rate,181.97,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,234.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,64.25,236.23,
76857 Us exam pelvic limited,3428336,CDM,402,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,50.58,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.63,90,,,Percent of total Billed charges,90% of total billed charges,20.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,116,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,110.02,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,107.63,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.71,70,,,percent of total billed charges,70% of total billed charges,107.63,90,,,percent of total billed charges,90% of total billed charges,113.61,95,,,percent of total billed charges,95% of total billed charges,113.61,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.85,86,,,percent of total billed charges,86% of total billed charges,95.67,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,116,97,,,percent of total billed charges,97% of total billed charges,107.63,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,97,,,percent of total billed charges,97% of total billed charges,111.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19,521.04,
SCMP US Thyroid:Read,3575245,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
US Appendix,3351899,CDM,402,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,50.58,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.63,90,,,Percent of total Billed charges,90% of total billed charges,20.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,116,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,110.02,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,107.63,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.71,70,,,percent of total billed charges,70% of total billed charges,107.63,90,,,percent of total billed charges,90% of total billed charges,113.61,95,,,percent of total billed charges,95% of total billed charges,113.61,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,102.85,86,,,percent of total billed charges,86% of total billed charges,95.67,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,116,97,,,percent of total billed charges,97% of total billed charges,107.63,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,97,,,percent of total billed charges,97% of total billed charges,111.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19,521.04,
US HKBT Pelvis Limited:Read,3317850,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
US HKBT Thyroid:Read,3317772,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
WHFMT US NON OB Pelvic Limited,3563031,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
"WHFMT US Non OB Pelvic, Limited",3561666,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
WHMP US NON OB Pelvic Limited,3548731,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
"WHMP US NON OB Pelvic, Limited",3372921,CDM,972,RC,76857,HCPCS,Outpatient,,,119.59,59.80,,107.63,90,,,percent of total billed charges,90% of total Billed charges,44.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,31.19,155,,,Fee Schedule,155% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.47,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,68.07,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,47.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.63,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.19,140,,,Fee Schedule,140% of CMS OPPS Rate,61.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.28,180.24,
URMC US Kidney,3584947,CDM,402,RC,76870,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,154.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,521.05,
Read,3575299,CDM,972,RC,76881,HCPCS,Outpatient,,,146.59,73.30,,131.93,90,,,percent of total billed charges,90% of total Billed charges,35.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,155,,,Fee Schedule,155% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,49.14,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.18,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,222.18,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.75,222.18,
RHEUM US Complete Diagnostic MSK,3999132,CDM,402,RC,76881,HCPCS,Outpatient,,,146.59,73.30,,131.93,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.98,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.93,90,,,Percent of total Billed charges,90% of total billed charges,72.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,142.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.86,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,131.93,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.61,70,,,percent of total billed charges,70% of total billed charges,131.93,90,,,percent of total billed charges,90% of total billed charges,139.26,95,,,percent of total billed charges,95% of total billed charges,139.26,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,126.07,86,,,percent of total billed charges,86% of total billed charges,117.27,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,142.19,97,,,percent of total billed charges,97% of total billed charges,131.93,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.19,97,,,percent of total billed charges,97% of total billed charges,136.33,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.18,521.04,
RHEUM US Complete Diagnostic MSK,3999131,CDM,983,RC,76881,HCPCS,Outpatient,,,146.59,73.30,,131.93,90,,,percent of total billed charges,90% of total Billed charges,35.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,155,,,Fee Schedule,155% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,49.14,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.18,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,222.18,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.75,222.18,
RHEUM US Complete Diagnostic MSK PR,3997152,CDM,402,RC,76881,HCPCS,Outpatient,,,146.59,73.30,,131.93,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.98,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.93,90,,,Percent of total Billed charges,90% of total billed charges,72.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,142.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.86,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,131.93,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.61,70,,,percent of total billed charges,70% of total billed charges,131.93,90,,,percent of total billed charges,90% of total billed charges,139.26,95,,,percent of total billed charges,95% of total billed charges,139.26,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,126.07,86,,,percent of total billed charges,86% of total billed charges,117.27,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,142.19,97,,,percent of total billed charges,97% of total billed charges,131.93,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.19,97,,,percent of total billed charges,97% of total billed charges,136.33,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.18,521.04,
RHEUM US Complete Diagnostic MSK PR,3997151,CDM,983,RC,76881,HCPCS,Outpatient,,,146.59,73.30,,131.93,90,,,percent of total billed charges,90% of total Billed charges,35.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,155,,,Fee Schedule,155% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,107.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.65,140,,,Fee Schedule,140% of CMS OPPS Rate,49.14,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,158.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,9.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.18,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,222.18,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.75,222.18,
76882 US Extrem limited/nonvasc anatomic struct,3428337,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,125.27,
Read,,,972,RC,76882,HCPCS,Outpatient,,,58.17,29.09,,52.35,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,115.72,
Read,3352342,CDM,972,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,125.27,
RHEUM US Limited Diagnostic MSK,3997154,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.27,90,,,Percent of total Billed charges,90% of total billed charges,8.64,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.01,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,128.05,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.43,70,,,percent of total billed charges,70% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.7,86,,,percent of total billed charges,86% of total billed charges,111.35,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.01,97,,,percent of total billed charges,97% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.01,97,,,percent of total billed charges,97% of total billed charges,129.45,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.01,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.85,521.05,
RHEUM US Limited Diagnostic MSK,3997153,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,125.27,
RHEUM US Limited Diagnostic MSK PR,3999134,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.27,90,,,Percent of total Billed charges,90% of total billed charges,8.64,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.01,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,128.05,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.43,70,,,percent of total billed charges,70% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.7,86,,,percent of total billed charges,86% of total billed charges,111.35,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.01,97,,,percent of total billed charges,97% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.01,97,,,percent of total billed charges,97% of total billed charges,129.45,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.01,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.85,521.05,
RHEUM US Limited Diagnostic MSK PR,3999133,CDM,983,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,125.27,
US Lower Extremity Lt Non Vascular,3352341,CDM,402,RC,76882,HCPCS,Outpatient,,,139.19,69.60,,125.27,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,69.3,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.27,90,,,Percent of total Billed charges,90% of total billed charges,8.64,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,135.01,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,128.05,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.43,70,,,percent of total billed charges,70% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,132.23,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.7,86,,,percent of total billed charges,86% of total billed charges,111.35,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,135.01,97,,,percent of total billed charges,97% of total billed charges,125.27,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.01,97,,,percent of total billed charges,97% of total billed charges,129.45,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,135.01,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.85,521.05,
US Compression of Pseudoaneurysm Lt:Read,596526,CDM,972,RC,76936,HCPCS,Outpatient,,,653.18,326.59,,587.86,90,,,percent of total billed charges,90% of total Billed charges,296.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.76,155,,,Fee Schedule,155% of CMS OPPS Rate,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,523.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,373.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,373.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.76,140,,,Fee Schedule,140% of CMS OPPS Rate,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.76,140,,,Fee Schedule,140% of CMS OPPS Rate,415.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,357,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,556.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146.26,587.86,
US Compression of Pseudoanuerysm Rt:Read,596529,CDM,972,RC,76936,HCPCS,Outpatient,,,653.18,326.59,,587.86,90,,,percent of total billed charges,90% of total Billed charges,296.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.76,155,,,Fee Schedule,155% of CMS OPPS Rate,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,465.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,146.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,523.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,523.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,373.77,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,373.77,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,217.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,292.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,249.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.76,140,,,Fee Schedule,140% of CMS OPPS Rate,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.76,140,,,Fee Schedule,140% of CMS OPPS Rate,415.76,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,357,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,146.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,556.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,556.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,146.26,587.86,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,402,RC,76937,HCPCS,Outpatient,,,96.94,48.47,,87.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,87.25,90,,,Percent of total Billed charges,90% of total billed charges,13.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,94.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,89.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,61.91,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,76.25,78.65,,,percent of total billed charges,78.65% of total billed charges,86.6,89.33,,,percent of total billed charges,89.33% of total billed charges,87.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.86,70,,,percent of total billed charges,70% of total billed charges,87.25,90,,,percent of total billed charges,90% of total billed charges,92.09,95,,,percent of total billed charges,95% of total billed charges,92.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.37,86,,,percent of total billed charges,86% of total billed charges,77.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,94.03,97,,,percent of total billed charges,97% of total billed charges,87.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,94.03,97,,,percent of total billed charges,97% of total billed charges,90.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,94.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,94.03,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,146.15,73.08,,131.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,131.54,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,141.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,134.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,93.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,114.95,78.65,,,percent of total billed charges,78.65% of total billed charges,130.56,89.33,,,percent of total billed charges,89.33% of total billed charges,131.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,102.31,70,,,percent of total billed charges,70% of total billed charges,131.54,90,,,percent of total billed charges,90% of total billed charges,138.84,95,,,percent of total billed charges,95% of total billed charges,138.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.69,86,,,percent of total billed charges,86% of total billed charges,116.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,141.77,97,,,percent of total billed charges,97% of total billed charges,131.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,141.77,97,,,percent of total billed charges,97% of total billed charges,135.92,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,141.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,141.77,
RHEUM US Procedural Ultrasound,3997156,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
RHEUM US Procedural Ultrasound PR,3997158,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
SCMP US Exam,3575236,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
SCMP US Exam,3575238,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
SCMP US Exam,3575242,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
SCSN US Exam,3575314,CDM,402,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,116.64,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,125.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,119.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,82.77,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,101.93,78.65,,,percent of total billed charges,78.65% of total billed charges,115.77,89.33,,,percent of total billed charges,89.33% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.72,70,,,percent of total billed charges,70% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,123.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.46,86,,,percent of total billed charges,86% of total billed charges,103.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,116.64,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,125.71,97,,,percent of total billed charges,97% of total billed charges,120.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,125.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,125.71,
SCSN US Guided Mammotome Breast Bx PR,3575189,CDM,972,RC,76942,HCPCS,Outpatient,,,129.6,64.80,,116.64,90,,,percent of total billed charges,90% of total Billed charges,49.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,34.45,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,81.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.14,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.45,140,,,Fee Schedule,140% of CMS OPPS Rate,68.7,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,181.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,372.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,372.27,
76965 (26) Ultrasonic guidance for interstitial radioelement application,3621073,CDM,510,RC,76965,HCPCS,Outpatient,,,234.66,117.33,,211.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,215.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,149.86,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,184.57,78.65,,,percent of total billed charges,78.65% of total billed charges,209.63,89.33,,,percent of total billed charges,89.33% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.26,70,,,percent of total billed charges,70% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,222.93,95,,,percent of total billed charges,95% of total billed charges,222.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.81,86,,,percent of total billed charges,86% of total billed charges,187.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,218.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,227.62,
76965 (TC) Ultrasonic guidance for interstitial radioelement application,3621074,CDM,510,RC,76965,HCPCS,Outpatient,,,234.66,117.33,,211.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,211.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,215.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,149.86,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,184.57,78.65,,,percent of total billed charges,78.65% of total billed charges,209.63,89.33,,,percent of total billed charges,89.33% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.26,70,,,percent of total billed charges,70% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,222.93,95,,,percent of total billed charges,95% of total billed charges,222.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.81,86,,,percent of total billed charges,86% of total billed charges,187.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,211.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,218.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.8,227.62,
"77001 (26) Fluoroscopic guidance for central venous access device placement, replacement (catheter o",3620979,CDM,510,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,224.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,224.77,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,242.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,229.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,159.49,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,78.65,,,percent of total billed charges,78.65% of total billed charges,223.1,89.33,,,percent of total billed charges,89.33% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,174.82,70,,,percent of total billed charges,70% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,237.25,95,,,percent of total billed charges,95% of total billed charges,237.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.78,86,,,percent of total billed charges,86% of total billed charges,199.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,242.25,97,,,percent of total billed charges,97% of total billed charges,224.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,242.25,97,,,percent of total billed charges,97% of total billed charges,232.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,242.25,
Read,2960105,CDM,972,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,224.77,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.78,155,,,Fee Schedule,155% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,207.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.37,224.77,
Read,3575271,CDM,972,RC,77001,HCPCS,Outpatient,,,249.74,124.87,,224.77,90,,,percent of total billed charges,90% of total Billed charges,148.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,101.78,155,,,Fee Schedule,155% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,186.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,186.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,74.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,112.15,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.78,140,,,Fee Schedule,140% of CMS OPPS Rate,207.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,223.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,60.37,224.77,
MRI Breast Bilat UN and ENH,3347966,CDM,610,RC,77049,HCPCS,Outpatient,,,1713.94,856.97,,1542.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,609.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1542.55,90,,,Percent of total Billed charges,90% of total billed charges,241.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1662.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1576.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1094.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1348.05,78.65,,,percent of total billed charges,78.65% of total billed charges,1531.09,89.33,,,percent of total billed charges,89.33% of total billed charges,1542.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1199.76,70,,,percent of total billed charges,70% of total billed charges,1542.55,90,,,percent of total billed charges,90% of total billed charges,1628.24,95,,,percent of total billed charges,95% of total billed charges,1628.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1473.99,86,,,percent of total billed charges,86% of total billed charges,1371.15,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1662.52,97,,,percent of total billed charges,97% of total billed charges,1542.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1662.52,97,,,percent of total billed charges,97% of total billed charges,1593.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1662.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.46,1662.52,
"77063 - Screening digital breast tomosynthesis, bilateral (List separately in addition to code for p",3800936,CDM,983,RC,77063,HCPCS,Outpatient,,,132.26,66.13,,119.03,90,,,percent of total billed charges,90% of total Billed charges,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.37,155,,,Fee Schedule,155% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,140,,,Fee Schedule,140% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.37,140,,,Fee Schedule,140% of CMS OPPS Rate,58.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,119.03,
WHFMT MA Screening TOMO,3610995,CDM,972,RC,77063,HCPCS,Outpatient,,,132.26,66.13,,119.03,90,,,percent of total billed charges,90% of total Billed charges,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.03,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,29.37,155,,,Fee Schedule,155% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.37,140,,,Fee Schedule,140% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.37,140,,,Fee Schedule,140% of CMS OPPS Rate,58.46,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,119.03,
77065 - (TC) DX MAMMO INCL CAD UNI,3997213,CDM,983,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
77065 (26) - DIAGNOSTIC MAMMOGRAPHY COMPUTER-AIDED DETCJ UNI,4037790,CDM,983,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
WHFMT MA Mammo LT Unilat Diagnostic:WHFMT MA Exam,3561688,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
WHFMT MA Mammo RT Unilat Diagnostic:WHFMT MA Exam,3561690,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
WHFMT MA TOMO Mammo Diagnostic LT:WHFMT MA Exam,3561700,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
WHFMT MA TOMO Mammo Diagnostic RT:WHFMT MA Exam,3561702,CDM,972,RC,77065,HCPCS,Outpatient,,,309.04,154.52,,278.14,90,,,percent of total billed charges,90% of total Billed charges,154.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,102.41,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,107.09,155,,,Fee Schedule,155% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,238.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,238.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,182.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,134.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.09,140,,,Fee Schedule,140% of CMS OPPS Rate,216.16,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.49,278.14,
77066 - Dx Mammo Incl Cad Bil,4113118,CDM,983,RC,77066,HCPCS,Outpatient,,,348.23,174.12,,313.41,90,,,percent of total billed charges,90% of total Billed charges,196.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,129.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,136.46,155,,,Fee Schedule,155% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,300.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,275.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,313.41,
WHFMT MA Mammo Bilat Diagnostic:WHFMT MA Exam,3561686,CDM,972,RC,77066,HCPCS,Outpatient,,,390.02,195.01,,351.02,90,,,percent of total billed charges,90% of total Billed charges,196.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,129.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,136.46,155,,,Fee Schedule,155% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,300.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,275.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,351.02,
WHFMT MA TOMO Mammo Diagnostic Bilat:WHFMT MA Exam,3561698,CDM,972,RC,77066,HCPCS,Outpatient,,,390.02,195.01,,351.02,90,,,percent of total billed charges,90% of total Billed charges,196.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,129.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,136.46,155,,,Fee Schedule,155% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,300.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,300.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,134.31,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,171.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.46,140,,,Fee Schedule,140% of CMS OPPS Rate,275.45,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,97.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.47,351.02,
"77067 (TC) Screening mammography, bilateral (2-view study of each breast), including computer-aided",3621068,CDM,510,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,207.1,250,,,Fee Schedule,250% of Fee Schedule Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,282.54,90,,,Percent of total Billed charges,90% of total billed charges,82.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,304.51,97,,,Percent of total billed charges,97% of total billed charges,80.81,100,,,Fee Schedule,100% of CMS OPPS Rate,288.82,92,,,Percent of total billed charges,92% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,328.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,399.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,370.78,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,282.54,90,,,percent of total billed charges,90% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,219.75,70,,,percent of total billed charges,70% of total billed charges,282.54,90,,,percent of total billed charges,90% of total billed charges,298.23,95,,,percent of total billed charges,95% of total billed charges,298.23,95,,,percent of total billed charges,95% of total billed charges,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,269.98,86,,,percent of total billed charges,86% of total billed charges,251.14,80,,,percent of total billed charges,80% of total billed charges,95.25,111,,,Fee Schedule,111% of CMS OPPS Rate,304.51,97,,,percent of total billed charges,97% of total billed charges,282.54,90,,,percent of total billed charges,90% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.51,97,,,percent of total billed charges,97% of total billed charges,291.95,93,,,percent of total billed charges,93% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,304.51,97,,,percent of total billed charges,97% of total billed charges,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.86,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,68.73,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,68.73,399.64,
WHFMT MA Mammo Screening Bilat:WHFMT MA Exam,3561692,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
WHFMT MA Mammo Screening LT:WHFMT MA Exam,3561694,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
WHFMT MA Mammo Screening RT:WHFMT MA Exam,3561696,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
WHFMT MA TOMO Mammo Screening Bilat:WHFMT MA Exam,3561704,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
WHFMT MA TOMO Mammo Screening LT:WHFMT MA Exam,3561706,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
WHFMT MA TOMO Mammo Screening RT:WHFMT MA Exam,3561708,CDM,972,RC,77067,HCPCS,Outpatient,,,313.93,156.97,,282.54,90,,,percent of total billed charges,90% of total Billed charges,162.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,104.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,113.2,155,,,Fee Schedule,155% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,243.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,243.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,108.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.2,140,,,Fee Schedule,140% of CMS OPPS Rate,228.09,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.86,282.54,
Bone Age Lt Wrist and Hand,601931,CDM,320,RC,77072,HCPCS,Outpatient,,,64.7,32.35,,58.23,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,31.1,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.23,90,,,Percent of total Billed charges,90% of total billed charges,10.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,62.76,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.52,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,58.23,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45.29,70,,,percent of total billed charges,70% of total billed charges,58.23,90,,,percent of total billed charges,90% of total billed charges,61.47,95,,,percent of total billed charges,95% of total billed charges,61.47,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,55.64,86,,,percent of total billed charges,86% of total billed charges,51.76,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,62.76,97,,,percent of total billed charges,97% of total billed charges,58.23,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.76,97,,,percent of total billed charges,97% of total billed charges,60.17,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,62.76,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.8,521.05,
WW Bone Age Lt Wrist and Hand,3373156,CDM,972,RC,77072,HCPCS,Outpatient,,,64.7,32.35,,58.23,90,,,percent of total billed charges,90% of total Billed charges,30.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.57,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21,155,,,Fee Schedule,155% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.24,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21,140,,,Fee Schedule,140% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,140,,,Fee Schedule,140% of CMS OPPS Rate,42.36,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.91,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,43.91,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15,58.23,
Bone Length Study,601935,CDM,320,RC,77073,HCPCS,Outpatient,,,110.92,55.46,,99.83,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,49.08,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.83,90,,,Percent of total Billed charges,90% of total billed charges,23.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,107.59,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.05,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,99.83,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,77.64,70,,,percent of total billed charges,70% of total billed charges,99.83,90,,,percent of total billed charges,90% of total billed charges,105.37,95,,,percent of total billed charges,95% of total billed charges,105.37,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,95.39,86,,,percent of total billed charges,86% of total billed charges,88.74,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,107.59,97,,,percent of total billed charges,97% of total billed charges,99.83,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.59,97,,,percent of total billed charges,97% of total billed charges,103.16,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.59,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.94,521.05,
Bone Survey Metastases,601939,CDM,320,RC,77074,HCPCS,Outpatient,,,160.67,80.34,,144.6,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,94.75,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.6,90,,,Percent of total Billed charges,90% of total billed charges,33.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,155.85,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,147.82,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,144.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,112.47,70,,,percent of total billed charges,70% of total billed charges,144.6,90,,,percent of total billed charges,90% of total billed charges,152.64,95,,,percent of total billed charges,95% of total billed charges,152.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.18,86,,,percent of total billed charges,86% of total billed charges,128.54,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,155.85,97,,,percent of total billed charges,97% of total billed charges,144.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.85,97,,,percent of total billed charges,97% of total billed charges,149.42,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,155.85,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.22,521.05,
Bone Survey Infant,601937,CDM,320,RC,77076,HCPCS,Outpatient,,,263.4,131.70,,237.06,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,138.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.06,90,,,Percent of total Billed charges,90% of total billed charges,30.87,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,255.5,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,242.33,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,237.06,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,184.38,70,,,percent of total billed charges,70% of total billed charges,237.06,90,,,percent of total billed charges,90% of total billed charges,250.23,95,,,percent of total billed charges,95% of total billed charges,250.23,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,226.52,86,,,percent of total billed charges,86% of total billed charges,210.72,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,255.5,97,,,percent of total billed charges,97% of total billed charges,237.06,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.5,97,,,percent of total billed charges,97% of total billed charges,244.96,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,255.5,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.06,521.05,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.09,90,,,Percent of total Billed charges,90% of total billed charges,57.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.4,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.07,70,,,percent of total billed charges,70% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77.49,86,,,percent of total billed charges,86% of total billed charges,72.08,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,87.4,97,,,percent of total billed charges,97% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.4,97,,,percent of total billed charges,97% of total billed charges,83.79,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.4,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.94,521.04,
"77080(26)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3620959,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.09,90,,,Percent of total Billed charges,90% of total billed charges,57.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.4,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.07,70,,,percent of total billed charges,70% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77.49,86,,,percent of total billed charges,86% of total billed charges,72.08,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,87.4,97,,,percent of total billed charges,97% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.4,97,,,percent of total billed charges,97% of total billed charges,83.79,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.4,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.94,521.04,
"77080(TC)- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623737,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.09,90,,,Percent of total Billed charges,90% of total billed charges,57.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.4,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.07,70,,,percent of total billed charges,70% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77.49,86,,,percent of total billed charges,86% of total billed charges,72.08,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,87.4,97,,,percent of total billed charges,97% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.4,97,,,percent of total billed charges,97% of total billed charges,83.79,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.4,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.94,521.04,
GYN Dexa Exam,3575424,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,49.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,69.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.2,188.1,
HW GYN Dexa,3776905,CDM,510,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.09,90,,,Percent of total Billed charges,90% of total billed charges,57.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.4,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,82.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,63.07,70,,,percent of total billed charges,70% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,85.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77.49,86,,,percent of total billed charges,86% of total billed charges,72.08,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,87.4,97,,,percent of total billed charges,97% of total billed charges,81.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.4,97,,,percent of total billed charges,97% of total billed charges,83.79,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.4,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.94,521.04,
Read,3575423,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,49.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,69.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.2,188.1,
WHFMT Bone Density:WHFMT DR Exam,3561654,CDM,972,RC,77080,HCPCS,Outpatient,,,90.1,45.05,,81.09,90,,,percent of total billed charges,90% of total Billed charges,49.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.78,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,53.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.69,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,69.52,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.1,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,188.1,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.2,188.1,
"77081 - Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular sk",3640925,CDM,510,RC,77081,HCPCS,Outpatient,,,75.87,37.94,,68.28,90,,,percent of total billed charges,90% of total Billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,49.08,250,,,Fee Schedule,250% of Fee Schedule Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.28,90,,,Percent of total Billed charges,90% of total billed charges,19.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,73.59,97,,,Percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,69.8,92,,,Percent of total billed charges,92% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,209.74,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,68.28,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,53.11,70,,,percent of total billed charges,70% of total billed charges,68.28,90,,,percent of total billed charges,90% of total billed charges,72.08,95,,,percent of total billed charges,95% of total billed charges,72.08,95,,,percent of total billed charges,95% of total billed charges,78.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,65.25,86,,,percent of total billed charges,86% of total billed charges,60.7,80,,,percent of total billed charges,80% of total billed charges,82.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,73.59,97,,,percent of total billed charges,97% of total billed charges,68.28,90,,,percent of total billed charges,90% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.59,97,,,percent of total billed charges,97% of total billed charges,70.56,93,,,percent of total billed charges,93% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.59,97,,,percent of total billed charges,97% of total billed charges,78.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.68,423.55,
"77085- DEXA - Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial ske",3715130,CDM,510,RC,77085,HCPCS,Outpatient,,,123.79,61.90,,111.41,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,83.53,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.08,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,113.89,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.41,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,86.65,70,,,percent of total billed charges,70% of total billed charges,111.41,90,,,percent of total billed charges,90% of total billed charges,117.6,95,,,percent of total billed charges,95% of total billed charges,117.6,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,106.46,86,,,percent of total billed charges,86% of total billed charges,99.03,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.08,97,,,percent of total billed charges,97% of total billed charges,111.41,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.08,97,,,percent of total billed charges,97% of total billed charges,115.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,120.08,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.51,521.05,
GYN VFA with DEXA:GYN Dexa Exam,3576813,CDM,972,RC,77085,HCPCS,Outpatient,,,123.79,61.90,,111.41,90,,,percent of total billed charges,90% of total Billed charges,64.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.88,155,,,Fee Schedule,155% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.75,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.88,140,,,Fee Schedule,140% of CMS OPPS Rate,90.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,111.41,
GYN Dexa Exam,3575426,CDM,972,RC,77086,HCPCS,Outpatient,,,79.44,39.72,,71.5,90,,,percent of total billed charges,90% of total Billed charges,43.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,155,,,Fee Schedule,155% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.91,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.79,140,,,Fee Schedule,140% of CMS OPPS Rate,61.29,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.06,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.99,71.5,
77263-RADIATION THERAPY PLANNING,3400483,CDM,983,RC,77263,HCPCS,Outpatient,,,400.09,200.05,,360.08,90,,,percent of total billed charges,90% of total Billed charges,328.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,148.47,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,230.48,155,,,Fee Schedule,155% of CMS OPPS Rate,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,164.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,277.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,277.7,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,129.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,329.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,280.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,184.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,230.48,140,,,Fee Schedule,140% of CMS OPPS Rate,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.48,140,,,Fee Schedule,140% of CMS OPPS Rate,460.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,172,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,164.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,313.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,313.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,129.13,460.39,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,670.77,335.39,,603.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,536.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,603.69,90,,,Percent of total Billed charges,90% of total billed charges,151.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,650.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,617.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,428.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,527.58,78.65,,,percent of total billed charges,78.65% of total billed charges,599.21,89.33,,,percent of total billed charges,89.33% of total billed charges,603.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,469.54,70,,,percent of total billed charges,70% of total billed charges,603.69,90,,,percent of total billed charges,90% of total billed charges,637.23,95,,,percent of total billed charges,95% of total billed charges,637.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,576.86,86,,,percent of total billed charges,86% of total billed charges,536.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,650.65,97,,,percent of total billed charges,97% of total billed charges,603.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,650.65,97,,,percent of total billed charges,97% of total billed charges,623.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,650.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,650.65,
77770 - (26) Remote afterloading high dose rate radionuclide,3938961,CDM,333,RC,77770,HCPCS,Outpatient,,,832.59,416.30,,749.33,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.33,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,807.61,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,765.98,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,749.33,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,582.81,70,,,percent of total billed charges,70% of total billed charges,749.33,90,,,percent of total billed charges,90% of total billed charges,790.96,95,,,percent of total billed charges,95% of total billed charges,790.96,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.03,86,,,percent of total billed charges,86% of total billed charges,666.07,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,807.61,97,,,percent of total billed charges,97% of total billed charges,749.33,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,807.61,97,,,percent of total billed charges,97% of total billed charges,774.31,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,807.61,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,342,RC,77770,HCPCS,Outpatient,,,832.59,416.30,,749.33,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.33,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,807.61,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,765.98,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,749.33,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,582.81,70,,,percent of total billed charges,70% of total billed charges,749.33,90,,,percent of total billed charges,90% of total billed charges,790.96,95,,,percent of total billed charges,95% of total billed charges,790.96,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.03,86,,,percent of total billed charges,86% of total billed charges,666.07,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,807.61,97,,,percent of total billed charges,97% of total billed charges,749.33,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,807.61,97,,,percent of total billed charges,97% of total billed charges,774.31,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,807.61,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77771 - (26) Remote afterloading high dose rate radionuclide,3938958,CDM,342,RC,77771,HCPCS,Outpatient,,,1437.26,718.63,,1293.53,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1293.53,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1394.14,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.28,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1293.53,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.08,70,,,percent of total billed charges,70% of total billed charges,1293.53,90,,,percent of total billed charges,90% of total billed charges,1365.4,95,,,percent of total billed charges,95% of total billed charges,1365.4,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1236.04,86,,,percent of total billed charges,86% of total billed charges,1149.81,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1394.14,97,,,percent of total billed charges,97% of total billed charges,1293.53,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1394.14,97,,,percent of total billed charges,97% of total billed charges,1336.65,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1394.14,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,333,RC,77771,HCPCS,Outpatient,,,1437.26,718.63,,1293.53,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1293.53,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1394.14,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.28,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1293.53,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1006.08,70,,,percent of total billed charges,70% of total billed charges,1293.53,90,,,percent of total billed charges,90% of total billed charges,1365.4,95,,,percent of total billed charges,95% of total billed charges,1365.4,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1236.04,86,,,percent of total billed charges,86% of total billed charges,1149.81,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1394.14,97,,,percent of total billed charges,97% of total billed charges,1293.53,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1394.14,97,,,percent of total billed charges,97% of total billed charges,1336.65,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1394.14,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
78428 (26) - Cardiac shunt detection,4037737,CDM,974,RC,78428,HCPCS,Outpatient,,,435.14,217.57,,391.63,90,,,percent of total billed charges,90% of total Billed charges,249.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,171.71,155,,,Fee Schedule,155% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,253.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,149.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,217.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.71,140,,,Fee Schedule,140% of CMS OPPS Rate,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.71,140,,,Fee Schedule,140% of CMS OPPS Rate,349.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,122.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,341.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,113.05,391.63,
78451 - (TC) Myocardial Spect SNGL Study at Rest or Stress,3899087,CDM,960,RC,78451,HCPCS,Outpatient,,,781.58,390.79,,703.42,90,,,percent of total billed charges,90% of total Billed charges,450.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,309.22,155,,,Fee Schedule,155% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,640.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,640.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,459.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,441.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,398.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.22,140,,,Fee Schedule,140% of CMS OPPS Rate,631.36,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,367.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,220.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,658.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,658.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,220.87,703.42,
78452-NM Myocardial EF Rest Stress Spect Add-on,4263188,CDM,340,RC,78452,HCPCS,Outpatient,,,6790.79,3395.40,,6111.71,90,,,percent of total billed charges,90% of total Billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,853.13,250,,,Fee Schedule,250% of Fee Schedule Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,6111.71,90,,,Percent of total Billed charges,90% of total billed charges,306.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6587.07,97,,,Percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,6247.53,92,,,Percent of total billed charges,92% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,3204.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5108.43,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6470.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6111.71,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,4753.55,70,,,percent of total billed charges,70% of total billed charges,6111.71,90,,,percent of total billed charges,90% of total billed charges,6451.25,95,,,percent of total billed charges,95% of total billed charges,6451.25,95,,,percent of total billed charges,95% of total billed charges,1205.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2411.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5840.08,86,,,percent of total billed charges,86% of total billed charges,5432.63,80,,,percent of total billed charges,80% of total billed charges,1315.28,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6587.07,97,,,percent of total billed charges,97% of total billed charges,6111.71,90,,,percent of total billed charges,90% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,6587.07,97,,,percent of total billed charges,97% of total billed charges,6315.43,93,,,percent of total billed charges,93% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6587.07,97,,,percent of total billed charges,97% of total billed charges,1205.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,1205.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1024.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.34,6587.07,
78466 - (TC) MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUA,3999225,CDM,960,RC,78466,HCPCS,Outpatient,,,448.18,224.09,,403.36,90,,,percent of total billed charges,90% of total Billed charges,258.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.62,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,173.35,155,,,Fee Schedule,155% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,380.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,380.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,271.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,243.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.35,140,,,Fee Schedule,140% of CMS OPPS Rate,362.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,322.46,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,322.46,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.62,403.36,
80081 Obstetric panel,3430518,CDM,960,RC,80081,HCPCS,Outpatient,,,99.53,49.77,,89.58,90,,,percent of total billed charges,90% of total Billed charges,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.06,155,,,Fee Schedule,155% of CMS OPPS Rate,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,112.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.86,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.58,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.06,145,,,Fee Schedule,145% of CMS OPPS Rate,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.06,145,,,Fee Schedule,145% of CMS OPPS Rate,101.06,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,112.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.86,149.72,
"80305 - Drug test(s), presumptive, any number of drug classe",3918905,CDM,300,RC,80305,HCPCS,Outpatient,,,171.93,85.97,,154.74,90,,,percent of total billed charges,90% of total Billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,137.54,80,,,Percent of total Billed charges,80% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.74,90,,,Percent of total Billed charges,90% of total billed charges,13.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,166.77,97,,,Percent of total billed charges,97% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,158.18,92,,,Percent of total billed charges,92% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,51.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,57.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.74,90,,,percent of total billed charges,90% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,120.35,70,,,percent of total billed charges,70% of total billed charges,154.74,90,,,percent of total billed charges,90% of total billed charges,163.33,95,,,percent of total billed charges,95% of total billed charges,163.33,95,,,percent of total billed charges,95% of total billed charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,147.86,86,,,percent of total billed charges,86% of total billed charges,137.54,80,,,percent of total billed charges,80% of total billed charges,13.98,111,,,Fee Schedule,111% of CMS OPPS Rate,166.77,97,,,percent of total billed charges,97% of total billed charges,154.74,90,,,percent of total billed charges,90% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.77,97,,,percent of total billed charges,97% of total billed charges,159.89,93,,,percent of total billed charges,93% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,166.77,97,,,percent of total billed charges,97% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.71,166.77,
Drug Screening POC,3444188,CDM,300,RC,80305,HCPCS,Outpatient,,,171.93,85.97,,154.74,90,,,percent of total billed charges,90% of total Billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,137.54,80,,,Percent of total Billed charges,80% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.74,90,,,Percent of total Billed charges,90% of total billed charges,13.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,166.77,97,,,Percent of total billed charges,97% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,158.18,92,,,Percent of total billed charges,92% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,51.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,57.77,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.74,90,,,percent of total billed charges,90% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,120.35,70,,,percent of total billed charges,70% of total billed charges,154.74,90,,,percent of total billed charges,90% of total billed charges,163.33,95,,,percent of total billed charges,95% of total billed charges,163.33,95,,,percent of total billed charges,95% of total billed charges,12.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,147.86,86,,,percent of total billed charges,86% of total billed charges,137.54,80,,,percent of total billed charges,80% of total billed charges,13.98,111,,,Fee Schedule,111% of CMS OPPS Rate,166.77,97,,,percent of total billed charges,97% of total billed charges,154.74,90,,,percent of total billed charges,90% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.77,97,,,percent of total billed charges,97% of total billed charges,159.89,93,,,percent of total billed charges,93% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,166.77,97,,,percent of total billed charges,97% of total billed charges,12.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.71,166.77,
611S Steroid Testing,4285461,CDM,300,RC,80307,HCPCS,Outpatient,,,106,53.00,,95.4,90,,,percent of total billed charges,90% of total Billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,84.8,80,,,Percent of total Billed charges,80% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.4,90,,,Percent of total Billed charges,90% of total billed charges,70.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,102.82,97,,,Percent of total billed charges,97% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,97.52,92,,,Percent of total billed charges,92% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,252.07,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,62.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,307.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,284.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.4,90,,,percent of total billed charges,90% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,74.2,70,,,percent of total billed charges,70% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,100.7,95,,,percent of total billed charges,95% of total billed charges,62.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.16,86,,,percent of total billed charges,86% of total billed charges,84.8,80,,,percent of total billed charges,80% of total billed charges,68.97,111,,,Fee Schedule,111% of CMS OPPS Rate,102.82,97,,,percent of total billed charges,97% of total billed charges,95.4,90,,,percent of total billed charges,90% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.82,97,,,percent of total billed charges,97% of total billed charges,98.58,93,,,percent of total billed charges,93% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.82,97,,,percent of total billed charges,97% of total billed charges,62.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.82,307.11,
81000 Urinalysis nonauto w/scope (also listed as AMB POC,3430519,CDM,300,RC,81000,HCPCS,Outpatient,,,5.34,2.67,,4.81,90,,,percent of total billed charges,90% of total Billed charges,4.01,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,80,,,Percent of total Billed charges,80% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.81,90,,,Percent of total Billed charges,90% of total billed charges,4.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5.18,97,,,Percent of total billed charges,97% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate,4.91,92,,,Percent of total billed charges,92% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate,16.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,18.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,4.81,90,,,percent of total billed charges,90% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate,3.74,70,,,percent of total billed charges,70% of total billed charges,4.81,90,,,percent of total billed charges,90% of total billed charges,5.07,95,,,percent of total billed charges,95% of total billed charges,5.07,95,,,percent of total billed charges,95% of total billed charges,4.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4.59,86,,,percent of total billed charges,86% of total billed charges,4.27,80,,,percent of total billed charges,80% of total billed charges,4.46,111,,,Fee Schedule,111% of CMS OPPS Rate,5.18,97,,,percent of total billed charges,97% of total billed charges,4.81,90,,,percent of total billed charges,90% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.18,97,,,percent of total billed charges,97% of total billed charges,4.97,93,,,percent of total billed charges,93% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5.18,97,,,percent of total billed charges,97% of total billed charges,4.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.42,19.86,
Urinalysis Dipstick POC,3444209,CDM,300,RC,81002,HCPCS,Outpatient,,,9.26,4.63,,8.33,90,,,percent of total billed charges,90% of total Billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,7.41,80,,,Percent of total Billed charges,80% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.33,90,,,Percent of total Billed charges,90% of total billed charges,3.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8.98,97,,,Percent of total billed charges,97% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,8.52,92,,,Percent of total billed charges,92% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,14.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.19,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,8.33,90,,,percent of total billed charges,90% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,6.48,70,,,percent of total billed charges,70% of total billed charges,8.33,90,,,percent of total billed charges,90% of total billed charges,8.8,95,,,percent of total billed charges,95% of total billed charges,8.8,95,,,percent of total billed charges,95% of total billed charges,3.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7.96,86,,,percent of total billed charges,86% of total billed charges,7.41,80,,,percent of total billed charges,80% of total billed charges,3.86,111,,,Fee Schedule,111% of CMS OPPS Rate,8.98,97,,,percent of total billed charges,97% of total billed charges,8.33,90,,,percent of total billed charges,90% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.98,97,,,percent of total billed charges,97% of total billed charges,8.61,93,,,percent of total billed charges,93% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8.98,97,,,percent of total billed charges,97% of total billed charges,3.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.48,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2.96,17.19,
81003 - Urine Dipstick 2GP POC,3918906,CDM,300,RC,81003,HCPCS,Outpatient,,,6.63,3.32,,5.97,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.97,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6.43,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.1,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5.97,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,4.64,70,,,percent of total billed charges,70% of total billed charges,5.97,90,,,percent of total billed charges,90% of total billed charges,6.3,95,,,percent of total billed charges,95% of total billed charges,6.3,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5.7,86,,,percent of total billed charges,86% of total billed charges,5.3,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,6.43,97,,,percent of total billed charges,97% of total billed charges,5.97,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.43,97,,,percent of total billed charges,97% of total billed charges,6.17,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6.43,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,11.12,
81003- Urinalysis Dipstick POC,3572706,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
OB Urine Dipstick 2 GP POC,3549808,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
Urinalysis Dipstick,1365116,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
Urine Dipstick 10 POC,3444215,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
Urine Dipstick 2GP POC,3444214,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
81025 - Urine Pregnancy Test,3918907,CDM,300,RC,81025,HCPCS,Outpatient,,,44.5,22.25,,40.05,90,,,percent of total billed charges,90% of total Billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,80,,,Percent of total Billed charges,80% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.05,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.17,97,,,Percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,40.94,92,,,Percent of total billed charges,92% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,34.92,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.05,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,31.15,70,,,percent of total billed charges,70% of total billed charges,40.05,90,,,percent of total billed charges,90% of total billed charges,42.28,95,,,percent of total billed charges,95% of total billed charges,42.28,95,,,percent of total billed charges,95% of total billed charges,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.27,86,,,percent of total billed charges,86% of total billed charges,35.6,80,,,percent of total billed charges,80% of total billed charges,9.55,111,,,Fee Schedule,111% of CMS OPPS Rate,43.17,97,,,percent of total billed charges,97% of total billed charges,40.05,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.17,97,,,percent of total billed charges,97% of total billed charges,41.39,93,,,percent of total billed charges,93% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.17,97,,,percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,43.17,
CLINIC In-Office Urine Pregnancy Test,3347274,CDM,300,RC,81025,HCPCS,Outpatient,,,89.08,44.54,,80.17,90,,,percent of total billed charges,90% of total Billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,71.26,80,,,Percent of total Billed charges,80% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.17,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,86.41,97,,,Percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,81.95,92,,,Percent of total billed charges,92% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,34.92,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.17,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,62.36,70,,,percent of total billed charges,70% of total billed charges,80.17,90,,,percent of total billed charges,90% of total billed charges,84.63,95,,,percent of total billed charges,95% of total billed charges,84.63,95,,,percent of total billed charges,95% of total billed charges,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,76.61,86,,,percent of total billed charges,86% of total billed charges,71.26,80,,,percent of total billed charges,80% of total billed charges,9.55,111,,,Fee Schedule,111% of CMS OPPS Rate,86.41,97,,,percent of total billed charges,97% of total billed charges,80.17,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.41,97,,,percent of total billed charges,97% of total billed charges,82.84,93,,,percent of total billed charges,93% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.41,97,,,percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,86.41,
"HCG, Urine POC",3444192,CDM,300,RC,81025,HCPCS,Outpatient,,,44.5,22.25,,40.05,90,,,percent of total billed charges,90% of total Billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,35.6,80,,,Percent of total Billed charges,80% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.05,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.17,97,,,Percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,40.94,92,,,Percent of total billed charges,92% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,34.92,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.05,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,31.15,70,,,percent of total billed charges,70% of total billed charges,40.05,90,,,percent of total billed charges,90% of total billed charges,42.28,95,,,percent of total billed charges,95% of total billed charges,42.28,95,,,percent of total billed charges,95% of total billed charges,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.27,86,,,percent of total billed charges,86% of total billed charges,35.6,80,,,percent of total billed charges,80% of total billed charges,9.55,111,,,Fee Schedule,111% of CMS OPPS Rate,43.17,97,,,percent of total billed charges,97% of total billed charges,40.05,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.17,97,,,percent of total billed charges,97% of total billed charges,41.39,93,,,percent of total billed charges,93% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.17,97,,,percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,43.17,
81528  Oncology colorectal scr,3430522,CDM,960,RC,81528,HCPCS,Outpatient,,,676.62,338.31,,608.96,90,,,percent of total billed charges,90% of total Billed charges,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.97,155,,,Fee Schedule,155% of CMS OPPS Rate,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,508.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,610.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,610.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,763.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,763.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,202.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1017.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,636.09,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,686.97,145,,,Fee Schedule,145% of CMS OPPS Rate,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,686.97,145,,,Fee Schedule,145% of CMS OPPS Rate,686.97,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,551.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,508.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.99,1017.74,
Urine Microalbumin POC,3444210,CDM,300,RC,82043,HCPCS,Outpatient,,,17.08,8.54,,15.37,90,,,percent of total billed charges,90% of total Billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,80,,,Percent of total Billed charges,80% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.37,90,,,Percent of total Billed charges,90% of total billed charges,8.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,16.57,97,,,Percent of total billed charges,97% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,15.71,92,,,Percent of total billed charges,92% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,23.44,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,15.37,90,,,percent of total billed charges,90% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,11.96,70,,,percent of total billed charges,70% of total billed charges,15.37,90,,,percent of total billed charges,90% of total billed charges,16.23,95,,,percent of total billed charges,95% of total billed charges,16.23,95,,,percent of total billed charges,95% of total billed charges,5.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14.69,86,,,percent of total billed charges,86% of total billed charges,13.66,80,,,percent of total billed charges,80% of total billed charges,6.41,111,,,Fee Schedule,111% of CMS OPPS Rate,16.57,97,,,percent of total billed charges,97% of total billed charges,15.37,90,,,percent of total billed charges,90% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.57,97,,,percent of total billed charges,97% of total billed charges,15.88,93,,,percent of total billed charges,93% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,16.57,97,,,percent of total billed charges,97% of total billed charges,5.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.91,28.56,
82044 Ur albumin semiquantitative,3430523,CDM,960,RC,82044,HCPCS,Outpatient,,,8.29,4.15,,7.46,90,,,percent of total billed charges,90% of total Billed charges,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,8.41,155,,,Fee Schedule,155% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,9.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,9.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.79,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.41,145,,,Fee Schedule,145% of CMS OPPS Rate,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.41,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,6.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,2.49,12.46,
82075 Breath Alcohol,3435571,CDM,510,RC,82075,HCPCS,Outpatient,,,33.24,16.62,,29.92,90,,,percent of total billed charges,90% of total Billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,26.59,80,,,Percent of total Billed charges,80% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.24,97,,,Percent of total billed charges,97% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,30.58,92,,,Percent of total billed charges,92% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,121.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,137.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.92,90,,,percent of total billed charges,90% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,23.27,70,,,percent of total billed charges,70% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,30,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,28.59,86,,,percent of total billed charges,86% of total billed charges,26.59,80,,,percent of total billed charges,80% of total billed charges,33.3,111,,,Fee Schedule,111% of CMS OPPS Rate,32.24,97,,,percent of total billed charges,97% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.24,97,,,percent of total billed charges,97% of total billed charges,30.91,93,,,percent of total billed charges,93% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate,30,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32.24,97,,,percent of total billed charges,97% of total billed charges,30,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,25.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.27,148.26,
82270 Occult blood feces,3428342,CDM,300,RC,82270,HCPCS,Outpatient,,,26,13.00,,23.4,90,,,percent of total billed charges,90% of total Billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,20.8,80,,,Percent of total Billed charges,80% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.4,90,,,Percent of total Billed charges,90% of total billed charges,3.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,25.22,97,,,Percent of total billed charges,97% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,23.92,92,,,Percent of total billed charges,92% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,17.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,20.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.4,90,,,percent of total billed charges,90% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,18.2,70,,,percent of total billed charges,70% of total billed charges,23.4,90,,,percent of total billed charges,90% of total billed charges,24.7,95,,,percent of total billed charges,95% of total billed charges,24.7,95,,,percent of total billed charges,95% of total billed charges,4.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.36,86,,,percent of total billed charges,86% of total billed charges,20.8,80,,,percent of total billed charges,80% of total billed charges,4.86,111,,,Fee Schedule,111% of CMS OPPS Rate,25.22,97,,,percent of total billed charges,97% of total billed charges,23.4,90,,,percent of total billed charges,90% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.22,97,,,percent of total billed charges,97% of total billed charges,24.18,93,,,percent of total billed charges,93% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.22,97,,,percent of total billed charges,97% of total billed charges,4.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.47,25.22,
Occult Blood,593508,CDM,300,RC,82272,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,85.71,80,,,Percent of total Billed charges,80% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.43,90,,,Percent of total Billed charges,90% of total billed charges,3.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.93,97,,,Percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,98.57,92,,,Percent of total billed charges,92% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.43,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,75,70,,,percent of total billed charges,70% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.14,86,,,percent of total billed charges,86% of total billed charges,85.71,80,,,percent of total billed charges,80% of total billed charges,4.69,111,,,Fee Schedule,111% of CMS OPPS Rate,103.93,97,,,percent of total billed charges,97% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.93,97,,,percent of total billed charges,97% of total billed charges,99.64,93,,,percent of total billed charges,93% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.93,97,,,percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.6,103.93,
Stool for Occult Blood POC,3444208,CDM,300,RC,82272,HCPCS,Outpatient,,,15.95,7.98,,14.36,90,,,percent of total billed charges,90% of total Billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12.76,80,,,Percent of total Billed charges,80% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.36,90,,,Percent of total Billed charges,90% of total billed charges,3.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.47,97,,,Percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,14.67,92,,,Percent of total billed charges,92% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.36,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,11.17,70,,,percent of total billed charges,70% of total billed charges,14.36,90,,,percent of total billed charges,90% of total billed charges,15.15,95,,,percent of total billed charges,95% of total billed charges,15.15,95,,,percent of total billed charges,95% of total billed charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.72,86,,,percent of total billed charges,86% of total billed charges,12.76,80,,,percent of total billed charges,80% of total billed charges,4.69,111,,,Fee Schedule,111% of CMS OPPS Rate,15.47,97,,,percent of total billed charges,97% of total billed charges,14.36,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.47,97,,,percent of total billed charges,97% of total billed charges,14.83,93,,,percent of total billed charges,93% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.47,97,,,percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.6,20.9,
FIT POC,3444189,CDM,300,RC,82274,HCPCS,Outpatient,,,46.99,23.50,,42.29,90,,,percent of total billed charges,90% of total Billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,37.59,80,,,Percent of total Billed charges,80% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.29,90,,,Percent of total Billed charges,90% of total billed charges,3.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,45.58,97,,,Percent of total billed charges,97% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,43.23,92,,,Percent of total billed charges,92% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,64.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,72.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.29,90,,,percent of total billed charges,90% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,32.89,70,,,percent of total billed charges,70% of total billed charges,42.29,90,,,percent of total billed charges,90% of total billed charges,44.64,95,,,percent of total billed charges,95% of total billed charges,44.64,95,,,percent of total billed charges,95% of total billed charges,15.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40.41,86,,,percent of total billed charges,86% of total billed charges,37.59,80,,,percent of total billed charges,80% of total billed charges,17.67,111,,,Fee Schedule,111% of CMS OPPS Rate,45.58,97,,,percent of total billed charges,97% of total billed charges,42.29,90,,,percent of total billed charges,90% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.58,97,,,percent of total billed charges,97% of total billed charges,43.7,93,,,percent of total billed charges,93% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.58,97,,,percent of total billed charges,97% of total billed charges,15.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13.53,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2.8,78.68,
Chloride POC,4326414,CDM,300,RC,82435,HCPCS,Outpatient,,,25.76,12.88,,23.18,90,,,percent of total billed charges,90% of total Billed charges,4.59,100,,,Fee Schedule,100% of CMS OPPS Rate,20.61,80,,,Percent of total Billed charges,80% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.18,90,,,Percent of total Billed charges,90% of total billed charges,6.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,24.99,97,,,Percent of total billed charges,97% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,23.7,92,,,Percent of total billed charges,92% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.66,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,21.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.18,90,,,percent of total billed charges,90% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,18.03,70,,,percent of total billed charges,70% of total billed charges,23.18,90,,,percent of total billed charges,90% of total billed charges,24.47,95,,,percent of total billed charges,95% of total billed charges,24.47,95,,,percent of total billed charges,95% of total billed charges,4.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.15,86,,,percent of total billed charges,86% of total billed charges,20.61,80,,,percent of total billed charges,80% of total billed charges,5.1,111,,,Fee Schedule,111% of CMS OPPS Rate,24.99,97,,,percent of total billed charges,97% of total billed charges,23.18,90,,,percent of total billed charges,90% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.99,97,,,percent of total billed charges,97% of total billed charges,23.96,93,,,percent of total billed charges,93% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,24.99,97,,,percent of total billed charges,97% of total billed charges,4.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.91,24.99,
Blood Gas (Art) CG4 POC,4323216,CDM,300,RC,82803,HCPCS,Outpatient,,,145.99,73.00,,131.39,90,,,percent of total billed charges,90% of total Billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,116.79,80,,,Percent of total Billed charges,80% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.39,90,,,Percent of total Billed charges,90% of total billed charges,29.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,141.61,97,,,Percent of total billed charges,97% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.31,92,,,Percent of total billed charges,92% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,105.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,119.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.39,90,,,percent of total billed charges,90% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.19,70,,,percent of total billed charges,70% of total billed charges,131.39,90,,,percent of total billed charges,90% of total billed charges,138.69,95,,,percent of total billed charges,95% of total billed charges,138.69,95,,,percent of total billed charges,95% of total billed charges,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,125.55,86,,,percent of total billed charges,86% of total billed charges,116.79,80,,,percent of total billed charges,80% of total billed charges,28.93,111,,,Fee Schedule,111% of CMS OPPS Rate,141.61,97,,,percent of total billed charges,97% of total billed charges,131.39,90,,,percent of total billed charges,90% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.61,97,,,percent of total billed charges,97% of total billed charges,135.77,93,,,percent of total billed charges,93% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,141.61,97,,,percent of total billed charges,97% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.16,141.61,
pH (Ven POC BG),4326420,CDM,300,RC,82803,HCPCS,Outpatient,,,145.99,73.00,,131.39,90,,,percent of total billed charges,90% of total Billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,116.79,80,,,Percent of total Billed charges,80% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.39,90,,,Percent of total Billed charges,90% of total billed charges,29.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,141.61,97,,,Percent of total billed charges,97% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,134.31,92,,,Percent of total billed charges,92% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,105.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,119.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131.39,90,,,percent of total billed charges,90% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.19,70,,,percent of total billed charges,70% of total billed charges,131.39,90,,,percent of total billed charges,90% of total billed charges,138.69,95,,,percent of total billed charges,95% of total billed charges,138.69,95,,,percent of total billed charges,95% of total billed charges,26.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,125.55,86,,,percent of total billed charges,86% of total billed charges,116.79,80,,,percent of total billed charges,80% of total billed charges,28.93,111,,,Fee Schedule,111% of CMS OPPS Rate,141.61,97,,,percent of total billed charges,97% of total billed charges,131.39,90,,,percent of total billed charges,90% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,141.61,97,,,percent of total billed charges,97% of total billed charges,135.77,93,,,percent of total billed charges,93% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,141.61,97,,,percent of total billed charges,97% of total billed charges,26.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.16,141.61,
O2 Saturation POC,3444202,CDM,300,RC,82810,HCPCS,Outpatient,,,25.98,12.99,,23.38,90,,,percent of total billed charges,90% of total Billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,20.78,80,,,Percent of total Billed charges,80% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.38,90,,,Percent of total Billed charges,90% of total billed charges,13.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,25.2,97,,,Percent of total billed charges,97% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,23.9,92,,,Percent of total billed charges,92% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,39.63,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.28,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,44.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.38,90,,,percent of total billed charges,90% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,18.19,70,,,percent of total billed charges,70% of total billed charges,23.38,90,,,percent of total billed charges,90% of total billed charges,24.68,95,,,percent of total billed charges,95% of total billed charges,24.68,95,,,percent of total billed charges,95% of total billed charges,9.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.34,86,,,percent of total billed charges,86% of total billed charges,20.78,80,,,percent of total billed charges,80% of total billed charges,10.84,111,,,Fee Schedule,111% of CMS OPPS Rate,25.2,97,,,percent of total billed charges,97% of total billed charges,23.38,90,,,percent of total billed charges,90% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.2,97,,,percent of total billed charges,97% of total billed charges,24.16,93,,,percent of total billed charges,93% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.2,97,,,percent of total billed charges,97% of total billed charges,9.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.3,48.28,
82947 - Glucose POC,3918908,CDM,960,RC,82947,HCPCS,Outpatient,,,13.4,6.70,,12.06,90,,,percent of total billed charges,90% of total Billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,5.31,155,,,Fee Schedule,155% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,5.9,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,5.9,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.02,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4.91,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.31,145,,,Fee Schedule,145% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.31,145,,,Fee Schedule,145% of CMS OPPS Rate,5.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.52,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,5.52,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,3.93,12.06,
Glucose POC,4326416,CDM,300,RC,82947,HCPCS,Outpatient,,,22.01,11.01,,19.81,90,,,percent of total billed charges,90% of total Billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,17.61,80,,,Percent of total Billed charges,80% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.81,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,21.35,97,,,Percent of total billed charges,97% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,20.25,92,,,Percent of total billed charges,92% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.42,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,18.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.81,90,,,percent of total billed charges,90% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.41,70,,,percent of total billed charges,70% of total billed charges,19.81,90,,,percent of total billed charges,90% of total billed charges,20.91,95,,,percent of total billed charges,95% of total billed charges,20.91,95,,,percent of total billed charges,95% of total billed charges,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18.93,86,,,percent of total billed charges,86% of total billed charges,17.61,80,,,percent of total billed charges,80% of total billed charges,4.36,111,,,Fee Schedule,111% of CMS OPPS Rate,21.35,97,,,percent of total billed charges,97% of total billed charges,19.81,90,,,percent of total billed charges,90% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.35,97,,,percent of total billed charges,97% of total billed charges,20.47,93,,,percent of total billed charges,93% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.35,97,,,percent of total billed charges,97% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.34,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.34,21.35,
Glucose POC,3444190,CDM,300,RC,82947,HCPCS,Outpatient,,,13.4,6.70,,12.06,90,,,percent of total billed charges,90% of total Billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,10.72,80,,,Percent of total Billed charges,80% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.06,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13,97,,,Percent of total billed charges,97% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12.33,92,,,Percent of total billed charges,92% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,15.94,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.42,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,18.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.06,90,,,percent of total billed charges,90% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,9.38,70,,,percent of total billed charges,70% of total billed charges,12.06,90,,,percent of total billed charges,90% of total billed charges,12.73,95,,,percent of total billed charges,95% of total billed charges,12.73,95,,,percent of total billed charges,95% of total billed charges,3.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.52,86,,,percent of total billed charges,86% of total billed charges,10.72,80,,,percent of total billed charges,80% of total billed charges,4.36,111,,,Fee Schedule,111% of CMS OPPS Rate,13,97,,,percent of total billed charges,97% of total billed charges,12.06,90,,,percent of total billed charges,90% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,13,97,,,percent of total billed charges,97% of total billed charges,12.46,93,,,percent of total billed charges,93% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13,97,,,percent of total billed charges,97% of total billed charges,3.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.34,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.34,19.42,
82962 Gluc Bld Cluc Mntr Dev Cleared FDA Spec Home Use,3436058,CDM,761,RC,82962,HCPCS,Outpatient,,,8.72,4.36,,7.85,90,,,percent of total billed charges,90% of total Billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,6.98,80,,,Percent of total Billed charges,80% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.85,90,,,Percent of total Billed charges,90% of total billed charges,2.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8.46,97,,,Percent of total billed charges,97% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,8.02,92,,,Percent of total billed charges,92% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,13.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.21,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,7.85,90,,,percent of total billed charges,90% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,6.1,70,,,percent of total billed charges,70% of total billed charges,7.85,90,,,percent of total billed charges,90% of total billed charges,8.28,95,,,percent of total billed charges,95% of total billed charges,8.28,95,,,percent of total billed charges,95% of total billed charges,3.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7.5,86,,,percent of total billed charges,86% of total billed charges,6.98,80,,,percent of total billed charges,80% of total billed charges,3.64,111,,,Fee Schedule,111% of CMS OPPS Rate,8.46,97,,,percent of total billed charges,97% of total billed charges,7.85,90,,,percent of total billed charges,90% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.46,97,,,percent of total billed charges,97% of total billed charges,8.11,93,,,percent of total billed charges,93% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8.46,97,,,percent of total billed charges,97% of total billed charges,3.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2,16.21,
Lead Level POC,3444199,CDM,300,RC,83655,HCPCS,Outpatient,,,35.78,17.89,,32.2,90,,,percent of total billed charges,90% of total Billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,28.62,80,,,Percent of total Billed charges,80% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.2,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,34.71,97,,,Percent of total billed charges,97% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,32.92,92,,,Percent of total billed charges,92% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,49.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.85,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,55.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,32.2,90,,,percent of total billed charges,90% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,25.05,70,,,percent of total billed charges,70% of total billed charges,32.2,90,,,percent of total billed charges,90% of total billed charges,33.99,95,,,percent of total billed charges,95% of total billed charges,33.99,95,,,percent of total billed charges,95% of total billed charges,12.11,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30.77,86,,,percent of total billed charges,86% of total billed charges,28.62,80,,,percent of total billed charges,80% of total billed charges,13.44,111,,,Fee Schedule,111% of CMS OPPS Rate,34.71,97,,,percent of total billed charges,97% of total billed charges,32.2,90,,,percent of total billed charges,90% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.71,97,,,percent of total billed charges,97% of total billed charges,33.28,93,,,percent of total billed charges,93% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.71,97,,,percent of total billed charges,97% of total billed charges,12.11,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.11,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,59.85,
Potassium POC,4326413,CDM,300,RC,84132,HCPCS,Outpatient,,,26.66,13.33,,23.99,90,,,percent of total billed charges,90% of total Billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,21.33,80,,,Percent of total Billed charges,80% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.99,90,,,Percent of total Billed charges,90% of total billed charges,6.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,25.86,97,,,Percent of total billed charges,97% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,24.53,92,,,Percent of total billed charges,92% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,19.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,21.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,23.99,90,,,percent of total billed charges,90% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,18.66,70,,,percent of total billed charges,70% of total billed charges,23.99,90,,,percent of total billed charges,90% of total billed charges,25.33,95,,,percent of total billed charges,95% of total billed charges,25.33,95,,,percent of total billed charges,95% of total billed charges,4.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.93,86,,,percent of total billed charges,86% of total billed charges,21.33,80,,,percent of total billed charges,80% of total billed charges,5.28,111,,,Fee Schedule,111% of CMS OPPS Rate,25.86,97,,,percent of total billed charges,97% of total billed charges,23.99,90,,,percent of total billed charges,90% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.86,97,,,percent of total billed charges,97% of total billed charges,24.79,93,,,percent of total billed charges,93% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.86,97,,,percent of total billed charges,97% of total billed charges,4.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.05,25.86,
Sodium POC,4326412,CDM,300,RC,84295,HCPCS,Outpatient,,,26.94,13.47,,24.25,90,,,percent of total billed charges,90% of total Billed charges,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,21.55,80,,,Percent of total Billed charges,80% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.25,90,,,Percent of total Billed charges,90% of total billed charges,7.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,26.13,97,,,Percent of total billed charges,97% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,24.78,92,,,Percent of total billed charges,92% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,19.51,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24.25,90,,,percent of total billed charges,90% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,18.86,70,,,percent of total billed charges,70% of total billed charges,24.25,90,,,percent of total billed charges,90% of total billed charges,25.59,95,,,percent of total billed charges,95% of total billed charges,25.59,95,,,percent of total billed charges,95% of total billed charges,4.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.17,86,,,percent of total billed charges,86% of total billed charges,21.55,80,,,percent of total billed charges,80% of total billed charges,5.33,111,,,Fee Schedule,111% of CMS OPPS Rate,26.13,97,,,percent of total billed charges,97% of total billed charges,24.25,90,,,percent of total billed charges,90% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.13,97,,,percent of total billed charges,97% of total billed charges,25.05,93,,,percent of total billed charges,93% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,26.13,97,,,percent of total billed charges,97% of total billed charges,4.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.09,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.09,26.13,
Troponin I POC,1251035,CDM,510,RC,84484,HCPCS,Outpatient,,,74.02,37.01,,66.62,90,,,percent of total billed charges,90% of total Billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,59.22,80,,,Percent of total Billed charges,80% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.62,90,,,Percent of total Billed charges,90% of total billed charges,10.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,71.8,97,,,Percent of total billed charges,97% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,68.1,92,,,Percent of total billed charges,92% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,50.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,57.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,66.62,90,,,percent of total billed charges,90% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,51.81,70,,,percent of total billed charges,70% of total billed charges,66.62,90,,,percent of total billed charges,90% of total billed charges,70.32,95,,,percent of total billed charges,95% of total billed charges,70.32,95,,,percent of total billed charges,95% of total billed charges,12.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,63.66,86,,,percent of total billed charges,86% of total billed charges,59.22,80,,,percent of total billed charges,80% of total billed charges,13.84,111,,,Fee Schedule,111% of CMS OPPS Rate,71.8,97,,,percent of total billed charges,97% of total billed charges,66.62,90,,,percent of total billed charges,90% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.8,97,,,percent of total billed charges,97% of total billed charges,68.84,93,,,percent of total billed charges,93% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.8,97,,,percent of total billed charges,97% of total billed charges,12.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.87,71.8,
BUN POC,4326417,CDM,300,RC,84520,HCPCS,Outpatient,,,22.12,11.06,,19.91,90,,,percent of total billed charges,90% of total Billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,17.7,80,,,Percent of total Billed charges,80% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.91,90,,,Percent of total Billed charges,90% of total billed charges,5.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,21.46,97,,,Percent of total billed charges,97% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,20.35,92,,,Percent of total billed charges,92% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,16.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,18.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.91,90,,,percent of total billed charges,90% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,15.48,70,,,percent of total billed charges,70% of total billed charges,19.91,90,,,percent of total billed charges,90% of total billed charges,21.01,95,,,percent of total billed charges,95% of total billed charges,21.01,95,,,percent of total billed charges,95% of total billed charges,3.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,19.02,86,,,percent of total billed charges,86% of total billed charges,17.7,80,,,percent of total billed charges,80% of total billed charges,4.38,111,,,Fee Schedule,111% of CMS OPPS Rate,21.46,97,,,percent of total billed charges,97% of total billed charges,19.91,90,,,percent of total billed charges,90% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.46,97,,,percent of total billed charges,97% of total billed charges,20.57,93,,,percent of total billed charges,93% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.46,97,,,percent of total billed charges,97% of total billed charges,3.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.36,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.36,21.46,
Urine Pregnancy Test,1365117,CDM,510,RC,84703,HCPCS,Outpatient,,,44.64,22.32,,40.18,90,,,percent of total billed charges,90% of total Billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,35.71,80,,,Percent of total Billed charges,80% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.18,90,,,Percent of total Billed charges,90% of total billed charges,11.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.3,97,,,Percent of total billed charges,97% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,41.07,92,,,Percent of total billed charges,92% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,34.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,40.18,90,,,percent of total billed charges,90% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,31.25,70,,,percent of total billed charges,70% of total billed charges,40.18,90,,,percent of total billed charges,90% of total billed charges,42.41,95,,,percent of total billed charges,95% of total billed charges,42.41,95,,,percent of total billed charges,95% of total billed charges,7.52,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.39,86,,,percent of total billed charges,86% of total billed charges,35.71,80,,,percent of total billed charges,80% of total billed charges,8.34,111,,,Fee Schedule,111% of CMS OPPS Rate,43.3,97,,,percent of total billed charges,97% of total billed charges,40.18,90,,,percent of total billed charges,90% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.3,97,,,percent of total billed charges,97% of total billed charges,41.52,93,,,percent of total billed charges,93% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.3,97,,,percent of total billed charges,97% of total billed charges,7.52,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.52,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.39,43.3,
Hct POC,4326419,CDM,300,RC,85014,HCPCS,Outpatient,,,13.27,6.64,,11.94,90,,,percent of total billed charges,90% of total Billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,10.62,80,,,Percent of total Billed charges,80% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.94,90,,,Percent of total Billed charges,90% of total billed charges,3.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.87,97,,,Percent of total billed charges,97% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12.21,92,,,Percent of total billed charges,92% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9.61,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.94,90,,,percent of total billed charges,90% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9.29,70,,,percent of total billed charges,70% of total billed charges,11.94,90,,,percent of total billed charges,90% of total billed charges,12.61,95,,,percent of total billed charges,95% of total billed charges,12.61,95,,,percent of total billed charges,95% of total billed charges,2.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.41,86,,,percent of total billed charges,86% of total billed charges,10.62,80,,,percent of total billed charges,80% of total billed charges,2.63,111,,,Fee Schedule,111% of CMS OPPS Rate,12.87,97,,,percent of total billed charges,97% of total billed charges,11.94,90,,,percent of total billed charges,90% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.87,97,,,percent of total billed charges,97% of total billed charges,12.34,93,,,percent of total billed charges,93% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.87,97,,,percent of total billed charges,97% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.37,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2.01,12.87,
POC Hemoglobin Capillary,2990102,CDM,300,RC,85018,HCPCS,Outpatient,,,14.07,7.04,,12.66,90,,,percent of total billed charges,90% of total Billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,80,,,Percent of total Billed charges,80% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.66,90,,,Percent of total Billed charges,90% of total billed charges,3.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13.65,97,,,Percent of total billed charges,97% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,12.94,92,,,Percent of total billed charges,92% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9.61,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.66,90,,,percent of total billed charges,90% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,9.85,70,,,percent of total billed charges,70% of total billed charges,12.66,90,,,percent of total billed charges,90% of total billed charges,13.37,95,,,percent of total billed charges,95% of total billed charges,13.37,95,,,percent of total billed charges,95% of total billed charges,2.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12.1,86,,,percent of total billed charges,86% of total billed charges,11.26,80,,,percent of total billed charges,80% of total billed charges,2.63,111,,,Fee Schedule,111% of CMS OPPS Rate,13.65,97,,,percent of total billed charges,97% of total billed charges,12.66,90,,,percent of total billed charges,90% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.65,97,,,percent of total billed charges,97% of total billed charges,13.09,93,,,percent of total billed charges,93% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13.65,97,,,percent of total billed charges,97% of total billed charges,2.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.37,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2.01,13.65,
85025 - Complete Blood Count POC,3918909,CDM,300,RC,85025,HCPCS,Outpatient,,,124.98,62.49,,112.48,90,,,percent of total billed charges,90% of total Billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.7,150,,,Fee Schedule,150% of Fee Schedule Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.48,90,,,Percent of total Billed charges,90% of total billed charges,6.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.23,97,,,Percent of total billed charges,97% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,114.98,92,,,Percent of total billed charges,92% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,31.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,35.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.48,90,,,percent of total billed charges,90% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,87.49,70,,,percent of total billed charges,70% of total billed charges,112.48,90,,,percent of total billed charges,90% of total billed charges,118.73,95,,,percent of total billed charges,95% of total billed charges,118.73,95,,,percent of total billed charges,95% of total billed charges,7.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.48,86,,,percent of total billed charges,86% of total billed charges,99.98,80,,,percent of total billed charges,80% of total billed charges,8.62,111,,,Fee Schedule,111% of CMS OPPS Rate,121.23,97,,,percent of total billed charges,97% of total billed charges,112.48,90,,,percent of total billed charges,90% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.23,97,,,percent of total billed charges,97% of total billed charges,116.23,93,,,percent of total billed charges,93% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.23,97,,,percent of total billed charges,97% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6,121.23,
Complete Blood Count POC,3528247,CDM,300,RC,85025,HCPCS,Outpatient,,,124.98,62.49,,112.48,90,,,percent of total billed charges,90% of total Billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.7,150,,,Fee Schedule,150% of Fee Schedule Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.48,90,,,Percent of total Billed charges,90% of total billed charges,6.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.23,97,,,Percent of total billed charges,97% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,114.98,92,,,Percent of total billed charges,92% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,31.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,7.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,38.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,35.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,112.48,90,,,percent of total billed charges,90% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,87.49,70,,,percent of total billed charges,70% of total billed charges,112.48,90,,,percent of total billed charges,90% of total billed charges,118.73,95,,,percent of total billed charges,95% of total billed charges,118.73,95,,,percent of total billed charges,95% of total billed charges,7.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.48,86,,,percent of total billed charges,86% of total billed charges,99.98,80,,,percent of total billed charges,80% of total billed charges,8.62,111,,,Fee Schedule,111% of CMS OPPS Rate,121.23,97,,,percent of total billed charges,97% of total billed charges,112.48,90,,,percent of total billed charges,90% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.23,97,,,percent of total billed charges,97% of total billed charges,116.23,93,,,percent of total billed charges,93% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.23,97,,,percent of total billed charges,97% of total billed charges,7.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6,121.23,
Pathology Billing Peripheral Smear with Path Interp,592827,CDM,971,RC,85060,HCPCS,Outpatient,,,55.51,27.76,,49.96,90,,,percent of total billed charges,90% of total Billed charges,47.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.89,155,,,Fee Schedule,155% of CMS OPPS Rate,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.65,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,26.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.89,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.34,145,,,Fee Schedule,145% of CMS OPPS Rate,33.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,45.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.65,68.34,
Pathology Billing BM Aspirate Smear Interpretation,644404,CDM,971,RC,85097,HCPCS,Outpatient,,,153.05,76.53,,137.75,90,,,percent of total billed charges,90% of total Billed charges,110.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,66.85,155,,,Fee Schedule,155% of CMS OPPS Rate,46.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.78,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.99,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,100.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,100.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,45.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,66.78,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.69,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,66.85,145,,,Fee Schedule,145% of CMS OPPS Rate,46.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.92,145,,,Fee Schedule,145% of CMS OPPS Rate,66.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.2,160.92,
85610- Prothrombin time,3430526,CDM,300,RC,85610,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.9,150,,,Fee Schedule,150% of Fee Schedule Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,17.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,4.76,111,,,Fee Schedule,111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.29,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,21.2,
H Pylori POC,3444191,CDM,300,RC,86318,HCPCS,Outpatient,,,48.1,24.05,,43.29,90,,,percent of total billed charges,90% of total Billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,38.48,80,,,Percent of total Billed charges,80% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.29,90,,,Percent of total Billed charges,90% of total billed charges,19.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,46.66,97,,,Percent of total billed charges,97% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,44.25,92,,,Percent of total billed charges,92% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,73.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,18.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,82.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.29,90,,,percent of total billed charges,90% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,33.67,70,,,percent of total billed charges,70% of total billed charges,43.29,90,,,percent of total billed charges,90% of total billed charges,45.7,95,,,percent of total billed charges,95% of total billed charges,45.7,95,,,percent of total billed charges,95% of total billed charges,18.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.37,86,,,percent of total billed charges,86% of total billed charges,38.48,80,,,percent of total billed charges,80% of total billed charges,20.07,111,,,Fee Schedule,111% of CMS OPPS Rate,46.66,97,,,percent of total billed charges,97% of total billed charges,43.29,90,,,percent of total billed charges,90% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.66,97,,,percent of total billed charges,97% of total billed charges,44.73,93,,,percent of total billed charges,93% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.66,97,,,percent of total billed charges,97% of total billed charges,18.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,15.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.38,89.4,
BladderChek POC,3444187,CDM,300,RC,86386,HCPCS,Outpatient,,,35.9,17.95,,32.31,90,,,percent of total billed charges,90% of total Billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,28.72,80,,,Percent of total Billed charges,80% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.31,90,,,Percent of total Billed charges,90% of total billed charges,19.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,34.82,97,,,Percent of total billed charges,97% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,33.03,92,,,Percent of total billed charges,92% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,88.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,99.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,32.31,90,,,percent of total billed charges,90% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.13,70,,,percent of total billed charges,70% of total billed charges,32.31,90,,,percent of total billed charges,90% of total billed charges,34.11,95,,,percent of total billed charges,95% of total billed charges,34.11,95,,,percent of total billed charges,95% of total billed charges,21.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30.87,86,,,percent of total billed charges,86% of total billed charges,28.72,80,,,percent of total billed charges,80% of total billed charges,24.17,111,,,Fee Schedule,111% of CMS OPPS Rate,34.82,97,,,percent of total billed charges,97% of total billed charges,32.31,90,,,percent of total billed charges,90% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.82,97,,,percent of total billed charges,97% of total billed charges,33.39,93,,,percent of total billed charges,93% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.82,97,,,percent of total billed charges,97% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.09,107.64,
Monospot: Whole Blood POC,3444201,CDM,300,RC,86403,HCPCS,Outpatient,,,30.69,15.35,,27.62,90,,,percent of total billed charges,90% of total Billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,24.55,80,,,Percent of total Billed charges,80% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.62,90,,,Percent of total Billed charges,90% of total billed charges,15.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,29.77,97,,,Percent of total billed charges,97% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,28.23,92,,,Percent of total billed charges,92% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,46.81,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.03,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,52.91,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.62,90,,,percent of total billed charges,90% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,70,,,percent of total billed charges,70% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,11.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.39,86,,,percent of total billed charges,86% of total billed charges,24.55,80,,,percent of total billed charges,80% of total billed charges,12.8,111,,,Fee Schedule,111% of CMS OPPS Rate,29.77,97,,,percent of total billed charges,97% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.77,97,,,percent of total billed charges,97% of total billed charges,28.54,93,,,percent of total billed charges,93% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.77,97,,,percent of total billed charges,97% of total billed charges,11.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,9.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.81,57.03,
86580 Tb intradermal test,3428347,CDM,983,RC,86580,HCPCS,Outpatient,,,24.79,12.40,,22.31,90,,,percent of total billed charges,90% of total Billed charges,18.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.88,155,,,Fee Schedule,155% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.44,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,145,,,Fee Schedule,145% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.39,145,,,Fee Schedule,145% of CMS OPPS Rate,12.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,13.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.5,26.39,
AMB PPD Charge:5 unit PPD Inj,3444386,CDM,960,RC,86580,HCPCS,Outpatient,,,24.79,12.40,,22.31,90,,,percent of total billed charges,90% of total Billed charges,18.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.88,155,,,Fee Schedule,155% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.44,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.88,145,,,Fee Schedule,145% of CMS OPPS Rate,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.39,145,,,Fee Schedule,145% of CMS OPPS Rate,12.88,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,13.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.5,26.39,
87210 Smear wet mount saline/ink,3428350,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,80,,,Percent of total Billed charges,80% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.93,90,,,Percent of total Billed charges,90% of total billed charges,6.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.02,97,,,Percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,92,,,Percent of total billed charges,92% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,70,,,percent of total billed charges,70% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.31,86,,,percent of total billed charges,86% of total billed charges,12.38,80,,,percent of total billed charges,80% of total billed charges,6.46,111,,,Fee Schedule,111% of CMS OPPS Rate,15.02,97,,,percent of total billed charges,97% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.02,97,,,percent of total billed charges,97% of total billed charges,14.4,93,,,percent of total billed charges,93% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.02,97,,,percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.95,28.76,
KOH POC,3989023,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,80,,,Percent of total Billed charges,80% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.93,90,,,Percent of total Billed charges,90% of total billed charges,6.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.02,97,,,Percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,92,,,Percent of total billed charges,92% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,70,,,percent of total billed charges,70% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.31,86,,,percent of total billed charges,86% of total billed charges,12.38,80,,,percent of total billed charges,80% of total billed charges,6.46,111,,,Fee Schedule,111% of CMS OPPS Rate,15.02,97,,,percent of total billed charges,97% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.02,97,,,percent of total billed charges,97% of total billed charges,14.4,93,,,percent of total billed charges,93% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.02,97,,,percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.95,28.76,
KOH/Wet Prep POC,3444198,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,80,,,Percent of total Billed charges,80% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.93,90,,,Percent of total Billed charges,90% of total billed charges,6.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.02,97,,,Percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,92,,,Percent of total billed charges,92% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,70,,,percent of total billed charges,70% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.31,86,,,percent of total billed charges,86% of total billed charges,12.38,80,,,percent of total billed charges,80% of total billed charges,6.46,111,,,Fee Schedule,111% of CMS OPPS Rate,15.02,97,,,percent of total billed charges,97% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.02,97,,,percent of total billed charges,97% of total billed charges,14.4,93,,,percent of total billed charges,93% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.02,97,,,percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.95,28.76,
Wet Mount POC,3444213,CDM,300,RC,87210,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,80,,,Percent of total Billed charges,80% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.93,90,,,Percent of total Billed charges,90% of total billed charges,6.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.02,97,,,Percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,92,,,Percent of total billed charges,92% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,23.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,70,,,percent of total billed charges,70% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,5.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.31,86,,,percent of total billed charges,86% of total billed charges,12.38,80,,,percent of total billed charges,80% of total billed charges,6.46,111,,,Fee Schedule,111% of CMS OPPS Rate,15.02,97,,,percent of total billed charges,97% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.02,97,,,percent of total billed charges,97% of total billed charges,14.4,93,,,percent of total billed charges,93% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.02,97,,,percent of total billed charges,97% of total billed charges,5.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.95,28.76,
87220-KOH POC,3550577,CDM,300,RC,87220,HCPCS,Outpatient,,,117.01,58.51,,105.31,90,,,percent of total billed charges,90% of total Billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,93.61,80,,,Percent of total Billed charges,80% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.31,90,,,Percent of total Billed charges,90% of total billed charges,4.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,113.5,97,,,Percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,107.65,92,,,Percent of total billed charges,92% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.1,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.31,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,81.91,70,,,percent of total billed charges,70% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,100.63,86,,,percent of total billed charges,86% of total billed charges,93.61,80,,,percent of total billed charges,80% of total billed charges,4.73,111,,,Fee Schedule,111% of CMS OPPS Rate,113.5,97,,,percent of total billed charges,97% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,97,,,percent of total billed charges,97% of total billed charges,108.82,93,,,percent of total billed charges,93% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,97,,,percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.63,113.5,
KOH POC,3986925,CDM,300,RC,87220,HCPCS,Outpatient,,,25.34,12.67,,22.81,90,,,percent of total billed charges,90% of total Billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,20.27,80,,,Percent of total Billed charges,80% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.81,90,,,Percent of total Billed charges,90% of total billed charges,4.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,24.58,97,,,Percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,23.31,92,,,Percent of total billed charges,92% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.1,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.81,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.74,70,,,percent of total billed charges,70% of total billed charges,22.81,90,,,percent of total billed charges,90% of total billed charges,24.07,95,,,percent of total billed charges,95% of total billed charges,24.07,95,,,percent of total billed charges,95% of total billed charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,21.79,86,,,percent of total billed charges,86% of total billed charges,20.27,80,,,percent of total billed charges,80% of total billed charges,4.73,111,,,Fee Schedule,111% of CMS OPPS Rate,24.58,97,,,percent of total billed charges,97% of total billed charges,22.81,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.58,97,,,percent of total billed charges,97% of total billed charges,23.57,93,,,percent of total billed charges,93% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,24.58,97,,,percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.63,24.58,
KOH POC,3444196,CDM,300,RC,87220,HCPCS,Outpatient,,,117.01,58.51,,105.31,90,,,percent of total billed charges,90% of total Billed charges,4.26,100,,,Fee Schedule,100% of CMS OPPS Rate,93.61,80,,,Percent of total Billed charges,80% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.31,90,,,Percent of total Billed charges,90% of total billed charges,4.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,113.5,97,,,Percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,107.65,92,,,Percent of total billed charges,92% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,17.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.1,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,105.31,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,81.91,70,,,percent of total billed charges,70% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,4.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,100.63,86,,,percent of total billed charges,86% of total billed charges,93.61,80,,,percent of total billed charges,80% of total billed charges,4.73,111,,,Fee Schedule,111% of CMS OPPS Rate,113.5,97,,,percent of total billed charges,97% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,97,,,percent of total billed charges,97% of total billed charges,108.82,93,,,percent of total billed charges,93% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,97,,,percent of total billed charges,97% of total billed charges,4.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.63,113.5,
87320 Chylmd trach dna quant,3430528,CDM,960,RC,87320,HCPCS,Outpatient,,,19.95,9.98,,17.96,90,,,percent of total billed charges,90% of total Billed charges,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,155,,,Fee Schedule,155% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,5.99,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.75,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.25,145,,,Fee Schedule,145% of CMS OPPS Rate,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.25,145,,,Fee Schedule,145% of CMS OPPS Rate,20.25,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,16.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,5.99,30,
87426 - Covid Antigen POC,3918910,CDM,960,RC,87426,HCPCS,Outpatient,,,214.08,107.04,,192.67,90,,,percent of total billed charges,90% of total Billed charges,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,155,,,Fee Schedule,155% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,145,,,Fee Schedule,145% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.7,145,,,Fee Schedule,145% of CMS OPPS Rate,47.7,135,,,Fee Schedule,135% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,192.67,
Covid Antigen POC,3571323,CDM,960,RC,87426,HCPCS,Outpatient,,,214.08,107.04,,192.67,90,,,percent of total billed charges,90% of total Billed charges,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,155,,,Fee Schedule,155% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,67.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,67.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,145,,,Fee Schedule,145% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.7,145,,,Fee Schedule,145% of CMS OPPS Rate,47.7,135,,,Fee Schedule,135% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,45.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.18,192.67,
Candidiasis Vaginitis,4283365,CDM,306,RC,87481,HCPCS,Outpatient,,,148.4,74.20,,133.56,90,,,percent of total billed charges,90% of total Billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,118.72,80,,,Percent of total Billed charges,80% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.56,90,,,Percent of total Billed charges,90% of total billed charges,43.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,143.95,97,,,Percent of total billed charges,97% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,136.53,92,,,Percent of total billed charges,92% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,142.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,35.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,173.42,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,160.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.56,90,,,percent of total billed charges,90% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,103.88,70,,,percent of total billed charges,70% of total billed charges,133.56,90,,,percent of total billed charges,90% of total billed charges,140.98,95,,,percent of total billed charges,95% of total billed charges,140.98,95,,,percent of total billed charges,95% of total billed charges,35.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.62,86,,,percent of total billed charges,86% of total billed charges,118.72,80,,,percent of total billed charges,80% of total billed charges,38.94,111,,,Fee Schedule,111% of CMS OPPS Rate,143.95,97,,,percent of total billed charges,97% of total billed charges,133.56,90,,,percent of total billed charges,90% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.95,97,,,percent of total billed charges,97% of total billed charges,138.01,93,,,percent of total billed charges,93% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.95,97,,,percent of total billed charges,97% of total billed charges,35.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.83,173.42,
87804 - Influenze POC,3918911,CDM,300,RC,87804,HCPCS,Outpatient,,,44.01,22.01,,39.61,90,,,percent of total billed charges,90% of total Billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,35.21,80,,,Percent of total Billed charges,80% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.61,90,,,Percent of total Billed charges,90% of total billed charges,12.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.69,97,,,Percent of total billed charges,97% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.49,92,,,Percent of total billed charges,92% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,67.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.61,90,,,percent of total billed charges,90% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,70,,,percent of total billed charges,70% of total billed charges,39.61,90,,,percent of total billed charges,90% of total billed charges,41.81,95,,,percent of total billed charges,95% of total billed charges,41.81,95,,,percent of total billed charges,95% of total billed charges,16.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.85,86,,,percent of total billed charges,86% of total billed charges,35.21,80,,,percent of total billed charges,80% of total billed charges,18.37,111,,,Fee Schedule,111% of CMS OPPS Rate,42.69,97,,,percent of total billed charges,97% of total billed charges,39.61,90,,,percent of total billed charges,90% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.69,97,,,percent of total billed charges,97% of total billed charges,40.93,93,,,percent of total billed charges,93% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.69,97,,,percent of total billed charges,97% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.35,81.79,
Influenza POC,3444195,CDM,300,RC,87804,HCPCS,Outpatient,,,44.01,22.01,,39.61,90,,,percent of total billed charges,90% of total Billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,35.21,80,,,Percent of total Billed charges,80% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.61,90,,,Percent of total Billed charges,90% of total billed charges,12.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.69,97,,,Percent of total billed charges,97% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,40.49,92,,,Percent of total billed charges,92% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,67.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,75.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.61,90,,,percent of total billed charges,90% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,30.81,70,,,percent of total billed charges,70% of total billed charges,39.61,90,,,percent of total billed charges,90% of total billed charges,41.81,95,,,percent of total billed charges,95% of total billed charges,41.81,95,,,percent of total billed charges,95% of total billed charges,16.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.85,86,,,percent of total billed charges,86% of total billed charges,35.21,80,,,percent of total billed charges,80% of total billed charges,18.37,111,,,Fee Schedule,111% of CMS OPPS Rate,42.69,97,,,percent of total billed charges,97% of total billed charges,39.61,90,,,percent of total billed charges,90% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.69,97,,,percent of total billed charges,97% of total billed charges,40.93,93,,,percent of total billed charges,93% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.69,97,,,percent of total billed charges,97% of total billed charges,16.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.55,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.35,81.79,
87807 - RSV POC,3918912,CDM,300,RC,87807,HCPCS,Outpatient,,,42.25,21.13,,38.03,90,,,percent of total billed charges,90% of total Billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,33.8,80,,,Percent of total Billed charges,80% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.03,90,,,Percent of total Billed charges,90% of total billed charges,13.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,40.98,97,,,Percent of total billed charges,97% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,38.87,92,,,Percent of total billed charges,92% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,53.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,60.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.03,90,,,percent of total billed charges,90% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,29.58,70,,,percent of total billed charges,70% of total billed charges,38.03,90,,,percent of total billed charges,90% of total billed charges,40.14,95,,,percent of total billed charges,95% of total billed charges,40.14,95,,,percent of total billed charges,95% of total billed charges,13.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.34,86,,,percent of total billed charges,86% of total billed charges,33.8,80,,,percent of total billed charges,80% of total billed charges,14.54,111,,,Fee Schedule,111% of CMS OPPS Rate,40.98,97,,,percent of total billed charges,97% of total billed charges,38.03,90,,,percent of total billed charges,90% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.98,97,,,percent of total billed charges,97% of total billed charges,39.29,93,,,percent of total billed charges,93% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.98,97,,,percent of total billed charges,97% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.1,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.14,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.14,64.74,
RSV POC,3444205,CDM,300,RC,87807,HCPCS,Outpatient,,,42.25,21.13,,38.03,90,,,percent of total billed charges,90% of total Billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,33.8,80,,,Percent of total Billed charges,80% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.03,90,,,Percent of total Billed charges,90% of total billed charges,13.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,40.98,97,,,Percent of total billed charges,97% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,38.87,92,,,Percent of total billed charges,92% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,53.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.74,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,60.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.03,90,,,percent of total billed charges,90% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,29.58,70,,,percent of total billed charges,70% of total billed charges,38.03,90,,,percent of total billed charges,90% of total billed charges,40.14,95,,,percent of total billed charges,95% of total billed charges,40.14,95,,,percent of total billed charges,95% of total billed charges,13.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.34,86,,,percent of total billed charges,86% of total billed charges,33.8,80,,,percent of total billed charges,80% of total billed charges,14.54,111,,,Fee Schedule,111% of CMS OPPS Rate,40.98,97,,,percent of total billed charges,97% of total billed charges,38.03,90,,,percent of total billed charges,90% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.98,97,,,percent of total billed charges,97% of total billed charges,39.29,93,,,percent of total billed charges,93% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.98,97,,,percent of total billed charges,97% of total billed charges,13.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.1,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.14,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.14,64.74,
87810 Chylmd trach assay w/optic,3430529,CDM,960,RC,87810,HCPCS,Outpatient,,,46.92,23.46,,42.23,90,,,percent of total billed charges,90% of total Billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.64,155,,,Fee Schedule,155% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.26,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.08,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.11,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.64,145,,,Fee Schedule,145% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.64,145,,,Fee Schedule,145% of CMS OPPS Rate,47.64,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.88,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,16.88,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.08,70.58,
87880 - Rapid Strep POC,3918913,CDM,300,RC,87880,HCPCS,Outpatient,,,30.69,15.35,,27.62,90,,,percent of total billed charges,90% of total Billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,24.55,80,,,Percent of total Billed charges,80% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.62,90,,,Percent of total Billed charges,90% of total billed charges,6.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,29.77,97,,,Percent of total billed charges,97% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.23,92,,,Percent of total billed charges,92% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,75.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.62,90,,,percent of total billed charges,90% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,70,,,percent of total billed charges,70% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,16.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.39,86,,,percent of total billed charges,86% of total billed charges,24.55,80,,,percent of total billed charges,80% of total billed charges,18.34,111,,,Fee Schedule,111% of CMS OPPS Rate,29.77,97,,,percent of total billed charges,97% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.77,97,,,percent of total billed charges,97% of total billed charges,28.54,93,,,percent of total billed charges,93% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.77,97,,,percent of total billed charges,97% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.3,81.69,
Rapid Strep POC,3444206,CDM,300,RC,87880,HCPCS,Outpatient,,,30.69,15.35,,27.62,90,,,percent of total billed charges,90% of total Billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,24.55,80,,,Percent of total Billed charges,80% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.62,90,,,Percent of total Billed charges,90% of total billed charges,6.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,29.77,97,,,Percent of total billed charges,97% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,28.23,92,,,Percent of total billed charges,92% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,67.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,16.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,81.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,75.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,27.62,90,,,percent of total billed charges,90% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,21.48,70,,,percent of total billed charges,70% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,16.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.39,86,,,percent of total billed charges,86% of total billed charges,24.55,80,,,percent of total billed charges,80% of total billed charges,18.34,111,,,Fee Schedule,111% of CMS OPPS Rate,29.77,97,,,percent of total billed charges,97% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.77,97,,,percent of total billed charges,97% of total billed charges,28.54,93,,,percent of total billed charges,93% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,29.77,97,,,percent of total billed charges,97% of total billed charges,16.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.3,81.69,
Pathology Billing Non-Gyn Cytology,295380,CDM,310,RC,88104,HCPCS,Outpatient,,,149.82,74.91,,134.84,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,119.86,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.84,90,,,Percent of total Billed charges,90% of total billed charges,7.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.33,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,137.83,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,134.84,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,104.87,70,,,percent of total billed charges,70% of total billed charges,134.84,90,,,percent of total billed charges,90% of total billed charges,142.33,95,,,percent of total billed charges,95% of total billed charges,142.33,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,128.85,86,,,percent of total billed charges,86% of total billed charges,119.86,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.33,97,,,percent of total billed charges,97% of total billed charges,134.84,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.33,97,,,percent of total billed charges,97% of total billed charges,139.33,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.33,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.5,165.55,
Pathology Billing Non-Gyn Cytology Concentration Technique,592809,CDM,310,RC,88108,HCPCS,Outpatient,,,141.91,70.96,,127.72,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,113.53,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.72,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,137.65,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,130.56,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,127.72,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,99.34,70,,,percent of total billed charges,70% of total billed charges,127.72,90,,,percent of total billed charges,90% of total billed charges,134.81,95,,,percent of total billed charges,95% of total billed charges,134.81,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.04,86,,,percent of total billed charges,86% of total billed charges,113.53,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,137.65,97,,,percent of total billed charges,97% of total billed charges,127.72,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.65,97,,,percent of total billed charges,97% of total billed charges,131.98,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,137.65,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,165.55,
"Pathology Billing Cytopathology NG Thin Prep, with interpretation, except cervical or vaginal Profee",3549242,CDM,971,RC,88112,HCPCS,Outpatient,,,144.67,72.34,,130.2,90,,,percent of total billed charges,90% of total Billed charges,69.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.47,155,,,Fee Schedule,155% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.11,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.47,145,,,Fee Schedule,145% of CMS OPPS Rate,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.15,145,,,Fee Schedule,145% of CMS OPPS Rate,50.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,119.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,190.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.81,190.07,
"88120 Urovysion, ISH",3513388,CDM,300,RC,88120,HCPCS,Outpatient,,,1248.57,624.29,,1123.71,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,998.86,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1123.71,90,,,Percent of total Billed charges,90% of total billed charges,340.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1211.11,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,1148.68,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1123.71,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,874,70,,,percent of total billed charges,70% of total billed charges,1123.71,90,,,percent of total billed charges,90% of total billed charges,1186.14,95,,,percent of total billed charges,95% of total billed charges,1186.14,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1073.77,86,,,percent of total billed charges,86% of total billed charges,998.86,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1211.11,97,,,percent of total billed charges,97% of total billed charges,1123.71,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,1211.11,97,,,percent of total billed charges,97% of total billed charges,1161.17,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1211.11,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.4,1211.11,
Pathology Billing Gyn Cytology with Pathologist Interpretation Profee,3549245,CDM,971,RC,88141,HCPCS,Outpatient,,,50.32,25.16,,45.29,90,,,percent of total billed charges,90% of total Billed charges,41.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.71,155,,,Fee Schedule,155% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,24.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,30.71,145,,,Fee Schedule,145% of CMS OPPS Rate,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.71,145,,,Fee Schedule,145% of CMS OPPS Rate,30.71,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,57.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.53,60.71,
88143 Cytopath c/v thin layer redo,3430530,CDM,960,RC,88143,HCPCS,Outpatient,,,30.63,15.32,,27.57,90,,,percent of total billed charges,90% of total Billed charges,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.1,155,,,Fee Schedule,155% of CMS OPPS Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,34.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,34.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.19,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.8,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.1,145,,,Fee Schedule,145% of CMS OPPS Rate,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,145,,,Fee Schedule,145% of CMS OPPS Rate,31.1,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.51,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28.51,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.19,46.08,
88147 Cytopath c/v automated,3430531,CDM,960,RC,88147,HCPCS,Outpatient,,,67.24,33.62,,60.52,90,,,percent of total billed charges,90% of total Billed charges,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.26,155,,,Fee Schedule,155% of CMS OPPS Rate,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.17,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,101.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,63.2,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.26,145,,,Fee Schedule,145% of CMS OPPS Rate,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.26,145,,,Fee Schedule,145% of CMS OPPS Rate,68.26,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,50.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,16.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.02,101.12,
88148 Cytopath c/v auto screen,3430532,CDM,960,RC,88148,HCPCS,Outpatient,,,21.27,10.64,,19.14,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,155,,,Fee Schedule,155% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.38,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.39,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,21.39,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.38,34.62,
88150 Cytopath c/v manual,3430533,CDM,960,RC,88150,HCPCS,Outpatient,,,20.1,10.05,,18.09,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,155,,,Fee Schedule,155% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.9,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.03,34.62,
88152 Cythopath c/v auto redo,3430534,CDM,960,RC,88152,HCPCS,Outpatient,,,36.76,18.38,,33.08,90,,,percent of total billed charges,90% of total Billed charges,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.31,155,,,Fee Schedule,155% of CMS OPPS Rate,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.55,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.31,145,,,Fee Schedule,145% of CMS OPPS Rate,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,145,,,Fee Schedule,145% of CMS OPPS Rate,37.31,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.03,55.28,
88153 Cythopath c/v redo,3430536,CDM,960,RC,88153,HCPCS,Outpatient,,,31.95,15.98,,28.76,90,,,percent of total billed charges,90% of total Billed charges,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,155,,,Fee Schedule,155% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.59,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.04,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.44,145,,,Fee Schedule,145% of CMS OPPS Rate,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.44,145,,,Fee Schedule,145% of CMS OPPS Rate,32.44,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9.59,48.06,
88165 Cytopath tbs c/v redo,3430537,CDM,960,RC,88165,HCPCS,Outpatient,,,56.14,28.07,,50.53,90,,,percent of total billed charges,90% of total Billed charges,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57,155,,,Fee Schedule,155% of CMS OPPS Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,63.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,63.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.84,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.78,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57,145,,,Fee Schedule,145% of CMS OPPS Rate,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,57,145,,,Fee Schedule,145% of CMS OPPS Rate,57,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,42.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.87,84.44,
88166 Cytopath tbs c/v auto redo,3430538,CDM,960,RC,88166,HCPCS,Outpatient,,,20.1,10.05,,18.09,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,155,,,Fee Schedule,155% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.9,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.03,34.62,
88167 Cytopath tbs c/v select,3430539,CDM,960,RC,88167,HCPCS,Outpatient,,,20.1,10.05,,18.09,90,,,percent of total billed charges,90% of total Billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,155,,,Fee Schedule,155% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.84,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.68,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.9,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.37,145,,,Fee Schedule,145% of CMS OPPS Rate,23.37,135,,,Fee Schedule,135% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.03,34.62,
Pathology Billing FNA Immediate Read,295386,CDM,311,RC,88172,HCPCS,Outpatient,,,350.46,175.23,,315.41,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,280.37,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,339.95,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,322.42,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,315.41,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,245.32,70,,,percent of total billed charges,70% of total billed charges,315.41,90,,,percent of total billed charges,90% of total billed charges,332.94,95,,,percent of total billed charges,95% of total billed charges,332.94,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,301.4,86,,,percent of total billed charges,86% of total billed charges,280.37,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.95,97,,,percent of total billed charges,97% of total billed charges,315.41,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.95,97,,,percent of total billed charges,97% of total billed charges,325.93,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,339.95,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.4,766.61,
Pathology Billing FNA Interp and Report,295388,CDM,311,RC,88173,HCPCS,Outpatient,,,350.46,175.23,,315.41,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,280.37,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,315.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,339.95,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,322.42,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,315.41,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,245.32,70,,,percent of total billed charges,70% of total billed charges,315.41,90,,,percent of total billed charges,90% of total billed charges,332.94,95,,,percent of total billed charges,95% of total billed charges,332.94,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,301.4,86,,,percent of total billed charges,86% of total billed charges,280.37,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.95,97,,,percent of total billed charges,97% of total billed charges,315.41,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.95,97,,,percent of total billed charges,97% of total billed charges,325.93,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,339.95,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,339.95,
Pathology Billing FNA Interp and Report Profee,3549244,CDM,971,RC,88173,HCPCS,Outpatient,,,350.46,175.23,,315.41,90,,,percent of total billed charges,90% of total Billed charges,158.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.26,155,,,Fee Schedule,155% of CMS OPPS Rate,81.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,199.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,199.55,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.1,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.1,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,105.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.26,145,,,Fee Schedule,145% of CMS OPPS Rate,81.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.01,145,,,Fee Schedule,145% of CMS OPPS Rate,118.26,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,260.85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,81.56,315.41,
Pathology Billing Flow Cytometry,644405,CDM,971,RC,88180,HCPCS,Outpatient,,,171.53,85.77,,154.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.46,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.46,154.38,
"Anti-IgE Receptor, Ea Add Marker",1373096,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,44.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.81,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.22,90,,,Percent of total Billed charges,90% of total billed charges,20.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.39,70,,,percent of total billed charges,70% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,86,,,percent of total billed charges,86% of total billed charges,39.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,45.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,56.81,
"IGE Receptor, Each Additional Marker",3010110,CDM,300,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,44.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.81,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.22,90,,,Percent of total Billed charges,90% of total billed charges,20.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.39,70,,,percent of total billed charges,70% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,86,,,percent of total billed charges,86% of total billed charges,39.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,45.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,56.81,
Leuk/Lymphoma Flow Cyt-each add Marker,1337216,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,44.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.81,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.22,90,,,Percent of total Billed charges,90% of total billed charges,20.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.39,70,,,percent of total billed charges,70% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,86,,,percent of total billed charges,86% of total billed charges,39.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,45.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,56.81,
Pathology Billing Flow Cyto Each Add Marker,653858,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,44.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.81,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.22,90,,,Percent of total Billed charges,90% of total billed charges,20.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.39,70,,,percent of total billed charges,70% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,86,,,percent of total billed charges,86% of total billed charges,39.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,45.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,56.81,
"ZAP-70, Flow Cytometry each add marker",1337218,CDM,311,RC,88185,HCPCS,Outpatient,,,49.13,24.57,,44.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.81,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.22,90,,,Percent of total Billed charges,90% of total billed charges,20.09,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.39,70,,,percent of total billed charges,70% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,46.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.25,86,,,percent of total billed charges,86% of total billed charges,39.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,44.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.66,97,,,percent of total billed charges,97% of total billed charges,45.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.26,56.81,
Pathology Billing Flow Cyto Interp 2-8 Markers,653859,CDM,971,RC,88187,HCPCS,Outpatient,,,81.61,40.81,,73.45,90,,,percent of total billed charges,90% of total Billed charges,69.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.98,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,49.82,155,,,Fee Schedule,155% of CMS OPPS Rate,34.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.36,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.36,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.48,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,41.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.82,145,,,Fee Schedule,145% of CMS OPPS Rate,34.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.54,145,,,Fee Schedule,145% of CMS OPPS Rate,49.82,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,133.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.48,133.05,
"ZAP-70, Flow Cytometry Interpretation",1337219,CDM,311,RC,88187,HCPCS,Outpatient,,,81.61,40.81,,73.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,65.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,73.45,90,,,Percent of total Billed charges,90% of total billed charges,59.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,79.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,75.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,57.13,70,,,percent of total billed charges,70% of total billed charges,73.45,90,,,percent of total billed charges,90% of total billed charges,77.53,95,,,percent of total billed charges,95% of total billed charges,77.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.18,86,,,percent of total billed charges,86% of total billed charges,65.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,79.16,97,,,percent of total billed charges,97% of total billed charges,73.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.16,97,,,percent of total billed charges,97% of total billed charges,75.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.98,79.16,
Pathology Billing Flow Cyto Interp 9-15 Markers,653860,CDM,971,RC,88188,HCPCS,Outpatient,,,141.41,70.71,,127.27,90,,,percent of total billed charges,90% of total Billed charges,120.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,59.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.35,155,,,Fee Schedule,155% of CMS OPPS Rate,59.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,83.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,83.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.42,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.55,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,67.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.35,145,,,Fee Schedule,145% of CMS OPPS Rate,59.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.61,145,,,Fee Schedule,145% of CMS OPPS Rate,86.35,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,59.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,59.55,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.13,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,167.13,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.42,174.61,
Leuk/Lymphoma Flow Cyt Interpretation,1337217,CDM,971,RC,88189,HCPCS,Outpatient,,,192,96.00,,172.8,90,,,percent of total billed charges,90% of total Billed charges,162.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.23,155,,,Fee Schedule,155% of CMS OPPS Rate,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.23,145,,,Fee Schedule,145% of CMS OPPS Rate,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.93,145,,,Fee Schedule,145% of CMS OPPS Rate,117.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.9,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,199.9,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.6,235.93,
Pathology Billing Flow Cyto Interp 16>Markers,653861,CDM,971,RC,88189,HCPCS,Outpatient,,,192,96.00,,172.8,90,,,percent of total billed charges,90% of total Billed charges,162.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.68,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.23,155,,,Fee Schedule,155% of CMS OPPS Rate,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,112.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,112.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,116.26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,91.67,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.23,145,,,Fee Schedule,145% of CMS OPPS Rate,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.93,145,,,Fee Schedule,145% of CMS OPPS Rate,117.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.85,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.9,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,199.9,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.6,235.93,
Pathology Billing Chrom Anal BM MBC,644609,CDM,971,RC,88291,HCPCS,Outpatient,,,84.65,42.33,,76.19,90,,,percent of total billed charges,90% of total Billed charges,62.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.53,155,,,Fee Schedule,155% of CMS OPPS Rate,30.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.53,145,,,Fee Schedule,145% of CMS OPPS Rate,30.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.67,145,,,Fee Schedule,145% of CMS OPPS Rate,44.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.36,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.36,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.4,90.67,
"Pathology Billing, Gross Only",295346,CDM,310,RC,88300,HCPCS,Outpatient,,,34.76,17.38,,31.28,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,27.81,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.28,90,,,Percent of total Billed charges,90% of total billed charges,1.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33.72,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,31.98,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,31.28,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,24.33,70,,,percent of total billed charges,70% of total billed charges,31.28,90,,,percent of total billed charges,90% of total billed charges,33.02,95,,,percent of total billed charges,95% of total billed charges,33.02,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,29.89,86,,,percent of total billed charges,86% of total billed charges,27.81,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33.72,97,,,percent of total billed charges,97% of total billed charges,31.28,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.72,97,,,percent of total billed charges,97% of total billed charges,32.33,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33.72,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.5,121.68,
"Pathology Billing, Gross Only Profee",3549255,CDM,971,RC,88300,HCPCS,Outpatient,,,34.76,17.38,,31.28,90,,,percent of total billed charges,90% of total Billed charges,19.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,155,,,Fee Schedule,155% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,21.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,21.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.43,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.98,145,,,Fee Schedule,145% of CMS OPPS Rate,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.91,145,,,Fee Schedule,145% of CMS OPPS Rate,14.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.33,53.09,
Pathology Billing Surgical Pathology Level II Complexity Profee,3549250,CDM,971,RC,88302,HCPCS,Outpatient,,,69.93,34.97,,62.94,90,,,percent of total billed charges,90% of total Billed charges,44.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.15,155,,,Fee Schedule,155% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.98,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.16,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.15,145,,,Fee Schedule,145% of CMS OPPS Rate,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.74,145,,,Fee Schedule,145% of CMS OPPS Rate,33.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.59,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,101.59,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.98,101.59,
88304- Tissue exam by pathologist; Level III,3430540,CDM,310,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,81.91,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,53.49,150,,,Fee Schedule,150% of Fee Schedule Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.91,90,,,Percent of total Billed charges,90% of total billed charges,7.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.28,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,83.73,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.91,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,63.71,70,,,percent of total billed charges,70% of total billed charges,81.91,90,,,percent of total billed charges,90% of total billed charges,86.46,95,,,percent of total billed charges,95% of total billed charges,86.46,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.27,86,,,percent of total billed charges,86% of total billed charges,72.81,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.28,97,,,percent of total billed charges,97% of total billed charges,81.91,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.28,97,,,percent of total billed charges,97% of total billed charges,84.64,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.28,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.5,244.43,
Pathology Billing Surgical Pathology Level III Complexity Profee,3549251,CDM,971,RC,88304,HCPCS,Outpatient,,,91.01,45.51,,81.91,90,,,percent of total billed charges,90% of total Billed charges,54.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.92,155,,,Fee Schedule,155% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,53.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,27.3,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.92,145,,,Fee Schedule,145% of CMS OPPS Rate,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.4,145,,,Fee Schedule,145% of CMS OPPS Rate,39.92,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,60.35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.11,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,110.11,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.3,110.11,
Pathology Billing Surgical Pathology Level IV Complexity Profee,3549252,CDM,971,RC,88305,HCPCS,Outpatient,,,155.81,77.91,,140.23,90,,,percent of total billed charges,90% of total Billed charges,60.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,155,,,Fee Schedule,155% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.74,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.14,145,,,Fee Schedule,145% of CMS OPPS Rate,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.35,145,,,Fee Schedule,145% of CMS OPPS Rate,44.14,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.44,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,193.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30.44,193.34,
Pathology Billing Surgical Pathology Level VI Complexity,295356,CDM,310,RC,88309,HCPCS,Outpatient,,,935.8,467.90,,842.22,90,,,percent of total billed charges,90% of total Billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,748.64,80,,,Percent of total Billed charges,80% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,842.22,90,,,Percent of total Billed charges,90% of total billed charges,19.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,907.73,97,,,Percent of total billed charges,97% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,860.94,92,,,Percent of total billed charges,92% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1874.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,705.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2988.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3785.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,842.22,90,,,percent of total billed charges,90% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,655.06,70,,,percent of total billed charges,70% of total billed charges,842.22,90,,,percent of total billed charges,90% of total billed charges,889.01,95,,,percent of total billed charges,95% of total billed charges,889.01,95,,,percent of total billed charges,95% of total billed charges,705.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1410.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,804.79,86,,,percent of total billed charges,86% of total billed charges,748.64,80,,,percent of total billed charges,80% of total billed charges,649.48,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,907.73,97,,,percent of total billed charges,97% of total billed charges,842.22,90,,,percent of total billed charges,90% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,907.73,97,,,percent of total billed charges,97% of total billed charges,870.29,93,,,percent of total billed charges,93% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,907.73,97,,,percent of total billed charges,97% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,599.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.5,3785.58,
Pathology Billing Surgical Pathology Level VI Complexity Profee,3549254,CDM,971,RC,88309,HCPCS,Outpatient,,,935.8,467.90,,842.22,90,,,percent of total billed charges,90% of total Billed charges,513.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,257.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.93,155,,,Fee Schedule,155% of CMS OPPS Rate,257.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,482.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,257.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,542.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,542.36,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,573.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,573.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,280.74,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,515.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,318.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.93,145,,,Fee Schedule,145% of CMS OPPS Rate,257.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,744,145,,,Fee Schedule,145% of CMS OPPS Rate,373.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,257.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,242,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,257.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,672.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,672.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,242,842.22,
Pathology Billing Decalcification Profee,3549243,CDM,971,RC,88311,HCPCS,Outpatient,,,45.57,22.79,,41.01,90,,,percent of total billed charges,90% of total Billed charges,14.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,155,,,Fee Schedule,155% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,30.59,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,30.59,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.67,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,145,,,Fee Schedule,145% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.69,145,,,Fee Schedule,145% of CMS OPPS Rate,10.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.7,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,36.7,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.42,41.01,
Pathology Billing Special Stains Group I,295362,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Special Stain AFB Stain,295230,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
SPECIAL STAIN BACTERIA,605495,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Special Stain GMS Stain,295258,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Special Stain GMS Stain Profee,3549260,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,151.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,155,,,Fee Schedule,155% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.57,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,145,,,Fee Schedule,145% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.17,145,,,Fee Schedule,145% of CMS OPPS Rate,109.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71.57,219.17,
Special Stain PAS FUNGUS,295294,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Special Stain PAS FUNGUS Profee,3549262,CDM,971,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,151.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,155,,,Fee Schedule,155% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,142.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.57,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,92.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.21,145,,,Fee Schedule,145% of CMS OPPS Rate,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,219.17,145,,,Fee Schedule,145% of CMS OPPS Rate,109.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,71.57,219.17,
Special Stain SPIROCH,605661,CDM,310,RC,88312,HCPCS,Outpatient,,,238.55,119.28,,214.7,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,190.84,80,,,Percent of total Billed charges,80% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.7,90,,,Percent of total Billed charges,90% of total billed charges,57.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,231.39,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,219.47,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,166.99,70,,,percent of total billed charges,70% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,226.62,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,205.15,86,,,percent of total billed charges,86% of total billed charges,190.84,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.39,97,,,percent of total billed charges,97% of total billed charges,214.7,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.39,97,,,percent of total billed charges,97% of total billed charges,221.85,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,231.39,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.7,244.43,
Pathology Billing Special Stains Group II,295364,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
SPECIAL STAIN ALCIAN BLUE pH 0.4,605479,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Congo Red Stain,295246,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Giemsa Stain,295262,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Iron Stain,295274,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Melanin,605640,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain MUCIN,605654,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Oil Red O Stain,295290,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain PAS with Diastase Stain,295302,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain PAS without Diastase Stain,295306,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain Reticulin Stain,295298,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain SUDAN BLACK,605565,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain TRICHROM,605663,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Special Stain WRIGHT,605665,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
"Special Stain, CRYSTALV",605559,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
SS Alcian Blue pH 1.0 Stain,295234,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
SS Alcian Blue pH 2.5,295240,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
SS ELASTIC,763980,CDM,310,RC,88313,HCPCS,Outpatient,,,172.19,86.10,,154.97,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.26,150,,,Fee Schedule,150% of Fee Schedule Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.97,90,,,Percent of total Billed charges,90% of total billed charges,45.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,167.02,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,158.41,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,120.53,70,,,percent of total billed charges,70% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,163.58,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,148.08,86,,,percent of total billed charges,86% of total billed charges,137.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,167.02,97,,,percent of total billed charges,97% of total billed charges,154.97,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.02,97,,,percent of total billed charges,97% of total billed charges,160.14,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,167.02,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,167.02,
Pathology Billing Muscle Bx Histochem Stain for FS,644639,CDM,971,RC,88314,HCPCS,Outpatient,,,192.56,96.28,,173.3,90,,,percent of total billed charges,90% of total Billed charges,129.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.93,155,,,Fee Schedule,155% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,124.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.93,145,,,Fee Schedule,145% of CMS OPPS Rate,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.69,145,,,Fee Schedule,145% of CMS OPPS Rate,88.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.23,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,161.23,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57,187.69,
Pathology Billing Muscle Bx ID Enz Constituents,644638,CDM,971,RC,88319,HCPCS,Outpatient,,,286.5,143.25,,257.85,90,,,percent of total billed charges,90% of total Billed charges,194.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,155,,,Fee Schedule,155% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,144.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,150.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,150.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,85.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,99.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.16,145,,,Fee Schedule,145% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.87,145,,,Fee Schedule,145% of CMS OPPS Rate,138.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,270.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,85.95,281.87,
Pathology Billing Consultation Fee Outside Slides and Report,295358,CDM,971,RC,88321,HCPCS,Outpatient,,,219.56,109.78,,197.6,90,,,percent of total billed charges,90% of total Billed charges,173.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,116.33,155,,,Fee Schedule,155% of CMS OPPS Rate,80.23,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,80.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.87,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,114.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,90.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,116.33,145,,,Fee Schedule,145% of CMS OPPS Rate,80.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.31,145,,,Fee Schedule,145% of CMS OPPS Rate,116.33,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,80.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,90.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,80.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.3,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,176.3,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,251.31,
Pathology Billing Fee Outside Consultation requiring slide prep,2970102,CDM,971,RC,88323,HCPCS,Outpatient,,,255.15,127.58,,229.64,90,,,percent of total billed charges,90% of total Billed charges,48.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.68,155,,,Fee Schedule,155% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.21,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.21,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,166.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,166.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.55,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.08,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.68,145,,,Fee Schedule,145% of CMS OPPS Rate,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.86,145,,,Fee Schedule,145% of CMS OPPS Rate,35.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,142.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,24.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.44,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.44,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.61,265.44,
Pathology Billing Non-Gyn Cytology Intraoperative Consultation,592811,CDM,310,RC,88329,HCPCS,Outpatient,,,124.42,62.21,,111.98,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,99.54,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,111.98,90,,,Percent of total Billed charges,90% of total billed charges,32.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.69,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,114.47,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,111.98,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,87.09,70,,,percent of total billed charges,70% of total billed charges,111.98,90,,,percent of total billed charges,90% of total billed charges,118.2,95,,,percent of total billed charges,95% of total billed charges,118.2,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107,86,,,percent of total billed charges,86% of total billed charges,99.54,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,120.69,97,,,percent of total billed charges,97% of total billed charges,111.98,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.69,97,,,percent of total billed charges,97% of total billed charges,115.71,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.69,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,165.55,
Pathology Billing Non-Gyn Cytology Intraoperative Consultation w/o FS,592951,CDM,971,RC,88329,HCPCS,Outpatient,,,124.42,62.21,,111.98,90,,,percent of total billed charges,90% of total Billed charges,87.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.77,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,49.34,155,,,Fee Schedule,155% of CMS OPPS Rate,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.33,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,40.06,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.34,145,,,Fee Schedule,145% of CMS OPPS Rate,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.12,145,,,Fee Schedule,145% of CMS OPPS Rate,49.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.59,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,101.59,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.77,127.12,
"Freeze, Cut and Stain (H&E)",294976,CDM,310,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,201.65,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,179.24,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.65,90,,,Percent of total Billed charges,90% of total billed charges,8.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,217.33,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,206.13,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,156.84,70,,,percent of total billed charges,70% of total billed charges,201.65,90,,,percent of total billed charges,90% of total billed charges,212.85,95,,,percent of total billed charges,95% of total billed charges,212.85,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.68,86,,,percent of total billed charges,86% of total billed charges,179.24,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,217.33,97,,,percent of total billed charges,97% of total billed charges,201.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.33,97,,,percent of total billed charges,97% of total billed charges,208.37,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.33,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.5,766.61,
"Freeze, Cut and Stain (H&E) Profee",3549241,CDM,971,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,201.65,90,,,percent of total billed charges,90% of total Billed charges,71.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.17,155,,,Fee Schedule,155% of CMS OPPS Rate,35.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,138.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,67.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.69,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.17,145,,,Fee Schedule,145% of CMS OPPS Rate,35.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.99,145,,,Fee Schedule,145% of CMS OPPS Rate,52.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,35.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,35.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.92,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,178.92,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.98,201.65,
Pathology Billing Frozen Single Specimen,592817,CDM,310,RC,88331,HCPCS,Outpatient,,,224.05,112.03,,201.65,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,179.24,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.65,90,,,Percent of total Billed charges,90% of total billed charges,8.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,217.33,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,206.13,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,156.84,70,,,percent of total billed charges,70% of total billed charges,201.65,90,,,percent of total billed charges,90% of total billed charges,212.85,95,,,percent of total billed charges,95% of total billed charges,212.85,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.68,86,,,percent of total billed charges,86% of total billed charges,179.24,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,217.33,97,,,percent of total billed charges,97% of total billed charges,201.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.33,97,,,percent of total billed charges,97% of total billed charges,208.37,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.33,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.5,766.61,
Cut and Stain Add'l Frozen H&E Slide,294978,CDM,310,RC,88332,HCPCS,Outpatient,,,68.55,34.28,,61.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,54.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.7,90,,,Percent of total Billed charges,90% of total billed charges,8.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,63.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,43.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,53.92,78.65,,,percent of total billed charges,78.65% of total billed charges,61.24,89.33,,,percent of total billed charges,89.33% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.99,70,,,percent of total billed charges,70% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,65.12,95,,,percent of total billed charges,95% of total billed charges,65.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.95,86,,,percent of total billed charges,86% of total billed charges,54.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,66.49,97,,,percent of total billed charges,97% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.49,97,,,percent of total billed charges,97% of total billed charges,63.75,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,66.49,
Pathology Billing Frozen add'l block,592815,CDM,310,RC,88332,HCPCS,Outpatient,,,68.55,34.28,,61.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,54.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.7,90,,,Percent of total Billed charges,90% of total billed charges,8.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,63.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,43.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,53.92,78.65,,,percent of total billed charges,78.65% of total billed charges,61.24,89.33,,,percent of total billed charges,89.33% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.99,70,,,percent of total billed charges,70% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,65.12,95,,,percent of total billed charges,95% of total billed charges,65.12,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.95,86,,,percent of total billed charges,86% of total billed charges,54.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,66.49,97,,,percent of total billed charges,97% of total billed charges,61.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.49,97,,,percent of total billed charges,97% of total billed charges,63.75,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.79,66.49,
Pathology Billing Cyto Exam Initial Site,1285503,CDM,310,RC,88333,HCPCS,Outpatient,,,205.48,102.74,,184.93,90,,,percent of total billed charges,90% of total Billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,164.38,80,,,Percent of total Billed charges,80% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.93,90,,,Percent of total Billed charges,90% of total billed charges,17.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,199.32,97,,,Percent of total billed charges,97% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,189.04,92,,,Percent of total billed charges,92% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1874.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,705.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2988.65,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3785.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,184.93,90,,,percent of total billed charges,90% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,143.84,70,,,percent of total billed charges,70% of total billed charges,184.93,90,,,percent of total billed charges,90% of total billed charges,195.21,95,,,percent of total billed charges,95% of total billed charges,195.21,95,,,percent of total billed charges,95% of total billed charges,705.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1410.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,176.71,86,,,percent of total billed charges,86% of total billed charges,164.38,80,,,percent of total billed charges,80% of total billed charges,649.48,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,199.32,97,,,percent of total billed charges,97% of total billed charges,184.93,90,,,percent of total billed charges,90% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.32,97,,,percent of total billed charges,97% of total billed charges,191.1,93,,,percent of total billed charges,93% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.32,97,,,percent of total billed charges,97% of total billed charges,705.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,599.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.01,3785.58,
"Pathology Billing, Cytologic Exam add?l site",1713100,CDM,310,RC,88334,HCPCS,Outpatient,,,124.1,62.05,,111.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,99.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,111.69,90,,,Percent of total Billed charges,90% of total billed charges,10.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,114.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,79.25,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,97.61,78.65,,,percent of total billed charges,78.65% of total billed charges,110.86,89.33,,,percent of total billed charges,89.33% of total billed charges,111.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,86.87,70,,,percent of total billed charges,70% of total billed charges,111.69,90,,,percent of total billed charges,90% of total billed charges,117.9,95,,,percent of total billed charges,95% of total billed charges,117.9,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.73,86,,,percent of total billed charges,86% of total billed charges,99.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,120.38,97,,,percent of total billed charges,97% of total billed charges,111.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.38,97,,,percent of total billed charges,97% of total billed charges,115.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.78,120.38,
Pathology Billing Derm SO IHC Stain,646173,CDM,310,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,193.28,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,121.11,150,,,Fee Schedule,150% of Fee Schedule Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.28,90,,,Percent of total Billed charges,90% of total billed charges,44.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,208.31,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,197.57,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,193.28,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,150.33,70,,,percent of total billed charges,70% of total billed charges,193.28,90,,,percent of total billed charges,90% of total billed charges,204.01,95,,,percent of total billed charges,95% of total billed charges,204.01,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.69,86,,,percent of total billed charges,86% of total billed charges,171.8,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,208.31,97,,,percent of total billed charges,97% of total billed charges,193.28,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.31,97,,,percent of total billed charges,97% of total billed charges,199.72,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,208.31,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.14,766.61,
"Pathology Billing Immuno Cyto Chemistry, tissue,IP,ea ab Profee",3549248,CDM,971,RC,88342,HCPCS,Outpatient,,,214.75,107.38,,193.28,90,,,percent of total billed charges,90% of total Billed charges,115.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.43,155,,,Fee Schedule,155% of CMS OPPS Rate,57.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,135.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,143.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,143.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.43,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.43,145,,,Fee Schedule,145% of CMS OPPS Rate,57.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.98,145,,,Fee Schedule,145% of CMS OPPS Rate,83.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,57.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,196.62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,57.54,196.62,
88343 Bill Addtl IHC AB per block,3310560,CDM,310,RC,88343,HCPCS,Outpatient,,,273.91,136.96,,246.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,219.13,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,246.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,265.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,252,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,174.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,215.44,78.65,,,percent of total billed charges,78.65% of total billed charges,244.69,89.33,,,percent of total billed charges,89.33% of total billed charges,246.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,191.74,70,,,percent of total billed charges,70% of total billed charges,246.52,90,,,percent of total billed charges,90% of total billed charges,260.21,95,,,percent of total billed charges,95% of total billed charges,260.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,235.56,86,,,percent of total billed charges,86% of total billed charges,219.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,265.69,97,,,percent of total billed charges,97% of total billed charges,246.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,265.69,97,,,percent of total billed charges,97% of total billed charges,254.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.92,265.69,
88360 PD-L1 IHC,3513373,CDM,300,RC,88360,HCPCS,Outpatient,,,253.8,126.90,,228.42,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,203.04,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.42,90,,,Percent of total Billed charges,90% of total billed charges,39.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,246.19,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,233.5,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,228.42,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,177.66,70,,,percent of total billed charges,70% of total billed charges,228.42,90,,,percent of total billed charges,90% of total billed charges,241.11,95,,,percent of total billed charges,95% of total billed charges,241.11,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,218.27,86,,,percent of total billed charges,86% of total billed charges,203.04,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,246.19,97,,,percent of total billed charges,97% of total billed charges,228.42,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.19,97,,,percent of total billed charges,97% of total billed charges,236.03,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,246.19,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.48,766.61,
88360-26 IHC Manual Morph Ana Professional,3513821,CDM,971,RC,88360,HCPCS,Outpatient,,,253.8,126.90,,228.42,90,,,percent of total billed charges,90% of total Billed charges,137.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.8,155,,,Fee Schedule,155% of CMS OPPS Rate,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.8,145,,,Fee Schedule,145% of CMS OPPS Rate,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.71,145,,,Fee Schedule,145% of CMS OPPS Rate,97.8,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,67.45,232.01,
Pathology Billing IHC Man Morph Anal,3561382,CDM,971,RC,88360,HCPCS,Outpatient,,,185.09,92.55,,166.58,90,,,percent of total billed charges,90% of total Billed charges,137.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.8,155,,,Fee Schedule,155% of CMS OPPS Rate,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,170.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,170.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,55.53,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,96.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.8,145,,,Fee Schedule,145% of CMS OPPS Rate,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.71,145,,,Fee Schedule,145% of CMS OPPS Rate,97.8,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,67.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,232.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,55.53,232.01,
88361-26 IHC Morphometric Analysis Professional,3513819,CDM,971,RC,88361,HCPCS,Outpatient,,,254.94,127.47,,229.45,90,,,percent of total billed charges,90% of total Billed charges,133.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,155,,,Fee Schedule,155% of CMS OPPS Rate,65.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,163.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,173.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,173.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.48,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.8,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.27,145,,,Fee Schedule,145% of CMS OPPS Rate,65.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.15,145,,,Fee Schedule,145% of CMS OPPS Rate,95.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,277.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.7,277.89,
"88364-26 ISH, ea. add. Professional",3513828,CDM,971,RC,88364,HCPCS,Outpatient,,,290.18,145.09,,261.16,90,,,percent of total billed charges,90% of total Billed charges,180.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.34,155,,,Fee Schedule,155% of CMS OPPS Rate,89.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,89.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,178.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,178.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,87.05,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,179.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.34,145,,,Fee Schedule,145% of CMS OPPS Rate,89.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.25,145,,,Fee Schedule,145% of CMS OPPS Rate,130.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,89.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,100.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,89.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.05,262.25,
"88365-26 ISH, initial Professional",3513825,CDM,971,RC,88365,HCPCS,Outpatient,,,383.18,191.59,,344.86,90,,,percent of total billed charges,90% of total Billed charges,240.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.91,155,,,Fee Schedule,155% of CMS OPPS Rate,120.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,233.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,233.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,244.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,244.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,241.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,160.29,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,174.91,145,,,Fee Schedule,145% of CMS OPPS Rate,120.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.32,145,,,Fee Schedule,145% of CMS OPPS Rate,174.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,120.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,115.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,120.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.59,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,314.59,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,114.95,348.32,
Pathology Billing HER 2 NEU by FISH,644637,CDM,310,RC,88365,HCPCS,Outpatient,,,318.05,159.03,,286.25,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,254.44,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,286.25,90,,,Percent of total Billed charges,90% of total billed charges,12.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,308.51,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,292.61,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,286.25,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,222.64,70,,,percent of total billed charges,70% of total billed charges,286.25,90,,,percent of total billed charges,90% of total billed charges,302.15,95,,,percent of total billed charges,95% of total billed charges,302.15,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,273.52,86,,,percent of total billed charges,86% of total billed charges,254.44,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,308.51,97,,,percent of total billed charges,97% of total billed charges,286.25,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.51,97,,,percent of total billed charges,97% of total billed charges,295.79,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,308.51,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.54,766.61,
88377 Global MDM2 Fish,3513398,CDM,300,RC,88377,HCPCS,Outpatient,,,833.97,416.99,,750.57,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,667.18,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.57,90,,,Percent of total Billed charges,90% of total billed charges,121.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.95,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,767.25,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.57,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,583.78,70,,,percent of total billed charges,70% of total billed charges,750.57,90,,,percent of total billed charges,90% of total billed charges,792.27,95,,,percent of total billed charges,95% of total billed charges,792.27,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,717.21,86,,,percent of total billed charges,86% of total billed charges,667.18,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.95,97,,,percent of total billed charges,97% of total billed charges,750.57,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.95,97,,,percent of total billed charges,97% of total billed charges,775.59,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.95,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.29,808.95,
88377-26 HER-2 Breast/Gastric FISH Professional,3513823,CDM,971,RC,88377,HCPCS,Outpatient,,,833.97,416.99,,750.57,90,,,percent of total billed charges,90% of total Billed charges,589.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,290.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.27,155,,,Fee Schedule,155% of CMS OPPS Rate,290.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,464.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,290.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,522.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,522.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,541.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,541.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,250.19,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,581.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,398.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.27,145,,,Fee Schedule,145% of CMS OPPS Rate,290.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.72,145,,,Fee Schedule,145% of CMS OPPS Rate,421.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,290.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,222.45,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,290.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.45,854.72,
88381- Microdissection Global,3513368,CDM,300,RC,88381,HCPCS,Outpatient,,,424.16,212.08,,381.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,339.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,381.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,411.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,390.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,270.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,333.61,78.65,,,percent of total billed charges,78.65% of total billed charges,378.91,89.33,,,percent of total billed charges,89.33% of total billed charges,381.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,296.91,70,,,percent of total billed charges,70% of total billed charges,381.74,90,,,percent of total billed charges,90% of total billed charges,402.95,95,,,percent of total billed charges,95% of total billed charges,402.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.78,86,,,percent of total billed charges,86% of total billed charges,339.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,411.44,97,,,percent of total billed charges,97% of total billed charges,381.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,411.44,97,,,percent of total billed charges,97% of total billed charges,394.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.88,411.44,
"Pathology Billing, TP,FS,Consult for Chemo Assay",1565100,CDM,510,RC,88388,HCPCS,Outpatient,,,81.15,40.58,,73.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.92,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,73.04,90,,,Percent of total Billed charges,90% of total billed charges,3.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,74.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,63.83,78.65,,,percent of total billed charges,78.65% of total billed charges,72.49,89.33,,,percent of total billed charges,89.33% of total billed charges,73.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.81,70,,,percent of total billed charges,70% of total billed charges,73.04,90,,,percent of total billed charges,90% of total billed charges,77.09,95,,,percent of total billed charges,95% of total billed charges,77.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.79,86,,,percent of total billed charges,86% of total billed charges,64.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,78.72,97,,,percent of total billed charges,97% of total billed charges,73.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.72,97,,,percent of total billed charges,97% of total billed charges,75.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,78.72,
Specimen for RSV Testing,1449213,CDM,300,RC,89220,HCPCS,Outpatient,,,44.06,22.03,,39.65,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,35.25,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.65,90,,,Percent of total Billed charges,90% of total billed charges,12.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.74,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,70,,,percent of total billed charges,70% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.89,86,,,percent of total billed charges,86% of total billed charges,35.25,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.74,97,,,percent of total billed charges,97% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.74,97,,,percent of total billed charges,97% of total billed charges,40.98,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.74,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.57,766.61,
Sputum Induction,617719,CDM,300,RC,89220,HCPCS,Outpatient,,,44.06,22.03,,39.65,90,,,percent of total billed charges,90% of total Billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,35.25,80,,,Percent of total Billed charges,80% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.65,90,,,Percent of total Billed charges,90% of total billed charges,12.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.74,97,,,Percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,40.54,92,,,Percent of total billed charges,92% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,379.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,605.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,766.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,70,,,percent of total billed charges,70% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,142.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,285.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.89,86,,,percent of total billed charges,86% of total billed charges,35.25,80,,,percent of total billed charges,80% of total billed charges,148.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.74,97,,,percent of total billed charges,97% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.74,97,,,percent of total billed charges,97% of total billed charges,40.98,93,,,percent of total billed charges,93% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.74,97,,,percent of total billed charges,97% of total billed charges,142.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,142.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,121.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.57,766.61,
0.5 mL Beyfortus Vaccine,4313727,CDM,636,RC,90380,HCPCS,Outpatient,,,14850,7425.00,,13365,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,11880,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13365,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13662,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,9483.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,11679.85,78.65,,,percent of total billed charges,78.65% of total billed charges,13265.74,89.33,,,percent of total billed charges,89.33% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10395,70,,,percent of total billed charges,70% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,14107.5,95,,,percent of total billed charges,95% of total billed charges,14107.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12771,86,,,percent of total billed charges,86% of total billed charges,11880,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,13810.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9483.54,14404.5,
1 mL Beyfortus Vaccine,4313726,CDM,636,RC,90381,HCPCS,Outpatient,,,14850,7425.00,,13365,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,11880,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13365,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13662,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,9483.54,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,11679.85,78.65,,,percent of total billed charges,78.65% of total billed charges,13265.74,89.33,,,percent of total billed charges,89.33% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10395,70,,,percent of total billed charges,70% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,14107.5,95,,,percent of total billed charges,95% of total billed charges,14107.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12771,86,,,percent of total billed charges,86% of total billed charges,11880,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,13365,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,13810.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14404.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9483.54,14404.5,
90460- Vaccine admin upto 18 yrs w/couns;1st compnt,3569426,CDM,771,RC,90460,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,32.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,26.32,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,32.42,78.65,,,percent of total billed charges,78.65% of total billed charges,36.82,89.33,,,percent of total billed charges,89.33% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,39.98,
First Vaccine (Peds)- 90460,3574945,CDM,771,RC,90460,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,32.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,26.32,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,32.42,78.65,,,percent of total billed charges,78.65% of total billed charges,36.82,89.33,,,percent of total billed charges,89.33% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.32,39.98,
90461- Vaccine admin upto 18 yrs w/ couns;ea addl vac,3569428,CDM,771,RC,90461,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.76,78.65,,,percent of total billed charges,78.65% of total billed charges,28.12,89.33,,,percent of total billed charges,89.33% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.04,70,,,percent of total billed charges,70% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,86,,,percent of total billed charges,86% of total billed charges,25.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,30.54,
Each additional (Peds)- 90461,3574944,CDM,771,RC,90461,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.76,78.65,,,percent of total billed charges,78.65% of total billed charges,28.12,89.33,,,percent of total billed charges,89.33% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.04,70,,,percent of total billed charges,70% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,86,,,percent of total billed charges,86% of total billed charges,25.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,30.54,
90471 -Immunization admin,3430542,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.92,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.1,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.85,328.92,
AMB Admin Immunization Charge:First Vaccine 90471,3444228,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.92,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.1,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.85,328.92,
ID Admin Charge 90471,3550761,CDM,771,RC,90471,HCPCS,Outpatient,,,41.22,20.61,,37.1,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,32.98,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,37.92,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.1,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,28.85,70,,,percent of total billed charges,70% of total billed charges,37.1,90,,,percent of total billed charges,90% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,39.16,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.45,86,,,percent of total billed charges,86% of total billed charges,32.98,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,39.98,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.85,328.92,
90472 - Immunization admin each additional,3574865,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.76,78.65,,,percent of total billed charges,78.65% of total billed charges,28.12,89.33,,,percent of total billed charges,89.33% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.04,70,,,percent of total billed charges,70% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,86,,,percent of total billed charges,86% of total billed charges,25.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,30.54,
AMB Admin Immunization Charge:Each additional 90472,3444229,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.76,78.65,,,percent of total billed charges,78.65% of total billed charges,28.12,89.33,,,percent of total billed charges,89.33% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.04,70,,,percent of total billed charges,70% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,86,,,percent of total billed charges,86% of total billed charges,25.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,30.54,
AMB Admin Oral Immunization Charge -> Each additional 90472,3563071,CDM,771,RC,90472,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,25.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,20.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,24.76,78.65,,,percent of total billed charges,78.65% of total billed charges,28.12,89.33,,,percent of total billed charges,89.33% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.04,70,,,percent of total billed charges,70% of total billed charges,28.33,90,,,percent of total billed charges,90% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,29.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.07,86,,,percent of total billed charges,86% of total billed charges,25.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.1,30.54,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (12+ years) Admin Fee,4303194,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.40,,76.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,67.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,54.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,66.7,78.65,,,percent of total billed charges,78.65% of total billed charges,75.75,89.33,,,percent of total billed charges,89.33% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.36,70,,,percent of total billed charges,70% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,86,,,percent of total billed charges,86% of total billed charges,67.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.16,82.26,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (5y-12y) Admin Fee,4303195,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.40,,76.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,67.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,54.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,66.7,78.65,,,percent of total billed charges,78.65% of total billed charges,75.75,89.33,,,percent of total billed charges,89.33% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.36,70,,,percent of total billed charges,70% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,86,,,percent of total billed charges,86% of total billed charges,67.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.16,82.26,
AMB Admin Covid-19 Charge -> Covid-19 Vaccine (6m<5y) Admin Fee,4303196,CDM,771,RC,90480,HCPCS,Outpatient,,,84.8,42.40,,76.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,67.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,54.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,66.7,78.65,,,percent of total billed charges,78.65% of total billed charges,75.75,89.33,,,percent of total billed charges,89.33% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.36,70,,,percent of total billed charges,70% of total billed charges,76.32,90,,,percent of total billed charges,90% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,80.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.93,86,,,percent of total billed charges,86% of total billed charges,67.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.16,82.26,
90620 - Meningococcal (Bexsero),3918914,CDM,636,RC,90620,HCPCS,Outpatient,,,539.39,269.70,,485.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,431.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,485.45,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,523.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,496.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,344.47,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,424.24,78.65,,,percent of total billed charges,78.65% of total billed charges,481.85,89.33,,,percent of total billed charges,89.33% of total billed charges,485.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,377.57,70,,,percent of total billed charges,70% of total billed charges,485.45,90,,,percent of total billed charges,90% of total billed charges,512.42,95,,,percent of total billed charges,95% of total billed charges,512.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.88,86,,,percent of total billed charges,86% of total billed charges,431.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,523.21,97,,,percent of total billed charges,97% of total billed charges,485.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,523.21,97,,,percent of total billed charges,97% of total billed charges,501.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,523.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,523.21,
AMB meningococcal group B Charge:0.5 mL Bexsero Vaccine,3444353,CDM,636,RC,90620,HCPCS,Outpatient,,,543.15,271.58,,488.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,434.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,488.84,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,526.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,499.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,346.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,427.2,78.65,,,percent of total billed charges,78.65% of total billed charges,485.2,89.33,,,percent of total billed charges,89.33% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,380.21,70,,,percent of total billed charges,70% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,515.99,95,,,percent of total billed charges,95% of total billed charges,515.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.11,86,,,percent of total billed charges,86% of total billed charges,434.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,526.86,97,,,percent of total billed charges,97% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,526.86,97,,,percent of total billed charges,97% of total billed charges,505.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,526.86,
AMB meningococcal group B Charge:0.5 mL Bexsero Vaccine,3581623,CDM,636,RC,90620,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,78.65,,,percent of total billed charges,78.65% of total billed charges,0.01,89.33,,,percent of total billed charges,89.33% of total billed charges,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90632 - Adult Hep A,3918915,CDM,636,RC,90632,HCPCS,Outpatient,,,225.6,112.80,,203.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,180.48,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.04,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,207.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,144.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,177.44,78.65,,,percent of total billed charges,78.65% of total billed charges,201.53,89.33,,,percent of total billed charges,89.33% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.92,70,,,percent of total billed charges,70% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.02,86,,,percent of total billed charges,86% of total billed charges,180.48,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,218.83,97,,,percent of total billed charges,97% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,218.83,97,,,percent of total billed charges,97% of total billed charges,209.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,218.83,
AMB hepatitis A Adult Charge -> 1 mL Vaqta (HepA) Adult Vaccine,3549461,CDM,636,RC,90632,HCPCS,Outpatient,,,206.73,103.37,,186.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,165.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186.06,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,200.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,190.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,132.02,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,162.6,78.65,,,percent of total billed charges,78.65% of total billed charges,184.68,89.33,,,percent of total billed charges,89.33% of total billed charges,186.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,144.71,70,,,percent of total billed charges,70% of total billed charges,186.06,90,,,percent of total billed charges,90% of total billed charges,196.39,95,,,percent of total billed charges,95% of total billed charges,196.39,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.79,86,,,percent of total billed charges,86% of total billed charges,165.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,200.53,97,,,percent of total billed charges,97% of total billed charges,186.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,200.53,97,,,percent of total billed charges,97% of total billed charges,192.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,200.53,
AMB hepatitis A Adult Charge:1 mL Hepatitis A Adult Vaccine,3444307,CDM,636,RC,90632,HCPCS,Outpatient,,,206.67,103.34,,186,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,165.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,186,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,200.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,190.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,131.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,162.55,78.65,,,percent of total billed charges,78.65% of total billed charges,184.62,89.33,,,percent of total billed charges,89.33% of total billed charges,186,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,144.67,70,,,percent of total billed charges,70% of total billed charges,186,90,,,percent of total billed charges,90% of total billed charges,196.34,95,,,percent of total billed charges,95% of total billed charges,196.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.74,86,,,percent of total billed charges,86% of total billed charges,165.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,200.47,97,,,percent of total billed charges,97% of total billed charges,186,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,200.47,97,,,percent of total billed charges,97% of total billed charges,192.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,200.47,
90633 - Pediatric Hep A,3918916,CDM,636,RC,90633,HCPCS,Outpatient,,,225.6,112.80,,203.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,180.48,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.04,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,207.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,144.07,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,177.44,78.65,,,percent of total billed charges,78.65% of total billed charges,201.53,89.33,,,percent of total billed charges,89.33% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.92,70,,,percent of total billed charges,70% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.02,86,,,percent of total billed charges,86% of total billed charges,180.48,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,218.83,97,,,percent of total billed charges,97% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,218.83,97,,,percent of total billed charges,97% of total billed charges,209.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,218.83,
AMB hepatitis A Ped Charge -> 0.5 mL Havrix (HepA) Ped Vaccine,3549455,CDM,636,RC,90633,HCPCS,Outpatient,,,78.73,39.37,,70.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,62.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,70.86,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,76.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,72.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,50.28,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,61.92,78.65,,,percent of total billed charges,78.65% of total billed charges,70.33,89.33,,,percent of total billed charges,89.33% of total billed charges,70.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.11,70,,,percent of total billed charges,70% of total billed charges,70.86,90,,,percent of total billed charges,90% of total billed charges,74.79,95,,,percent of total billed charges,95% of total billed charges,74.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.71,86,,,percent of total billed charges,86% of total billed charges,62.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.37,97,,,percent of total billed charges,97% of total billed charges,70.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,76.37,97,,,percent of total billed charges,97% of total billed charges,73.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,76.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,76.37,
AMB hepatitis A Ped Charge:0.5 mL Hepatitis A Ped Vaccine,3444309,CDM,636,RC,90633,HCPCS,Outpatient,,,98.64,49.32,,88.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,78.91,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,88.78,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,95.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,90.75,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,62.99,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,77.58,78.65,,,percent of total billed charges,78.65% of total billed charges,88.12,89.33,,,percent of total billed charges,89.33% of total billed charges,88.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.05,70,,,percent of total billed charges,70% of total billed charges,88.78,90,,,percent of total billed charges,90% of total billed charges,93.71,95,,,percent of total billed charges,95% of total billed charges,93.71,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.83,86,,,percent of total billed charges,86% of total billed charges,78.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,95.68,97,,,percent of total billed charges,97% of total billed charges,88.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,95.68,97,,,percent of total billed charges,97% of total billed charges,91.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,95.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,95.68,
AMB hepatitis A Ped Charge:0.5 mL Hepatitis A Ped Vaccine,3444308,CDM,636,RC,90633,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,78.65,,,percent of total billed charges,78.65% of total billed charges,0.01,89.33,,,percent of total billed charges,89.33% of total billed charges,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
AMB hepatitis A-hepatitis B Charge:1 mL Twinrix Vaccine,3444310,CDM,636,RC,90636,HCPCS,Outpatient,,,314.66,157.33,,283.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,251.73,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,283.19,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,305.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,289.49,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,200.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,247.49,78.65,,,percent of total billed charges,78.65% of total billed charges,281.09,89.33,,,percent of total billed charges,89.33% of total billed charges,283.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,220.26,70,,,percent of total billed charges,70% of total billed charges,283.19,90,,,percent of total billed charges,90% of total billed charges,298.93,95,,,percent of total billed charges,95% of total billed charges,298.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.61,86,,,percent of total billed charges,86% of total billed charges,251.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,305.22,97,,,percent of total billed charges,97% of total billed charges,283.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.22,97,,,percent of total billed charges,97% of total billed charges,292.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,305.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,305.22,
90647 - Hib PRP-OMP (PedvaxHIB),3918917,CDM,636,RC,90647,HCPCS,Outpatient,,,75.26,37.63,,67.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,60.21,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,67.73,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,69.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,48.06,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,59.19,78.65,,,percent of total billed charges,78.65% of total billed charges,67.23,89.33,,,percent of total billed charges,89.33% of total billed charges,67.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,52.68,70,,,percent of total billed charges,70% of total billed charges,67.73,90,,,percent of total billed charges,90% of total billed charges,71.5,95,,,percent of total billed charges,95% of total billed charges,71.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.72,86,,,percent of total billed charges,86% of total billed charges,60.21,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,73,97,,,percent of total billed charges,97% of total billed charges,67.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,73,97,,,percent of total billed charges,97% of total billed charges,69.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,73,
AMB haemophilus b Ped Charge:0.5mL PedvaxHIB Vaccine,3444306,CDM,636,RC,90647,HCPCS,Outpatient,,,77.6,38.80,,69.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,62.08,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.84,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,75.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,71.39,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,49.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,61.03,78.65,,,percent of total billed charges,78.65% of total billed charges,69.32,89.33,,,percent of total billed charges,89.33% of total billed charges,69.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.32,70,,,percent of total billed charges,70% of total billed charges,69.84,90,,,percent of total billed charges,90% of total billed charges,73.72,95,,,percent of total billed charges,95% of total billed charges,73.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.74,86,,,percent of total billed charges,86% of total billed charges,62.08,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,75.27,97,,,percent of total billed charges,97% of total billed charges,69.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,75.27,97,,,percent of total billed charges,97% of total billed charges,72.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,75.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,75.27,
AMB haemophilus b Ped Charge:0.5mL PedvaxHIB Vaccine,3444305,CDM,636,RC,90647,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,78.65,,,percent of total billed charges,78.65% of total billed charges,0.01,89.33,,,percent of total billed charges,89.33% of total billed charges,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90648 - HIB,3918918,CDM,636,RC,90648,HCPCS,Outpatient,,,36.38,18.19,,32.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,29.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.74,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,35.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,33.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,23.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,28.61,78.65,,,percent of total billed charges,78.65% of total billed charges,32.5,89.33,,,percent of total billed charges,89.33% of total billed charges,32.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.47,70,,,percent of total billed charges,70% of total billed charges,32.74,90,,,percent of total billed charges,90% of total billed charges,34.56,95,,,percent of total billed charges,95% of total billed charges,34.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.29,86,,,percent of total billed charges,86% of total billed charges,29.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,35.29,97,,,percent of total billed charges,97% of total billed charges,32.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.29,97,,,percent of total billed charges,97% of total billed charges,33.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,35.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,35.29,
AMB haemophilus b Adult Charge:0.5 mL  ActHIB Vaccine,3444304,CDM,636,RC,90648,HCPCS,Outpatient,,,48.91,24.46,,44.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,39.13,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.02,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,47.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,31.24,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,38.47,78.65,,,percent of total billed charges,78.65% of total billed charges,43.69,89.33,,,percent of total billed charges,89.33% of total billed charges,44.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.24,70,,,percent of total billed charges,70% of total billed charges,44.02,90,,,percent of total billed charges,90% of total billed charges,46.46,95,,,percent of total billed charges,95% of total billed charges,46.46,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.06,86,,,percent of total billed charges,86% of total billed charges,39.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.44,97,,,percent of total billed charges,97% of total billed charges,44.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.44,97,,,percent of total billed charges,97% of total billed charges,45.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,47.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,47.44,
90651 - HPV (Gardasil),3918919,CDM,636,RC,90651,HCPCS,Outpatient,,,686.16,343.08,,617.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,548.93,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,617.54,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,665.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,631.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,438.2,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,539.68,78.65,,,percent of total billed charges,78.65% of total billed charges,612.96,89.33,,,percent of total billed charges,89.33% of total billed charges,617.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,480.31,70,,,percent of total billed charges,70% of total billed charges,617.54,90,,,percent of total billed charges,90% of total billed charges,651.85,95,,,percent of total billed charges,95% of total billed charges,651.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.1,86,,,percent of total billed charges,86% of total billed charges,548.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,665.58,97,,,percent of total billed charges,97% of total billed charges,617.54,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,665.58,97,,,percent of total billed charges,97% of total billed charges,638.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,665.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,665.58,
AMB HPV Charge:0.5 mL Gardasil 9 Vaccine,3444315,CDM,636,RC,90651,HCPCS,Outpatient,,,725.36,362.68,,652.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,580.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,652.82,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,703.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,667.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,463.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,570.51,78.65,,,percent of total billed charges,78.65% of total billed charges,647.98,89.33,,,percent of total billed charges,89.33% of total billed charges,652.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,507.75,70,,,percent of total billed charges,70% of total billed charges,652.82,90,,,percent of total billed charges,90% of total billed charges,689.09,95,,,percent of total billed charges,95% of total billed charges,689.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.81,86,,,percent of total billed charges,86% of total billed charges,580.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,703.6,97,,,percent of total billed charges,97% of total billed charges,652.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,703.6,97,,,percent of total billed charges,97% of total billed charges,674.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,703.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,703.6,
AMB HPV Charge:0.5 mL Gardasil 9 Vaccine,3444314,CDM,636,RC,90651,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,78.65,,,percent of total billed charges,78.65% of total billed charges,0.01,89.33,,,percent of total billed charges,89.33% of total billed charges,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90653 - Flu - Fluad,3918922,CDM,636,RC,90653,HCPCS,Outpatient,,,133.11,66.56,,119.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,106.49,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,119.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,122.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.18,70,,,percent of total billed charges,70% of total billed charges,119.8,90,,,percent of total billed charges,90% of total billed charges,126.45,95,,,percent of total billed charges,95% of total billed charges,126.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.47,86,,,percent of total billed charges,86% of total billed charges,106.49,80,,,percent of total billed charges,80% of total billed charges,66.08,111,,,Fee Schedule,111% of CMS OPPS Rate,129.12,97,,,percent of total billed charges,97% of total billed charges,119.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.12,97,,,percent of total billed charges,97% of total billed charges,123.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,129.12,
"90653 - Fluad - Influenza vaccine, inactivated (IIV), subuni",3918920,CDM,636,RC,90653,HCPCS,Outpatient,,,149.35,74.68,,134.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,119.48,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,134.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,144.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,137.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,104.55,70,,,percent of total billed charges,70% of total billed charges,134.42,90,,,percent of total billed charges,90% of total billed charges,141.88,95,,,percent of total billed charges,95% of total billed charges,141.88,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.44,86,,,percent of total billed charges,86% of total billed charges,119.48,80,,,percent of total billed charges,80% of total billed charges,66.08,111,,,Fee Schedule,111% of CMS OPPS Rate,144.87,97,,,percent of total billed charges,97% of total billed charges,134.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,144.87,97,,,percent of total billed charges,97% of total billed charges,138.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,144.87,
90653 - High Dose Flu,3918921,CDM,636,RC,90653,HCPCS,Outpatient,,,133.11,66.56,,119.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,106.49,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,119.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,122.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.18,70,,,percent of total billed charges,70% of total billed charges,119.8,90,,,percent of total billed charges,90% of total billed charges,126.45,95,,,percent of total billed charges,95% of total billed charges,126.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.47,86,,,percent of total billed charges,86% of total billed charges,106.49,80,,,percent of total billed charges,80% of total billed charges,66.08,111,,,Fee Schedule,111% of CMS OPPS Rate,129.12,97,,,percent of total billed charges,97% of total billed charges,119.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.12,97,,,percent of total billed charges,97% of total billed charges,123.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,129.12,
AMB Influenza Charge:Flu Vaccine Adjuvanted 65+,3444324,CDM,636,RC,90662,HCPCS,Outpatient,,,386.3,193.15,,347.67,90,,,percent of total billed charges,90% of total Billed charges,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,309.04,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,347.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,355.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,297.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,336.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,347.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.41,70,,,percent of total billed charges,70% of total billed charges,347.67,90,,,percent of total billed charges,90% of total billed charges,366.99,95,,,percent of total billed charges,95% of total billed charges,366.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.22,86,,,percent of total billed charges,86% of total billed charges,309.04,80,,,percent of total billed charges,80% of total billed charges,67.69,111,,,Fee Schedule,111% of CMS OPPS Rate,374.71,97,,,percent of total billed charges,97% of total billed charges,347.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.71,97,,,percent of total billed charges,97% of total billed charges,359.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,374.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.69,374.71,
"90670 - Pneumococcal conjugate vaccine, 13 valent (PCV13), f",3918923,CDM,636,RC,90670,HCPCS,Outpatient,,,577.37,288.69,,519.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,461.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,519.63,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,560.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,531.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,404.16,70,,,percent of total billed charges,70% of total billed charges,519.63,90,,,percent of total billed charges,90% of total billed charges,548.5,95,,,percent of total billed charges,95% of total billed charges,548.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.54,86,,,percent of total billed charges,86% of total billed charges,461.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,560.05,97,,,percent of total billed charges,97% of total billed charges,519.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,560.05,97,,,percent of total billed charges,97% of total billed charges,536.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,560.05,
90670 - Prevnar 13,3918924,CDM,636,RC,90670,HCPCS,Outpatient,,,577.37,288.69,,519.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,461.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,519.63,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,560.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,531.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,519.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,404.16,70,,,percent of total billed charges,70% of total billed charges,519.63,90,,,percent of total billed charges,90% of total billed charges,548.5,95,,,percent of total billed charges,95% of total billed charges,548.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.54,86,,,percent of total billed charges,86% of total billed charges,461.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,560.05,97,,,percent of total billed charges,97% of total billed charges,519.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,560.05,97,,,percent of total billed charges,97% of total billed charges,536.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,560.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,560.05,
AMB Prevnar 13 Charge:0.5 mL Prevnar Vaccine,3444388,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,549.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,488.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,549.93,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,562.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.72,70,,,percent of total billed charges,70% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.49,86,,,percent of total billed charges,86% of total billed charges,488.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,568.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,592.7,
AMB Prevnar 13 Charge:0.5 mL Prevnar Vaccine,3444387,CDM,636,RC,90670,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
PCV13 VACCINE IM,3435740,CDM,636,RC,90670,HCPCS,Outpatient,,,436.53,218.27,,392.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,349.22,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,392.88,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,423.43,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,401.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.57,70,,,percent of total billed charges,70% of total billed charges,392.88,90,,,percent of total billed charges,90% of total billed charges,414.7,95,,,percent of total billed charges,95% of total billed charges,414.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.42,86,,,percent of total billed charges,86% of total billed charges,349.22,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,423.43,97,,,percent of total billed charges,97% of total billed charges,392.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,423.43,97,,,percent of total billed charges,97% of total billed charges,405.97,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,423.43,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,423.43,
0.5 mL Prevnar 20 Vaccine,3886915,CDM,636,RC,90677,HCPCS,Outpatient,,,1194.6,597.30,,1075.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,955.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1075.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1099.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,836.22,70,,,percent of total billed charges,70% of total billed charges,1075.14,90,,,percent of total billed charges,90% of total billed charges,1134.87,95,,,percent of total billed charges,95% of total billed charges,1134.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.36,86,,,percent of total billed charges,86% of total billed charges,955.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,1075.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,1110.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,836.22,1158.76,
90677 - 0.5 mL Prevnar 20 Vaccine,4263577,CDM,636,RC,90677,HCPCS,Outpatient,,,1194.6,597.30,,1075.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,955.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1075.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1099.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1075.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,836.22,70,,,percent of total billed charges,70% of total billed charges,1075.14,90,,,percent of total billed charges,90% of total billed charges,1134.87,95,,,percent of total billed charges,95% of total billed charges,1134.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1027.36,86,,,percent of total billed charges,86% of total billed charges,955.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,1075.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,1110.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1158.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,836.22,1158.76,
AMB Prevnar 20 Charge -> VFC Vaccine,4331254,CDM,636,RC,90677,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
90680 - Rotavirus,3918925,CDM,636,RC,90680,HCPCS,Outpatient,,,254.64,127.32,,229.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,203.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,229.18,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,247,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,234.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,178.25,70,,,percent of total billed charges,70% of total billed charges,229.18,90,,,percent of total billed charges,90% of total billed charges,241.91,95,,,percent of total billed charges,95% of total billed charges,241.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.99,86,,,percent of total billed charges,86% of total billed charges,203.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,247,97,,,percent of total billed charges,97% of total billed charges,229.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,247,97,,,percent of total billed charges,97% of total billed charges,236.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,247,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,247,
AMB rotavirus Charge:2 mL RotaTeq Vaccine,3444394,CDM,636,RC,90680,HCPCS,Outpatient,,,251.28,125.64,,226.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,201.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,226.15,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,231.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.9,70,,,percent of total billed charges,70% of total billed charges,226.15,90,,,percent of total billed charges,90% of total billed charges,238.72,95,,,percent of total billed charges,95% of total billed charges,238.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.1,86,,,percent of total billed charges,86% of total billed charges,201.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.74,97,,,percent of total billed charges,97% of total billed charges,226.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,243.74,97,,,percent of total billed charges,97% of total billed charges,233.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,243.74,
AMB rotavirus Charge:2 mL RotaTeq Vaccine,3444393,CDM,636,RC,90680,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
AMB rotavirus Charge:1 mL RotaRix Vaccine,3580928,CDM,636,RC,90681,HCPCS,Outpatient,,,352.88,176.44,,317.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,282.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,317.59,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,342.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,324.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,247.02,70,,,percent of total billed charges,70% of total billed charges,317.59,90,,,percent of total billed charges,90% of total billed charges,335.24,95,,,percent of total billed charges,95% of total billed charges,335.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.48,86,,,percent of total billed charges,86% of total billed charges,282.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,342.29,97,,,percent of total billed charges,97% of total billed charges,317.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,342.29,97,,,percent of total billed charges,97% of total billed charges,328.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,342.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,342.29,
Flu Adult Recombinant (egg-free),4183112,CDM,636,RC,90682,HCPCS,Outpatient,,,117.85,58.93,,106.07,90,,,percent of total billed charges,90% of total Billed charges,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,94.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,106.07,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,114.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,108.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,297.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,336.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,106.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.5,70,,,percent of total billed charges,70% of total billed charges,106.07,90,,,percent of total billed charges,90% of total billed charges,111.96,95,,,percent of total billed charges,95% of total billed charges,111.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.35,86,,,percent of total billed charges,86% of total billed charges,94.28,80,,,percent of total billed charges,80% of total billed charges,67.69,111,,,Fee Schedule,111% of CMS OPPS Rate,114.31,97,,,percent of total billed charges,97% of total billed charges,106.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,114.31,97,,,percent of total billed charges,97% of total billed charges,109.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,362.77,
90685 - Influenza (Afluria/Fluzone) Peds,3918926,CDM,636,RC,90685,HCPCS,Outpatient,,,53.01,26.51,,47.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,42.41,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.71,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,51.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,48.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,37.11,70,,,percent of total billed charges,70% of total billed charges,47.71,90,,,percent of total billed charges,90% of total billed charges,50.36,95,,,percent of total billed charges,95% of total billed charges,50.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.59,86,,,percent of total billed charges,86% of total billed charges,42.41,80,,,percent of total billed charges,80% of total billed charges,23.45,111,,,Fee Schedule,111% of CMS OPPS Rate,51.42,97,,,percent of total billed charges,97% of total billed charges,47.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.42,97,,,percent of total billed charges,97% of total billed charges,49.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,51.42,
"90686 - Afluria/Fluzone (adult) flu vacc, quad (IIV4), split",3918927,CDM,636,RC,90686,HCPCS,Outpatient,,,55.19,27.60,,49.67,90,,,percent of total billed charges,90% of total Billed charges,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,44.15,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,49.67,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,53.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,50.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.46,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,102.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,38.63,70,,,percent of total billed charges,70% of total billed charges,49.67,90,,,percent of total billed charges,90% of total billed charges,52.43,95,,,percent of total billed charges,95% of total billed charges,52.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.46,86,,,percent of total billed charges,86% of total billed charges,44.15,80,,,percent of total billed charges,80% of total billed charges,21.73,111,,,Fee Schedule,111% of CMS OPPS Rate,53.53,97,,,percent of total billed charges,97% of total billed charges,49.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.53,97,,,percent of total billed charges,97% of total billed charges,51.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,110.46,
AMB Influenza Charge: Flu Vaccine Adult Dose,3562705,CDM,636,RC,90686,HCPCS,Outpatient,,,117.85,58.93,,106.07,90,,,percent of total billed charges,90% of total Billed charges,22.35,100,,,Fee Schedule,100% of CMS OPPS Rate,94.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,106.07,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,114.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,108.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,90.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.46,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,102.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,106.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.5,70,,,percent of total billed charges,70% of total billed charges,106.07,90,,,percent of total billed charges,90% of total billed charges,111.96,95,,,percent of total billed charges,95% of total billed charges,111.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.35,86,,,percent of total billed charges,86% of total billed charges,94.28,80,,,percent of total billed charges,80% of total billed charges,21.73,111,,,Fee Schedule,111% of CMS OPPS Rate,114.31,97,,,percent of total billed charges,97% of total billed charges,106.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,114.31,97,,,percent of total billed charges,97% of total billed charges,109.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,114.31,
0.5 mL Quadracel  Vaccine,4215693,CDM,636,RC,90696,HCPCS,Outpatient,,,156.22,78.11,,140.6,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,124.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,140.6,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,151.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,143.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.35,70,,,percent of total billed charges,70% of total billed charges,140.6,90,,,percent of total billed charges,90% of total billed charges,148.41,95,,,percent of total billed charges,95% of total billed charges,148.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.35,86,,,percent of total billed charges,86% of total billed charges,124.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,151.53,97,,,percent of total billed charges,97% of total billed charges,140.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,151.53,97,,,percent of total billed charges,97% of total billed charges,145.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,151.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,151.53,
AMB DTaP/IPV Charge:0.5 mL DTaP/IPV Vaccine,3444281,CDM,636,RC,90696,HCPCS,Outpatient,,,153.14,76.57,,137.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,122.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,137.83,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,148.55,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,140.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,107.2,70,,,percent of total billed charges,70% of total billed charges,137.83,90,,,percent of total billed charges,90% of total billed charges,145.48,95,,,percent of total billed charges,95% of total billed charges,145.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131.7,86,,,percent of total billed charges,86% of total billed charges,122.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,148.55,97,,,percent of total billed charges,97% of total billed charges,137.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,148.55,97,,,percent of total billed charges,97% of total billed charges,142.42,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.55,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,148.55,
AMB DTaP/IPV Charge:0.5 mL DTaP/IPV Vaccine,3581586,CDM,636,RC,90696,HCPCS,Outpatient,,,175.62,87.81,,158.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,140.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,158.06,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,170.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,161.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.93,70,,,percent of total billed charges,70% of total billed charges,158.06,90,,,percent of total billed charges,90% of total billed charges,166.84,95,,,percent of total billed charges,95% of total billed charges,166.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.03,86,,,percent of total billed charges,86% of total billed charges,140.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,170.35,97,,,percent of total billed charges,97% of total billed charges,158.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,170.35,97,,,percent of total billed charges,97% of total billed charges,163.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,170.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,170.35,
AMB DTaP-IPV-Hib-HepB Charge -> 0.5 mL DTaP-IPV-Hib-HepB Vaccine,4361229,CDM,636,RC,90697,HCPCS,Outpatient,,,878.11,439.06,,790.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,702.49,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,790.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,807.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,790.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,614.68,70,,,percent of total billed charges,70% of total billed charges,790.3,90,,,percent of total billed charges,90% of total billed charges,834.2,95,,,percent of total billed charges,95% of total billed charges,834.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,755.17,86,,,percent of total billed charges,86% of total billed charges,702.49,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,851.77,97,,,percent of total billed charges,97% of total billed charges,790.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,851.77,97,,,percent of total billed charges,97% of total billed charges,816.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,851.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,614.68,851.77,
90698 - Dtap-IPV-Hib (Pentacel),3918929,CDM,636,RC,90698,HCPCS,Outpatient,,,298.55,149.28,,268.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,238.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,268.7,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,289.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,274.67,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.99,70,,,percent of total billed charges,70% of total billed charges,268.7,90,,,percent of total billed charges,90% of total billed charges,283.62,95,,,percent of total billed charges,95% of total billed charges,283.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.75,86,,,percent of total billed charges,86% of total billed charges,238.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.59,97,,,percent of total billed charges,97% of total billed charges,268.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.59,97,,,percent of total billed charges,97% of total billed charges,277.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,289.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,289.59,
AMB DTaP-IPV-Hib Charge:0.5 mL Pentacel Vaccine,3444283,CDM,636,RC,90698,HCPCS,Outpatient,,,142.49,71.25,,128.24,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,128.24,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,138.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,131.09,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,99.74,70,,,percent of total billed charges,70% of total billed charges,128.24,90,,,percent of total billed charges,90% of total billed charges,135.37,95,,,percent of total billed charges,95% of total billed charges,135.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.54,86,,,percent of total billed charges,86% of total billed charges,113.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,138.22,97,,,percent of total billed charges,97% of total billed charges,128.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,138.22,97,,,percent of total billed charges,97% of total billed charges,132.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,138.22,
AMB DTaP-IPV-Hib Charge:0.5 mL Pentacel Vaccine,3581592,CDM,636,RC,90698,HCPCS,Outpatient,,,298.55,149.28,,268.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,238.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,268.7,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,289.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,274.67,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.99,70,,,percent of total billed charges,70% of total billed charges,268.7,90,,,percent of total billed charges,90% of total billed charges,283.62,95,,,percent of total billed charges,95% of total billed charges,283.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.75,86,,,percent of total billed charges,86% of total billed charges,238.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.59,97,,,percent of total billed charges,97% of total billed charges,268.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.59,97,,,percent of total billed charges,97% of total billed charges,277.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,289.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,289.59,
0.5 mL Daptacel (DTaP) Vaccine,4215700,CDM,636,RC,90700,HCPCS,Outpatient,,,91.19,45.60,,82.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,72.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.07,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,83.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.83,70,,,percent of total billed charges,70% of total billed charges,82.07,90,,,percent of total billed charges,90% of total billed charges,86.63,95,,,percent of total billed charges,95% of total billed charges,86.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.42,86,,,percent of total billed charges,86% of total billed charges,72.95,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,88.45,97,,,percent of total billed charges,97% of total billed charges,82.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.45,97,,,percent of total billed charges,97% of total billed charges,84.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,88.45,
90700 - Pediatric DTaP,3918930,CDM,636,RC,90700,HCPCS,Outpatient,,,82.79,41.40,,74.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,66.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,74.51,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,76.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,57.95,70,,,percent of total billed charges,70% of total billed charges,74.51,90,,,percent of total billed charges,90% of total billed charges,78.65,95,,,percent of total billed charges,95% of total billed charges,78.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.2,86,,,percent of total billed charges,86% of total billed charges,66.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,80.31,97,,,percent of total billed charges,97% of total billed charges,74.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.31,97,,,percent of total billed charges,97% of total billed charges,76.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,80.31,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3444279,CDM,636,RC,90700,HCPCS,Outpatient,,,71.55,35.78,,64.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,57.24,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.4,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,69.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,65.83,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.09,70,,,percent of total billed charges,70% of total billed charges,64.4,90,,,percent of total billed charges,90% of total billed charges,67.97,95,,,percent of total billed charges,95% of total billed charges,67.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.53,86,,,percent of total billed charges,86% of total billed charges,57.24,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.4,97,,,percent of total billed charges,97% of total billed charges,64.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.4,97,,,percent of total billed charges,97% of total billed charges,66.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,69.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,69.4,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3444280,CDM,636,RC,90700,HCPCS,Outpatient,,,82.79,41.40,,74.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,66.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,74.51,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,76.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,57.95,70,,,percent of total billed charges,70% of total billed charges,74.51,90,,,percent of total billed charges,90% of total billed charges,78.65,95,,,percent of total billed charges,95% of total billed charges,78.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.2,86,,,percent of total billed charges,86% of total billed charges,66.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,80.31,97,,,percent of total billed charges,97% of total billed charges,74.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.31,97,,,percent of total billed charges,97% of total billed charges,76.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,80.31,
90707 - MMR Vaccine,3918931,CDM,636,RC,90707,HCPCS,Outpatient,,,235.83,117.92,,212.25,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,188.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,212.25,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,228.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,216.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,212.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,165.08,70,,,percent of total billed charges,70% of total billed charges,212.25,90,,,percent of total billed charges,90% of total billed charges,224.04,95,,,percent of total billed charges,95% of total billed charges,224.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.81,86,,,percent of total billed charges,86% of total billed charges,188.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,228.76,97,,,percent of total billed charges,97% of total billed charges,212.25,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.76,97,,,percent of total billed charges,97% of total billed charges,219.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,228.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,228.76,
AMB MMR Charge:0.5 mL MMR Vaccine,3444365,CDM,636,RC,90707,HCPCS,Outpatient,,,241.63,120.82,,217.47,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,193.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.47,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,234.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,222.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,169.14,70,,,percent of total billed charges,70% of total billed charges,217.47,90,,,percent of total billed charges,90% of total billed charges,229.55,95,,,percent of total billed charges,95% of total billed charges,229.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.8,86,,,percent of total billed charges,86% of total billed charges,193.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,234.38,97,,,percent of total billed charges,97% of total billed charges,217.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.38,97,,,percent of total billed charges,97% of total billed charges,224.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,234.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,234.38,
AMB MMR Charge:0.5 mL MMR Vaccine,3444364,CDM,636,RC,90707,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90710 - MMRV - ProQuad,3918932,CDM,636,RC,90710,HCPCS,Outpatient,,,676.12,338.06,,608.51,90,,,percent of total billed charges,90% of total Billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,540.9,80,,,Percent of total Billed charges,80% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,608.51,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,655.84,97,,,Percent of total billed charges,97% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,622.03,92,,,Percent of total billed charges,92% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,425.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,858.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,608.51,90,,,percent of total billed charges,90% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,473.28,70,,,percent of total billed charges,70% of total billed charges,608.51,90,,,percent of total billed charges,90% of total billed charges,642.31,95,,,percent of total billed charges,95% of total billed charges,642.31,95,,,percent of total billed charges,95% of total billed charges,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,581.46,86,,,percent of total billed charges,86% of total billed charges,540.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,655.84,97,,,percent of total billed charges,97% of total billed charges,608.51,90,,,percent of total billed charges,90% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.84,97,,,percent of total billed charges,97% of total billed charges,628.79,93,,,percent of total billed charges,93% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,655.84,97,,,percent of total billed charges,97% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,160,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,136,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,858.8,
AMB MMRV Charge:0.5 mL MMRV Vaccine,3444366,CDM,636,RC,90710,HCPCS,Outpatient,,,707.04,353.52,,636.34,90,,,percent of total billed charges,90% of total Billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,565.63,80,,,Percent of total Billed charges,80% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,636.34,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,685.83,97,,,Percent of total billed charges,97% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,650.48,92,,,Percent of total billed charges,92% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,425.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,858.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,636.34,90,,,percent of total billed charges,90% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,494.93,70,,,percent of total billed charges,70% of total billed charges,636.34,90,,,percent of total billed charges,90% of total billed charges,671.69,95,,,percent of total billed charges,95% of total billed charges,671.69,95,,,percent of total billed charges,95% of total billed charges,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,608.05,86,,,percent of total billed charges,86% of total billed charges,565.63,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,685.83,97,,,percent of total billed charges,97% of total billed charges,636.34,90,,,percent of total billed charges,90% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,685.83,97,,,percent of total billed charges,97% of total billed charges,657.55,93,,,percent of total billed charges,93% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,685.83,97,,,percent of total billed charges,97% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,160,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,136,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10,858.8,
AMB MMRV Charge:0.5 mL MMRV Vaccine,3581634,CDM,636,RC,90710,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,425.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,678.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,858.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,160,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,320,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,160,100,,,Fee Schedule,100% of CMS OPPS Rate ,160,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,136,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,858.8,
90713 - Poliovirus (IPOL),3918933,CDM,636,RC,90713,HCPCS,Outpatient,,,115.4,57.70,,103.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,92.32,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,103.86,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,111.94,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,106.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.78,70,,,percent of total billed charges,70% of total billed charges,103.86,90,,,percent of total billed charges,90% of total billed charges,109.63,95,,,percent of total billed charges,95% of total billed charges,109.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.24,86,,,percent of total billed charges,86% of total billed charges,92.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,111.94,97,,,percent of total billed charges,97% of total billed charges,103.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,111.94,97,,,percent of total billed charges,97% of total billed charges,107.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.94,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,111.94,
AMB IPV Charge:0.5 mL IPV Vaccine,3444329,CDM,636,RC,90713,HCPCS,Outpatient,,,104.27,52.14,,93.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,83.42,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.84,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,101.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,95.93,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.99,70,,,percent of total billed charges,70% of total billed charges,93.84,90,,,percent of total billed charges,90% of total billed charges,99.06,95,,,percent of total billed charges,95% of total billed charges,99.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.67,86,,,percent of total billed charges,86% of total billed charges,83.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,101.14,97,,,percent of total billed charges,97% of total billed charges,93.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,101.14,97,,,percent of total billed charges,97% of total billed charges,96.97,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,101.14,
AMB IPV Charge:0.5 mL IPV Vaccine,3444328,CDM,636,RC,90713,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90714 - Td Adult (Tenivac),3918934,CDM,636,RC,90714,HCPCS,Outpatient,,,63.65,31.83,,57.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,50.92,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,57.29,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,61.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,58.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.56,70,,,percent of total billed charges,70% of total billed charges,57.29,90,,,percent of total billed charges,90% of total billed charges,60.47,95,,,percent of total billed charges,95% of total billed charges,60.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.74,86,,,percent of total billed charges,86% of total billed charges,50.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.74,97,,,percent of total billed charges,97% of total billed charges,57.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.74,97,,,percent of total billed charges,97% of total billed charges,59.19,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,61.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,61.74,
AMB Td Adult Charge:0.5 mL Tenivac Vaccine,3444407,CDM,636,RC,90714,HCPCS,Outpatient,,,101.7,50.85,,91.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,81.36,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,91.53,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,98.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,93.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,71.19,70,,,percent of total billed charges,70% of total billed charges,91.53,90,,,percent of total billed charges,90% of total billed charges,96.62,95,,,percent of total billed charges,95% of total billed charges,96.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.46,86,,,percent of total billed charges,86% of total billed charges,81.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,98.65,97,,,percent of total billed charges,97% of total billed charges,91.53,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.65,97,,,percent of total billed charges,97% of total billed charges,94.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,98.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,98.65,
90715 - Tdap - Adult,3918936,CDM,636,RC,90715,HCPCS,Outpatient,,,85.44,42.72,,76.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,68.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.9,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,82.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.81,70,,,percent of total billed charges,70% of total billed charges,76.9,90,,,percent of total billed charges,90% of total billed charges,81.17,95,,,percent of total billed charges,95% of total billed charges,81.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.48,86,,,percent of total billed charges,86% of total billed charges,68.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.88,97,,,percent of total billed charges,97% of total billed charges,76.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.88,97,,,percent of total billed charges,97% of total billed charges,79.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,82.88,
"90715 - Tetanus, diptheria toxoids & acellular prtussis vacc",3918935,CDM,636,RC,90715,HCPCS,Outpatient,,,85.44,42.72,,76.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,68.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.9,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,82.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.81,70,,,percent of total billed charges,70% of total billed charges,76.9,90,,,percent of total billed charges,90% of total billed charges,81.17,95,,,percent of total billed charges,95% of total billed charges,81.17,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.48,86,,,percent of total billed charges,86% of total billed charges,68.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.88,97,,,percent of total billed charges,97% of total billed charges,76.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.88,97,,,percent of total billed charges,97% of total billed charges,79.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,82.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,82.88,
AMB Tdap Adult Charge -> 0.5 mL Boostrix Vaccine,3546997,CDM,636,RC,90715,HCPCS,Outpatient,,,119.95,59.98,,107.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,95.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,107.96,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,116.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,110.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.97,70,,,percent of total billed charges,70% of total billed charges,107.96,90,,,percent of total billed charges,90% of total billed charges,113.95,95,,,percent of total billed charges,95% of total billed charges,113.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.16,86,,,percent of total billed charges,86% of total billed charges,95.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,116.35,97,,,percent of total billed charges,97% of total billed charges,107.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,116.35,97,,,percent of total billed charges,97% of total billed charges,111.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,116.35,
AMB Tdap Adult Charge -> VFC Vaccine,3581655,CDM,636,RC,90715,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
AMB Tdap Adult Charge:0.5 mL Adacel Vaccine,3444408,CDM,636,RC,90715,HCPCS,Outpatient,,,135.29,67.65,,121.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,108.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,121.76,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,131.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,124.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,94.7,70,,,percent of total billed charges,70% of total billed charges,121.76,90,,,percent of total billed charges,90% of total billed charges,128.53,95,,,percent of total billed charges,95% of total billed charges,128.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.35,86,,,percent of total billed charges,86% of total billed charges,108.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,97,,,percent of total billed charges,97% of total billed charges,121.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,131.23,97,,,percent of total billed charges,97% of total billed charges,125.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,131.23,
90716 - Varicella,3918937,CDM,636,RC,90716,HCPCS,Outpatient,,,407.68,203.84,,366.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,326.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,366.91,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,395.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,375.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,285.38,70,,,percent of total billed charges,70% of total billed charges,366.91,90,,,percent of total billed charges,90% of total billed charges,387.3,95,,,percent of total billed charges,95% of total billed charges,387.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.6,86,,,percent of total billed charges,86% of total billed charges,326.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,395.45,97,,,percent of total billed charges,97% of total billed charges,366.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,395.45,97,,,percent of total billed charges,97% of total billed charges,379.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,395.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,395.45,
AMB varicella virus Charge:0.5 mL Varivax Vaccine,3444421,CDM,636,RC,90716,HCPCS,Outpatient,,,431.64,215.82,,388.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,345.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,388.48,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,418.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,397.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,302.15,70,,,percent of total billed charges,70% of total billed charges,388.48,90,,,percent of total billed charges,90% of total billed charges,410.06,95,,,percent of total billed charges,95% of total billed charges,410.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.21,86,,,percent of total billed charges,86% of total billed charges,345.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,418.69,97,,,percent of total billed charges,97% of total billed charges,388.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,418.69,97,,,percent of total billed charges,97% of total billed charges,401.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,418.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,418.69,
AMB varicella virus Charge:0.5 mL Varivax Vaccine,3444420,CDM,636,RC,90716,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90723 - Dtap-HepB-IPV (Pediarix),3918938,CDM,636,RC,90723,HCPCS,Outpatient,,,250.88,125.44,,225.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,200.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.79,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,230.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.62,70,,,percent of total billed charges,70% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.76,86,,,percent of total billed charges,86% of total billed charges,200.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,233.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,243.35,
AMB DTaP Peds Charge:0.5 mL Infanrix (DTaP) Vaccine,3581580,CDM,636,RC,90723,HCPCS,Outpatient,,,250.88,125.44,,225.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,200.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.79,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,230.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.62,70,,,percent of total billed charges,70% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.76,86,,,percent of total billed charges,86% of total billed charges,200.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,233.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,243.35,
AMB DTaP-HepB-IPV Charge:0.5 mL PEDIARIX Vaccine,3444282,CDM,636,RC,90723,HCPCS,Outpatient,,,223.88,111.94,,201.49,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,179.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,201.49,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,217.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,205.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,201.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,156.72,70,,,percent of total billed charges,70% of total billed charges,201.49,90,,,percent of total billed charges,90% of total billed charges,212.69,95,,,percent of total billed charges,95% of total billed charges,212.69,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.54,86,,,percent of total billed charges,86% of total billed charges,179.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.16,97,,,percent of total billed charges,97% of total billed charges,201.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.16,97,,,percent of total billed charges,97% of total billed charges,208.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,217.16,
90732 - Penumovax,3918939,CDM,636,RC,90732,HCPCS,Outpatient,,,250.88,125.44,,225.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,200.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.79,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,230.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.62,70,,,percent of total billed charges,70% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.76,86,,,percent of total billed charges,86% of total billed charges,200.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,233.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,243.35,
"90732 - Pneumovax 23 -Pneum polysacaride vac, admin to ind 2",3918981,CDM,636,RC,90732,HCPCS,Outpatient,,,250.88,125.44,,225.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,200.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.79,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,230.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,175.62,70,,,percent of total billed charges,70% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,238.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.76,86,,,percent of total billed charges,86% of total billed charges,200.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,225.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,243.35,97,,,percent of total billed charges,97% of total billed charges,233.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,243.35,
AMB Pneumovax 23 Charge:0.5 mL Pneumovax Vaccine,3444384,CDM,636,RC,90732,HCPCS,Outpatient,,,316.06,158.03,,284.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,252.85,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,284.45,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,306.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,290.78,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,221.24,70,,,percent of total billed charges,70% of total billed charges,284.45,90,,,percent of total billed charges,90% of total billed charges,300.26,95,,,percent of total billed charges,95% of total billed charges,300.26,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,271.81,86,,,percent of total billed charges,86% of total billed charges,252.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,306.58,97,,,percent of total billed charges,97% of total billed charges,284.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,306.58,97,,,percent of total billed charges,97% of total billed charges,293.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,306.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,306.58,
"90734 -  Menactra -Meningococcal conj vacc, A, C, W, Y, quad",3918940,CDM,636,RC,90734,HCPCS,Outpatient,,,386.36,193.18,,347.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,309.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,347.72,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,374.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,355.45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.45,70,,,percent of total billed charges,70% of total billed charges,347.72,90,,,percent of total billed charges,90% of total billed charges,367.04,95,,,percent of total billed charges,95% of total billed charges,367.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.27,86,,,percent of total billed charges,86% of total billed charges,309.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,374.77,97,,,percent of total billed charges,97% of total billed charges,347.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.77,97,,,percent of total billed charges,97% of total billed charges,359.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,374.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,374.77,
90734 - Menactra (meningococcal),3918941,CDM,636,RC,90734,HCPCS,Outpatient,,,386.36,193.18,,347.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,309.09,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,347.72,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,374.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,355.45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,270.45,70,,,percent of total billed charges,70% of total billed charges,347.72,90,,,percent of total billed charges,90% of total billed charges,367.04,95,,,percent of total billed charges,95% of total billed charges,367.04,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,332.27,86,,,percent of total billed charges,86% of total billed charges,309.09,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,374.77,97,,,percent of total billed charges,97% of total billed charges,347.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,374.77,97,,,percent of total billed charges,97% of total billed charges,359.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,374.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,374.77,
AMB meningococcal conjugate Charge:0.5 mL Menactra Vaccine,3444352,CDM,636,RC,90734,HCPCS,Outpatient,,,382.25,191.13,,344.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,305.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,344.03,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,370.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,351.67,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.58,70,,,percent of total billed charges,70% of total billed charges,344.03,90,,,percent of total billed charges,90% of total billed charges,363.14,95,,,percent of total billed charges,95% of total billed charges,363.14,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.74,86,,,percent of total billed charges,86% of total billed charges,305.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,370.78,97,,,percent of total billed charges,97% of total billed charges,344.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.78,97,,,percent of total billed charges,97% of total billed charges,355.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,370.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,370.78,
AMB meningococcal conjugate Charge:0.5 mL Menactra Vaccine,3444351,CDM,636,RC,90734,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
AMB Zostavax Charge:0.5 mL Zostavax Vaccine,3444423,CDM,636,RC,90736,HCPCS,Outpatient,,,656.05,328.03,,590.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,524.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,590.45,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,636.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,603.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,590.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,459.24,70,,,percent of total billed charges,70% of total billed charges,590.45,90,,,percent of total billed charges,90% of total billed charges,623.25,95,,,percent of total billed charges,95% of total billed charges,623.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,564.2,86,,,percent of total billed charges,86% of total billed charges,524.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,636.37,97,,,percent of total billed charges,97% of total billed charges,590.45,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,636.37,97,,,percent of total billed charges,97% of total billed charges,610.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,636.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,636.37,
90744 - Pediatric Hep B,3918942,CDM,636,RC,90744,HCPCS,Outpatient,,,225.6,112.80,,203.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,180.48,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.04,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,207.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.92,70,,,percent of total billed charges,70% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,214.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.02,86,,,percent of total billed charges,86% of total billed charges,180.48,80,,,percent of total billed charges,80% of total billed charges,121.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.83,97,,,percent of total billed charges,97% of total billed charges,203.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,218.83,97,,,percent of total billed charges,97% of total billed charges,209.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,218.83,
AMB hepatitis B Ped Charge:0.5 mL HepB (Engerix-B) Ped Vacci,3546992,CDM,636,RC,90744,HCPCS,Outpatient,,,70.76,35.38,,63.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.61,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.68,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,65.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,49.53,70,,,percent of total billed charges,70% of total billed charges,63.68,90,,,percent of total billed charges,90% of total billed charges,67.22,95,,,percent of total billed charges,95% of total billed charges,67.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.85,86,,,percent of total billed charges,86% of total billed charges,56.61,80,,,percent of total billed charges,80% of total billed charges,38.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.64,97,,,percent of total billed charges,97% of total billed charges,63.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.64,97,,,percent of total billed charges,97% of total billed charges,65.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,68.64,
AMB hepatitis B Ped Charge:0.5 mL HepB (Recombivax) Ped Vacc,3444313,CDM,636,RC,90744,HCPCS,Outpatient,,,70.81,35.41,,63.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,56.65,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.73,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,65.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,49.57,70,,,percent of total billed charges,70% of total billed charges,63.73,90,,,percent of total billed charges,90% of total billed charges,67.27,95,,,percent of total billed charges,95% of total billed charges,67.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.9,86,,,percent of total billed charges,86% of total billed charges,56.65,80,,,percent of total billed charges,80% of total billed charges,38.06,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.69,97,,,percent of total billed charges,97% of total billed charges,63.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.69,97,,,percent of total billed charges,97% of total billed charges,65.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,68.69,
AMB hepatitis B Ped Charge:0.5 mL HepB (Recombivax) Ped Vacc,3444312,CDM,636,RC,90744,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,11,
90746 - Adult Hep B,3918944,CDM,636,RC,90746,HCPCS,Outpatient,,,174.74,87.37,,157.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,139.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,157.27,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,169.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,160.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.32,70,,,percent of total billed charges,70% of total billed charges,157.27,90,,,percent of total billed charges,90% of total billed charges,166,95,,,percent of total billed charges,95% of total billed charges,166,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.28,86,,,percent of total billed charges,86% of total billed charges,139.79,80,,,percent of total billed charges,80% of total billed charges,93.92,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,169.5,97,,,percent of total billed charges,97% of total billed charges,157.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,169.5,97,,,percent of total billed charges,97% of total billed charges,162.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,169.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,169.5,
"90746 - Hepatitis B vaccine (HepB), pediatric/adolescent dos",3918943,CDM,636,RC,90746,HCPCS,Outpatient,,,174.74,87.37,,157.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,139.79,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,157.27,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,169.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,160.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.32,70,,,percent of total billed charges,70% of total billed charges,157.27,90,,,percent of total billed charges,90% of total billed charges,166,95,,,percent of total billed charges,95% of total billed charges,166,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.28,86,,,percent of total billed charges,86% of total billed charges,139.79,80,,,percent of total billed charges,80% of total billed charges,93.92,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,169.5,97,,,percent of total billed charges,97% of total billed charges,157.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,169.5,97,,,percent of total billed charges,97% of total billed charges,162.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,169.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,169.5,
AMB hepatitis B Adult Charge:1 mL Hepatitis B Adult Vaccine,3444311,CDM,636,RC,90746,HCPCS,Outpatient,,,173.3,86.65,,155.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,138.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,155.97,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,168.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,159.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,121.31,70,,,percent of total billed charges,70% of total billed charges,155.97,90,,,percent of total billed charges,90% of total billed charges,164.64,95,,,percent of total billed charges,95% of total billed charges,164.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.04,86,,,percent of total billed charges,86% of total billed charges,138.64,80,,,percent of total billed charges,80% of total billed charges,93.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,168.1,97,,,percent of total billed charges,97% of total billed charges,155.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,168.1,97,,,percent of total billed charges,97% of total billed charges,161.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,168.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,168.1,
90750 - Shingrix,3918945,CDM,636,RC,90750,HCPCS,Outpatient,,,868.25,434.13,,781.43,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,694.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,781.43,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,842.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,798.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,781.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,607.78,70,,,percent of total billed charges,70% of total billed charges,781.43,90,,,percent of total billed charges,90% of total billed charges,824.84,95,,,percent of total billed charges,95% of total billed charges,824.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.7,86,,,percent of total billed charges,86% of total billed charges,694.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,842.2,97,,,percent of total billed charges,97% of total billed charges,781.43,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,842.2,97,,,percent of total billed charges,97% of total billed charges,807.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,842.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,842.2,
AMB Shingrix Charge. -> 0.5 mL Shingrix Vaccine,3556762,CDM,636,RC,90750,HCPCS,Outpatient,,,463.23,231.62,,416.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,370.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,416.91,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,449.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,426.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,416.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,324.26,70,,,percent of total billed charges,70% of total billed charges,416.91,90,,,percent of total billed charges,90% of total billed charges,440.07,95,,,percent of total billed charges,95% of total billed charges,440.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,398.38,86,,,percent of total billed charges,86% of total billed charges,370.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,449.33,97,,,percent of total billed charges,97% of total billed charges,416.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,449.33,97,,,percent of total billed charges,97% of total billed charges,430.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,449.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,449.33,
90785- Interactive Complexity (Add-on),3437826,CDM,983,RC,90785,HCPCS,Outpatient,,,38.58,19.29,,34.72,90,,,percent of total billed charges,90% of total Billed charges,27.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.94,155,,,Fee Schedule,155% of CMS OPPS Rate,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,20.87,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.57,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3.5,100,,,Case rate,Pays based on per visit rate,3.5,100,,,Case rate,pays based on per visit rate,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,18.94,145,,,Fee Schedule,145% of CMS OPPS Rate,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.96,145,,,Fee Schedule,145% of CMS OPPS Rate,18.94,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4.42,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.5,39.96,
90791- Psych Diagnostic Eval W/O Med Mgmt,3437827,CDM,983,RC,90791,HCPCS,Outpatient,,,462.16,231.08,,415.94,90,,,percent of total billed charges,90% of total Billed charges,323.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.44,155,,,Fee Schedule,155% of CMS OPPS Rate,149.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,133.26,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,298.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81,100,,,Case rate,Pays based on per visit rate,81,100,,,Case rate,pays based on per visit rate,132.81,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,216.44,145,,,Fee Schedule,145% of CMS OPPS Rate,149.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,468.44,145,,,Fee Schedule,145% of CMS OPPS Rate,216.44,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,149.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,136.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,468.44,
90792- Psych Diagnostic Eval With Med Mgmt,3437828,CDM,983,RC,90792,HCPCS,Outpatient,,,516.87,258.44,,465.18,90,,,percent of total billed charges,90% of total Billed charges,364.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,246.86,155,,,Fee Schedule,155% of CMS OPPS Rate,170.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,171.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,171.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,211.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,211.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,149.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,340.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81,100,,,Case rate,Pays based on per visit rate,81,100,,,Case rate,pays based on per visit rate,146.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,246.86,145,,,Fee Schedule,145% of CMS OPPS Rate,170.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,528.68,145,,,Fee Schedule,145% of CMS OPPS Rate,246.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,170.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,170.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81,528.68,
"90832- Psychotherapy, 30 Minutes",3437832,CDM,983,RC,90832,HCPCS,Outpatient,,,202.09,101.05,,181.88,90,,,percent of total billed charges,90% of total Billed charges,141.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.31,155,,,Fee Schedule,155% of CMS OPPS Rate,65.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38,100,,,Case rate,Pays based on per visit rate,38,100,,,Case rate,pays based on per visit rate,66.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,95.31,145,,,Fee Schedule,145% of CMS OPPS Rate,65.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,205.48,145,,,Fee Schedule,145% of CMS OPPS Rate,95.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,56.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38,205.48,
"90833- Psychotherapy, 30 Mins (E&M Add-on)",3437833,CDM,983,RC,90833,HCPCS,Outpatient,,,184.45,92.23,,166.01,90,,,percent of total billed charges,90% of total Billed charges,130.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.84,155,,,Fee Schedule,155% of CMS OPPS Rate,61.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,61.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,79.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,79.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,98.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,98.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,68.89,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.41,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,68.93,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.84,145,,,Fee Schedule,145% of CMS OPPS Rate,61.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.41,145,,,Fee Schedule,145% of CMS OPPS Rate,88.84,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,61.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,38.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,61.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.2,189.41,
"90834- Psychotherapy, 45 Minutes",3437834,CDM,983,RC,90834,HCPCS,Outpatient,,,266.6,133.30,,239.94,90,,,percent of total billed charges,90% of total Billed charges,187.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,87.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.47,155,,,Fee Schedule,155% of CMS OPPS Rate,87.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,87.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,126.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,126.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57,100,,,Case rate,Pays based on per visit rate,57,100,,,Case rate,pays based on per visit rate,89.14,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,126.47,145,,,Fee Schedule,145% of CMS OPPS Rate,87.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.83,145,,,Fee Schedule,145% of CMS OPPS Rate,126.47,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,87.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.13,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,87.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57,271.83,
90836- Psychother/45min/pt and/or fam/E&M,3435671,CDM,510,RC,90836,HCPCS,Outpatient,,,232.65,116.33,,209.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,186.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,209.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,214.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,162.86,70,,,percent of total billed charges,70% of total billed charges,209.39,90,,,percent of total billed charges,90% of total billed charges,221.02,95,,,percent of total billed charges,95% of total billed charges,221.02,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.08,86,,,percent of total billed charges,86% of total billed charges,186.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,225.67,97,,,percent of total billed charges,97% of total billed charges,209.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.67,97,,,percent of total billed charges,97% of total billed charges,216.36,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.86,225.67,
90837- Psychotherapy Add-on,3437835,CDM,983,RC,90837,HCPCS,Outpatient,,,390.97,195.49,,351.87,90,,,percent of total billed charges,90% of total Billed charges,275.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.79,155,,,Fee Schedule,155% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,75,100,,,Case rate,Pays based on per visit rate,75,100,,,Case rate,pays based on per visit rate,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.79,145,,,Fee Schedule,145% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.95,145,,,Fee Schedule,145% of CMS OPPS Rate,185.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75,398.95,
"90837- Psychotherapy, 60 Minutes",3437836,CDM,983,RC,90837,HCPCS,Outpatient,,,390.97,195.49,,351.87,90,,,percent of total billed charges,90% of total Billed charges,275.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.79,155,,,Fee Schedule,155% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,153.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,153.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,132.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,256.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,75,100,,,Case rate,Pays based on per visit rate,75,100,,,Case rate,pays based on per visit rate,132.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.79,145,,,Fee Schedule,145% of CMS OPPS Rate,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,398.95,145,,,Fee Schedule,145% of CMS OPPS Rate,185.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,108.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,128.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75,398.95,
90838- Psychother/60min/pt and/or fam/E&M,3435672,CDM,510,RC,90838,HCPCS,Outpatient,,,305.84,152.92,,275.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,244.67,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,275.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,296.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,281.37,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,275.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,214.09,70,,,percent of total billed charges,70% of total billed charges,275.26,90,,,percent of total billed charges,90% of total billed charges,290.55,95,,,percent of total billed charges,95% of total billed charges,290.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.02,86,,,percent of total billed charges,86% of total billed charges,244.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,296.66,97,,,percent of total billed charges,97% of total billed charges,275.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,296.66,97,,,percent of total billed charges,97% of total billed charges,284.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.09,296.66,
90839- Crisis Psychotherapy,3437837,CDM,983,RC,90839,HCPCS,Outpatient,,,373.94,186.97,,336.55,90,,,percent of total billed charges,90% of total Billed charges,264.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.45,155,,,Fee Schedule,155% of CMS OPPS Rate,123.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,160.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,160.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,197.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,197.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,113,100,,,Case rate,Pays based on per visit rate,113,100,,,Case rate,pays based on per visit rate,137.86,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,179.45,145,,,Fee Schedule,145% of CMS OPPS Rate,123.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,383.32,145,,,Fee Schedule,145% of CMS OPPS Rate,179.45,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113,383.32,
"90840- Crisis Psychotherapy, Additional 30 Mins",3437838,CDM,983,RC,90840,HCPCS,Outpatient,,,187.29,93.65,,168.56,90,,,percent of total billed charges,90% of total Billed charges,132.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.09,155,,,Fee Schedule,155% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,124.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,56,100,,,Case rate,Pays based on per visit rate,56,100,,,Case rate,pays based on per visit rate,66.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,90.09,145,,,Fee Schedule,145% of CMS OPPS Rate,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.2,145,,,Fee Schedule,145% of CMS OPPS Rate,90.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,58.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56,192.2,
90846- Family Therapy W/O Patient,3428351,CDM,960,RC,90846,HCPCS,Outpatient,,,258.43,129.22,,232.59,90,,,percent of total billed charges,90% of total Billed charges,191.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.65,155,,,Fee Schedule,155% of CMS OPPS Rate,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77,100,,,Case rate,Pays based on per visit rate,77,100,,,Case rate,pays based on per visit rate,106.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,136.65,145,,,Fee Schedule,145% of CMS OPPS Rate,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.54,145,,,Fee Schedule,145% of CMS OPPS Rate,136.65,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,136.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,277.54,
"90846- Family, Couples Psychotherapy W/O Patient",3428352,CDM,960,RC,90846,HCPCS,Outpatient,,,258.43,129.22,,232.59,90,,,percent of total billed charges,90% of total Billed charges,191.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.65,155,,,Fee Schedule,155% of CMS OPPS Rate,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,123.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,152.7,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,152.7,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,188.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77,100,,,Case rate,Pays based on per visit rate,77,100,,,Case rate,pays based on per visit rate,106.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,136.65,145,,,Fee Schedule,145% of CMS OPPS Rate,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.54,145,,,Fee Schedule,145% of CMS OPPS Rate,136.65,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,105.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,136.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,277.54,
90847- Family Therapy with Patient,3428353,CDM,960,RC,90847,HCPCS,Outpatient,,,267.63,133.82,,240.87,90,,,percent of total billed charges,90% of total Billed charges,198.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.4,155,,,Fee Schedule,155% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,158.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,158.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77,100,,,Case rate,Pays based on per visit rate,77,100,,,Case rate,pays based on per visit rate,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.4,145,,,Fee Schedule,145% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.32,145,,,Fee Schedule,145% of CMS OPPS Rate,142.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,288.32,
"90847- Family, Couples Psychotherapy With Patient",3428354,CDM,960,RC,90847,HCPCS,Outpatient,,,267.63,133.82,,240.87,90,,,percent of total billed charges,90% of total Billed charges,198.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142.4,155,,,Fee Schedule,155% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,98.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,128.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,158.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,158.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,106.51,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,77,100,,,Case rate,Pays based on per visit rate,77,100,,,Case rate,pays based on per visit rate,110.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,142.4,145,,,Fee Schedule,145% of CMS OPPS Rate,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,288.32,145,,,Fee Schedule,145% of CMS OPPS Rate,142.4,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,98.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.49,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,170.49,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77,288.32,
90853- Group Therapy,3428355,CDM,960,RC,90853,HCPCS,Outpatient,,,70.71,35.36,,63.64,90,,,percent of total billed charges,90% of total Billed charges,49.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.61,155,,,Fee Schedule,155% of CMS OPPS Rate,23.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,23.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,27,100,,,Case rate,Pays based on per visit rate,27,100,,,Case rate,pays based on per visit rate,25.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,33.61,145,,,Fee Schedule,145% of CMS OPPS Rate,23.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.17,145,,,Fee Schedule,145% of CMS OPPS Rate,33.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.18,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.18,72.17,
90863 Pharmacologic mgmt w/psytx,3430543,CDM,960,RC,90863,HCPCS,Outpatient,,,69.14,34.57,,62.23,90,,,percent of total billed charges,90% of total Billed charges,48.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.09,155,,,Fee Schedule,155% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,37.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.74,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,34.09,145,,,Fee Schedule,145% of CMS OPPS Rate,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.47,145,,,Fee Schedule,145% of CMS OPPS Rate,34.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.74,70.47,
90870- Electroconvulsive Therapy,3437839,CDM,983,RC,90870,HCPCS,Outpatient,,,438.98,219.49,,395.08,90,,,percent of total billed charges,90% of total Billed charges,268.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,150.61,155,,,Fee Schedule,155% of CMS OPPS Rate,103.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,65.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,148.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,115.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,150.61,145,,,Fee Schedule,145% of CMS OPPS Rate,103.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.96,145,,,Fee Schedule,145% of CMS OPPS Rate,150.61,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.11,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,281.11,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45,395.08,
ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT,4227186,CDM,960,RC,91010,HCPCS,Outpatient,,,424.83,212.42,,382.35,90,,,percent of total billed charges,90% of total Billed charges,282.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,138.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,200.69,155,,,Fee Schedule,155% of CMS OPPS Rate,138.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,138.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,337.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,337.96,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,276.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,276.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,154.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,276.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,159.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.69,145,,,Fee Schedule,145% of CMS OPPS Rate,138.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.26,145,,,Fee Schedule,145% of CMS OPPS Rate,200.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,138.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,178.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,138.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,289.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,289.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.5,410.26,
91034-TRANSNASAL PH,3431292,CDM,750,RC,91034,HCPCS,Outpatient,,,344.57,172.29,,310.11,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,275.66,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.11,90,,,Percent of total Billed charges,90% of total billed charges,144.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,334.23,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,317,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,310.11,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,241.2,70,,,percent of total billed charges,70% of total billed charges,310.11,90,,,percent of total billed charges,90% of total billed charges,327.34,95,,,percent of total billed charges,95% of total billed charges,327.34,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,296.33,86,,,percent of total billed charges,86% of total billed charges,275.66,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,334.23,97,,,percent of total billed charges,97% of total billed charges,310.11,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.23,97,,,percent of total billed charges,97% of total billed charges,320.45,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,334.23,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,131.38,2356.78,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,3205.39,1602.70,,2884.85,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2564.31,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2884.85,90,,,Percent of total Billed charges,90% of total billed charges,314.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3109.23,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2948.96,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2884.85,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2243.77,70,,,percent of total billed charges,70% of total billed charges,2884.85,90,,,percent of total billed charges,90% of total billed charges,3045.12,95,,,percent of total billed charges,95% of total billed charges,3045.12,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2756.64,86,,,percent of total billed charges,86% of total billed charges,2564.31,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3109.23,97,,,percent of total billed charges,97% of total billed charges,2884.85,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,3109.23,97,,,percent of total billed charges,97% of total billed charges,2981.01,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3109.23,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.85,3109.23,
91035-BRAVO REFLUX TESTING SYSTEM,3431293,CDM,750,RC,91035,HCPCS,Outpatient,,,946.27,473.14,,851.64,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,757.02,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,851.64,90,,,Percent of total Billed charges,90% of total billed charges,314.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,917.88,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,870.57,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,851.64,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,662.39,70,,,percent of total billed charges,70% of total billed charges,851.64,90,,,percent of total billed charges,90% of total billed charges,898.96,95,,,percent of total billed charges,95% of total billed charges,898.96,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,813.79,86,,,percent of total billed charges,86% of total billed charges,757.02,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,917.88,97,,,percent of total billed charges,97% of total billed charges,851.64,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,917.88,97,,,percent of total billed charges,97% of total billed charges,880.03,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,917.88,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.85,2356.78,
91037-IMPEDANCE,3431294,CDM,750,RC,91037,HCPCS,Outpatient,,,292.48,146.24,,263.23,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,233.98,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.23,90,,,Percent of total Billed charges,90% of total billed charges,80.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,283.71,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,269.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,263.23,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,204.74,70,,,percent of total billed charges,70% of total billed charges,263.23,90,,,percent of total billed charges,90% of total billed charges,277.86,95,,,percent of total billed charges,95% of total billed charges,277.86,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,251.53,86,,,percent of total billed charges,86% of total billed charges,233.98,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,283.71,97,,,percent of total billed charges,97% of total billed charges,263.23,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,283.71,97,,,percent of total billed charges,97% of total billed charges,272.01,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,283.71,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73.39,1365.32,
91038- Esoph function test >1 hr/to 24 hr,3431442,CDM,510,RC,91038,HCPCS,Outpatient,,,875.5,437.75,,787.95,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,700.4,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.95,90,,,Percent of total Billed charges,90% of total billed charges,57.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,849.24,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,805.46,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,787.95,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,612.85,70,,,percent of total billed charges,70% of total billed charges,787.95,90,,,percent of total billed charges,90% of total billed charges,831.73,95,,,percent of total billed charges,95% of total billed charges,831.73,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,752.93,86,,,percent of total billed charges,86% of total billed charges,700.4,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,849.24,97,,,percent of total billed charges,97% of total billed charges,787.95,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.24,97,,,percent of total billed charges,97% of total billed charges,814.22,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,849.24,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.29,2356.78,
91112- GI trans/pres meas/capsule/int/rep,3431280,CDM,510,RC,91112,HCPCS,Outpatient,,,3848.87,1924.44,,3463.98,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3079.1,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3463.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3733.4,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3540.96,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3463.98,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2694.21,70,,,percent of total billed charges,70% of total billed charges,3463.98,90,,,percent of total billed charges,90% of total billed charges,3656.43,95,,,percent of total billed charges,95% of total billed charges,3656.43,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3310.03,86,,,percent of total billed charges,86% of total billed charges,3079.1,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3733.4,97,,,percent of total billed charges,97% of total billed charges,3463.98,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3733.4,97,,,percent of total billed charges,97% of total billed charges,3579.45,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3733.4,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4024.46,
91117- Colon motility stdy/6 hr/inter/rep,3431281,CDM,510,RC,91117,HCPCS,Outpatient,,,352.39,176.20,,317.15,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,281.91,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,317.15,90,,,Percent of total Billed charges,90% of total billed charges,132.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,341.82,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,324.2,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,317.15,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,246.67,70,,,percent of total billed charges,70% of total billed charges,317.15,90,,,percent of total billed charges,90% of total billed charges,334.77,95,,,percent of total billed charges,95% of total billed charges,334.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,303.06,86,,,percent of total billed charges,86% of total billed charges,281.91,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,341.82,97,,,percent of total billed charges,97% of total billed charges,317.15,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,341.82,97,,,percent of total billed charges,97% of total billed charges,327.72,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,120.41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,341.82,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,120.41,1365.32,
91300 - SARSCOV2 VAC 30MCG/0.3ML IM,3997215,CDM,636,RC,91300,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
91301 - SARSCOV2 VAC 100MCG/0.5ML IM,3999146,CDM,636,RC,91301,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
91303 - SARSCOV2 VAC AD26 .5ML IM,3997216,CDM,636,RC,91303,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
91306 - SARSCOV2 VAC 50MCG/0.25ML IM,3997217,CDM,636,RC,91306,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
91307 - SARSCOV2 VAC 10 MCG TRS-SUCR,3999147,CDM,636,RC,91307,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (5y-12y) CVX 310,4303192,CDM,636,RC,91319,HCPCS,Outpatient,,,428.51,214.26,,385.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,342.81,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,385.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,415.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,394.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,385.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.96,70,,,percent of total billed charges,70% of total billed charges,385.66,90,,,percent of total billed charges,90% of total billed charges,407.08,95,,,percent of total billed charges,95% of total billed charges,407.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.52,86,,,percent of total billed charges,86% of total billed charges,342.81,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,415.65,97,,,percent of total billed charges,97% of total billed charges,385.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,415.65,97,,,percent of total billed charges,97% of total billed charges,398.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,415.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,299.96,415.65,
AMB Covid-19 Charge -> 0.3 mL Covid-19 Inj (12+ years) CVX 309,4303193,CDM,636,RC,91320,HCPCS,Outpatient,,,667.8,333.90,,601.02,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,534.24,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,601.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,647.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,614.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,601.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,467.46,70,,,percent of total billed charges,70% of total billed charges,601.02,90,,,percent of total billed charges,90% of total billed charges,634.41,95,,,percent of total billed charges,95% of total billed charges,634.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,574.31,86,,,percent of total billed charges,86% of total billed charges,534.24,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,647.77,97,,,percent of total billed charges,97% of total billed charges,601.02,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,647.77,97,,,percent of total billed charges,97% of total billed charges,621.05,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.46,647.77,
92002- Opthal serv/exam/eval inter/new pt,3435576,CDM,962,RC,92002,HCPCS,Outpatient,,,756.81,378.41,,681.13,90,,,percent of total billed charges,90% of total Billed charges,123.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.5,155,,,Fee Schedule,155% of CMS OPPS Rate,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,69.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,69.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.79,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,47.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,63.5,145,,,Fee Schedule,145% of CMS OPPS Rate,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.37,145,,,Fee Schedule,145% of CMS OPPS Rate,63.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.79,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.72,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,131.72,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.2,681.13,
92004- Opthal serv/exam/eval/comp/new pt,3435577,CDM,510,RC,92004,HCPCS,Outpatient,,,852.36,426.18,,767.12,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,681.89,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,767.12,90,,,Percent of total Billed charges,90% of total billed charges,64.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,826.79,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,784.17,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,767.12,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,596.65,70,,,percent of total billed charges,70% of total billed charges,767.12,90,,,percent of total billed charges,90% of total billed charges,809.74,95,,,percent of total billed charges,95% of total billed charges,809.74,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,733.03,86,,,percent of total billed charges,86% of total billed charges,681.89,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,826.79,97,,,percent of total billed charges,97% of total billed charges,767.12,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,826.79,97,,,percent of total billed charges,97% of total billed charges,792.69,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,826.79,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.77,826.79,
92012- Opthal serv/exam/eval/inter/est pt,3435578,CDM,962,RC,92012,HCPCS,Outpatient,,,765.88,382.94,,689.29,90,,,percent of total billed charges,90% of total Billed charges,131.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.08,155,,,Fee Schedule,155% of CMS OPPS Rate,48.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,47.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,52.33,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.08,145,,,Fee Schedule,145% of CMS OPPS Rate,48.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.11,145,,,Fee Schedule,145% of CMS OPPS Rate,70.08,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.6,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,140.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,41.15,689.29,
92014- Opthal serv/exam/eval/comp/est pt,3435579,CDM,962,RC,92014,HCPCS,Outpatient,,,815.89,407.95,,734.3,90,,,percent of total billed charges,90% of total Billed charges,190.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.28,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,105.21,155,,,Fee Schedule,155% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.5,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.5,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.22,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,79.76,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,105.21,145,,,Fee Schedule,145% of CMS OPPS Rate,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,275.91,145,,,Fee Schedule,145% of CMS OPPS Rate,105.21,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.13,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,204.13,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,45.28,734.3,
"92020- Gonioscopy, separate procedure",3435583,CDM,510,RC,92020,HCPCS,Outpatient,,,69.89,34.95,,62.9,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,55.91,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.9,90,,,Percent of total Billed charges,90% of total billed charges,17.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,67.79,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,64.3,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,62.9,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,48.92,70,,,percent of total billed charges,70% of total billed charges,62.9,90,,,percent of total billed charges,90% of total billed charges,66.4,95,,,percent of total billed charges,95% of total billed charges,66.4,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.11,86,,,percent of total billed charges,86% of total billed charges,55.91,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,67.79,97,,,percent of total billed charges,97% of total billed charges,62.9,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.79,97,,,percent of total billed charges,97% of total billed charges,65,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.79,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16,566.05,
92025- Computer corneal topogra/uni/bi/I&,3435584,CDM,510,RC,92025,HCPCS,Outpatient,,,39.78,19.89,,35.8,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,31.82,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.8,90,,,Percent of total Billed charges,90% of total billed charges,9.91,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,38.59,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,36.6,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.8,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,70,,,percent of total billed charges,70% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.21,86,,,percent of total billed charges,86% of total billed charges,31.82,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,38.59,97,,,percent of total billed charges,97% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.59,97,,,percent of total billed charges,97% of total billed charges,37,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.59,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.01,280.22,
92060 - OCC EYE Sensorimotor Exam,3549604,CDM,983,RC,92060,HCPCS,Outpatient,,,381.05,190.53,,342.95,90,,,percent of total billed charges,90% of total Billed charges,46.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34,155,,,Fee Schedule,155% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,109.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34,145,,,Fee Schedule,145% of CMS OPPS Rate,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.32,145,,,Fee Schedule,145% of CMS OPPS Rate,34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,23.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.06,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,106.06,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.45,342.95,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,510,RC,92060,HCPCS,Outpatient,,,381.05,190.53,,342.95,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,304.84,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.95,90,,,Percent of total Billed charges,90% of total billed charges,12.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,369.62,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,350.57,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,342.95,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,266.74,70,,,percent of total billed charges,70% of total billed charges,342.95,90,,,percent of total billed charges,90% of total billed charges,362,95,,,percent of total billed charges,95% of total billed charges,362,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,327.7,86,,,percent of total billed charges,86% of total billed charges,304.84,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,369.62,97,,,percent of total billed charges,97% of total billed charges,342.95,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,369.62,97,,,percent of total billed charges,97% of total billed charges,354.38,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,369.62,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.59,369.62,
92065- Orthoptic/pleoptic train/med eval,3435586,CDM,962,RC,92065,HCPCS,Outpatient,,,361.53,180.77,,325.38,90,,,percent of total billed charges,90% of total Billed charges,38.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,10.76,155,,,Fee Schedule,155% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.41,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.41,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.76,145,,,Fee Schedule,145% of CMS OPPS Rate,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.69,145,,,Fee Schedule,145% of CMS OPPS Rate,10.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.67,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,86.67,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.42,325.38,
92071- Fit/cont lens/ocular surf disease,3435587,CDM,510,RC,92071,HCPCS,Outpatient,,,93.08,46.54,,83.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,74.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,83.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,85.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.16,70,,,percent of total billed charges,70% of total billed charges,83.77,90,,,percent of total billed charges,90% of total billed charges,88.43,95,,,percent of total billed charges,95% of total billed charges,88.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.05,86,,,percent of total billed charges,86% of total billed charges,74.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,90.29,97,,,percent of total billed charges,97% of total billed charges,83.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.29,97,,,percent of total billed charges,97% of total billed charges,86.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.16,90.29,
92072- Ini fit/contact lens/keratoconus,3435588,CDM,510,RC,92072,HCPCS,Outpatient,,,321.52,160.76,,289.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,257.22,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,311.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,295.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,225.06,70,,,percent of total billed charges,70% of total billed charges,289.37,90,,,percent of total billed charges,90% of total billed charges,305.44,95,,,percent of total billed charges,95% of total billed charges,305.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.51,86,,,percent of total billed charges,86% of total billed charges,257.22,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,311.87,97,,,percent of total billed charges,97% of total billed charges,289.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,311.87,97,,,percent of total billed charges,97% of total billed charges,299.01,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,225.06,311.87,
92081-OCC Vis field exam/uni/bi/I&R/limited,3536981,CDM,983,RC,92081,HCPCS,Outpatient,,,340.22,170.11,,306.2,90,,,percent of total billed charges,90% of total Billed charges,30.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,155,,,Fee Schedule,155% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,57.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,33.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.17,145,,,Fee Schedule,145% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.3,145,,,Fee Schedule,145% of CMS OPPS Rate,22.17,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15.29,306.2,
92082- Vis field exam/uni/bi/I&R/intermed,3435590,CDM,510,RC,92082,HCPCS,Outpatient,,,349.55,174.78,,314.6,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,279.64,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.6,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,339.06,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,321.59,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,314.6,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,244.69,70,,,percent of total billed charges,70% of total billed charges,314.6,90,,,percent of total billed charges,90% of total billed charges,332.07,95,,,percent of total billed charges,95% of total billed charges,332.07,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,300.61,86,,,percent of total billed charges,86% of total billed charges,279.64,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,339.06,97,,,percent of total billed charges,97% of total billed charges,314.6,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,339.06,97,,,percent of total billed charges,97% of total billed charges,325.08,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,339.06,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,339.06,
92083- Vis field exam/uni/bi/I&R/extended,3435591,CDM,962,RC,92083,HCPCS,Outpatient,,,697.45,348.73,,627.71,90,,,percent of total billed charges,90% of total Billed charges,62.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.41,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,86.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,86.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.41,145,,,Fee Schedule,145% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.22,145,,,Fee Schedule,145% of CMS OPPS Rate,45.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,147.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.32,627.71,
92083-OCC Vis field exam/uni/bi/I&R/extended,3536982,CDM,983,RC,92083,HCPCS,Outpatient,,,697.45,348.73,,627.71,90,,,percent of total billed charges,90% of total Billed charges,62.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.41,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,108.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,108.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,86.88,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,86.88,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.74,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.94,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.41,145,,,Fee Schedule,145% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.22,145,,,Fee Schedule,145% of CMS OPPS Rate,45.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,79.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,147.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.32,627.71,
92132- OCT Anterior Segment w/I+R Uni/Bi,3431345,CDM,960,RC,92132,HCPCS,Outpatient,,,340.81,170.41,,306.73,90,,,percent of total billed charges,90% of total Billed charges,27.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.63,155,,,Fee Schedule,155% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,54.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,54.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.04,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.04,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.41,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,145,,,Fee Schedule,145% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.16,145,,,Fee Schedule,145% of CMS OPPS Rate,19.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.7,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.54,306.73,
92133- OCT/posterio seg/I & R/optic nerve,3431346,CDM,960,RC,92133,HCPCS,Outpatient,,,350.73,175.37,,315.66,90,,,percent of total billed charges,90% of total Billed charges,27.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.63,155,,,Fee Schedule,155% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,52.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,52.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.72,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.63,145,,,Fee Schedule,145% of CMS OPPS Rate,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.16,145,,,Fee Schedule,145% of CMS OPPS Rate,19.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.7,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,74.7,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.54,315.66,
92134- OCT/posterior seg/I & R/ retina,3431347,CDM,960,RC,92134,HCPCS,Outpatient,,,357.2,178.60,,321.48,90,,,percent of total billed charges,90% of total Billed charges,27.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.84,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,20.05,155,,,Fee Schedule,155% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,70.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,57.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,57.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.05,145,,,Fee Schedule,145% of CMS OPPS Rate,13.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.02,145,,,Fee Schedule,145% of CMS OPPS Rate,20.05,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.84,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,40.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.7,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,74.7,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.83,321.48,
92250- Fundus photography w/I&R,3435599,CDM,962,RC,92250,HCPCS,Outpatient,,,685.72,342.86,,617.15,90,,,percent of total billed charges,90% of total Billed charges,28.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.28,90,,,Percent of total Billed charges,90% of total billed charges,53.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,20.89,155,,,Fee Schedule,155% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.89,145,,,Fee Schedule,145% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.72,145,,,Fee Schedule,145% of CMS OPPS Rate,20.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,124.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.41,617.15,
92250-OCC Fundus photography w/I&R,3536983,CDM,983,RC,92250,HCPCS,Outpatient,,,685.72,342.86,,617.15,90,,,percent of total billed charges,90% of total Billed charges,28.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.28,90,,,Percent of total Billed charges,90% of total billed charges,53.17,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,20.89,155,,,Fee Schedule,155% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,77.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,62.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,62.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.34,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.74,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.89,145,,,Fee Schedule,145% of CMS OPPS Rate,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.72,145,,,Fee Schedule,145% of CMS OPPS Rate,20.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.17,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.87,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,124.87,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14.41,617.15,
92260- Ophthalmodynamometry,3435600,CDM,962,RC,92260,HCPCS,Outpatient,,,223.9,111.95,,201.51,90,,,percent of total billed charges,90% of total Billed charges,28.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.67,155,,,Fee Schedule,155% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,16.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,16.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,11.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,14.67,145,,,Fee Schedule,145% of CMS OPPS Rate,10.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.24,145,,,Fee Schedule,145% of CMS OPPS Rate,14.67,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.79,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,30.79,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.49,201.51,
92283- Color vision exam/extended,3435604,CDM,962,RC,92283,HCPCS,Outpatient,,,325.8,162.90,,293.22,90,,,percent of total billed charges,90% of total Billed charges,79.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.7,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,57.25,155,,,Fee Schedule,155% of CMS OPPS Rate,39.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,70.86,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,70.86,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,44.78,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.54,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.25,145,,,Fee Schedule,145% of CMS OPPS Rate,39.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.67,145,,,Fee Schedule,145% of CMS OPPS Rate,57.25,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,41.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.53,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85.53,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.7,293.22,
92284- Dark adaptation exam/I&R,3435605,CDM,962,RC,92284,HCPCS,Outpatient,,,2079.39,1039.70,,1871.45,90,,,percent of total billed charges,90% of total Billed charges,80.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,40.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,58.51,155,,,Fee Schedule,155% of CMS OPPS Rate,40.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.16,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,80.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.51,145,,,Fee Schedule,145% of CMS OPPS Rate,40.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.96,145,,,Fee Schedule,145% of CMS OPPS Rate,58.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,40.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,40.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.65,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,94.65,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.35,1871.45,
92285- Ext ocular photo/I&R/med progress,3435606,CDM,962,RC,92285,HCPCS,Outpatient,,,208.7,104.35,,187.83,90,,,percent of total billed charges,90% of total Billed charges,35.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.55,155,,,Fee Schedule,155% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.55,145,,,Fee Schedule,145% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.11,145,,,Fee Schedule,145% of CMS OPPS Rate,25.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.25,187.83,
92285-OCC Ext ocular photo/I&R/med progress,3536984,CDM,983,RC,92285,HCPCS,Outpatient,,,208.7,104.35,,187.83,90,,,percent of total billed charges,90% of total Billed charges,35.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,25.55,155,,,Fee Schedule,155% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.55,145,,,Fee Schedule,145% of CMS OPPS Rate,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.11,145,,,Fee Schedule,145% of CMS OPPS Rate,25.55,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,52.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,17.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,31.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.25,187.83,
92286- Ant seg image/I & R/micro/cell ana,3435607,CDM,962,RC,92286,HCPCS,Outpatient,,,686.91,343.46,,618.22,90,,,percent of total billed charges,90% of total Billed charges,31.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,22.59,155,,,Fee Schedule,155% of CMS OPPS Rate,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,54.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,54.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,19.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.59,145,,,Fee Schedule,145% of CMS OPPS Rate,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.14,145,,,Fee Schedule,145% of CMS OPPS Rate,22.59,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.43,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,198.43,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15.58,618.22,
92287- Ant seg image/I & R/fluorescein an,3435608,CDM,962,RC,92287,HCPCS,Outpatient,,,701.29,350.65,,631.16,90,,,percent of total billed charges,90% of total Billed charges,213.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.11,155,,,Fee Schedule,155% of CMS OPPS Rate,94.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,213.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,213.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,109.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,131.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.11,145,,,Fee Schedule,145% of CMS OPPS Rate,94.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.66,145,,,Fee Schedule,145% of CMS OPPS Rate,137.11,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,139.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94.56,631.16,
92511- Nasopharyngoscopy w/endoscope,3435636,CDM,510,RC,92511,HCPCS,Outpatient,,,287.96,143.98,,259.16,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,230.37,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,279.32,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,264.92,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,259.16,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,201.57,70,,,percent of total billed charges,70% of total billed charges,259.16,90,,,percent of total billed charges,90% of total billed charges,273.56,95,,,percent of total billed charges,95% of total billed charges,273.56,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,247.65,86,,,percent of total billed charges,86% of total billed charges,230.37,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,279.32,97,,,percent of total billed charges,97% of total billed charges,259.16,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.32,97,,,percent of total billed charges,97% of total billed charges,267.8,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,279.32,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,137.99,871.42,
92526- Tx swallow dysfunc/oral func/feed,3435639,CDM,430,RC,92526,HCPCS,Outpatient,,,503.81,251.91,,453.43,90,,,percent of total billed charges,90% of total Billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,403.05,80,,,Percent of total Billed charges,80% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,488.7,97,,,Percent of total billed charges,97% of total billed charges,80.45,100,,,Fee Schedule,100% of CMS OPPS Rate,463.51,92,,,Percent of total billed charges,92% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,327.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,80.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.72,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,453.43,90,,,percent of total billed charges,90% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,352.67,70,,,percent of total billed charges,70% of total billed charges,453.43,90,,,percent of total billed charges,90% of total billed charges,478.62,95,,,percent of total billed charges,95% of total billed charges,478.62,95,,,percent of total billed charges,95% of total billed charges,80.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,433.28,86,,,percent of total billed charges,86% of total billed charges,403.05,80,,,percent of total billed charges,80% of total billed charges,93.6,111,,,Fee Schedule,111% of CMS OPPS Rate,488.7,97,,,percent of total billed charges,97% of total billed charges,453.43,90,,,percent of total billed charges,90% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.7,97,,,percent of total billed charges,97% of total billed charges,468.54,93,,,percent of total billed charges,93% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,488.7,97,,,percent of total billed charges,97% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,68.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,68.54,488.7,
92551 Audiogram,3435572,CDM,510,RC,92551,HCPCS,Outpatient,,,33.24,16.62,,29.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,26.59,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.92,90,,,Percent of total Billed charges,90% of total billed charges,8.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,32.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,30.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.27,70,,,percent of total billed charges,70% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,31.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.59,86,,,percent of total billed charges,86% of total billed charges,26.59,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.24,97,,,percent of total billed charges,97% of total billed charges,29.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.24,97,,,percent of total billed charges,97% of total billed charges,30.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,32.24,
Hearing Screen POC,3444193,CDM,471,RC,92551,HCPCS,Outpatient,,,27.92,13.96,,25.13,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,22.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,25.13,90,,,Percent of total Billed charges,90% of total billed charges,8.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,27.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,25.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.54,70,,,percent of total billed charges,70% of total billed charges,25.13,90,,,percent of total billed charges,90% of total billed charges,26.52,95,,,percent of total billed charges,95% of total billed charges,26.52,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.01,86,,,percent of total billed charges,86% of total billed charges,22.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.08,97,,,percent of total billed charges,97% of total billed charges,25.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.08,97,,,percent of total billed charges,97% of total billed charges,25.97,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,27.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8,27.08,
92552 Pure tone audiometry air,3584886,CDM,960,RC,92552,HCPCS,Outpatient,,,78.47,39.24,,70.62,90,,,percent of total billed charges,90% of total Billed charges,60.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,44.98,155,,,Fee Schedule,155% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.51,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.51,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,25.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.35,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.98,145,,,Fee Schedule,145% of CMS OPPS Rate,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.77,145,,,Fee Schedule,145% of CMS OPPS Rate,44.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.76,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,46.76,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8,87.77,
92553 Audiometry air & bone,3584887,CDM,960,RC,92553,HCPCS,Outpatient,,,95.07,47.54,,85.56,90,,,percent of total billed charges,90% of total Billed charges,73.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,55.13,155,,,Fee Schedule,155% of CMS OPPS Rate,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,38.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,56.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,50.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,50.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,45.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.13,145,,,Fee Schedule,145% of CMS OPPS Rate,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.95,145,,,Fee Schedule,145% of CMS OPPS Rate,55.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,38.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.45,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.45,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,14,106.95,
92556 Speech audiometry complete,3584888,CDM,960,RC,92556,HCPCS,Outpatient,,,93.48,46.74,,84.13,90,,,percent of total billed charges,90% of total Billed charges,72.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,53.85,155,,,Fee Schedule,155% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.85,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.85,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.85,145,,,Fee Schedule,145% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.82,145,,,Fee Schedule,145% of CMS OPPS Rate,53.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.03,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,53.03,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,15,104.82,
92557 Comprehensive audiometry threshold evaluation and speech recognition,3584889,CDM,960,RC,92557,HCPCS,Outpatient,,,96.75,48.38,,87.08,90,,,percent of total billed charges,90% of total Billed charges,66.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.48,90,,,Percent of total Billed charges,90% of total billed charges,29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,44.24,155,,,Fee Schedule,155% of CMS OPPS Rate,30.51,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,55.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,55.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.51,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.58,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,34.29,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.24,145,,,Fee Schedule,145% of CMS OPPS Rate,30.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.98,145,,,Fee Schedule,145% of CMS OPPS Rate,44.24,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.51,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29,96.98,
92561- Bekesy audiometry/diagnostic,3435645,CDM,510,RC,92561,HCPCS,Outpatient,,,91.19,45.60,,82.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,72.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.07,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,83.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.83,70,,,percent of total billed charges,70% of total billed charges,82.07,90,,,percent of total billed charges,90% of total billed charges,86.63,95,,,percent of total billed charges,95% of total billed charges,86.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.42,86,,,percent of total billed charges,86% of total billed charges,72.95,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.45,97,,,percent of total billed charges,97% of total billed charges,82.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.45,97,,,percent of total billed charges,97% of total billed charges,84.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.5,112.72,
92562- Loudness balance test/bi/monaural,3435646,CDM,510,RC,92562,HCPCS,Outpatient,,,107.71,53.86,,96.94,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,86.17,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.94,90,,,Percent of total Billed charges,90% of total billed charges,16.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,104.48,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,99.09,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,96.94,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,75.4,70,,,percent of total billed charges,70% of total billed charges,96.94,90,,,percent of total billed charges,90% of total billed charges,102.32,95,,,percent of total billed charges,95% of total billed charges,102.32,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.63,86,,,percent of total billed charges,86% of total billed charges,86.17,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,104.48,97,,,percent of total billed charges,97% of total billed charges,96.94,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.48,97,,,percent of total billed charges,97% of total billed charges,100.17,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.48,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.24,708.98,
92564- Short increment sensitivity index,3435647,CDM,510,RC,92564,HCPCS,Outpatient,,,58.75,29.38,,52.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,52.88,90,,,Percent of total Billed charges,90% of total billed charges,18.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,56.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,54.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.13,70,,,percent of total billed charges,70% of total billed charges,52.88,90,,,percent of total billed charges,90% of total billed charges,55.81,95,,,percent of total billed charges,95% of total billed charges,55.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.53,86,,,percent of total billed charges,86% of total billed charges,47,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,56.99,97,,,percent of total billed charges,97% of total billed charges,52.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.99,97,,,percent of total billed charges,97% of total billed charges,54.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,56.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.26,56.99,
92567 Tympanometry,3584890,CDM,960,RC,92567,HCPCS,Outpatient,,,41.63,20.82,,37.47,90,,,percent of total billed charges,90% of total Billed charges,26.05,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.72,90,,,Percent of total Billed charges,90% of total billed charges,12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,15.09,155,,,Fee Schedule,155% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,11.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,11.55,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,15.09,145,,,Fee Schedule,145% of CMS OPPS Rate,10.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.77,145,,,Fee Schedule,145% of CMS OPPS Rate,15.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.38,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,23.38,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.41,37.77,
92572- Staggered spondaic word test,3435648,CDM,510,RC,92572,HCPCS,Outpatient,,,95.87,47.94,,86.28,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,76.7,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.28,90,,,Percent of total Billed charges,90% of total billed charges,3.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.99,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,88.2,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.28,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,67.11,70,,,percent of total billed charges,70% of total billed charges,86.28,90,,,percent of total billed charges,90% of total billed charges,91.08,95,,,percent of total billed charges,95% of total billed charges,91.08,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,82.45,86,,,percent of total billed charges,86% of total billed charges,76.7,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,92.99,97,,,percent of total billed charges,97% of total billed charges,86.28,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.99,97,,,percent of total billed charges,97% of total billed charges,89.16,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.99,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.38,708.98,
92575- Sensorineural acuity level test,3435649,CDM,510,RC,92575,HCPCS,Outpatient,,,164.69,82.35,,148.22,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,131.75,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.22,90,,,Percent of total Billed charges,90% of total billed charges,11.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,159.75,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,151.51,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.22,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,115.28,70,,,percent of total billed charges,70% of total billed charges,148.22,90,,,percent of total billed charges,90% of total billed charges,156.46,95,,,percent of total billed charges,95% of total billed charges,156.46,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,141.63,86,,,percent of total billed charges,86% of total billed charges,131.75,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,159.75,97,,,percent of total billed charges,97% of total billed charges,148.22,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.75,97,,,percent of total billed charges,97% of total billed charges,153.16,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159.75,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.87,165.55,
92576- Synthetic sentence ID test,3435650,CDM,510,RC,92576,HCPCS,Outpatient,,,88.74,44.37,,79.87,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,70.99,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.87,90,,,Percent of total Billed charges,90% of total billed charges,7.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,86.08,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.64,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,79.87,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,62.12,70,,,percent of total billed charges,70% of total billed charges,79.87,90,,,percent of total billed charges,90% of total billed charges,84.3,95,,,percent of total billed charges,95% of total billed charges,84.3,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,76.32,86,,,percent of total billed charges,86% of total billed charges,70.99,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,86.08,97,,,percent of total billed charges,97% of total billed charges,79.87,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.08,97,,,percent of total billed charges,97% of total billed charges,82.53,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.08,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.5,165.55,
92582 Conditioning play audiometry,3585094,CDM,960,RC,92582,HCPCS,Outpatient,,,180.65,90.33,,162.59,90,,,percent of total billed charges,90% of total Billed charges,139.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.72,155,,,Fee Schedule,155% of CMS OPPS Rate,71.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.86,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.86,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,96.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,53.94,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,143.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.81,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.72,145,,,Fee Schedule,145% of CMS OPPS Rate,71.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.22,145,,,Fee Schedule,145% of CMS OPPS Rate,103.72,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,71.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,71.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.93,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,96.93,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,30,202.22,
92583- Select picture audiometry,3435651,CDM,510,RC,92583,HCPCS,Outpatient,,,117.97,58.99,,106.17,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,94.38,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.17,90,,,Percent of total Billed charges,90% of total billed charges,43.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,114.43,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,108.53,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,106.17,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,82.58,70,,,percent of total billed charges,70% of total billed charges,106.17,90,,,percent of total billed charges,90% of total billed charges,112.07,95,,,percent of total billed charges,95% of total billed charges,112.07,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,101.45,86,,,percent of total billed charges,86% of total billed charges,94.38,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,114.43,97,,,percent of total billed charges,97% of total billed charges,106.17,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.43,97,,,percent of total billed charges,97% of total billed charges,109.71,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,114.43,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.56,280.22,
92588 Evoked auditory tst complete,3584892,CDM,960,RC,92588,HCPCS,Outpatient,,,12.95,6.48,,11.66,90,,,percent of total billed charges,90% of total Billed charges,9.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.89,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,6.96,155,,,Fee Schedule,155% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,49.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,49.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.72,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.96,145,,,Fee Schedule,145% of CMS OPPS Rate,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.01,145,,,Fee Schedule,145% of CMS OPPS Rate,6.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,4.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.04,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,114.04,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.8,114.04,
92596- Ear protector attenuation measure,3435652,CDM,510,RC,92596,HCPCS,Outpatient,,,159.82,79.91,,143.84,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,127.86,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.03,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,147.03,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.84,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,111.87,70,,,percent of total billed charges,70% of total billed charges,143.84,90,,,percent of total billed charges,90% of total billed charges,151.83,95,,,percent of total billed charges,95% of total billed charges,151.83,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,137.45,86,,,percent of total billed charges,86% of total billed charges,127.86,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,155.03,97,,,percent of total billed charges,97% of total billed charges,143.84,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.03,97,,,percent of total billed charges,97% of total billed charges,148.63,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,155.03,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,165.55,
92612- Endoscop eval/swallow/cine/video,3435660,CDM,510,RC,92612,HCPCS,Outpatient,,,472.35,236.18,,425.12,90,,,percent of total billed charges,90% of total Billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,377.88,80,,,Percent of total Billed charges,80% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.12,90,,,Percent of total Billed charges,90% of total billed charges,69.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,458.18,97,,,Percent of total billed charges,97% of total billed charges,63.97,100,,,Fee Schedule,100% of CMS OPPS Rate,434.56,92,,,Percent of total billed charges,92% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,260.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,64.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,317.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,294.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,425.12,90,,,percent of total billed charges,90% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,330.65,70,,,percent of total billed charges,70% of total billed charges,425.12,90,,,percent of total billed charges,90% of total billed charges,448.73,95,,,percent of total billed charges,95% of total billed charges,448.73,95,,,percent of total billed charges,95% of total billed charges,64.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,406.22,86,,,percent of total billed charges,86% of total billed charges,377.88,80,,,percent of total billed charges,80% of total billed charges,75.47,111,,,Fee Schedule,111% of CMS OPPS Rate,458.18,97,,,percent of total billed charges,97% of total billed charges,425.12,90,,,percent of total billed charges,90% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.18,97,,,percent of total billed charges,97% of total billed charges,439.29,93,,,percent of total billed charges,93% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.88,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,458.18,97,,,percent of total billed charges,97% of total billed charges,64.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,54.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.62,458.18,
92614- Endoscop eval/laryngeal sens test,3435662,CDM,510,RC,92614,HCPCS,Outpatient,,,360.21,180.11,,324.19,90,,,percent of total billed charges,90% of total Billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,288.17,80,,,Percent of total Billed charges,80% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.19,90,,,Percent of total Billed charges,90% of total billed charges,69.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,349.4,97,,,Percent of total billed charges,97% of total billed charges,63.48,100,,,Fee Schedule,100% of CMS OPPS Rate,331.39,92,,,Percent of total billed charges,92% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,258.85,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,63.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,292.6,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,324.19,90,,,percent of total billed charges,90% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,252.15,70,,,percent of total billed charges,70% of total billed charges,324.19,90,,,percent of total billed charges,90% of total billed charges,342.2,95,,,percent of total billed charges,95% of total billed charges,342.2,95,,,percent of total billed charges,95% of total billed charges,63.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,309.78,86,,,percent of total billed charges,86% of total billed charges,288.17,80,,,percent of total billed charges,80% of total billed charges,74.25,111,,,Fee Schedule,111% of CMS OPPS Rate,349.4,97,,,percent of total billed charges,97% of total billed charges,324.19,90,,,percent of total billed charges,90% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.4,97,,,percent of total billed charges,97% of total billed charges,335,93,,,percent of total billed charges,93% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.88,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,349.4,97,,,percent of total billed charges,97% of total billed charges,63.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,54.24,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.24,349.4,
"92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretat",3584893,CDM,960,RC,92652,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,0.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,155,,,Fee Schedule,155% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.03,145,,,Fee Schedule,145% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.03,
"92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report",3584894,CDM,960,RC,92653,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,0.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,155,,,Fee Schedule,155% of CMS OPPS Rate,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,0.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.03,145,,,Fee Schedule,145% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.03,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,3500.88,1750.44,,3150.79,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2800.7,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3150.79,90,,,Percent of total Billed charges,90% of total billed charges,95.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3395.85,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3220.81,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3150.79,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2450.62,70,,,percent of total billed charges,70% of total billed charges,3150.79,90,,,percent of total billed charges,90% of total billed charges,3325.84,95,,,percent of total billed charges,95% of total billed charges,3325.84,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3010.76,86,,,percent of total billed charges,86% of total billed charges,2800.7,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3395.85,97,,,percent of total billed charges,97% of total billed charges,3150.79,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3395.85,97,,,percent of total billed charges,97% of total billed charges,3255.82,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3395.85,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87,3395.85,
92961- Cardioversion/elective/internal,3430928,CDM,510,RC,92961,HCPCS,Outpatient,,,3346.36,1673.18,,3011.72,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2677.09,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3011.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3245.97,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3078.65,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3011.72,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2342.45,70,,,percent of total billed charges,70% of total billed charges,3011.72,90,,,percent of total billed charges,90% of total billed charges,3179.04,95,,,percent of total billed charges,95% of total billed charges,3179.04,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2877.87,86,,,percent of total billed charges,86% of total billed charges,2677.09,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3245.97,97,,,percent of total billed charges,97% of total billed charges,3011.72,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3245.97,97,,,percent of total billed charges,97% of total billed charges,3112.11,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3245.97,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,454.04,3245.97,
"93000- Electrocardiogram (ECG), Routine 12-Lead, Tracing and I&R (Global)",3430947,CDM,960,RC,93000,HCPCS,Outpatient,,,28.01,14.01,,25.21,90,,,percent of total billed charges,90% of total Billed charges,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.69,90,,,Percent of total Billed charges,90% of total billed charges,19.22,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,19.73,155,,,Fee Schedule,155% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,145,,,Fee Schedule,145% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.37,145,,,Fee Schedule,145% of CMS OPPS Rate,19.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,29.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.61,43.69,
Clinic EKG,3527352,CDM,731,RC,93000,HCPCS,Outpatient,,,323,161.50,,290.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,258.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,290.7,90,,,Percent of total Billed charges,90% of total billed charges,21.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,313.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,297.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,226.1,70,,,percent of total billed charges,70% of total billed charges,290.7,90,,,percent of total billed charges,90% of total billed charges,306.85,95,,,percent of total billed charges,95% of total billed charges,306.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.78,86,,,percent of total billed charges,86% of total billed charges,258.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,313.31,97,,,percent of total billed charges,97% of total billed charges,290.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,313.31,97,,,percent of total billed charges,97% of total billed charges,300.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,313.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.22,313.31,
93005- Electrocardiogram tracing,3430948,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,299.61,
EKG Pre/Post Unit,645285,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,299.61,
Electrocardiogram-Outpatient,604550,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,299.61,
PAT EKG,653557,CDM,730,RC,93005,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,11.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.46,299.61,
93015- Cardio stress/cont ECG/superv/I&R,3430949,CDM,960,RC,93015,HCPCS,Outpatient,,,1556.43,778.22,,1400.79,90,,,percent of total billed charges,90% of total Billed charges,131.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.98,90,,,Percent of total Billed charges,90% of total billed charges,89.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.69,155,,,Fee Schedule,155% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.69,145,,,Fee Schedule,145% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.86,145,,,Fee Schedule,145% of CMS OPPS Rate,94.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,123.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,134.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.3,1400.79,
CL Stress Test,4201286,CDM,983,RC,93015,HCPCS,Outpatient,,,1556.43,778.22,,1400.79,90,,,percent of total billed charges,90% of total Billed charges,131.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.98,90,,,Percent of total Billed charges,90% of total billed charges,89.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.69,155,,,Fee Schedule,155% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,99.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,99.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.47,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.69,145,,,Fee Schedule,145% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.86,145,,,Fee Schedule,145% of CMS OPPS Rate,94.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,123.99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,134.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.3,1400.79,
93017- Cardio stress test/tracing only,3430951,CDM,960,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,62.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,45.6,155,,,Fee Schedule,155% of CMS OPPS Rate,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.09,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.62,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.6,145,,,Fee Schedule,145% of CMS OPPS Rate,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.71,145,,,Fee Schedule,145% of CMS OPPS Rate,45.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,73.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.45,1426.52,
NM Cardiolite Stress Test,4261243,CDM,482,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1537.47,
Stress Test,604564,CDM,482,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1537.47,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,1653.28,826.64,,1487.95,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1322.62,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1487.95,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1603.68,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1521.02,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1487.95,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1157.3,70,,,percent of total billed charges,70% of total billed charges,1487.95,90,,,percent of total billed charges,90% of total billed charges,1570.62,95,,,percent of total billed charges,95% of total billed charges,1570.62,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1421.82,86,,,percent of total billed charges,86% of total billed charges,1322.62,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1603.68,97,,,percent of total billed charges,97% of total billed charges,1487.95,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1603.68,97,,,percent of total billed charges,97% of total billed charges,1537.55,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1603.68,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1603.68,
93025- Microvolt T-wave alternans,3430953,CDM,510,RC,93025,HCPCS,Outpatient,,,196.45,98.23,,176.81,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,157.16,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,190.56,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,180.73,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,176.81,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,137.52,70,,,percent of total billed charges,70% of total billed charges,176.81,90,,,percent of total billed charges,90% of total billed charges,186.63,95,,,percent of total billed charges,95% of total billed charges,186.63,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,168.95,86,,,percent of total billed charges,86% of total billed charges,157.16,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,190.56,97,,,percent of total billed charges,97% of total billed charges,176.81,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.56,97,,,percent of total billed charges,97% of total billed charges,182.7,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,190.56,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,708.98,
CL Holter Monitor 24-48 hour,3430958,CDM,731,RC,93225,HCPCS,Outpatient,,,678.3,339.15,,610.47,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,542.64,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,610.47,90,,,Percent of total Billed charges,90% of total billed charges,20.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,657.95,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,624.04,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,610.47,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,474.81,70,,,percent of total billed charges,70% of total billed charges,610.47,90,,,percent of total billed charges,90% of total billed charges,644.39,95,,,percent of total billed charges,95% of total billed charges,644.39,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,583.34,86,,,percent of total billed charges,86% of total billed charges,542.64,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,657.95,97,,,percent of total billed charges,97% of total billed charges,610.47,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,657.95,97,,,percent of total billed charges,97% of total billed charges,630.82,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,657.95,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.25,657.95,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,224.39,112.20,,201.95,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.66,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,206.44,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.95,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,157.07,70,,,percent of total billed charges,70% of total billed charges,201.95,90,,,percent of total billed charges,90% of total billed charges,213.17,95,,,percent of total billed charges,95% of total billed charges,213.17,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.98,86,,,percent of total billed charges,86% of total billed charges,179.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.66,97,,,percent of total billed charges,97% of total billed charges,201.95,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.66,97,,,percent of total billed charges,97% of total billed charges,208.68,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,217.66,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,217.66,
CL Holter Monitor 3-7 day,4221151,CDM,731,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,196.43,
Holter Monitor 3-7 days,4221153,CDM,731,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,196.43,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,224.39,112.20,,201.95,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,179.51,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.66,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,206.44,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.95,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,157.07,70,,,percent of total billed charges,70% of total billed charges,201.95,90,,,percent of total billed charges,90% of total billed charges,213.17,95,,,percent of total billed charges,95% of total billed charges,213.17,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.98,86,,,percent of total billed charges,86% of total billed charges,179.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.66,97,,,percent of total billed charges,97% of total billed charges,201.95,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.66,97,,,percent of total billed charges,97% of total billed charges,208.68,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,217.66,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
CL Holter Monitor 8+ days,4221152,CDM,731,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
Holter Monitor 8+ days,4221154,CDM,731,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,106.09,53.05,,95.48,90,,,percent of total billed charges,90% of total Billed charges,81.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.16,155,,,Fee Schedule,155% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.16,145,,,Fee Schedule,145% of CMS OPPS Rate,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.84,145,,,Fee Schedule,145% of CMS OPPS Rate,50.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.85,118.84,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,106.09,53.05,,95.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,84.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,95.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,102.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,97.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,74.26,70,,,percent of total billed charges,70% of total billed charges,95.48,90,,,percent of total billed charges,90% of total billed charges,100.79,95,,,percent of total billed charges,95% of total billed charges,100.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.24,86,,,percent of total billed charges,86% of total billed charges,84.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,102.91,97,,,percent of total billed charges,97% of total billed charges,95.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,102.91,97,,,percent of total billed charges,97% of total billed charges,98.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.26,102.91,
93270- Ext pt/auto ECG/30 day/MD interp,3430766,CDM,731,RC,93270,HCPCS,Outpatient,,,205.72,102.86,,185.15,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,164.58,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.15,90,,,Percent of total Billed charges,90% of total billed charges,16.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,199.55,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,189.26,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,185.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,144,70,,,percent of total billed charges,70% of total billed charges,185.15,90,,,percent of total billed charges,90% of total billed charges,195.43,95,,,percent of total billed charges,95% of total billed charges,195.43,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,176.92,86,,,percent of total billed charges,86% of total billed charges,164.58,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,199.55,97,,,percent of total billed charges,97% of total billed charges,185.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.55,97,,,percent of total billed charges,97% of total billed charges,191.32,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.55,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.7,199.55,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,205.72,102.86,,185.15,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,164.58,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.15,90,,,Percent of total Billed charges,90% of total billed charges,16.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,199.55,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,189.26,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,185.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,144,70,,,percent of total billed charges,70% of total billed charges,185.15,90,,,percent of total billed charges,90% of total billed charges,195.43,95,,,percent of total billed charges,95% of total billed charges,195.43,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,176.92,86,,,percent of total billed charges,86% of total billed charges,164.58,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,199.55,97,,,percent of total billed charges,97% of total billed charges,185.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,199.55,97,,,percent of total billed charges,97% of total billed charges,191.32,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,199.55,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.7,199.55,
93271- Event rec/to 30 days/transmis/anal,3430965,CDM,731,RC,93271,HCPCS,Outpatient,,,355.64,177.82,,320.08,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,284.51,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,320.08,90,,,Percent of total Billed charges,90% of total billed charges,82.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,344.97,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,327.19,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,320.08,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,248.95,70,,,percent of total billed charges,70% of total billed charges,320.08,90,,,percent of total billed charges,90% of total billed charges,337.86,95,,,percent of total billed charges,95% of total billed charges,337.86,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,305.85,86,,,percent of total billed charges,86% of total billed charges,284.51,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,344.97,97,,,percent of total billed charges,97% of total billed charges,320.08,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,344.97,97,,,percent of total billed charges,97% of total billed charges,330.75,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,344.97,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.12,486.58,
93278- Signal avg ECG w or w/o ECG,3430967,CDM,510,RC,93278,HCPCS,Outpatient,,,39.01,19.51,,35.11,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,31.21,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.11,90,,,Percent of total Billed charges,90% of total billed charges,23.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,37.84,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,35.89,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.11,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,27.31,70,,,percent of total billed charges,70% of total billed charges,35.11,90,,,percent of total billed charges,90% of total billed charges,37.06,95,,,percent of total billed charges,95% of total billed charges,37.06,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33.55,86,,,percent of total billed charges,86% of total billed charges,31.21,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37.84,97,,,percent of total billed charges,97% of total billed charges,35.11,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.84,97,,,percent of total billed charges,97% of total billed charges,36.28,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.84,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.53,280.22,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,251.76,125.88,,226.58,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,201.41,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.58,90,,,Percent of total Billed charges,90% of total billed charges,11.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,244.21,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,231.62,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,226.58,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,176.23,70,,,percent of total billed charges,70% of total billed charges,226.58,90,,,percent of total billed charges,90% of total billed charges,239.17,95,,,percent of total billed charges,95% of total billed charges,239.17,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,216.51,86,,,percent of total billed charges,86% of total billed charges,201.41,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,244.21,97,,,percent of total billed charges,97% of total billed charges,226.58,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.21,97,,,percent of total billed charges,97% of total billed charges,234.14,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.21,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.54,244.21,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,263.08,131.54,,236.77,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,210.46,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,236.77,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,255.19,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,242.03,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,236.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,184.16,70,,,percent of total billed charges,70% of total billed charges,236.77,90,,,percent of total billed charges,90% of total billed charges,249.93,95,,,percent of total billed charges,95% of total billed charges,249.93,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,226.25,86,,,percent of total billed charges,86% of total billed charges,210.46,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,255.19,97,,,percent of total billed charges,97% of total billed charges,236.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.19,97,,,percent of total billed charges,97% of total billed charges,244.66,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,255.19,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,255.19,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,271.97,135.99,,244.77,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,217.58,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.77,90,,,Percent of total Billed charges,90% of total billed charges,15.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,263.81,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,250.21,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,244.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,190.38,70,,,percent of total billed charges,70% of total billed charges,244.77,90,,,percent of total billed charges,90% of total billed charges,258.37,95,,,percent of total billed charges,95% of total billed charges,258.37,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,233.89,86,,,percent of total billed charges,86% of total billed charges,217.58,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,263.81,97,,,percent of total billed charges,97% of total billed charges,244.77,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.81,97,,,percent of total billed charges,97% of total billed charges,252.93,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,263.81,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.11,263.81,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,271.35,135.68,,244.22,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,217.08,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,244.22,90,,,Percent of total Billed charges,90% of total billed charges,13.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,263.21,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,249.64,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,244.22,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,189.95,70,,,percent of total billed charges,70% of total billed charges,244.22,90,,,percent of total billed charges,90% of total billed charges,257.78,95,,,percent of total billed charges,95% of total billed charges,257.78,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,233.36,86,,,percent of total billed charges,86% of total billed charges,217.08,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,263.21,97,,,percent of total billed charges,97% of total billed charges,244.22,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,263.21,97,,,percent of total billed charges,97% of total billed charges,252.36,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,263.21,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.64,263.21,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,300.29,150.15,,270.26,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,240.23,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.26,90,,,Percent of total Billed charges,90% of total billed charges,15.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,291.28,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,276.27,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,270.26,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,210.2,70,,,percent of total billed charges,70% of total billed charges,270.26,90,,,percent of total billed charges,90% of total billed charges,285.28,95,,,percent of total billed charges,95% of total billed charges,285.28,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,258.25,86,,,percent of total billed charges,86% of total billed charges,240.23,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,291.28,97,,,percent of total billed charges,97% of total billed charges,270.26,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.28,97,,,percent of total billed charges,97% of total billed charges,279.27,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,291.28,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.53,291.28,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,309.62,154.81,,278.66,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,247.7,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.66,90,,,Percent of total Billed charges,90% of total billed charges,18.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,300.33,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,284.85,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,278.66,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,216.73,70,,,percent of total billed charges,70% of total billed charges,278.66,90,,,percent of total billed charges,90% of total billed charges,294.14,95,,,percent of total billed charges,95% of total billed charges,294.14,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,266.27,86,,,percent of total billed charges,86% of total billed charges,247.7,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,300.33,97,,,percent of total billed charges,97% of total billed charges,278.66,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.33,97,,,percent of total billed charges,97% of total billed charges,287.95,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.33,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.63,300.33,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,240.36,120.18,,216.32,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,192.29,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.32,90,,,Percent of total Billed charges,90% of total billed charges,10.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.15,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,221.13,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.32,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,168.25,70,,,percent of total billed charges,70% of total billed charges,216.32,90,,,percent of total billed charges,90% of total billed charges,228.34,95,,,percent of total billed charges,95% of total billed charges,228.34,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.71,86,,,percent of total billed charges,86% of total billed charges,192.29,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.15,97,,,percent of total billed charges,97% of total billed charges,216.32,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.15,97,,,percent of total billed charges,97% of total billed charges,223.53,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.15,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.7,233.15,
Pre/Post MRI Defibrillator Interrogation,4231187,CDM,480,RC,93287,HCPCS,Outpatient,,,46.72,23.36,,42.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,37.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,29.84,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,36.75,78.65,,,percent of total billed charges,78.65% of total billed charges,41.74,89.33,,,percent of total billed charges,89.33% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.7,70,,,percent of total billed charges,70% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,44.38,95,,,percent of total billed charges,95% of total billed charges,44.38,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.18,86,,,percent of total billed charges,86% of total billed charges,37.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,42.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,43.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.84,45.32,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,230.77,115.39,,207.69,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,184.62,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.69,90,,,Percent of total Billed charges,90% of total billed charges,10.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.85,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,212.31,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,207.69,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.54,70,,,percent of total billed charges,70% of total billed charges,207.69,90,,,percent of total billed charges,90% of total billed charges,219.23,95,,,percent of total billed charges,95% of total billed charges,219.23,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,198.46,86,,,percent of total billed charges,86% of total billed charges,184.62,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,223.85,97,,,percent of total billed charges,97% of total billed charges,207.69,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.85,97,,,percent of total billed charges,97% of total billed charges,214.62,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.85,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.91,223.85,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,262.02,131.01,,235.82,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,209.62,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.82,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,254.16,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,241.06,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,235.82,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,183.41,70,,,percent of total billed charges,70% of total billed charges,235.82,90,,,percent of total billed charges,90% of total billed charges,248.92,95,,,percent of total billed charges,95% of total billed charges,248.92,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.34,86,,,percent of total billed charges,86% of total billed charges,209.62,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.16,97,,,percent of total billed charges,97% of total billed charges,235.82,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.16,97,,,percent of total billed charges,97% of total billed charges,243.68,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.16,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,254.16,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,262.02,131.01,,235.82,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,209.62,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.82,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,254.16,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,241.06,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,235.82,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,183.41,70,,,percent of total billed charges,70% of total billed charges,235.82,90,,,percent of total billed charges,90% of total billed charges,248.92,95,,,percent of total billed charges,95% of total billed charges,248.92,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,225.34,86,,,percent of total billed charges,86% of total billed charges,209.62,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,254.16,97,,,percent of total billed charges,97% of total billed charges,235.82,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.16,97,,,percent of total billed charges,97% of total billed charges,243.68,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,254.16,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,254.16,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,185.34,92.67,,166.81,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,148.27,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.81,90,,,Percent of total Billed charges,90% of total billed charges,13.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,179.78,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,170.51,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,166.81,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,129.74,70,,,percent of total billed charges,70% of total billed charges,166.81,90,,,percent of total billed charges,90% of total billed charges,176.07,95,,,percent of total billed charges,95% of total billed charges,176.07,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,159.39,86,,,percent of total billed charges,86% of total billed charges,148.27,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,179.78,97,,,percent of total billed charges,97% of total billed charges,166.81,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.78,97,,,percent of total billed charges,97% of total billed charges,172.37,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,179.78,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.98,179.78,
93296- PM remote trans/90 day/tech review,3430985,CDM,480,RC,93296,HCPCS,Outpatient,,,229.06,114.53,,206.15,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,183.25,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.15,90,,,Percent of total Billed charges,90% of total billed charges,21.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,222.19,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,210.74,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,206.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,160.34,70,,,percent of total billed charges,70% of total billed charges,206.15,90,,,percent of total billed charges,90% of total billed charges,217.61,95,,,percent of total billed charges,95% of total billed charges,217.61,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,196.99,86,,,percent of total billed charges,86% of total billed charges,183.25,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,222.19,97,,,percent of total billed charges,97% of total billed charges,206.15,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.19,97,,,percent of total billed charges,97% of total billed charges,213.03,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,222.19,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.99,222.19,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2834.66,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2834.66,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2834.66,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2834.66,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,1158.13,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.45,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.13,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1248.21,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.87,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,900.77,70,,,percent of total billed charges,70% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1106.66,86,,,percent of total billed charges,86% of total billed charges,1029.45,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1248.21,97,,,percent of total billed charges,97% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.21,97,,,percent of total billed charges,97% of total billed charges,1196.73,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1248.21,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1248.21,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,1158.13,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.45,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.13,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1248.21,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.87,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,900.77,70,,,percent of total billed charges,70% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1106.66,86,,,percent of total billed charges,86% of total billed charges,1029.45,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1248.21,97,,,percent of total billed charges,97% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.21,97,,,percent of total billed charges,97% of total billed charges,1196.73,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1248.21,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1248.21,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,1158.13,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.45,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.13,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1248.21,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.87,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,900.77,70,,,percent of total billed charges,70% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1106.66,86,,,percent of total billed charges,86% of total billed charges,1029.45,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1248.21,97,,,percent of total billed charges,97% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.21,97,,,percent of total billed charges,97% of total billed charges,1196.73,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1248.21,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1248.21,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,1286.81,643.41,,1158.13,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.45,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1158.13,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1248.21,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1183.87,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,900.77,70,,,percent of total billed charges,70% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,1222.47,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1106.66,86,,,percent of total billed charges,86% of total billed charges,1029.45,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1248.21,97,,,percent of total billed charges,97% of total billed charges,1158.13,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1248.21,97,,,percent of total billed charges,97% of total billed charges,1196.73,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1248.21,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1248.21,
93321- Dop echo/pulse/cont wave/spec/lim,3431005,CDM,483,RC,93321,HCPCS,Outpatient,,,494.73,247.37,,445.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,395.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,445.26,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,479.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,455.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,315.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,389.12,78.65,,,percent of total billed charges,78.65% of total billed charges,441.95,89.33,,,percent of total billed charges,89.33% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,346.31,70,,,percent of total billed charges,70% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,469.99,95,,,percent of total billed charges,95% of total billed charges,469.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.47,86,,,percent of total billed charges,86% of total billed charges,395.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,479.89,97,,,percent of total billed charges,97% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,479.89,97,,,percent of total billed charges,97% of total billed charges,460.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,479.89,
93321 Doppler echo pulsed wave,4061246,CDM,483,RC,93321,HCPCS,Outpatient,,,494.73,247.37,,445.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,395.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,445.26,90,,,Percent of total Billed charges,90% of total billed charges,22.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,479.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,455.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,315.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,389.12,78.65,,,percent of total billed charges,78.65% of total billed charges,441.95,89.33,,,percent of total billed charges,89.33% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,346.31,70,,,percent of total billed charges,70% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,469.99,95,,,percent of total billed charges,95% of total billed charges,469.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,425.47,86,,,percent of total billed charges,86% of total billed charges,395.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,479.89,97,,,percent of total billed charges,97% of total billed charges,445.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,479.89,97,,,percent of total billed charges,97% of total billed charges,460.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,479.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.55,479.89,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,466.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,414.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,466.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,476.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,330.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,407.4,78.65,,,percent of total billed charges,78.65% of total billed charges,462.72,89.33,,,percent of total billed charges,89.33% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,362.59,70,,,percent of total billed charges,70% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,86,,,percent of total billed charges,86% of total billed charges,414.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,481.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.79,502.44,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,466.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,414.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,466.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,476.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,330.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,407.4,78.65,,,percent of total billed charges,78.65% of total billed charges,462.72,89.33,,,percent of total billed charges,89.33% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,362.59,70,,,percent of total billed charges,70% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,86,,,percent of total billed charges,86% of total billed charges,414.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,481.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.79,502.44,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,517.98,258.99,,466.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,414.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,466.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,476.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,330.79,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,407.4,78.65,,,percent of total billed charges,78.65% of total billed charges,462.72,89.33,,,percent of total billed charges,89.33% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,362.59,70,,,percent of total billed charges,70% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,492.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,445.46,86,,,percent of total billed charges,86% of total billed charges,414.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,466.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,481.72,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,502.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,330.79,502.44,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2834.66,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2834.66,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2834.66,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2834.66,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,2922.33,1461.17,,2630.1,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2337.86,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2630.1,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2834.66,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2688.54,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2045.63,70,,,percent of total billed charges,70% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,2776.21,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2513.2,86,,,percent of total billed charges,86% of total billed charges,2337.86,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2834.66,97,,,percent of total billed charges,97% of total billed charges,2630.1,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2834.66,97,,,percent of total billed charges,97% of total billed charges,2717.77,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2834.66,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2834.66,
93352- Echo contrast w/stress echo,3431010,CDM,510,RC,93352,HCPCS,Outpatient,,,81.26,40.63,,73.13,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,65.01,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,73.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,74.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,51.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,63.91,78.65,,,percent of total billed charges,78.65% of total billed charges,72.59,89.33,,,percent of total billed charges,89.33% of total billed charges,73.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.88,70,,,percent of total billed charges,70% of total billed charges,73.13,90,,,percent of total billed charges,90% of total billed charges,77.2,95,,,percent of total billed charges,95% of total billed charges,77.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.88,86,,,percent of total billed charges,86% of total billed charges,65.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,78.82,97,,,percent of total billed charges,97% of total billed charges,73.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.82,97,,,percent of total billed charges,97% of total billed charges,75.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.89,78.82,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,214.77,107.39,,193.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,171.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,193.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,197.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,137.16,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,168.92,78.65,,,percent of total billed charges,78.65% of total billed charges,191.86,89.33,,,percent of total billed charges,89.33% of total billed charges,193.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,150.34,70,,,percent of total billed charges,70% of total billed charges,193.29,90,,,percent of total billed charges,90% of total billed charges,204.03,95,,,percent of total billed charges,95% of total billed charges,204.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.7,86,,,percent of total billed charges,86% of total billed charges,171.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,208.33,97,,,percent of total billed charges,97% of total billed charges,193.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.33,97,,,percent of total billed charges,97% of total billed charges,199.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.16,208.33,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,16943.16,8471.58,,15248.84,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13554.53,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,15248.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16434.87,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15587.71,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15248.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11860.21,70,,,percent of total billed charges,70% of total billed charges,15248.84,90,,,percent of total billed charges,90% of total billed charges,16096,95,,,percent of total billed charges,95% of total billed charges,16096,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14571.12,86,,,percent of total billed charges,86% of total billed charges,13554.53,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16434.87,97,,,percent of total billed charges,97% of total billed charges,15248.84,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,16434.87,97,,,percent of total billed charges,97% of total billed charges,15757.14,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16434.87,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2283.98,16434.87,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,38904,19452.00,,35013.6,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31123.2,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,35013.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,37736.88,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35791.68,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35013.6,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,27232.8,70,,,percent of total billed charges,70% of total billed charges,35013.6,90,,,percent of total billed charges,90% of total billed charges,36958.8,95,,,percent of total billed charges,95% of total billed charges,36958.8,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33457.44,86,,,percent of total billed charges,86% of total billed charges,31123.2,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37736.88,97,,,percent of total billed charges,97% of total billed charges,35013.6,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,37736.88,97,,,percent of total billed charges,97% of total billed charges,36180.72,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37736.88,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5197.81,37736.88,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,38904,19452.00,,35013.6,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,31123.2,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,35013.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,37736.88,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35791.68,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35013.6,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,27232.8,70,,,percent of total billed charges,70% of total billed charges,35013.6,90,,,percent of total billed charges,90% of total billed charges,36958.8,95,,,percent of total billed charges,95% of total billed charges,36958.8,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33457.44,86,,,percent of total billed charges,86% of total billed charges,31123.2,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37736.88,97,,,percent of total billed charges,97% of total billed charges,35013.6,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,37736.88,97,,,percent of total billed charges,97% of total billed charges,36180.72,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37736.88,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5197.81,37736.88,
93799 - Unlisted cardiovascular service or procedure,3783249,CDM,481,RC,93799,HCPCS,Outpatient,,,151.54,75.77,,136.39,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,121.23,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,146.99,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,139.42,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,136.39,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,106.08,70,,,percent of total billed charges,70% of total billed charges,136.39,90,,,percent of total billed charges,90% of total billed charges,143.96,95,,,percent of total billed charges,95% of total billed charges,143.96,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,130.32,86,,,percent of total billed charges,86% of total billed charges,121.23,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,146.99,97,,,percent of total billed charges,97% of total billed charges,136.39,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.99,97,,,percent of total billed charges,97% of total billed charges,140.93,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.99,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,106.08,708.98,
93880 - (TC) Duplex scan of extracranial arteries; complete,3898960,CDM,510,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,1182.93,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.5,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.93,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1274.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.22,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,920.06,70,,,percent of total billed charges,70% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.36,86,,,percent of total billed charges,86% of total billed charges,1051.5,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.94,97,,,percent of total billed charges,97% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.94,97,,,percent of total billed charges,97% of total billed charges,1222.36,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1274.94,
93880-(TC)-Dup scan/extracran art/bilat/comp,3435542,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,1182.93,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.5,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.93,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1274.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.22,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,920.06,70,,,percent of total billed charges,70% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.36,86,,,percent of total billed charges,86% of total billed charges,1051.5,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.94,97,,,percent of total billed charges,97% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.94,97,,,percent of total billed charges,97% of total billed charges,1222.36,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1274.94,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,1182.93,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.5,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.93,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1274.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.22,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,920.06,70,,,percent of total billed charges,70% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.36,86,,,percent of total billed charges,86% of total billed charges,1051.5,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.94,97,,,percent of total billed charges,97% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.94,97,,,percent of total billed charges,97% of total billed charges,1222.36,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1274.94,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,1314.37,657.19,,1182.93,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1051.5,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1182.93,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1274.94,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1209.22,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,920.06,70,,,percent of total billed charges,70% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,1248.65,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1130.36,86,,,percent of total billed charges,86% of total billed charges,1051.5,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1274.94,97,,,percent of total billed charges,97% of total billed charges,1182.93,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1274.94,97,,,percent of total billed charges,97% of total billed charges,1222.36,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1274.94,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1274.94,
SCMP US Carotid,3370902,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
SCMP US Carotid,3575234,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
SCSN US Carotid Duplex,3370940,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
SCSN US Exam,3575288,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,603.81,301.91,,543.43,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,483.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,543.43,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,585.7,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,555.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,422.67,70,,,percent of total billed charges,70% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,573.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,519.28,86,,,percent of total billed charges,86% of total billed charges,483.05,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,585.7,97,,,percent of total billed charges,97% of total billed charges,543.43,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.7,97,,,percent of total billed charges,97% of total billed charges,561.54,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,585.7,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,585.7,
93922 Non-Invas Physiologic STD Extremity Art 2 Level,3436059,CDM,761,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,148.8,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,132.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.8,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.37,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,152.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.73,70,,,percent of total billed charges,70% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.18,86,,,percent of total billed charges,86% of total billed charges,132.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.37,97,,,percent of total billed charges,97% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.37,97,,,percent of total billed charges,97% of total billed charges,153.76,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.37,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,566.05,
93922-CL US Lower Extrem Art Limited BILAT,3432069,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,148.8,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,132.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.8,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.37,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,152.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.73,70,,,percent of total billed charges,70% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.18,86,,,percent of total billed charges,86% of total billed charges,132.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.37,97,,,percent of total billed charges,97% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.37,97,,,percent of total billed charges,97% of total billed charges,153.76,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.37,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,566.05,
93922-CL US Lower Extrem Art Limited RT,3432070,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,148.8,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,132.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.8,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.37,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,152.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.73,70,,,percent of total billed charges,70% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.18,86,,,percent of total billed charges,86% of total billed charges,132.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.37,97,,,percent of total billed charges,97% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.37,97,,,percent of total billed charges,97% of total billed charges,153.76,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.37,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,566.05,
93922-CL US Lower Extrem Arterial Limited LT,3432071,CDM,921,RC,93922,HCPCS,Outpatient,,,165.33,82.67,,148.8,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,132.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.8,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,160.37,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,152.1,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.73,70,,,percent of total billed charges,70% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,157.06,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,142.18,86,,,percent of total billed charges,86% of total billed charges,132.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,160.37,97,,,percent of total billed charges,97% of total billed charges,148.8,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,160.37,97,,,percent of total billed charges,97% of total billed charges,153.76,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.37,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,566.05,
SCSN US Duplex Scan,3370943,CDM,510,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,625.71,
93923 - (TC) Non-Invasive Physiologic Study Extremity 3 Lvls,3897039,CDM,510,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,833.36,416.68,,750.02,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,666.69,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,750.02,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,808.36,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,766.69,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,583.35,70,,,percent of total billed charges,70% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,791.69,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,716.69,86,,,percent of total billed charges,86% of total billed charges,666.69,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,808.36,97,,,percent of total billed charges,97% of total billed charges,750.02,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,808.36,97,,,percent of total billed charges,97% of total billed charges,775.02,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,808.36,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,808.36,
SCSN US Arterial w Seg Pressures BILAT,3569747,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
SCSN US Arterial w Seg Pressures BILAT,3569753,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
SCSN US Arterial w Seg Pressures BILAT,3575260,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,753.69,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,669.94,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.69,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.31,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,770.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,586.2,70,,,percent of total billed charges,70% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.19,86,,,percent of total billed charges,86% of total billed charges,669.94,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.31,97,,,percent of total billed charges,97% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.31,97,,,percent of total billed charges,97% of total billed charges,778.81,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.31,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,753.69,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,669.94,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.69,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.31,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,770.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,586.2,70,,,percent of total billed charges,70% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.19,86,,,percent of total billed charges,86% of total billed charges,669.94,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.31,97,,,percent of total billed charges,97% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.31,97,,,percent of total billed charges,97% of total billed charges,778.81,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.31,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,753.69,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,669.94,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.69,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.31,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,770.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,586.2,70,,,percent of total billed charges,70% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.19,86,,,percent of total billed charges,86% of total billed charges,669.94,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.31,97,,,percent of total billed charges,97% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.31,97,,,percent of total billed charges,97% of total billed charges,778.81,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.31,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,753.69,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,669.94,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.69,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.31,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,770.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,586.2,70,,,percent of total billed charges,70% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.19,86,,,percent of total billed charges,86% of total billed charges,669.94,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.31,97,,,percent of total billed charges,97% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.31,97,,,percent of total billed charges,97% of total billed charges,778.81,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.31,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,837.43,418.72,,753.69,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,669.94,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,753.69,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,812.31,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,770.44,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,586.2,70,,,percent of total billed charges,70% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,795.56,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,720.19,86,,,percent of total billed charges,86% of total billed charges,669.94,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,812.31,97,,,percent of total billed charges,97% of total billed charges,753.69,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.31,97,,,percent of total billed charges,97% of total billed charges,778.81,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,812.31,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
SCSN US Arterial w Exercise RT Interp,3575270,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
SCSN US Arterials w Exercise Bilat Interp,3575266,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
SCSN US Arterials w Exercise LT,3569755,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
SCSN US Arterials w Exercise LT Interp,3575268,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
SCSN US Arterials w Exercise RT,3569757,CDM,920,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,439.6,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,390.75,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.6,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,473.79,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,449.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,341.91,70,,,percent of total billed charges,70% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,420.06,86,,,percent of total billed charges,86% of total billed charges,390.75,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.79,97,,,percent of total billed charges,97% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.79,97,,,percent of total billed charges,97% of total billed charges,454.25,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.79,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,439.6,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,390.75,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.6,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,473.79,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,449.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,341.91,70,,,percent of total billed charges,70% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,420.06,86,,,percent of total billed charges,86% of total billed charges,390.75,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.79,97,,,percent of total billed charges,97% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.79,97,,,percent of total billed charges,97% of total billed charges,454.25,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.79,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,921,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,439.6,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,390.75,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.6,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,473.79,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,449.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,341.91,70,,,percent of total billed charges,70% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,420.06,86,,,percent of total billed charges,86% of total billed charges,390.75,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.79,97,,,percent of total billed charges,97% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.79,97,,,percent of total billed charges,97% of total billed charges,454.25,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.79,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93925 TC Duplex scan of lower extremity arteries or arteri,3622802,CDM,510,RC,93925,HCPCS,Outpatient,,,488.44,244.22,,439.6,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,390.75,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.6,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,473.79,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,449.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,341.91,70,,,percent of total billed charges,70% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,464.02,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,420.06,86,,,percent of total billed charges,86% of total billed charges,390.75,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,473.79,97,,,percent of total billed charges,97% of total billed charges,439.6,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,473.79,97,,,percent of total billed charges,97% of total billed charges,454.25,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,473.79,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,542.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,481.82,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.05,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,584.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,554.1,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,421.6,70,,,percent of total billed charges,70% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.96,86,,,percent of total billed charges,86% of total billed charges,481.82,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.21,97,,,percent of total billed charges,97% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.21,97,,,percent of total billed charges,97% of total billed charges,560.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,584.21,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,542.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,481.82,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.05,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,584.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,554.1,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,421.6,70,,,percent of total billed charges,70% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.96,86,,,percent of total billed charges,86% of total billed charges,481.82,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.21,97,,,percent of total billed charges,97% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.21,97,,,percent of total billed charges,97% of total billed charges,560.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,584.21,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,542.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,481.82,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.05,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,584.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,554.1,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,421.6,70,,,percent of total billed charges,70% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.96,86,,,percent of total billed charges,86% of total billed charges,481.82,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.21,97,,,percent of total billed charges,97% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.21,97,,,percent of total billed charges,97% of total billed charges,560.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,584.21,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,542.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,481.82,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.05,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,584.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,554.1,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,421.6,70,,,percent of total billed charges,70% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.96,86,,,percent of total billed charges,86% of total billed charges,481.82,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.21,97,,,percent of total billed charges,97% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.21,97,,,percent of total billed charges,97% of total billed charges,560.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,584.21,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,602.28,301.14,,542.05,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,481.82,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,542.05,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,584.21,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,554.1,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,421.6,70,,,percent of total billed charges,70% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,572.17,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,517.96,86,,,percent of total billed charges,86% of total billed charges,481.82,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,584.21,97,,,percent of total billed charges,97% of total billed charges,542.05,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,584.21,97,,,percent of total billed charges,97% of total billed charges,560.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,584.21,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,584.21,
SCMP US Exam,3575244,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
SCMP US Lower Extremity,3370913,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
SCSN US Arterial w Seg Pressures LT,3569749,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
SCSN US Arterial w Seg Pressures LT,3575262,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
SCSN US Arterial w Seg Pressures LT,3575264,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
SCSN US Arterial w Seg Pressures RT,3569751,CDM,920,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,921,RC,93930,HCPCS,Outpatient,,,378.7,189.35,,340.83,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,302.96,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,340.83,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,367.34,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,348.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,340.83,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,265.09,70,,,percent of total billed charges,70% of total billed charges,340.83,90,,,percent of total billed charges,90% of total billed charges,359.77,95,,,percent of total billed charges,95% of total billed charges,359.77,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,325.68,86,,,percent of total billed charges,86% of total billed charges,302.96,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,367.34,97,,,percent of total billed charges,97% of total billed charges,340.83,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.34,97,,,percent of total billed charges,97% of total billed charges,352.19,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,367.34,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.54,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.6,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,221.42,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,168.47,70,,,percent of total billed charges,70% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.98,86,,,percent of total billed charges,86% of total billed charges,192.54,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.45,97,,,percent of total billed charges,97% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.45,97,,,percent of total billed charges,97% of total billed charges,223.82,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
Clinic Selected Subclavian Artery Scan Left,3347693,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.54,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.6,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,221.42,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,168.47,70,,,percent of total billed charges,70% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.98,86,,,percent of total billed charges,86% of total billed charges,192.54,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.45,97,,,percent of total billed charges,97% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.45,97,,,percent of total billed charges,97% of total billed charges,223.82,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
Clinic Selected Subclavian Artery Scan Right,3347692,CDM,921,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,192.54,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.6,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,233.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,221.42,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,168.47,70,,,percent of total billed charges,70% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,228.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.98,86,,,percent of total billed charges,86% of total billed charges,192.54,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,233.45,97,,,percent of total billed charges,97% of total billed charges,216.6,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,233.45,97,,,percent of total billed charges,97% of total billed charges,223.82,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,233.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
Read,3351995,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
Read,3351999,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
Read,3575247,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
SCMP US Exam,3575248,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
SCMP US Upper Extemity,3370917,CDM,972,RC,93931,HCPCS,Outpatient,,,240.67,120.34,,216.6,90,,,percent of total billed charges,90% of total Billed charges,178.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,128.01,155,,,Fee Schedule,155% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,261.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,174.23,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,103.02,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.01,145,,,Fee Schedule,145% of CMS OPPS Rate,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.22,145,,,Fee Schedule,145% of CMS OPPS Rate,128.01,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,264.57,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,264.57,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,88.28,264.57,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
93970 TC Duplex scan of extremity veins including response,3621411,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,369.39,184.70,,332.45,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,295.51,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.45,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,358.31,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,339.84,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,258.57,70,,,percent of total billed charges,70% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,350.92,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,317.68,86,,,percent of total billed charges,86% of total billed charges,295.51,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,358.31,97,,,percent of total billed charges,97% of total billed charges,332.45,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,358.31,97,,,percent of total billed charges,97% of total billed charges,343.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,358.31,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,1304.11,652.06,,1173.7,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1043.29,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1173.7,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1264.99,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.78,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,912.88,70,,,percent of total billed charges,70% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,1238.9,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1121.53,86,,,percent of total billed charges,86% of total billed charges,1043.29,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1264.99,97,,,percent of total billed charges,97% of total billed charges,1173.7,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1264.99,97,,,percent of total billed charges,97% of total billed charges,1212.82,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1264.99,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1264.99,
SCMP US Exam,3575250,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCMP US Upper Extremity Vein Mapping,3370919,CDM,972,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,275.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.13,155,,,Fee Schedule,155% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.13,145,,,Fee Schedule,145% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.52,145,,,Fee Schedule,145% of CMS OPPS Rate,198.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,136.64,1113.65,
SCMP US Vein Mapping,3370922,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCMP US Vein Mapping:Read,3575252,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN US Venous Lower BILAT,3569777,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN US Venous Lower Bilat Interp,3575318,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN US Venous Upper BILAT,3569783,CDM,402,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN US Venous Upper Bilat Interp,3575324,CDM,510,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN Venous Insuff Bilat,3569789,CDM,920,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN Venous Insufficiency Bilat Interp,3575330,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN Venous Insufficiency Bilat Interp,3575329,CDM,510,RC,93970,HCPCS,Outpatient,,,66.72,33.36,,60.05,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,53.38,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.05,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.72,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,61.38,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,46.7,70,,,percent of total billed charges,70% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,63.38,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,57.38,86,,,percent of total billed charges,86% of total billed charges,53.38,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,64.72,97,,,percent of total billed charges,97% of total billed charges,60.05,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.72,97,,,percent of total billed charges,97% of total billed charges,62.05,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.72,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.7,1138.43,
US Extremity Complete Bilat Lower for DVT:Read,3347590,CDM,972,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,275.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,146.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,198.13,155,,,Fee Schedule,155% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,352.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,396.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,396.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,262.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,158.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,273.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,189.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.13,145,,,Fee Schedule,145% of CMS OPPS Rate,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.52,145,,,Fee Schedule,145% of CMS OPPS Rate,198.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,146.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,273.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,411.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,411.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,136.64,1113.65,
US Vein Map/Marking Lower Extrem Bilat,3352012,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
WHC US Extremity Vein Complete,2198103,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93971 (TC) Duplex scan of extremity veins including responses to compression and other maneuvers; un,3620982,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
93971 Dup-Scan XTR Veins Unilateral/Limited Study,3436061,CDM,761,RC,93971,HCPCS,Outpatient,,,234.34,117.17,,210.91,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,187.47,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,210.91,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,227.31,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,215.59,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,210.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,164.04,70,,,percent of total billed charges,70% of total billed charges,210.91,90,,,percent of total billed charges,90% of total billed charges,222.62,95,,,percent of total billed charges,95% of total billed charges,222.62,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,201.53,86,,,percent of total billed charges,86% of total billed charges,187.47,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,227.31,97,,,percent of total billed charges,97% of total billed charges,210.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,227.31,97,,,percent of total billed charges,97% of total billed charges,217.94,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,227.31,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL Periph Venous US Lower RT,3427535,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL Periph Venous US Upper LT,3427538,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL Periph Venous US Upper RT,3427569,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL Upper Periph Arterial Duplex LT,3427572,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Vein Map Mark Lower Extrem LT,3427464,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Vein Map Mark Lower Extrem RT,3427497,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Vein Map Mark Upper Extrem LT,3427499,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Vein Map Mark Upper Extrem RT,3427500,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Venous Insuff Upper Extrem LT,3427511,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
CL US Venous Insuff Upper Extrem RT,3427512,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
SCSN US Exam,3575296,CDM,972,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,174.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.05,155,,,Fee Schedule,155% of CMS OPPS Rate,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.05,145,,,Fee Schedule,145% of CMS OPPS Rate,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.82,145,,,Fee Schedule,145% of CMS OPPS Rate,125.05,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.24,514.08,
SCSN US Exam,3575298,CDM,402,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Non Vascular Extremity Left,3370952,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Non Vascular Extremity Right,3370954,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Lower LT,3569779,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Lower LT Interp,3575320,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Lower RT,3569781,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Lower RT Interp,3575322,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Upper LT,3569785,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Upper LT,3575326,CDM,972,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,174.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,125.05,155,,,Fee Schedule,155% of CMS OPPS Rate,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,219.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,247.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,96.2,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,172.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.51,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125.05,145,,,Fee Schedule,145% of CMS OPPS Rate,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.82,145,,,Fee Schedule,145% of CMS OPPS Rate,125.05,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,180,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,86.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.56,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,268.56,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.24,514.08,
SCSN US Venous Upper RT,3569787,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN US Venous Upper RT Interp,3575328,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN Venous Insuff LT,3569791,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN Venous Insuff LT Interp,3575332,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN Venous Insuff RT,3569793,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
SCSN Venous Insuff RT Interp,3575334,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Lt for DVT,1257042,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Extremity Vein Unilat Lt Lower for DVT,3347593,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Extremity Vein Unilat Lt Upper for DVT,3347595,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Extremity Vein Unilat Rt for DVT,1257044,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Extremity Vein Unilat Rt Lower for DVT,3347597,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Extremity Vein Unilat Rt Upper for DVT,3347599,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Vein Map/Marking Lower Extremity Lt,3352010,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Vein Map/Marking Lower Extremity Rt,3352014,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Vein Map/Marking Upper Extrem Bilat,3352016,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Vein Map/Marking Upper Extrem Lt,3352018,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Vein Map/Marking Upper Extrem Rt,3352020,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Venous Insufficiency Lower Extrem Lt,3352022,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
US Venous Insufficiency Lower Extrem Rt,3352024,CDM,921,RC,93971,HCPCS,Outpatient,,,613.6,306.80,,552.24,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,490.88,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,552.24,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,595.19,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,564.51,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,429.52,70,,,percent of total billed charges,70% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,582.92,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,527.7,86,,,percent of total billed charges,86% of total billed charges,490.88,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,595.19,97,,,percent of total billed charges,97% of total billed charges,552.24,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,595.19,97,,,percent of total billed charges,97% of total billed charges,570.65,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,595.19,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,595.19,
WHC US Extremity Vein Lt,2198105,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
WHC US Extremity Vein Rt,2198107,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93975- Dup scan/abd/pelvic/scrotal/comp,3435551,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
CL Renal Artery Ultrasound BILAT,3427575,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
Clinic Celiac Artery Ultrasound,3347690,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
Clinic Superior Mesenteric Artery Ultrasound,3347685,CDM,921,RC,93975,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
93976- Dup scan/abd/pelvic/scrotal/ltd,3435552,CDM,921,RC,93976,HCPCS,Outpatient,,,287.26,143.63,,258.53,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,229.81,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.53,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,278.64,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,264.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,258.53,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,201.08,70,,,percent of total billed charges,70% of total billed charges,258.53,90,,,percent of total billed charges,90% of total billed charges,272.9,95,,,percent of total billed charges,95% of total billed charges,272.9,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,247.04,86,,,percent of total billed charges,86% of total billed charges,229.81,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,278.64,97,,,percent of total billed charges,97% of total billed charges,258.53,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.64,97,,,percent of total billed charges,97% of total billed charges,267.15,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,278.64,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
US Duplex Abd Pelvic Retro Limited:Read,596589,CDM,972,RC,93976,HCPCS,Outpatient,,,287.26,143.63,,258.53,90,,,percent of total billed charges,90% of total Billed charges,214.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,106.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,131,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,153.79,155,,,Fee Schedule,155% of CMS OPPS Rate,106.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,296.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,106.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,333.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,222.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,222.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,161.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,146.93,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,151.22,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,153.79,145,,,Fee Schedule,145% of CMS OPPS Rate,106.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,310.4,145,,,Fee Schedule,145% of CMS OPPS Rate,153.79,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,106.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,131,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,213.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,106.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,343.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,343.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,106.06,343.26,
93978- Dup scan/aort/IVC/iliac/BP gft/com,3435553,CDM,921,RC,93978,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,99.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,90.63,1200.27,
Clinic Abdominal Aortic Ultrasound,3347684,CDM,402,RC,93978,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,99.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,90.63,1200.27,
93979- Dup scan/aort/IVC/iliac/BP gft/ltd,3435554,CDM,921,RC,93979,HCPCS,Outpatient,,,224.87,112.44,,202.38,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,179.9,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.38,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,206.88,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,202.38,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,157.41,70,,,percent of total billed charges,70% of total billed charges,202.38,90,,,percent of total billed charges,90% of total billed charges,213.63,95,,,percent of total billed charges,95% of total billed charges,213.63,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,193.39,86,,,percent of total billed charges,86% of total billed charges,179.9,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,218.12,97,,,percent of total billed charges,97% of total billed charges,202.38,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.12,97,,,percent of total billed charges,97% of total billed charges,209.13,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.05,
US Duplex Aorta IVC Limited:Read,596583,CDM,972,RC,93979,HCPCS,Outpatient,,,224.87,112.44,,202.38,90,,,percent of total billed charges,90% of total Billed charges,167.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,82.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,99.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,119.97,155,,,Fee Schedule,155% of CMS OPPS Rate,82.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,218.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,245.81,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,95.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,113.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.97,145,,,Fee Schedule,145% of CMS OPPS Rate,82.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.59,145,,,Fee Schedule,145% of CMS OPPS Rate,119.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,82.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,134.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,82.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.99,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,267.99,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,82.74,267.99,
93980- Dup scan/art/ven/penile ves/comp,3435555,CDM,510,RC,93980,HCPCS,Outpatient,,,134.54,67.27,,121.09,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,107.63,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.09,90,,,Percent of total Billed charges,90% of total billed charges,103.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,130.5,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.78,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,121.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,94.18,70,,,percent of total billed charges,70% of total billed charges,121.09,90,,,percent of total billed charges,90% of total billed charges,127.81,95,,,percent of total billed charges,95% of total billed charges,127.81,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,115.7,86,,,percent of total billed charges,86% of total billed charges,107.63,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,130.5,97,,,percent of total billed charges,97% of total billed charges,121.09,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.5,97,,,percent of total billed charges,97% of total billed charges,125.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,130.5,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,521.04,
93981- Dup scan/art/ven/penile ves/f/u lt,3435556,CDM,510,RC,93981,HCPCS,Outpatient,,,115.59,57.80,,104.03,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,92.47,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.03,90,,,Percent of total Billed charges,90% of total billed charges,62.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,112.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,106.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,104.03,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,80.91,70,,,percent of total billed charges,70% of total billed charges,104.03,90,,,percent of total billed charges,90% of total billed charges,109.81,95,,,percent of total billed charges,95% of total billed charges,109.81,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,99.41,86,,,percent of total billed charges,86% of total billed charges,92.47,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,112.12,97,,,percent of total billed charges,97% of total billed charges,104.03,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.12,97,,,percent of total billed charges,97% of total billed charges,107.5,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,112.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57,521.04,
CL US Ext AVF Comp Bilat Upper Pre-Op Wavelinq,3427458,CDM,921,RC,93985,HCPCS,Outpatient,,,508.97,254.49,,458.07,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,407.18,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,458.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,493.7,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,468.25,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,458.07,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,356.28,70,,,percent of total billed charges,70% of total billed charges,458.07,90,,,percent of total billed charges,90% of total billed charges,483.52,95,,,percent of total billed charges,95% of total billed charges,483.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,437.71,86,,,percent of total billed charges,86% of total billed charges,407.18,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,493.7,97,,,percent of total billed charges,97% of total billed charges,458.07,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,493.7,97,,,percent of total billed charges,97% of total billed charges,473.34,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,493.7,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.28,1138.43,
CL US Ext AVF Comp Upper Pre-Op Wavelinq LT,3427460,CDM,921,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,269.18,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,239.27,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,290.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,275.16,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,269.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,70,,,percent of total billed charges,70% of total billed charges,269.18,90,,,percent of total billed charges,90% of total billed charges,284.14,95,,,percent of total billed charges,95% of total billed charges,284.14,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,257.22,86,,,percent of total billed charges,86% of total billed charges,239.27,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,290.12,97,,,percent of total billed charges,97% of total billed charges,269.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.12,97,,,percent of total billed charges,97% of total billed charges,278.15,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,290.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,521.04,
CL US Ext AVF Comp Upper Pre-Op Wavelinq RT,3427462,CDM,921,RC,93986,HCPCS,Outpatient,,,299.09,149.55,,269.18,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,239.27,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,269.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,290.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,275.16,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,269.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,209.36,70,,,percent of total billed charges,70% of total billed charges,269.18,90,,,percent of total billed charges,90% of total billed charges,284.14,95,,,percent of total billed charges,95% of total billed charges,284.14,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,257.22,86,,,percent of total billed charges,86% of total billed charges,239.27,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,290.12,97,,,percent of total billed charges,97% of total billed charges,269.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,290.12,97,,,percent of total billed charges,97% of total billed charges,278.15,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,290.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,521.04,
93990- Dup scan/hemodialysis access,3435559,CDM,921,RC,93990,HCPCS,Outpatient,,,295.93,147.97,,266.34,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,236.74,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,266.34,90,,,Percent of total Billed charges,90% of total billed charges,88.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,287.05,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,272.26,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,266.34,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,207.15,70,,,percent of total billed charges,70% of total billed charges,266.34,90,,,percent of total billed charges,90% of total billed charges,281.13,95,,,percent of total billed charges,95% of total billed charges,281.13,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,254.5,86,,,percent of total billed charges,86% of total billed charges,236.74,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,287.05,97,,,percent of total billed charges,97% of total billed charges,266.34,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.05,97,,,percent of total billed charges,97% of total billed charges,275.21,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,287.05,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.51,521.05,
Ventilator Initial,617727,CDM,410,RC,94002,HCPCS,Outpatient,,,244.53,122.27,,220.08,90,,,percent of total billed charges,90% of total Billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,195.62,80,,,Percent of total Billed charges,80% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.19,97,,,Percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,224.97,92,,,Percent of total billed charges,92% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2142.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2714.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.08,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,171.17,70,,,percent of total billed charges,70% of total billed charges,220.08,90,,,percent of total billed charges,90% of total billed charges,232.3,95,,,percent of total billed charges,95% of total billed charges,232.3,95,,,percent of total billed charges,95% of total billed charges,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,210.3,86,,,percent of total billed charges,86% of total billed charges,195.62,80,,,percent of total billed charges,80% of total billed charges,480.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,237.19,97,,,percent of total billed charges,97% of total billed charges,220.08,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.19,97,,,percent of total billed charges,97% of total billed charges,227.41,93,,,percent of total billed charges,93% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,237.19,97,,,percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,429.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,171.17,2714.08,
Pressure Ventilator,617749,CDM,410,RC,94003,HCPCS,Outpatient,,,171.37,85.69,,154.23,90,,,percent of total billed charges,90% of total Billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,137.1,80,,,Percent of total Billed charges,80% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.23,97,,,Percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,157.66,92,,,Percent of total billed charges,92% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2142.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2714.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.23,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,119.96,70,,,percent of total billed charges,70% of total billed charges,154.23,90,,,percent of total billed charges,90% of total billed charges,162.8,95,,,percent of total billed charges,95% of total billed charges,162.8,95,,,percent of total billed charges,95% of total billed charges,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,147.38,86,,,percent of total billed charges,86% of total billed charges,137.1,80,,,percent of total billed charges,80% of total billed charges,480.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,166.23,97,,,percent of total billed charges,97% of total billed charges,154.23,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.23,97,,,percent of total billed charges,97% of total billed charges,159.37,93,,,percent of total billed charges,93% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,166.23,97,,,percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,429.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.96,2714.08,
Ventilator Management,617754,CDM,410,RC,94003,HCPCS,Outpatient,,,171.37,85.69,,154.23,90,,,percent of total billed charges,90% of total Billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,137.1,80,,,Percent of total Billed charges,80% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.23,97,,,Percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,157.66,92,,,Percent of total billed charges,92% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,1344.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2142.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2714.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,154.23,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,119.96,70,,,percent of total billed charges,70% of total billed charges,154.23,90,,,percent of total billed charges,90% of total billed charges,162.8,95,,,percent of total billed charges,95% of total billed charges,162.8,95,,,percent of total billed charges,95% of total billed charges,505.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.29,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,147.38,86,,,percent of total billed charges,86% of total billed charges,137.1,80,,,percent of total billed charges,80% of total billed charges,480.25,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,166.23,97,,,percent of total billed charges,97% of total billed charges,154.23,90,,,percent of total billed charges,90% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.23,97,,,percent of total billed charges,97% of total billed charges,159.37,93,,,percent of total billed charges,93% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,166.23,97,,,percent of total billed charges,97% of total billed charges,505.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,505.64,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,429.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.96,2714.08,
94010- Spirometry/include graphic record,3435315,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
PFT (Bedside),617688,CDM,460,RC,94010,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,35,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,708.98,
94011- Spirometric force exp flow/to 2yrs,3435677,CDM,510,RC,94011,HCPCS,Outpatient,,,224.5,112.25,,202.05,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,179.6,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,202.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.77,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,206.54,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,202.05,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,157.15,70,,,percent of total billed charges,70% of total billed charges,202.05,90,,,percent of total billed charges,90% of total billed charges,213.28,95,,,percent of total billed charges,95% of total billed charges,213.28,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,193.07,86,,,percent of total billed charges,86% of total billed charges,179.6,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,217.77,97,,,percent of total billed charges,97% of total billed charges,202.05,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.77,97,,,percent of total billed charges,97% of total billed charges,208.79,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,217.77,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,708.98,
94012- Spiro force exp flow/dilator/to 2y,3435678,CDM,510,RC,94012,HCPCS,Outpatient,,,368.02,184.01,,331.22,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,294.42,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,356.98,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,338.58,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,331.22,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,257.61,70,,,percent of total billed charges,70% of total billed charges,331.22,90,,,percent of total billed charges,90% of total billed charges,349.62,95,,,percent of total billed charges,95% of total billed charges,349.62,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,316.5,86,,,percent of total billed charges,86% of total billed charges,294.42,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,356.98,97,,,percent of total billed charges,97% of total billed charges,331.22,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,356.98,97,,,percent of total billed charges,97% of total billed charges,342.26,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,356.98,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,216.21,1365.32,
94015- Pt init/spiromet rec/hookup,3435681,CDM,510,RC,94015,HCPCS,Outpatient,,,71.37,35.69,,64.23,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,57.1,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.23,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,65.66,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,64.23,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,49.96,70,,,percent of total billed charges,70% of total billed charges,64.23,90,,,percent of total billed charges,90% of total billed charges,67.8,95,,,percent of total billed charges,95% of total billed charges,67.8,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,61.38,86,,,percent of total billed charges,86% of total billed charges,57.1,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,69.23,97,,,percent of total billed charges,97% of total billed charges,64.23,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,69.23,97,,,percent of total billed charges,97% of total billed charges,66.37,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,69.23,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.96,1365.32,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1444.87,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.33,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.87,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1557.25,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.98,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.79,70,,,percent of total billed charges,70% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1380.65,86,,,percent of total billed charges,86% of total billed charges,1284.33,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1557.25,97,,,percent of total billed charges,97% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1557.25,97,,,percent of total billed charges,97% of total billed charges,1493.03,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1557.25,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1557.25,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1444.87,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.33,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.87,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1557.25,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.98,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.79,70,,,percent of total billed charges,70% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1380.65,86,,,percent of total billed charges,86% of total billed charges,1284.33,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1557.25,97,,,percent of total billed charges,97% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1557.25,97,,,percent of total billed charges,97% of total billed charges,1493.03,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1557.25,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1557.25,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1444.87,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.33,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.87,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1557.25,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.98,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.79,70,,,percent of total billed charges,70% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1380.65,86,,,percent of total billed charges,86% of total billed charges,1284.33,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1557.25,97,,,percent of total billed charges,97% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1557.25,97,,,percent of total billed charges,97% of total billed charges,1493.03,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1557.25,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1557.25,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,1605.41,802.71,,1444.87,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1284.33,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1444.87,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1557.25,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1476.98,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1123.79,70,,,percent of total billed charges,70% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,1525.14,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1380.65,86,,,percent of total billed charges,86% of total billed charges,1284.33,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1557.25,97,,,percent of total billed charges,97% of total billed charges,1444.87,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1557.25,97,,,percent of total billed charges,97% of total billed charges,1493.03,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1557.25,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1557.25,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.60,,620.28,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,551.36,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.28,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,668.52,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,634.06,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,482.44,70,,,percent of total billed charges,70% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,592.71,86,,,percent of total billed charges,86% of total billed charges,551.36,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,668.52,97,,,percent of total billed charges,97% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.52,97,,,percent of total billed charges,97% of total billed charges,640.96,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,668.52,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,668.52,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.60,,620.28,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,551.36,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.28,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,668.52,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,634.06,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,482.44,70,,,percent of total billed charges,70% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,592.71,86,,,percent of total billed charges,86% of total billed charges,551.36,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,668.52,97,,,percent of total billed charges,97% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.52,97,,,percent of total billed charges,97% of total billed charges,640.96,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,668.52,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,668.52,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.60,,620.28,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,551.36,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.28,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,668.52,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,634.06,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,482.44,70,,,percent of total billed charges,70% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,592.71,86,,,percent of total billed charges,86% of total billed charges,551.36,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,668.52,97,,,percent of total billed charges,97% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.52,97,,,percent of total billed charges,97% of total billed charges,640.96,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,668.52,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,668.52,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,689.2,344.60,,620.28,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,551.36,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,620.28,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,668.52,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,634.06,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,482.44,70,,,percent of total billed charges,70% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,654.74,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,592.71,86,,,percent of total billed charges,86% of total billed charges,551.36,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,668.52,97,,,percent of total billed charges,97% of total billed charges,620.28,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,668.52,97,,,percent of total billed charges,97% of total billed charges,640.96,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,668.52,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,668.52,
Phys/QHP OP Puml Rehab WO Mntr,4109131,CDM,948,RC,94625,HCPCS,Outpatient,,,44.38,22.19,,39.94,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,35.5,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.05,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,40.83,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.94,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,70,,,percent of total billed charges,70% of total billed charges,39.94,90,,,percent of total billed charges,90% of total billed charges,42.16,95,,,percent of total billed charges,95% of total billed charges,42.16,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.17,86,,,percent of total billed charges,86% of total billed charges,35.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,43.05,97,,,percent of total billed charges,97% of total billed charges,39.94,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.05,97,,,percent of total billed charges,97% of total billed charges,41.27,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.05,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.36,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.07,280.2,
94640- Inhalation tx/AAO/therapeutic/diag,3435697,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.27,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,70,,,percent of total billed charges,70% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.69,86,,,percent of total billed charges,86% of total billed charges,21.1,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.59,97,,,percent of total billed charges,97% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.59,97,,,percent of total billed charges,97% of total billed charges,24.53,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.47,933.58,
Inhaler Treatment,617741,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.27,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,70,,,percent of total billed charges,70% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.69,86,,,percent of total billed charges,86% of total billed charges,21.1,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.59,97,,,percent of total billed charges,97% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.59,97,,,percent of total billed charges,97% of total billed charges,24.53,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.47,933.58,
IPPB w/ Nebulized Medication,617708,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.27,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,70,,,percent of total billed charges,70% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.69,86,,,percent of total billed charges,86% of total billed charges,21.1,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.59,97,,,percent of total billed charges,97% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.59,97,,,percent of total billed charges,97% of total billed charges,24.53,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.47,933.58,
Nebulizer,617710,CDM,410,RC,94640,HCPCS,Outpatient,,,26.38,13.19,,23.74,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,21.1,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,24.27,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,18.47,70,,,percent of total billed charges,70% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,25.06,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.69,86,,,percent of total billed charges,86% of total billed charges,21.1,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.59,97,,,percent of total billed charges,97% of total billed charges,23.74,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.59,97,,,percent of total billed charges,97% of total billed charges,24.53,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.47,933.58,
94642- Aresol inhale/pentamidine/pneum tx,3435698,CDM,410,RC,94642,HCPCS,Outpatient,,,31.55,15.78,,28.4,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,25.24,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.4,90,,,Percent of total Billed charges,90% of total billed charges,34.32,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,30.6,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,29.03,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,28.4,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,22.09,70,,,percent of total billed charges,70% of total billed charges,28.4,90,,,percent of total billed charges,90% of total billed charges,29.97,95,,,percent of total billed charges,95% of total billed charges,29.97,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,27.13,86,,,percent of total billed charges,86% of total billed charges,25.24,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,30.6,97,,,percent of total billed charges,97% of total billed charges,28.4,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.6,97,,,percent of total billed charges,97% of total billed charges,29.34,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,30.6,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.09,933.58,
"INH TX AERO,NEB,MDI,IPPB",3428469,CDM,981,RC,94642,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,63.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,17.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,17.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.7,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,63.11,
94644- Cont inhale/aerosol med/AAO/frst h,3435699,CDM,410,RC,94644,HCPCS,Outpatient,,,144.03,72.02,,129.63,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,115.22,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.63,90,,,Percent of total Billed charges,90% of total billed charges,28.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,139.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,132.51,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,129.63,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,100.82,70,,,percent of total billed charges,70% of total billed charges,129.63,90,,,percent of total billed charges,90% of total billed charges,136.83,95,,,percent of total billed charges,95% of total billed charges,136.83,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,123.87,86,,,percent of total billed charges,86% of total billed charges,115.22,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,139.71,97,,,percent of total billed charges,97% of total billed charges,129.63,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,139.71,97,,,percent of total billed charges,97% of total billed charges,133.95,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.7,566.05,
94645- Cont inhale/aerosol med/AAO /ad hr,3435700,CDM,410,RC,94645,HCPCS,Outpatient,,,37.42,18.71,,33.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,29.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,33.68,90,,,Percent of total Billed charges,90% of total billed charges,10.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,36.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,34.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,23.9,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,29.43,78.65,,,percent of total billed charges,78.65% of total billed charges,33.43,89.33,,,percent of total billed charges,89.33% of total billed charges,33.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.19,70,,,percent of total billed charges,70% of total billed charges,33.68,90,,,percent of total billed charges,90% of total billed charges,35.55,95,,,percent of total billed charges,95% of total billed charges,35.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.18,86,,,percent of total billed charges,86% of total billed charges,29.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,36.3,97,,,percent of total billed charges,97% of total billed charges,33.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.3,97,,,percent of total billed charges,97% of total billed charges,34.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,36.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.8,36.3,
"94660- CPAP vent, initiat/manage",3435701,CDM,410,RC,94660,HCPCS,Outpatient,,,160.57,80.29,,144.51,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,128.46,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.75,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,147.72,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,144.51,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,112.4,70,,,percent of total billed charges,70% of total billed charges,144.51,90,,,percent of total billed charges,90% of total billed charges,152.54,95,,,percent of total billed charges,95% of total billed charges,152.54,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.09,86,,,percent of total billed charges,86% of total billed charges,128.46,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,155.75,97,,,percent of total billed charges,97% of total billed charges,144.51,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.75,97,,,percent of total billed charges,97% of total billed charges,149.33,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,155.75,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.4,933.58,
BIPAP,617723,CDM,410,RC,94660,HCPCS,Outpatient,,,160.57,80.29,,144.51,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,128.46,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.75,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,147.72,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,144.51,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,112.4,70,,,percent of total billed charges,70% of total billed charges,144.51,90,,,percent of total billed charges,90% of total billed charges,152.54,95,,,percent of total billed charges,95% of total billed charges,152.54,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,138.09,86,,,percent of total billed charges,86% of total billed charges,128.46,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,155.75,97,,,percent of total billed charges,97% of total billed charges,144.51,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.75,97,,,percent of total billed charges,97% of total billed charges,149.33,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,155.75,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.4,933.58,
94664- Demo/eval/pt use aerosol/neb/IPPB,3435702,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,35.8,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,31.82,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.8,90,,,Percent of total Billed charges,90% of total billed charges,13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,38.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,36.6,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,70,,,percent of total billed charges,70% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.21,86,,,percent of total billed charges,86% of total billed charges,31.82,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,38.59,97,,,percent of total billed charges,97% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.59,97,,,percent of total billed charges,97% of total billed charges,37,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.82,933.58,
Flutter Valve,617739,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,35.8,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,31.82,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.8,90,,,Percent of total Billed charges,90% of total billed charges,13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,38.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,36.6,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,70,,,percent of total billed charges,70% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.21,86,,,percent of total billed charges,86% of total billed charges,31.82,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,38.59,97,,,percent of total billed charges,97% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.59,97,,,percent of total billed charges,97% of total billed charges,37,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.82,933.58,
Inhalation Initial Demo/Evaluation,658457,CDM,410,RC,94664,HCPCS,Outpatient,,,39.78,19.89,,35.8,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,31.82,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.8,90,,,Percent of total Billed charges,90% of total billed charges,13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,38.59,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,36.6,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,27.85,70,,,percent of total billed charges,70% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,37.79,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.21,86,,,percent of total billed charges,86% of total billed charges,31.82,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,38.59,97,,,percent of total billed charges,97% of total billed charges,35.8,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.59,97,,,percent of total billed charges,97% of total billed charges,37,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,38.59,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.82,933.58,
94667- Manip chest wall/init demo/eval,3435703,CDM,410,RC,94667,HCPCS,Outpatient,,,53.53,26.77,,48.18,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,42.82,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.92,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,49.25,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,48.18,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,37.47,70,,,percent of total billed charges,70% of total billed charges,48.18,90,,,percent of total billed charges,90% of total billed charges,50.85,95,,,percent of total billed charges,95% of total billed charges,50.85,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,46.04,86,,,percent of total billed charges,86% of total billed charges,42.82,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.92,97,,,percent of total billed charges,97% of total billed charges,48.18,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.92,97,,,percent of total billed charges,97% of total billed charges,49.78,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,51.92,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.47,566.05,
94668- Manip chest wall/subseq demo/eval,3435704,CDM,410,RC,94668,HCPCS,Outpatient,,,82.76,41.38,,74.48,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,66.21,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.28,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,57.93,70,,,percent of total billed charges,70% of total billed charges,74.48,90,,,percent of total billed charges,90% of total billed charges,78.62,95,,,percent of total billed charges,95% of total billed charges,78.62,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.17,86,,,percent of total billed charges,86% of total billed charges,66.21,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.28,97,,,percent of total billed charges,97% of total billed charges,74.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.28,97,,,percent of total billed charges,97% of total billed charges,76.97,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.28,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.93,566.05,
IPV Treatment,1083013,CDM,410,RC,94668,HCPCS,Outpatient,,,82.76,41.38,,74.48,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,66.21,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.28,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,76.14,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,74.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,57.93,70,,,percent of total billed charges,70% of total billed charges,74.48,90,,,percent of total billed charges,90% of total billed charges,78.62,95,,,percent of total billed charges,95% of total billed charges,78.62,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.17,86,,,percent of total billed charges,86% of total billed charges,66.21,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80.28,97,,,percent of total billed charges,97% of total billed charges,74.48,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.28,97,,,percent of total billed charges,97% of total billed charges,76.97,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.28,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.93,566.05,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1447.9,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.9,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1560.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.15,70,,,percent of total billed charges,70% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1383.55,86,,,percent of total billed charges,86% of total billed charges,1287.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1560.52,97,,,percent of total billed charges,97% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.52,97,,,percent of total billed charges,97% of total billed charges,1496.17,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1560.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1560.52,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1447.9,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.9,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1560.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.15,70,,,percent of total billed charges,70% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1383.55,86,,,percent of total billed charges,86% of total billed charges,1287.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1560.52,97,,,percent of total billed charges,97% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.52,97,,,percent of total billed charges,97% of total billed charges,1496.17,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1560.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1560.52,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1447.9,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.9,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1560.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.15,70,,,percent of total billed charges,70% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1383.55,86,,,percent of total billed charges,86% of total billed charges,1287.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1560.52,97,,,percent of total billed charges,97% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.52,97,,,percent of total billed charges,97% of total billed charges,1496.17,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1560.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1560.52,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1447.9,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.9,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1560.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.15,70,,,percent of total billed charges,70% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1383.55,86,,,percent of total billed charges,86% of total billed charges,1287.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1560.52,97,,,percent of total billed charges,97% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.52,97,,,percent of total billed charges,97% of total billed charges,1496.17,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1560.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1560.52,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,1608.78,804.39,,1447.9,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1287.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1447.9,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1560.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1480.08,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1126.15,70,,,percent of total billed charges,70% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,1528.34,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1383.55,86,,,percent of total billed charges,86% of total billed charges,1287.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1560.52,97,,,percent of total billed charges,97% of total billed charges,1447.9,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1560.52,97,,,percent of total billed charges,97% of total billed charges,1496.17,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1560.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1560.52,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,222.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,198.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.96,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,240.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,158.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.85,78.65,,,percent of total billed charges,78.65% of total billed charges,221.3,89.33,,,percent of total billed charges,89.33% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,173.41,70,,,percent of total billed charges,70% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.05,86,,,percent of total billed charges,86% of total billed charges,198.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,230.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,240.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,240.3,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,222.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,198.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.96,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,240.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,158.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.85,78.65,,,percent of total billed charges,78.65% of total billed charges,221.3,89.33,,,percent of total billed charges,89.33% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,173.41,70,,,percent of total billed charges,70% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.05,86,,,percent of total billed charges,86% of total billed charges,198.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,230.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,240.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,240.3,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,222.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,198.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.96,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,240.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,158.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.85,78.65,,,percent of total billed charges,78.65% of total billed charges,221.3,89.33,,,percent of total billed charges,89.33% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,173.41,70,,,percent of total billed charges,70% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.05,86,,,percent of total billed charges,86% of total billed charges,198.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,230.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,240.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,240.3,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,247.73,123.87,,222.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,198.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.96,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,240.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,227.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,158.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,194.85,78.65,,,percent of total billed charges,78.65% of total billed charges,221.3,89.33,,,percent of total billed charges,89.33% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,173.41,70,,,percent of total billed charges,70% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,235.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,213.05,86,,,percent of total billed charges,86% of total billed charges,198.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,222.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,240.3,97,,,percent of total billed charges,97% of total billed charges,230.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,240.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,240.3,
94760- Noninv ear/pulse ox/single determ,3435714,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,5.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.27,90,,,Percent of total Billed charges,90% of total billed charges,2.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.6,78.65,,,percent of total billed charges,78.65% of total billed charges,5.23,89.33,,,percent of total billed charges,89.33% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.1,70,,,percent of total billed charges,70% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,86,,,percent of total billed charges,86% of total billed charges,4.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,5.67,
Ear Oximeter,617770,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,5.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.27,90,,,Percent of total Billed charges,90% of total billed charges,2.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.6,78.65,,,percent of total billed charges,78.65% of total billed charges,5.23,89.33,,,percent of total billed charges,89.33% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.1,70,,,percent of total billed charges,70% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,86,,,percent of total billed charges,86% of total billed charges,4.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,5.67,
Pulse Oximetry Determination,1727099,CDM,460,RC,94760,HCPCS,Outpatient,,,5.85,2.93,,5.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.27,90,,,Percent of total Billed charges,90% of total billed charges,2.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3.74,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4.6,78.65,,,percent of total billed charges,78.65% of total billed charges,5.23,89.33,,,percent of total billed charges,89.33% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.1,70,,,percent of total billed charges,70% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,5.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.03,86,,,percent of total billed charges,86% of total billed charges,4.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.67,97,,,percent of total billed charges,97% of total billed charges,5.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.98,5.67,
94761- Noninv ear/pulse ox/multipl determ,3435715,CDM,460,RC,94761,HCPCS,Outpatient,,,8.22,4.11,,7.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,6.58,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7.4,90,,,Percent of total Billed charges,90% of total billed charges,4.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,7.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5.25,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,6.47,78.65,,,percent of total billed charges,78.65% of total billed charges,7.34,89.33,,,percent of total billed charges,89.33% of total billed charges,7.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.75,70,,,percent of total billed charges,70% of total billed charges,7.4,90,,,percent of total billed charges,90% of total billed charges,7.81,95,,,percent of total billed charges,95% of total billed charges,7.81,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.07,86,,,percent of total billed charges,86% of total billed charges,6.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,97,,,percent of total billed charges,97% of total billed charges,7.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.97,97,,,percent of total billed charges,97% of total billed charges,7.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.86,7.97,
"95044- Allg patch or app, # of tests",3428645,CDM,920,RC,95044,HCPCS,Outpatient,,,12.16,6.08,,10.94,90,,,percent of total billed charges,90% of total Billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,9.73,80,,,Percent of total Billed charges,80% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.94,90,,,Percent of total Billed charges,90% of total billed charges,5.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,11.8,97,,,Percent of total billed charges,97% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,92,,,Percent of total billed charges,92% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.84,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10.94,90,,,percent of total billed charges,90% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,8.51,70,,,percent of total billed charges,70% of total billed charges,10.94,90,,,percent of total billed charges,90% of total billed charges,11.55,95,,,percent of total billed charges,95% of total billed charges,11.55,95,,,percent of total billed charges,95% of total billed charges,848.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10.46,86,,,percent of total billed charges,86% of total billed charges,9.73,80,,,percent of total billed charges,80% of total billed charges,939.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11.8,97,,,percent of total billed charges,97% of total billed charges,10.94,90,,,percent of total billed charges,90% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.8,97,,,percent of total billed charges,97% of total billed charges,11.31,93,,,percent of total billed charges,93% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,11.8,97,,,percent of total billed charges,97% of total billed charges,848.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.36,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.74,4555.22,
95060- Ophthalmic Mucous Membrane Tests,3428646,CDM,960,RC,95060,HCPCS,Outpatient,,,716,358.00,,644.4,90,,,percent of total billed charges,90% of total Billed charges,64.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,155,,,Fee Schedule,155% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,145,,,Fee Schedule,145% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.18,145,,,Fee Schedule,145% of CMS OPPS Rate,47.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.97,644.4,
95060-OCC Ophthalmic Mucous Membrane Tests,3536985,CDM,983,RC,95060,HCPCS,Outpatient,,,716,358.00,,644.4,90,,,percent of total billed charges,90% of total Billed charges,64.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,155,,,Fee Schedule,155% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.13,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.14,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.14,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.52,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.52,145,,,Fee Schedule,145% of CMS OPPS Rate,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.18,145,,,Fee Schedule,145% of CMS OPPS Rate,47.52,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.97,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,32.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,51.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,17.97,644.4,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,867.35,433.68,,780.62,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,693.88,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,780.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,841.33,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,797.96,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,780.62,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,607.15,70,,,percent of total billed charges,70% of total billed charges,780.62,90,,,percent of total billed charges,90% of total billed charges,823.98,95,,,percent of total billed charges,95% of total billed charges,823.98,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,745.92,86,,,percent of total billed charges,86% of total billed charges,693.88,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,841.33,97,,,percent of total billed charges,97% of total billed charges,780.62,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,841.33,97,,,percent of total billed charges,97% of total billed charges,806.64,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,841.33,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,841.33,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,389.8,194.90,,350.82,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,311.84,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,378.11,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,358.62,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,350.82,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,272.86,70,,,percent of total billed charges,70% of total billed charges,350.82,90,,,percent of total billed charges,90% of total billed charges,370.31,95,,,percent of total billed charges,95% of total billed charges,370.31,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,335.23,86,,,percent of total billed charges,86% of total billed charges,311.84,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,378.11,97,,,percent of total billed charges,97% of total billed charges,350.82,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,378.11,97,,,percent of total billed charges,97% of total billed charges,362.51,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,378.11,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,2819.94,1409.97,,2537.95,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.95,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2537.95,90,,,Percent of total Billed charges,90% of total billed charges,221.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2735.34,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2594.34,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2537.95,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1973.96,70,,,percent of total billed charges,70% of total billed charges,2537.95,90,,,percent of total billed charges,90% of total billed charges,2678.94,95,,,percent of total billed charges,95% of total billed charges,2678.94,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2425.15,86,,,percent of total billed charges,86% of total billed charges,2255.95,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2735.34,97,,,percent of total billed charges,97% of total billed charges,2537.95,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2735.34,97,,,percent of total billed charges,97% of total billed charges,2622.54,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2735.34,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,201.32,2735.34,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,875.89,437.95,,788.3,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,700.71,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,788.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,849.61,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,805.82,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,788.3,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,613.12,70,,,percent of total billed charges,70% of total billed charges,788.3,90,,,percent of total billed charges,90% of total billed charges,832.1,95,,,percent of total billed charges,95% of total billed charges,832.1,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,753.27,86,,,percent of total billed charges,86% of total billed charges,700.71,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,849.61,97,,,percent of total billed charges,97% of total billed charges,788.3,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,849.61,97,,,percent of total billed charges,97% of total billed charges,814.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,849.61,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,849.61,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,3168.77,1584.39,,2851.89,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2535.02,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2851.89,90,,,Percent of total Billed charges,90% of total billed charges,310.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3073.71,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2915.27,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2851.89,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2218.14,70,,,percent of total billed charges,70% of total billed charges,2851.89,90,,,percent of total billed charges,90% of total billed charges,3010.33,95,,,percent of total billed charges,95% of total billed charges,3010.33,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2725.14,86,,,percent of total billed charges,86% of total billed charges,2535.02,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3073.71,97,,,percent of total billed charges,97% of total billed charges,2851.89,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,3073.71,97,,,percent of total billed charges,97% of total billed charges,2946.96,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3073.71,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281.99,3073.71,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,5444.39,2722.20,,4899.95,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4355.51,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4899.95,90,,,Percent of total Billed charges,90% of total billed charges,301.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5281.06,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,5008.84,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4899.95,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3811.07,70,,,percent of total billed charges,70% of total billed charges,4899.95,90,,,percent of total billed charges,90% of total billed charges,5172.17,95,,,percent of total billed charges,95% of total billed charges,5172.17,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4682.18,86,,,percent of total billed charges,86% of total billed charges,4355.51,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5281.06,97,,,percent of total billed charges,97% of total billed charges,4899.95,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5281.06,97,,,percent of total billed charges,97% of total billed charges,5063.28,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5281.06,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,273.78,5281.06,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,5514.29,2757.15,,4962.86,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4411.43,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4962.86,90,,,Percent of total Billed charges,90% of total billed charges,297.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5348.86,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,5073.15,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4962.86,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3860,70,,,percent of total billed charges,70% of total billed charges,4962.86,90,,,percent of total billed charges,90% of total billed charges,5238.58,95,,,percent of total billed charges,95% of total billed charges,5238.58,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4742.29,86,,,percent of total billed charges,86% of total billed charges,4411.43,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5348.86,97,,,percent of total billed charges,97% of total billed charges,4962.86,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5348.86,97,,,percent of total billed charges,97% of total billed charges,5128.29,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5348.86,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,270.32,5348.86,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,5523.93,2761.97,,4971.54,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4419.14,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4971.54,90,,,Percent of total Billed charges,90% of total billed charges,569.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5358.21,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,5082.02,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4971.54,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3866.75,70,,,percent of total billed charges,70% of total billed charges,4971.54,90,,,percent of total billed charges,90% of total billed charges,5247.73,95,,,percent of total billed charges,95% of total billed charges,5247.73,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4750.58,86,,,percent of total billed charges,86% of total billed charges,4419.14,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5358.21,97,,,percent of total billed charges,97% of total billed charges,4971.54,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5358.21,97,,,percent of total billed charges,97% of total billed charges,5137.25,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5358.21,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,517.67,5358.21,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,1886.96,943.48,,1698.26,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.57,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1698.26,90,,,Percent of total Billed charges,90% of total billed charges,42.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1830.35,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1736,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1698.26,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1320.87,70,,,percent of total billed charges,70% of total billed charges,1698.26,90,,,percent of total billed charges,90% of total billed charges,1792.61,95,,,percent of total billed charges,95% of total billed charges,1792.61,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1622.79,86,,,percent of total billed charges,86% of total billed charges,1509.57,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1830.35,97,,,percent of total billed charges,97% of total billed charges,1698.26,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1830.35,97,,,percent of total billed charges,97% of total billed charges,1754.87,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1830.35,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.93,1830.35,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,2038.72,1019.36,,1834.85,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1630.98,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1834.85,90,,,Percent of total Billed charges,90% of total billed charges,48.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1977.56,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1875.62,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1834.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1427.1,70,,,percent of total billed charges,70% of total billed charges,1834.85,90,,,percent of total billed charges,90% of total billed charges,1936.78,95,,,percent of total billed charges,95% of total billed charges,1936.78,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1753.3,86,,,percent of total billed charges,86% of total billed charges,1630.98,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1977.56,97,,,percent of total billed charges,97% of total billed charges,1834.85,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.56,97,,,percent of total billed charges,97% of total billed charges,1896.01,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1977.56,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.45,1977.56,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,1448.11,724.06,,1303.3,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1158.49,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1303.3,90,,,Percent of total Billed charges,90% of total billed charges,14.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1404.67,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1332.26,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1303.3,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1013.68,70,,,percent of total billed charges,70% of total billed charges,1303.3,90,,,percent of total billed charges,90% of total billed charges,1375.7,95,,,percent of total billed charges,95% of total billed charges,1375.7,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1245.37,86,,,percent of total billed charges,86% of total billed charges,1158.49,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1404.67,97,,,percent of total billed charges,97% of total billed charges,1303.3,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1404.67,97,,,percent of total billed charges,97% of total billed charges,1346.74,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1404.67,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.5,1404.67,
95822 - (TC) Electroencephalogram (EEG); recording in coma or sleep only,3899092,CDM,983,RC,95822,HCPCS,Outpatient,,,1696.93,848.47,,1527.24,90,,,percent of total billed charges,90% of total Billed charges,632.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,455.91,155,,,Fee Schedule,155% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.91,145,,,Fee Schedule,145% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.82,145,,,Fee Schedule,145% of CMS OPPS Rate,455.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,1527.24,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,1696.93,848.47,,1527.24,90,,,percent of total billed charges,90% of total Billed charges,632.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,455.91,155,,,Fee Schedule,155% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.91,145,,,Fee Schedule,145% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.82,145,,,Fee Schedule,145% of CMS OPPS Rate,455.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,1527.24,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,988.42,494.21,,889.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,790.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,889.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,909.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,631.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,777.41,78.65,,,percent of total billed charges,78.65% of total billed charges,882.97,89.33,,,percent of total billed charges,89.33% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,691.89,70,,,percent of total billed charges,70% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,939,95,,,percent of total billed charges,95% of total billed charges,939,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.04,86,,,percent of total billed charges,86% of total billed charges,790.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,919.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.23,958.77,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,988.42,494.21,,889.58,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,790.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,889.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,909.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,631.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,777.41,78.65,,,percent of total billed charges,78.65% of total billed charges,882.97,89.33,,,percent of total billed charges,89.33% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,691.89,70,,,percent of total billed charges,70% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,939,95,,,percent of total billed charges,95% of total billed charges,939,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.04,86,,,percent of total billed charges,86% of total billed charges,790.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,889.58,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,919.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,958.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.23,958.77,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,510,RC,95905,HCPCS,Outpatient,,,1777.31,888.66,,1599.58,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1421.85,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1599.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1723.99,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1635.13,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1599.58,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1244.12,70,,,percent of total billed charges,70% of total billed charges,1599.58,90,,,percent of total billed charges,90% of total billed charges,1688.44,95,,,percent of total billed charges,95% of total billed charges,1688.44,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1528.49,86,,,percent of total billed charges,86% of total billed charges,1421.85,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1723.99,97,,,percent of total billed charges,97% of total billed charges,1599.58,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1723.99,97,,,percent of total billed charges,97% of total billed charges,1652.9,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1723.99,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.72,1840.7,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,920,RC,95983,HCPCS,Outpatient,,,550.18,275.09,,495.16,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,440.14,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,495.16,90,,,Percent of total Billed charges,90% of total billed charges,44.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,533.67,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,506.17,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,495.16,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,385.13,70,,,percent of total billed charges,70% of total billed charges,495.16,90,,,percent of total billed charges,90% of total billed charges,522.67,95,,,percent of total billed charges,95% of total billed charges,522.67,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,473.15,86,,,percent of total billed charges,86% of total billed charges,440.14,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,533.67,97,,,percent of total billed charges,97% of total billed charges,495.16,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,533.67,97,,,percent of total billed charges,97% of total billed charges,511.67,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,533.67,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.82,533.67,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,920,RC,95984,HCPCS,Outpatient,,,679.95,339.98,,611.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,543.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,611.96,90,,,Percent of total Billed charges,90% of total billed charges,39.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,659.55,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,625.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,434.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,534.8,78.65,,,percent of total billed charges,78.65% of total billed charges,607.41,89.33,,,percent of total billed charges,89.33% of total billed charges,611.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,475.97,70,,,percent of total billed charges,70% of total billed charges,611.96,90,,,percent of total billed charges,90% of total billed charges,645.95,95,,,percent of total billed charges,95% of total billed charges,645.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.76,86,,,percent of total billed charges,86% of total billed charges,543.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,659.55,97,,,percent of total billed charges,97% of total billed charges,611.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,659.55,97,,,percent of total billed charges,97% of total billed charges,632.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,659.55,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,659.55,
"96130 - Psychological Testing, first hour",3438204,CDM,983,RC,96130,HCPCS,Outpatient,,,314.04,157.02,,282.64,90,,,percent of total billed charges,90% of total Billed charges,225.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,88.66,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,155.24,155,,,Fee Schedule,155% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.81,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,133.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,133.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,164.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,164.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,214.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,109.73,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.77,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,155.24,145,,,Fee Schedule,145% of CMS OPPS Rate,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.47,145,,,Fee Schedule,145% of CMS OPPS Rate,155.24,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,129.33,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,107.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.66,326.47,
96150 Health and Behavior Initial assessment each 15 min,3438181,CDM,983,RC,96150,HCPCS,Outpatient,,,61.08,30.54,,54.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,28.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.32,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.95,100,,,Case rate,Pays based on per visit rate,32.95,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.07,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,33.07,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.32,54.97,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,630.86,315.43,,567.77,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,504.69,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,611.93,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,580.39,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,567.77,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,441.6,70,,,percent of total billed charges,70% of total billed charges,567.77,90,,,percent of total billed charges,90% of total billed charges,599.32,95,,,percent of total billed charges,95% of total billed charges,599.32,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,542.54,86,,,percent of total billed charges,86% of total billed charges,504.69,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,611.93,97,,,percent of total billed charges,97% of total billed charges,567.77,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,611.93,97,,,percent of total billed charges,97% of total billed charges,586.7,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,611.93,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,611.93,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,926.3,463.15,,833.67,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,741.04,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,833.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,898.51,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,852.2,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,833.67,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,648.41,70,,,percent of total billed charges,70% of total billed charges,833.67,90,,,percent of total billed charges,90% of total billed charges,879.99,95,,,percent of total billed charges,95% of total billed charges,879.99,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,796.62,86,,,percent of total billed charges,86% of total billed charges,741.04,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,898.51,97,,,percent of total billed charges,97% of total billed charges,833.67,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.51,97,,,percent of total billed charges,97% of total billed charges,861.46,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,898.51,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,898.51,
"96360- Hydration, first hour",3428356,CDM,981,RC,96360,HCPCS,Outpatient,,,82.6,41.30,,74.34,90,,,percent of total billed charges,90% of total Billed charges,60.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,42.35,155,,,Fee Schedule,155% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,46.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,46.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.66,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.21,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,41.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.35,145,,,Fee Schedule,145% of CMS OPPS Rate,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.38,145,,,Fee Schedule,145% of CMS OPPS Rate,42.35,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,29.21,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,87.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,29.21,110.49,
"96361- Hydration, each additional hour",3428357,CDM,981,RC,96361,HCPCS,Outpatient,,,31.48,15.74,,28.33,90,,,percent of total billed charges,90% of total Billed charges,23.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,16.86,155,,,Fee Schedule,155% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,18.45,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.45,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.54,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.54,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,14.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,23.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.86,145,,,Fee Schedule,145% of CMS OPPS Rate,11.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.03,145,,,Fee Schedule,145% of CMS OPPS Rate,16.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.26,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,11.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.38,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,23.38,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,9,34.03,
"96365- IV tx, first hour",3428358,CDM,483,RC,96365,HCPCS,Outpatient,,,161.93,80.97,,145.74,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,129.54,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.74,90,,,Percent of total Billed charges,90% of total billed charges,43.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,157.07,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,148.98,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.74,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,113.35,70,,,percent of total billed charges,70% of total billed charges,145.74,90,,,percent of total billed charges,90% of total billed charges,153.83,95,,,percent of total billed charges,95% of total billed charges,153.83,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,139.26,86,,,percent of total billed charges,86% of total billed charges,129.54,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,157.07,97,,,percent of total billed charges,97% of total billed charges,145.74,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.07,97,,,percent of total billed charges,97% of total billed charges,150.59,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,157.07,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,39.3,1007.05,
"96366- IV tx, each additional hour",3428359,CDM,960,RC,96366,HCPCS,Outpatient,,,51.62,25.81,,46.46,90,,,percent of total billed charges,90% of total Billed charges,38.17,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12.29,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,27.2,155,,,Fee Schedule,155% of CMS OPPS Rate,18.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,29.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,29.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,29.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.91,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.2,145,,,Fee Schedule,145% of CMS OPPS Rate,18.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.35,145,,,Fee Schedule,145% of CMS OPPS Rate,27.2,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,34.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.29,55.35,
"96367- IV tx, sequential infusion",3428360,CDM,960,RC,96367,HCPCS,Outpatient,,,73.39,36.70,,66.05,90,,,percent of total billed charges,90% of total Billed charges,53.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,37.85,155,,,Fee Schedule,155% of CMS OPPS Rate,26.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,26.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,42.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,42.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,42.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,29.45,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,52.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,38.02,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.85,145,,,Fee Schedule,145% of CMS OPPS Rate,26.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.85,145,,,Fee Schedule,145% of CMS OPPS Rate,37.85,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,34.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,26.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.24,77.85,
"96368- IV tx, concurrent infusion",3428361,CDM,960,RC,96368,HCPCS,Outpatient,,,49.9,24.95,,44.91,90,,,percent of total billed charges,90% of total Billed charges,36.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.43,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.65,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.65,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,28.91,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,28.91,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.97,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,145,,,Fee Schedule,145% of CMS OPPS Rate,18.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.49,145,,,Fee Schedule,145% of CMS OPPS Rate,26.29,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,31.2,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,30.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,11.43,53.49,
96372 - IM/SQ injectin,3918946,CDM,510,RC,96372,HCPCS,Outpatient,,,391.8,195.90,,352.62,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,313.44,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.62,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,380.05,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,360.46,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,352.62,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,274.26,70,,,percent of total billed charges,70% of total billed charges,352.62,90,,,percent of total billed charges,90% of total billed charges,372.21,95,,,percent of total billed charges,95% of total billed charges,372.21,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,336.95,86,,,percent of total billed charges,86% of total billed charges,313.44,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,380.05,97,,,percent of total billed charges,97% of total billed charges,352.62,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.05,97,,,percent of total billed charges,97% of total billed charges,364.37,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,380.05,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,380.05,
96372 Injection of drug/substance under skin or into muscle,4137108,CDM,761,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,327.7,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,291.29,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.7,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.19,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,334.98,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,254.88,70,,,percent of total billed charges,70% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.13,86,,,percent of total billed charges,86% of total billed charges,291.29,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.19,97,,,percent of total billed charges,97% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.19,97,,,percent of total billed charges,97% of total billed charges,338.62,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.19,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,353.19,
96372- Subq/IM Injection,3428362,CDM,761,RC,96372,HCPCS,Outpatient,,,391.8,195.90,,352.62,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,313.44,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.62,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,380.05,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,360.46,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,352.62,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,274.26,70,,,percent of total billed charges,70% of total billed charges,352.62,90,,,percent of total billed charges,90% of total billed charges,372.21,95,,,percent of total billed charges,95% of total billed charges,372.21,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,336.95,86,,,percent of total billed charges,86% of total billed charges,313.44,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,380.05,97,,,percent of total billed charges,97% of total billed charges,352.62,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,380.05,97,,,percent of total billed charges,97% of total billed charges,364.37,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,380.05,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,380.05,
AMB Admin Injection Charge:IM/SQ Admin Charge 96372,3444224,CDM,260,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,327.7,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,291.29,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.7,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.19,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,334.98,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,254.88,70,,,percent of total billed charges,70% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.13,86,,,percent of total billed charges,86% of total billed charges,291.29,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.19,97,,,percent of total billed charges,97% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.19,97,,,percent of total billed charges,97% of total billed charges,338.62,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.19,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,353.19,
96373- Intra-Arterial Injection,3428363,CDM,940,RC,96373,HCPCS,Outpatient,,,44.39,22.20,,39.95,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,35.51,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.95,90,,,Percent of total Billed charges,90% of total billed charges,11.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,43.06,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,40.84,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.95,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,31.07,70,,,percent of total billed charges,70% of total billed charges,39.95,90,,,percent of total billed charges,90% of total billed charges,42.17,95,,,percent of total billed charges,95% of total billed charges,42.17,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,38.18,86,,,percent of total billed charges,86% of total billed charges,35.51,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,43.06,97,,,percent of total billed charges,97% of total billed charges,39.95,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,97,,,percent of total billed charges,97% of total billed charges,41.28,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,43.06,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.8,1007.05,
96374 - Ther/proph/diag inj iv push,3430547,CDM,940,RC,96374,HCPCS,Outpatient,,,1082.37,541.19,,974.13,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,865.9,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.13,90,,,Percent of total Billed charges,90% of total billed charges,34.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1049.9,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,995.78,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,974.13,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,757.66,70,,,percent of total billed charges,70% of total billed charges,974.13,90,,,percent of total billed charges,90% of total billed charges,1028.25,95,,,percent of total billed charges,95% of total billed charges,1028.25,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,930.84,86,,,percent of total billed charges,86% of total billed charges,865.9,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1049.9,97,,,percent of total billed charges,97% of total billed charges,974.13,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.9,97,,,percent of total billed charges,97% of total billed charges,1006.6,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1049.9,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.02,1049.9,
"96374- IV Injection, single/initial",3428364,CDM,940,RC,96374,HCPCS,Outpatient,,,1150.57,575.29,,1035.51,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,920.46,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1035.51,90,,,Percent of total Billed charges,90% of total billed charges,34.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1116.05,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,1058.52,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1035.51,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,805.4,70,,,percent of total billed charges,70% of total billed charges,1035.51,90,,,percent of total billed charges,90% of total billed charges,1093.04,95,,,percent of total billed charges,95% of total billed charges,1093.04,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,989.49,86,,,percent of total billed charges,86% of total billed charges,920.46,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1116.05,97,,,percent of total billed charges,97% of total billed charges,1035.51,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1116.05,97,,,percent of total billed charges,97% of total billed charges,1070.03,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1116.05,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.02,1116.05,
AMB Admin Injection Charge:IV Push Admin Charge 96374,3444223,CDM,771,RC,96374,HCPCS,Outpatient,,,68.2,34.10,,61.38,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,54.56,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.38,90,,,Percent of total Billed charges,90% of total billed charges,34.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,66.15,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,62.74,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,61.38,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,47.74,70,,,percent of total billed charges,70% of total billed charges,61.38,90,,,percent of total billed charges,90% of total billed charges,64.79,95,,,percent of total billed charges,95% of total billed charges,64.79,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.65,86,,,percent of total billed charges,86% of total billed charges,54.56,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,66.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,66.15,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.12,1007.05,
"96375- IV Injection, add new drug",3428365,CDM,981,RC,96375,HCPCS,Outpatient,,,38.71,19.36,,34.84,90,,,percent of total billed charges,90% of total Billed charges,28.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,14.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,13.01,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,20.31,155,,,Fee Schedule,155% of CMS OPPS Rate,14.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.76,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,14.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,19.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.32,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,22.32,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,28.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.31,145,,,Fee Schedule,145% of CMS OPPS Rate,14.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.43,145,,,Fee Schedule,145% of CMS OPPS Rate,20.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,14.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,14.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,33.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.01,46.74,
FBC IVP New,2058177,CDM,940,RC,96375,HCPCS,Outpatient,,,38.71,19.36,,34.84,90,,,percent of total billed charges,90% of total Billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,30.97,80,,,Percent of total Billed charges,80% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.84,90,,,Percent of total Billed charges,90% of total billed charges,14.31,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,37.55,97,,,Percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,35.61,92,,,Percent of total billed charges,92% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.84,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,27.1,70,,,percent of total billed charges,70% of total billed charges,34.84,90,,,percent of total billed charges,90% of total billed charges,36.77,95,,,percent of total billed charges,95% of total billed charges,36.77,95,,,percent of total billed charges,95% of total billed charges,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33.29,86,,,percent of total billed charges,86% of total billed charges,30.97,80,,,percent of total billed charges,80% of total billed charges,39.39,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,37.55,97,,,percent of total billed charges,97% of total billed charges,34.84,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.55,97,,,percent of total billed charges,97% of total billed charges,36,93,,,percent of total billed charges,93% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,37.55,97,,,percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.01,206.55,
Admin leuprolide Charge:INJ Admin Charge 96401,3444231,CDM,331,RC,96401,HCPCS,Outpatient,,,517.95,258.98,,466.16,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,414.36,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,466.16,90,,,Percent of total Billed charges,90% of total billed charges,55.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,502.41,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,476.51,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,466.16,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,362.57,70,,,percent of total billed charges,70% of total billed charges,466.16,90,,,percent of total billed charges,90% of total billed charges,492.05,95,,,percent of total billed charges,95% of total billed charges,492.05,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,445.44,86,,,percent of total billed charges,86% of total billed charges,414.36,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,502.41,97,,,percent of total billed charges,97% of total billed charges,466.16,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,502.41,97,,,percent of total billed charges,97% of total billed charges,481.69,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,502.41,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.23,502.41,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,331,RC,96402,HCPCS,Outpatient,,,408.33,204.17,,367.5,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,326.66,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.5,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,396.08,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,375.66,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.5,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,285.83,70,,,percent of total billed charges,70% of total billed charges,367.5,90,,,percent of total billed charges,90% of total billed charges,387.91,95,,,percent of total billed charges,95% of total billed charges,387.91,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,351.16,86,,,percent of total billed charges,86% of total billed charges,326.66,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,396.08,97,,,percent of total billed charges,97% of total billed charges,367.5,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.08,97,,,percent of total billed charges,97% of total billed charges,379.75,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.08,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,396.08,
Admin leuprolide Charge -> INJ Admin Charge 96402,3556751,CDM,331,RC,96402,HCPCS,Outpatient,,,80.5,40.25,,72.45,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,64.4,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.45,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.09,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,74.06,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,56.35,70,,,percent of total billed charges,70% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,76.48,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.23,86,,,percent of total billed charges,86% of total billed charges,64.4,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.09,97,,,percent of total billed charges,97% of total billed charges,72.45,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.09,97,,,percent of total billed charges,97% of total billed charges,74.87,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.09,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,328.92,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,408.33,204.17,,367.5,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,326.66,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,367.5,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,396.08,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,375.66,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,367.5,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,285.83,70,,,percent of total billed charges,70% of total billed charges,367.5,90,,,percent of total billed charges,90% of total billed charges,387.91,95,,,percent of total billed charges,95% of total billed charges,387.91,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,351.16,86,,,percent of total billed charges,86% of total billed charges,326.66,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,396.08,97,,,percent of total billed charges,97% of total billed charges,367.5,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,396.08,97,,,percent of total billed charges,97% of total billed charges,379.75,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.08,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,396.08,
96522 Refill/maint pump/resvr syst,3428367,CDM,983,RC,96522,HCPCS,Outpatient,,,291.42,145.71,,262.28,90,,,percent of total billed charges,90% of total Billed charges,212.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,163.37,90,,,Percent of total Billed charges,90% of total billed charges,86.85,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,149.89,155,,,Fee Schedule,155% of CMS OPPS Rate,103.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,133.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,163.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,163.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,91.67,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,206.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.89,145,,,Fee Schedule,145% of CMS OPPS Rate,103.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,308.76,145,,,Fee Schedule,145% of CMS OPPS Rate,149.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,142.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.78,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,168.78,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,86.85,308.76,
96523  Irrig drug delivery device,3428368,CDM,983,RC,96523,HCPCS,Outpatient,,,63.53,31.77,,57.18,90,,,percent of total billed charges,90% of total Billed charges,46.35,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,22.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,32.58,155,,,Fee Schedule,155% of CMS OPPS Rate,22.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,33.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.92,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.92,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.36,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.58,145,,,Fee Schedule,145% of CMS OPPS Rate,22.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.21,145,,,Fee Schedule,145% of CMS OPPS Rate,32.58,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,26.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,22.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.63,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,37.63,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,19.48,67.21,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,1136.12,568.06,,1022.51,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,908.9,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1022.51,90,,,Percent of total Billed charges,90% of total billed charges,64.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1102.04,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1045.23,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1022.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,795.28,70,,,percent of total billed charges,70% of total billed charges,1022.51,90,,,percent of total billed charges,90% of total billed charges,1079.31,95,,,percent of total billed charges,95% of total billed charges,1079.31,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,977.06,86,,,percent of total billed charges,86% of total billed charges,908.9,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1102.04,97,,,percent of total billed charges,97% of total billed charges,1022.51,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1102.04,97,,,percent of total billed charges,97% of total billed charges,1056.59,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1102.04,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.68,1102.04,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,1152.85,576.43,,1037.57,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,922.28,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1037.57,90,,,Percent of total Billed charges,90% of total billed charges,65.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1118.26,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,1060.62,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1037.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,807,70,,,percent of total billed charges,70% of total billed charges,1037.57,90,,,percent of total billed charges,90% of total billed charges,1095.21,95,,,percent of total billed charges,95% of total billed charges,1095.21,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,991.45,86,,,percent of total billed charges,86% of total billed charges,922.28,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1118.26,97,,,percent of total billed charges,97% of total billed charges,1037.57,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1118.26,97,,,percent of total billed charges,97% of total billed charges,1072.15,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1118.26,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.1,1118.26,
97010 Application Modality 1/> Areas Hot/Cold Packs,3436063,CDM,761,RC,97010,HCPCS,Outpatient,,,38.12,19.06,,34.31,90,,,percent of total billed charges,90% of total Billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,80,,,Percent of total Billed charges,80% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.98,97,,,Percent of total billed charges,97% of total billed charges,5.91,100,,,Fee Schedule,100% of CMS OPPS Rate,35.07,92,,,Percent of total billed charges,92% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.28,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,34.31,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.68,70,,,percent of total billed charges,70% of total billed charges,34.31,90,,,percent of total billed charges,90% of total billed charges,36.21,95,,,percent of total billed charges,95% of total billed charges,36.21,95,,,percent of total billed charges,95% of total billed charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.78,86,,,percent of total billed charges,86% of total billed charges,30.5,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,36.98,97,,,percent of total billed charges,97% of total billed charges,34.31,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.98,97,,,percent of total billed charges,97% of total billed charges,35.45,93,,,percent of total billed charges,93% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.98,97,,,percent of total billed charges,97% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.06,36.98,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,50.39,25.20,,45.35,90,,,percent of total billed charges,90% of total Billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,40.31,80,,,Percent of total Billed charges,80% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.88,97,,,Percent of total billed charges,97% of total billed charges,5.91,100,,,Fee Schedule,100% of CMS OPPS Rate,46.36,92,,,Percent of total billed charges,92% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.28,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,45.35,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,35.27,70,,,percent of total billed charges,70% of total billed charges,45.35,90,,,percent of total billed charges,90% of total billed charges,47.87,95,,,percent of total billed charges,95% of total billed charges,47.87,95,,,percent of total billed charges,95% of total billed charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,43.34,86,,,percent of total billed charges,86% of total billed charges,40.31,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,48.88,97,,,percent of total billed charges,97% of total billed charges,45.35,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.88,97,,,percent of total billed charges,97% of total billed charges,46.86,93,,,percent of total billed charges,93% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48.88,97,,,percent of total billed charges,97% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.06,48.88,
97014 Appl Modality 1/> Areas Elec Stimj Unattended,3351852,CDM,761,RC,97014,HCPCS,Outpatient,,,55.47,27.74,,49.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,44.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,49.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.81,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,51.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,35.42,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,43.63,78.65,,,percent of total billed charges,78.65% of total billed charges,49.55,89.33,,,percent of total billed charges,89.33% of total billed charges,49.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,38.83,70,,,percent of total billed charges,70% of total billed charges,49.92,90,,,percent of total billed charges,90% of total billed charges,52.7,95,,,percent of total billed charges,95% of total billed charges,52.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.7,86,,,percent of total billed charges,86% of total billed charges,44.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,53.81,97,,,percent of total billed charges,97% of total billed charges,49.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.81,97,,,percent of total billed charges,97% of total billed charges,51.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.81,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.42,53.81,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,229.19,114.60,,206.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,183.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,206.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,222.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,210.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,146.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,180.26,78.65,,,percent of total billed charges,78.65% of total billed charges,204.74,89.33,,,percent of total billed charges,89.33% of total billed charges,206.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,160.43,70,,,percent of total billed charges,70% of total billed charges,206.27,90,,,percent of total billed charges,90% of total billed charges,217.73,95,,,percent of total billed charges,95% of total billed charges,217.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.1,86,,,percent of total billed charges,86% of total billed charges,183.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,222.31,97,,,percent of total billed charges,97% of total billed charges,206.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,222.31,97,,,percent of total billed charges,97% of total billed charges,213.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,222.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.37,222.31,
97016 Appl Modality 1/> Areas Vasopneumatic Devices,3436064,CDM,761,RC,97016,HCPCS,Outpatient,,,30.28,15.14,,27.25,90,,,percent of total billed charges,90% of total Billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,80,,,Percent of total Billed charges,80% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.37,97,,,Percent of total billed charges,97% of total billed charges,11.14,100,,,Fee Schedule,100% of CMS OPPS Rate,27.86,92,,,Percent of total billed charges,92% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,45.39,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51.31,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,27.25,90,,,percent of total billed charges,90% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,21.2,70,,,percent of total billed charges,70% of total billed charges,27.25,90,,,percent of total billed charges,90% of total billed charges,28.77,95,,,percent of total billed charges,95% of total billed charges,28.77,95,,,percent of total billed charges,95% of total billed charges,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.04,86,,,percent of total billed charges,86% of total billed charges,24.22,80,,,percent of total billed charges,80% of total billed charges,13.2,111,,,Fee Schedule,111% of CMS OPPS Rate,29.37,97,,,percent of total billed charges,97% of total billed charges,27.25,90,,,percent of total billed charges,90% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.37,97,,,percent of total billed charges,97% of total billed charges,28.16,93,,,percent of total billed charges,93% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.37,97,,,percent of total billed charges,97% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,9.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.51,55.3,
PT Whirlpool Extremity,633288,CDM,420,RC,97022,HCPCS,Outpatient,,,42.81,21.41,,38.53,90,,,percent of total billed charges,90% of total Billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,34.25,80,,,Percent of total Billed charges,80% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.53,97,,,Percent of total billed charges,97% of total billed charges,15.75,100,,,Fee Schedule,100% of CMS OPPS Rate,39.39,92,,,Percent of total billed charges,92% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,64.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.09,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,72.45,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,38.53,90,,,percent of total billed charges,90% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,29.97,70,,,percent of total billed charges,70% of total billed charges,38.53,90,,,percent of total billed charges,90% of total billed charges,40.67,95,,,percent of total billed charges,95% of total billed charges,40.67,95,,,percent of total billed charges,95% of total billed charges,15.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,36.82,86,,,percent of total billed charges,86% of total billed charges,34.25,80,,,percent of total billed charges,80% of total billed charges,18.64,111,,,Fee Schedule,111% of CMS OPPS Rate,41.53,97,,,percent of total billed charges,97% of total billed charges,38.53,90,,,percent of total billed charges,90% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.53,97,,,percent of total billed charges,97% of total billed charges,39.81,93,,,percent of total billed charges,93% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.53,97,,,percent of total billed charges,97% of total billed charges,15.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.43,78.09,
97026 Application Modality 1/> Areas Infrared,3351933,CDM,761,RC,97026,HCPCS,Outpatient,,,16.09,8.05,,14.48,90,,,percent of total billed charges,90% of total Billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.87,80,,,Percent of total Billed charges,80% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.61,97,,,Percent of total billed charges,97% of total billed charges,6.2,100,,,Fee Schedule,100% of CMS OPPS Rate,14.8,92,,,Percent of total billed charges,92% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,14.48,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,11.26,70,,,percent of total billed charges,70% of total billed charges,14.48,90,,,percent of total billed charges,90% of total billed charges,15.29,95,,,percent of total billed charges,95% of total billed charges,15.29,95,,,percent of total billed charges,95% of total billed charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.84,86,,,percent of total billed charges,86% of total billed charges,12.87,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,15.61,97,,,percent of total billed charges,97% of total billed charges,14.48,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.61,97,,,percent of total billed charges,97% of total billed charges,14.96,93,,,percent of total billed charges,93% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.61,97,,,percent of total billed charges,97% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.31,30.89,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,44.1,22.05,,39.69,90,,,percent of total billed charges,90% of total Billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,35.28,80,,,Percent of total Billed charges,80% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.78,97,,,Percent of total billed charges,97% of total billed charges,6.2,100,,,Fee Schedule,100% of CMS OPPS Rate,40.57,92,,,Percent of total billed charges,92% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,39.69,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,30.87,70,,,percent of total billed charges,70% of total billed charges,39.69,90,,,percent of total billed charges,90% of total billed charges,41.9,95,,,percent of total billed charges,95% of total billed charges,41.9,95,,,percent of total billed charges,95% of total billed charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.93,86,,,percent of total billed charges,86% of total billed charges,35.28,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,42.78,97,,,percent of total billed charges,97% of total billed charges,39.69,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.78,97,,,percent of total billed charges,97% of total billed charges,41.01,93,,,percent of total billed charges,93% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,42.78,97,,,percent of total billed charges,97% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.31,42.78,
97035 Appl Modality 1/> Areas Ultrasound Ea 15 Min,3351853,CDM,761,RC,97035,HCPCS,Outpatient,,,36.22,18.11,,32.6,90,,,percent of total billed charges,90% of total Billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,28.98,80,,,Percent of total Billed charges,80% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.13,97,,,Percent of total billed charges,97% of total billed charges,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,33.32,92,,,Percent of total billed charges,92% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,62.64,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,32.6,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,70,,,percent of total billed charges,70% of total billed charges,32.6,90,,,percent of total billed charges,90% of total billed charges,34.41,95,,,percent of total billed charges,95% of total billed charges,34.41,95,,,percent of total billed charges,95% of total billed charges,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,31.15,86,,,percent of total billed charges,86% of total billed charges,28.98,80,,,percent of total billed charges,80% of total billed charges,15.43,111,,,Fee Schedule,111% of CMS OPPS Rate,35.13,97,,,percent of total billed charges,97% of total billed charges,32.6,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.13,97,,,percent of total billed charges,97% of total billed charges,33.68,93,,,percent of total billed charges,93% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35.13,97,,,percent of total billed charges,97% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.61,67.51,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,242.48,121.24,,218.23,90,,,percent of total billed charges,90% of total Billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,193.98,80,,,Percent of total Billed charges,80% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,235.21,97,,,Percent of total billed charges,97% of total billed charges,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,223.08,92,,,Percent of total billed charges,92% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,62.64,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,218.23,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,169.74,70,,,percent of total billed charges,70% of total billed charges,218.23,90,,,percent of total billed charges,90% of total billed charges,230.36,95,,,percent of total billed charges,95% of total billed charges,230.36,95,,,percent of total billed charges,95% of total billed charges,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208.53,86,,,percent of total billed charges,86% of total billed charges,193.98,80,,,percent of total billed charges,80% of total billed charges,15.43,111,,,Fee Schedule,111% of CMS OPPS Rate,235.21,97,,,percent of total billed charges,97% of total billed charges,218.23,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,235.21,97,,,percent of total billed charges,97% of total billed charges,225.51,93,,,percent of total billed charges,93% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,235.21,97,,,percent of total billed charges,97% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.61,235.21,
97039 Unlist Modality Spec Type&Time Constant Attend,3351932,CDM,761,RC,97039,HCPCS,Outpatient,,,159.93,79.97,,143.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,127.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,143.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,147.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,143.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,111.95,70,,,percent of total billed charges,70% of total billed charges,143.94,90,,,percent of total billed charges,90% of total billed charges,151.93,95,,,percent of total billed charges,95% of total billed charges,151.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.54,86,,,percent of total billed charges,86% of total billed charges,127.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,155.13,97,,,percent of total billed charges,97% of total billed charges,143.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.13,97,,,percent of total billed charges,97% of total billed charges,148.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.95,155.13,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,222.18,111.09,,199.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,177.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,199.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,204.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,199.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,155.53,70,,,percent of total billed charges,70% of total billed charges,199.96,90,,,percent of total billed charges,90% of total billed charges,211.07,95,,,percent of total billed charges,95% of total billed charges,211.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,191.07,86,,,percent of total billed charges,86% of total billed charges,177.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,215.51,97,,,percent of total billed charges,97% of total billed charges,199.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.51,97,,,percent of total billed charges,97% of total billed charges,206.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.53,215.51,
97110 Therapeutic Px 1/> Areas Each 15 Min Exercises,3436066,CDM,761,RC,97110,HCPCS,Outpatient,,,75.21,37.61,,67.69,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,60.17,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.95,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.19,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,67.69,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,52.65,70,,,percent of total billed charges,70% of total billed charges,67.69,90,,,percent of total billed charges,90% of total billed charges,71.45,95,,,percent of total billed charges,95% of total billed charges,71.45,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,64.68,86,,,percent of total billed charges,86% of total billed charges,60.17,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,72.95,97,,,percent of total billed charges,97% of total billed charges,67.69,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.95,97,,,percent of total billed charges,97% of total billed charges,69.95,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.95,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,137.94,
Chest PDP,634104,CDM,460,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,298.17,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,265.04,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,321.36,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,304.8,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,231.91,70,,,percent of total billed charges,70% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.92,86,,,percent of total billed charges,86% of total billed charges,265.04,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,321.36,97,,,percent of total billed charges,97% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.36,97,,,percent of total billed charges,97% of total billed charges,308.11,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.36,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,321.36,
OT Therapeutic Procedure 15 min,2012112,CDM,430,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,298.17,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,265.04,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,321.36,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,304.8,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,231.91,70,,,percent of total billed charges,70% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.92,86,,,percent of total billed charges,86% of total billed charges,265.04,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,321.36,97,,,percent of total billed charges,97% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.36,97,,,percent of total billed charges,97% of total billed charges,308.11,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.36,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,321.36,
PT Kinetic Leg Exerciser/CPM Application,633283,CDM,420,RC,97110,HCPCS,Outpatient,,,31.3,15.65,,28.17,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,25.04,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.36,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,28.8,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,28.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,21.91,70,,,percent of total billed charges,70% of total billed charges,28.17,90,,,percent of total billed charges,90% of total billed charges,29.74,95,,,percent of total billed charges,95% of total billed charges,29.74,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.92,86,,,percent of total billed charges,86% of total billed charges,25.04,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,30.36,97,,,percent of total billed charges,97% of total billed charges,28.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.36,97,,,percent of total billed charges,97% of total billed charges,29.11,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.36,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.91,137.94,
Therapeutic Procedure,633286,CDM,420,RC,97110,HCPCS,Outpatient,,,331.3,165.65,,298.17,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,265.04,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,321.36,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,304.8,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,231.91,70,,,percent of total billed charges,70% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,314.74,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.92,86,,,percent of total billed charges,86% of total billed charges,265.04,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,321.36,97,,,percent of total billed charges,97% of total billed charges,298.17,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.36,97,,,percent of total billed charges,97% of total billed charges,308.11,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.36,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,321.36,
97112 Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,3984924,CDM,761,RC,97112,HCPCS,Outpatient,,,86.9,43.45,,78.21,90,,,percent of total billed charges,90% of total Billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,69.52,80,,,Percent of total Billed charges,80% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,84.29,97,,,Percent of total billed charges,97% of total billed charges,31.89,100,,,Fee Schedule,100% of CMS OPPS Rate,79.95,92,,,Percent of total billed charges,92% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,129.57,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,146.46,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,78.21,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,60.83,70,,,percent of total billed charges,70% of total billed charges,78.21,90,,,percent of total billed charges,90% of total billed charges,82.56,95,,,percent of total billed charges,95% of total billed charges,82.56,95,,,percent of total billed charges,95% of total billed charges,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,74.73,86,,,percent of total billed charges,86% of total billed charges,69.52,80,,,percent of total billed charges,80% of total billed charges,37.51,111,,,Fee Schedule,111% of CMS OPPS Rate,84.29,97,,,percent of total billed charges,97% of total billed charges,78.21,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.29,97,,,percent of total billed charges,97% of total billed charges,80.82,93,,,percent of total billed charges,93% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.29,97,,,percent of total billed charges,97% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.15,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.15,157.86,
OT Neuro-Muscular Re-Ed 15 min,2012113,CDM,430,RC,97112,HCPCS,Outpatient,,,268.55,134.28,,241.7,90,,,percent of total billed charges,90% of total Billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,214.84,80,,,Percent of total Billed charges,80% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,241.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,260.49,97,,,Percent of total billed charges,97% of total billed charges,31.89,100,,,Fee Schedule,100% of CMS OPPS Rate,247.07,92,,,Percent of total billed charges,92% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,129.57,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,146.46,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,241.7,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,187.99,70,,,percent of total billed charges,70% of total billed charges,241.7,90,,,percent of total billed charges,90% of total billed charges,255.12,95,,,percent of total billed charges,95% of total billed charges,255.12,95,,,percent of total billed charges,95% of total billed charges,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,230.95,86,,,percent of total billed charges,86% of total billed charges,214.84,80,,,percent of total billed charges,80% of total billed charges,37.51,111,,,Fee Schedule,111% of CMS OPPS Rate,260.49,97,,,percent of total billed charges,97% of total billed charges,241.7,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,260.49,97,,,percent of total billed charges,97% of total billed charges,249.75,93,,,percent of total billed charges,93% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,260.49,97,,,percent of total billed charges,97% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.15,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.15,260.49,
PT Gait Training,633292,CDM,420,RC,97116,HCPCS,Outpatient,,,75.21,37.61,,67.69,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,60.17,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.95,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,69.19,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,67.69,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,52.65,70,,,percent of total billed charges,70% of total billed charges,67.69,90,,,percent of total billed charges,90% of total billed charges,71.45,95,,,percent of total billed charges,95% of total billed charges,71.45,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,64.68,86,,,percent of total billed charges,86% of total billed charges,60.17,80,,,percent of total billed charges,80% of total billed charges,32.41,111,,,Fee Schedule,111% of CMS OPPS Rate,72.95,97,,,percent of total billed charges,97% of total billed charges,67.69,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.95,97,,,percent of total billed charges,97% of total billed charges,69.95,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,72.95,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,137.94,
97124 Ther Px 1/> Areas Each 15 Min Massage,3436070,CDM,983,RC,97124,HCPCS,Outpatient,,,74.38,37.19,,66.94,90,,,percent of total billed charges,90% of total Billed charges,55.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.75,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,40.63,155,,,Fee Schedule,155% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,20.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.63,145,,,Fee Schedule,145% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.17,145,,,Fee Schedule,145% of CMS OPPS Rate,40.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.19,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,42.19,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,16.75,85,
PT Massage Soft Tissue,633285,CDM,421,RC,97124,HCPCS,Outpatient,,,198.13,99.07,,178.32,90,,,percent of total billed charges,90% of total Billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,158.5,80,,,Percent of total Billed charges,80% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,192.19,97,,,Percent of total billed charges,97% of total billed charges,27.97,100,,,Fee Schedule,100% of CMS OPPS Rate,182.28,92,,,Percent of total billed charges,92% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,113.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,128.48,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,178.32,90,,,percent of total billed charges,90% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,138.69,70,,,percent of total billed charges,70% of total billed charges,178.32,90,,,percent of total billed charges,90% of total billed charges,188.22,95,,,percent of total billed charges,95% of total billed charges,188.22,95,,,percent of total billed charges,95% of total billed charges,28.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,170.39,86,,,percent of total billed charges,86% of total billed charges,158.5,80,,,percent of total billed charges,80% of total billed charges,30.65,111,,,Fee Schedule,111% of CMS OPPS Rate,192.19,97,,,percent of total billed charges,97% of total billed charges,178.32,90,,,percent of total billed charges,90% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.19,97,,,percent of total billed charges,97% of total billed charges,184.26,93,,,percent of total billed charges,93% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,192.19,97,,,percent of total billed charges,97% of total billed charges,28.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.82,192.19,
97140 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,3436071,CDM,761,RC,97140,HCPCS,Outpatient,,,69.41,34.71,,62.47,90,,,percent of total billed charges,90% of total Billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,55.53,80,,,Percent of total Billed charges,80% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.33,97,,,Percent of total billed charges,97% of total billed charges,25.73,100,,,Fee Schedule,100% of CMS OPPS Rate,63.86,92,,,Percent of total billed charges,92% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,118.21,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,62.47,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,48.59,70,,,percent of total billed charges,70% of total billed charges,62.47,90,,,percent of total billed charges,90% of total billed charges,65.94,95,,,percent of total billed charges,95% of total billed charges,65.94,95,,,percent of total billed charges,95% of total billed charges,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,59.69,86,,,percent of total billed charges,86% of total billed charges,55.53,80,,,percent of total billed charges,80% of total billed charges,30.24,111,,,Fee Schedule,111% of CMS OPPS Rate,67.33,97,,,percent of total billed charges,97% of total billed charges,62.47,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.33,97,,,percent of total billed charges,97% of total billed charges,64.55,93,,,percent of total billed charges,93% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,67.33,97,,,percent of total billed charges,97% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.91,127.41,
OT Manual Therapy 15 min,2012116,CDM,430,RC,97140,HCPCS,Outpatient,,,282.92,141.46,,254.63,90,,,percent of total billed charges,90% of total Billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,226.34,80,,,Percent of total Billed charges,80% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,274.43,97,,,Percent of total billed charges,97% of total billed charges,25.73,100,,,Fee Schedule,100% of CMS OPPS Rate,260.29,92,,,Percent of total billed charges,92% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,118.21,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,254.63,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,198.04,70,,,percent of total billed charges,70% of total billed charges,254.63,90,,,percent of total billed charges,90% of total billed charges,268.77,95,,,percent of total billed charges,95% of total billed charges,268.77,95,,,percent of total billed charges,95% of total billed charges,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,243.31,86,,,percent of total billed charges,86% of total billed charges,226.34,80,,,percent of total billed charges,80% of total billed charges,30.24,111,,,Fee Schedule,111% of CMS OPPS Rate,274.43,97,,,percent of total billed charges,97% of total billed charges,254.63,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.43,97,,,percent of total billed charges,97% of total billed charges,263.12,93,,,percent of total billed charges,93% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,274.43,97,,,percent of total billed charges,97% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.91,274.43,
PT Joint Mobilization,605148,CDM,420,RC,97140,HCPCS,Outpatient,,,282.92,141.46,,254.63,90,,,percent of total billed charges,90% of total Billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,226.34,80,,,Percent of total Billed charges,80% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,274.43,97,,,Percent of total billed charges,97% of total billed charges,25.73,100,,,Fee Schedule,100% of CMS OPPS Rate,260.29,92,,,Percent of total billed charges,92% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,118.21,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,254.63,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,198.04,70,,,percent of total billed charges,70% of total billed charges,254.63,90,,,percent of total billed charges,90% of total billed charges,268.77,95,,,percent of total billed charges,95% of total billed charges,268.77,95,,,percent of total billed charges,95% of total billed charges,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,243.31,86,,,percent of total billed charges,86% of total billed charges,226.34,80,,,percent of total billed charges,80% of total billed charges,30.24,111,,,Fee Schedule,111% of CMS OPPS Rate,274.43,97,,,percent of total billed charges,97% of total billed charges,254.63,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.43,97,,,percent of total billed charges,97% of total billed charges,263.12,93,,,percent of total billed charges,93% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,274.43,97,,,percent of total billed charges,97% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.91,274.43,
97162-PT EVAL MOD COMPLEXITY,3430555,CDM,434,RC,97162,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,91.08,111,,,Fee Schedule,111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,470.9,
97163-PT EVAL HIGH COMPLEXITY,3430556,CDM,420,RC,97163,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,91.08,111,,,Fee Schedule,111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,470.9,
97164-PT RE-EVAL,3430557,CDM,420,RC,97164,HCPCS,Outpatient,,,307,153.50,,276.3,90,,,percent of total billed charges,90% of total Billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,245.6,80,,,Percent of total Billed charges,80% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.3,90,,,Percent of total Billed charges,90% of total billed charges,47.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,297.79,97,,,Percent of total billed charges,97% of total billed charges,65.53,100,,,Fee Schedule,100% of CMS OPPS Rate,282.44,92,,,Percent of total billed charges,92% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,266.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,65.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.81,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,301.35,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,276.3,90,,,percent of total billed charges,90% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,214.9,70,,,percent of total billed charges,70% of total billed charges,276.3,90,,,percent of total billed charges,90% of total billed charges,291.65,95,,,percent of total billed charges,95% of total billed charges,291.65,95,,,percent of total billed charges,95% of total billed charges,65.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,264.02,86,,,percent of total billed charges,86% of total billed charges,245.6,80,,,percent of total billed charges,80% of total billed charges,62.09,111,,,Fee Schedule,111% of CMS OPPS Rate,297.79,97,,,percent of total billed charges,97% of total billed charges,276.3,90,,,percent of total billed charges,90% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.79,97,,,percent of total billed charges,97% of total billed charges,285.51,93,,,percent of total billed charges,93% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.79,97,,,percent of total billed charges,97% of total billed charges,65.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.72,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,55.86,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.12,324.81,
97165 OT Eval Low Complex 30 Minutes,3436073,CDM,761,RC,97165,HCPCS,Outpatient,,,257.61,128.81,,231.85,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,206.09,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.88,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,237,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,180.33,70,,,percent of total billed charges,70% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,221.54,86,,,percent of total billed charges,86% of total billed charges,206.09,80,,,percent of total billed charges,80% of total billed charges,96.23,111,,,Fee Schedule,111% of CMS OPPS Rate,249.88,97,,,percent of total billed charges,97% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.88,97,,,percent of total billed charges,97% of total billed charges,239.58,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.88,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
OT Evaluation Low Complexity,3334508,CDM,434,RC,97165,HCPCS,Outpatient,,,619.47,309.74,,557.52,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,495.58,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,557.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,600.89,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,569.91,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,557.52,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,433.63,70,,,percent of total billed charges,70% of total billed charges,557.52,90,,,percent of total billed charges,90% of total billed charges,588.5,95,,,percent of total billed charges,95% of total billed charges,588.5,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,532.74,86,,,percent of total billed charges,86% of total billed charges,495.58,80,,,percent of total billed charges,80% of total billed charges,96.23,111,,,Fee Schedule,111% of CMS OPPS Rate,600.89,97,,,percent of total billed charges,97% of total billed charges,557.52,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,600.89,97,,,percent of total billed charges,97% of total billed charges,576.11,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,600.89,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,600.89,
97166 OT Eval Mod Complex 45 Minutes,3436074,CDM,761,RC,97166,HCPCS,Outpatient,,,257.61,128.81,,231.85,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,206.09,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.88,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,237,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,180.33,70,,,percent of total billed charges,70% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,221.54,86,,,percent of total billed charges,86% of total billed charges,206.09,80,,,percent of total billed charges,80% of total billed charges,95.88,111,,,Fee Schedule,111% of CMS OPPS Rate,249.88,97,,,percent of total billed charges,97% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.88,97,,,percent of total billed charges,97% of total billed charges,239.58,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.88,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
97167 OT Eval High Complex 60 Minutes,3436075,CDM,761,RC,97167,HCPCS,Outpatient,,,257.61,128.81,,231.85,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,206.09,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,249.88,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,237,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,180.33,70,,,percent of total billed charges,70% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,244.73,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,221.54,86,,,percent of total billed charges,86% of total billed charges,206.09,80,,,percent of total billed charges,80% of total billed charges,95.88,111,,,Fee Schedule,111% of CMS OPPS Rate,249.88,97,,,percent of total billed charges,97% of total billed charges,231.85,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.88,97,,,percent of total billed charges,97% of total billed charges,239.58,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,249.88,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
97168 OT Re-Eval Est Plan Care 30 Minutes,3436076,CDM,761,RC,97168,HCPCS,Outpatient,,,175.67,87.84,,158.1,90,,,percent of total billed charges,90% of total Billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,140.54,80,,,Percent of total Billed charges,80% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.1,90,,,Percent of total Billed charges,90% of total billed charges,44.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,170.4,97,,,Percent of total billed charges,97% of total billed charges,65.24,100,,,Fee Schedule,100% of CMS OPPS Rate,161.62,92,,,Percent of total billed charges,92% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,265.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,300.02,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,158.1,90,,,percent of total billed charges,90% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,122.97,70,,,percent of total billed charges,70% of total billed charges,158.1,90,,,percent of total billed charges,90% of total billed charges,166.89,95,,,percent of total billed charges,95% of total billed charges,166.89,95,,,percent of total billed charges,95% of total billed charges,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.08,86,,,percent of total billed charges,86% of total billed charges,140.54,80,,,percent of total billed charges,80% of total billed charges,65.87,111,,,Fee Schedule,111% of CMS OPPS Rate,170.4,97,,,percent of total billed charges,97% of total billed charges,158.1,90,,,percent of total billed charges,90% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.4,97,,,percent of total billed charges,97% of total billed charges,163.37,93,,,percent of total billed charges,93% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,170.4,97,,,percent of total billed charges,97% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,55.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.69,323.38,
97530 Therapeut Activity Direct  Contact Each 15 Min,3436077,CDM,761,RC,97530,HCPCS,Outpatient,,,93.23,46.62,,83.91,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,74.58,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,83.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,90.43,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,85.77,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,83.91,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,65.26,70,,,percent of total billed charges,70% of total billed charges,83.91,90,,,percent of total billed charges,90% of total billed charges,88.57,95,,,percent of total billed charges,95% of total billed charges,88.57,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.18,86,,,percent of total billed charges,86% of total billed charges,74.58,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,90.43,97,,,percent of total billed charges,97% of total billed charges,83.91,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.43,97,,,percent of total billed charges,97% of total billed charges,86.7,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.43,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,170.86,
OT Therapeutic Activity 15 min,2012117,CDM,430,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,217.67,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.49,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.6,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,222.51,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,169.3,70,,,percent of total billed charges,70% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208,86,,,percent of total billed charges,86% of total billed charges,193.49,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,234.6,97,,,percent of total billed charges,97% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,97,,,percent of total billed charges,97% of total billed charges,224.93,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,234.6,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,234.6,
PT Cardiac Rehab,633290,CDM,421,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,217.67,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.49,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.6,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,222.51,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,169.3,70,,,percent of total billed charges,70% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208,86,,,percent of total billed charges,86% of total billed charges,193.49,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,234.6,97,,,percent of total billed charges,97% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,97,,,percent of total billed charges,97% of total billed charges,224.93,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,234.6,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,234.6,
PT for Transfer Training,605155,CDM,421,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,217.67,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.49,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.6,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,222.51,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,169.3,70,,,percent of total billed charges,70% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208,86,,,percent of total billed charges,86% of total billed charges,193.49,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,234.6,97,,,percent of total billed charges,97% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,97,,,percent of total billed charges,97% of total billed charges,224.93,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,234.6,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,234.6,
PT Functional Therapeutic Activity,605162,CDM,420,RC,97530,HCPCS,Outpatient,,,241.86,120.93,,217.67,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,193.49,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.6,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,222.51,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,169.3,70,,,percent of total billed charges,70% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,229.77,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,208,86,,,percent of total billed charges,86% of total billed charges,193.49,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,234.6,97,,,percent of total billed charges,97% of total billed charges,217.67,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,234.6,97,,,percent of total billed charges,97% of total billed charges,224.93,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,234.6,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,234.6,
97535 Self Care Mngment Training,3436078,CDM,761,RC,97535,HCPCS,Outpatient,,,83.1,41.55,,74.79,90,,,percent of total billed charges,90% of total Billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,66.48,80,,,Percent of total Billed charges,80% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.61,97,,,Percent of total billed charges,97% of total billed charges,30.78,100,,,Fee Schedule,100% of CMS OPPS Rate,76.45,92,,,Percent of total billed charges,92% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,125.07,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,141.37,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,74.79,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,58.17,70,,,percent of total billed charges,70% of total billed charges,74.79,90,,,percent of total billed charges,90% of total billed charges,78.95,95,,,percent of total billed charges,95% of total billed charges,78.95,95,,,percent of total billed charges,95% of total billed charges,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.47,86,,,percent of total billed charges,86% of total billed charges,66.48,80,,,percent of total billed charges,80% of total billed charges,36.19,111,,,Fee Schedule,111% of CMS OPPS Rate,80.61,97,,,percent of total billed charges,97% of total billed charges,74.79,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.61,97,,,percent of total billed charges,97% of total billed charges,77.28,93,,,percent of total billed charges,93% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.61,97,,,percent of total billed charges,97% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.83,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,152.37,
OT ADL's 15 min,2012120,CDM,430,RC,97535,HCPCS,Outpatient,,,237.28,118.64,,213.55,90,,,percent of total billed charges,90% of total Billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,189.82,80,,,Percent of total Billed charges,80% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,230.16,97,,,Percent of total billed charges,97% of total billed charges,30.78,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,92,,,Percent of total billed charges,92% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,125.07,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,141.37,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,213.55,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,166.1,70,,,percent of total billed charges,70% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.06,86,,,percent of total billed charges,86% of total billed charges,189.82,80,,,percent of total billed charges,80% of total billed charges,36.19,111,,,Fee Schedule,111% of CMS OPPS Rate,230.16,97,,,percent of total billed charges,97% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.16,97,,,percent of total billed charges,97% of total billed charges,220.67,93,,,percent of total billed charges,93% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.16,97,,,percent of total billed charges,97% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.83,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,230.16,
PT ADLs,633291,CDM,421,RC,97535,HCPCS,Outpatient,,,237.28,118.64,,213.55,90,,,percent of total billed charges,90% of total Billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,189.82,80,,,Percent of total Billed charges,80% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,230.16,97,,,Percent of total billed charges,97% of total billed charges,30.78,100,,,Fee Schedule,100% of CMS OPPS Rate,218.3,92,,,Percent of total billed charges,92% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,125.07,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,141.37,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,213.55,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,166.1,70,,,percent of total billed charges,70% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,225.42,95,,,percent of total billed charges,95% of total billed charges,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.06,86,,,percent of total billed charges,86% of total billed charges,189.82,80,,,percent of total billed charges,80% of total billed charges,36.19,111,,,Fee Schedule,111% of CMS OPPS Rate,230.16,97,,,percent of total billed charges,97% of total billed charges,213.55,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,230.16,97,,,percent of total billed charges,97% of total billed charges,220.67,93,,,percent of total billed charges,93% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,230.16,97,,,percent of total billed charges,97% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.83,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,230.16,
97537 Community or Work Reint Training Ea 15 Min,4305641,CDM,761,RC,97537,HCPCS,Outpatient,,,185.71,92.86,,167.14,90,,,percent of total billed charges,90% of total Billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,148.57,80,,,Percent of total Billed charges,80% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,167.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,180.14,97,,,Percent of total billed charges,97% of total billed charges,30.05,100,,,Fee Schedule,100% of CMS OPPS Rate,170.85,92,,,Percent of total billed charges,92% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,122.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,138.02,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,167.14,90,,,percent of total billed charges,90% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,130,70,,,percent of total billed charges,70% of total billed charges,167.14,90,,,percent of total billed charges,90% of total billed charges,176.42,95,,,percent of total billed charges,95% of total billed charges,176.42,95,,,percent of total billed charges,95% of total billed charges,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,159.71,86,,,percent of total billed charges,86% of total billed charges,148.57,80,,,percent of total billed charges,80% of total billed charges,34.99,111,,,Fee Schedule,111% of CMS OPPS Rate,180.14,97,,,percent of total billed charges,97% of total billed charges,167.14,90,,,percent of total billed charges,90% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.14,97,,,percent of total billed charges,97% of total billed charges,172.71,93,,,percent of total billed charges,93% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,180.14,97,,,percent of total billed charges,97% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.1,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,25.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.59,180.14,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,1083.14,541.57,,974.83,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,866.51,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.83,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1050.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,996.49,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,974.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,758.2,70,,,percent of total billed charges,70% of total billed charges,974.83,90,,,percent of total billed charges,90% of total billed charges,1028.98,95,,,percent of total billed charges,95% of total billed charges,1028.98,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,931.5,86,,,percent of total billed charges,86% of total billed charges,866.51,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1050.65,97,,,percent of total billed charges,97% of total billed charges,974.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1050.65,97,,,percent of total billed charges,97% of total billed charges,1007.32,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1050.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,1050.65,
97597 Debridement Open Wound 20 Sq Cm/<,3436079,CDM,761,RC,97597,HCPCS,Outpatient,,,251.52,125.76,,226.37,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,201.22,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.37,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,243.97,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,231.4,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,226.37,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,176.06,70,,,percent of total billed charges,70% of total billed charges,226.37,90,,,percent of total billed charges,90% of total billed charges,238.94,95,,,percent of total billed charges,95% of total billed charges,238.94,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,216.31,86,,,percent of total billed charges,86% of total billed charges,201.22,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,243.97,97,,,percent of total billed charges,97% of total billed charges,226.37,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.97,97,,,percent of total billed charges,97% of total billed charges,233.91,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,243.97,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,880.34,
Selective Debridement <20 sq centimeters,845982,CDM,420,RC,97597,HCPCS,Outpatient,,,1083.14,541.57,,974.83,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,866.51,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.83,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1050.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,996.49,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,974.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,758.2,70,,,percent of total billed charges,70% of total billed charges,974.83,90,,,percent of total billed charges,90% of total billed charges,1028.98,95,,,percent of total billed charges,95% of total billed charges,1028.98,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,931.5,86,,,percent of total billed charges,86% of total billed charges,866.51,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1050.65,97,,,percent of total billed charges,97% of total billed charges,974.83,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1050.65,97,,,percent of total billed charges,97% of total billed charges,1007.32,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1050.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,1050.65,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,404.93,202.47,,364.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,323.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,364.44,90,,,Percent of total Billed charges,90% of total billed charges,12.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,392.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,372.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,283.45,70,,,percent of total billed charges,70% of total billed charges,364.44,90,,,percent of total billed charges,90% of total billed charges,384.68,95,,,percent of total billed charges,95% of total billed charges,384.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.24,86,,,percent of total billed charges,86% of total billed charges,323.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,392.78,97,,,percent of total billed charges,97% of total billed charges,364.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,392.78,97,,,percent of total billed charges,97% of total billed charges,376.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,392.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,392.78,
97598 Debridement Open Wound Each Addtl 20 Sq Cm,3436082,CDM,761,RC,97598,HCPCS,Outpatient,,,115.34,57.67,,103.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,92.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,103.81,90,,,Percent of total Billed charges,90% of total billed charges,12.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,111.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,106.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80.74,70,,,percent of total billed charges,70% of total billed charges,103.81,90,,,percent of total billed charges,90% of total billed charges,109.57,95,,,percent of total billed charges,95% of total billed charges,109.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.19,86,,,percent of total billed charges,86% of total billed charges,92.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,111.88,97,,,percent of total billed charges,97% of total billed charges,103.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,111.88,97,,,percent of total billed charges,97% of total billed charges,107.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,111.88,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,1059.66,529.83,,953.69,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,847.73,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,953.69,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1027.87,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,974.89,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,953.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,741.76,70,,,percent of total billed charges,70% of total billed charges,953.69,90,,,percent of total billed charges,90% of total billed charges,1006.68,95,,,percent of total billed charges,95% of total billed charges,1006.68,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,911.31,86,,,percent of total billed charges,86% of total billed charges,847.73,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1027.87,97,,,percent of total billed charges,97% of total billed charges,953.69,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,1027.87,97,,,percent of total billed charges,97% of total billed charges,985.48,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1027.87,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,1027.87,
97602 Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,3436083,CDM,761,RC,97602,HCPCS,Outpatient,,,438.79,219.40,,394.91,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,351.03,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,394.91,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,425.63,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,403.69,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,394.91,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,307.15,70,,,percent of total billed charges,70% of total billed charges,394.91,90,,,percent of total billed charges,90% of total billed charges,416.85,95,,,percent of total billed charges,95% of total billed charges,416.85,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,377.36,86,,,percent of total billed charges,86% of total billed charges,351.03,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,425.63,97,,,percent of total billed charges,97% of total billed charges,394.91,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,425.63,97,,,percent of total billed charges,97% of total billed charges,408.07,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,425.63,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,880.35,
97605 Negative Pressure Wound Therapy DME <=50 Sq Cm,3436085,CDM,761,RC,97605,HCPCS,Outpatient,,,106.51,53.26,,95.86,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,85.21,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,103.31,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,97.99,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,74.56,70,,,percent of total billed charges,70% of total billed charges,95.86,90,,,percent of total billed charges,90% of total billed charges,101.18,95,,,percent of total billed charges,95% of total billed charges,101.18,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.6,86,,,percent of total billed charges,86% of total billed charges,85.21,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,103.31,97,,,percent of total billed charges,97% of total billed charges,95.86,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.31,97,,,percent of total billed charges,97% of total billed charges,99.05,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,103.31,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,74.56,880.35,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,2066.92,1033.46,,1860.23,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1653.54,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1860.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2004.91,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1901.57,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1860.23,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1446.84,70,,,percent of total billed charges,70% of total billed charges,1860.23,90,,,percent of total billed charges,90% of total billed charges,1963.57,95,,,percent of total billed charges,95% of total billed charges,1963.57,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1777.55,86,,,percent of total billed charges,86% of total billed charges,1653.54,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2004.91,97,,,percent of total billed charges,97% of total billed charges,1860.23,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,2004.91,97,,,percent of total billed charges,97% of total billed charges,1922.24,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2004.91,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,2004.91,
97606 Negative Pressure Wound Therapy DME >50 Sq Cm,3436088,CDM,761,RC,97606,HCPCS,Outpatient,,,125.33,62.67,,112.8,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,100.26,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,121.57,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,115.3,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.8,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,87.73,70,,,percent of total billed charges,70% of total billed charges,112.8,90,,,percent of total billed charges,90% of total billed charges,119.06,95,,,percent of total billed charges,95% of total billed charges,119.06,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.78,86,,,percent of total billed charges,86% of total billed charges,100.26,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.57,97,,,percent of total billed charges,97% of total billed charges,112.8,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.57,97,,,percent of total billed charges,97% of total billed charges,116.56,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,121.57,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87.73,1818.76,
97607 Negative Pressure Wound Therapy Non DME <=50 Sq Cm,3351838,CDM,761,RC,97607,HCPCS,Outpatient,,,913.56,456.78,,822.2,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,730.85,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,822.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,886.15,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,840.48,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,822.2,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,639.49,70,,,percent of total billed charges,70% of total billed charges,822.2,90,,,percent of total billed charges,90% of total billed charges,867.88,95,,,percent of total billed charges,95% of total billed charges,867.88,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,785.66,86,,,percent of total billed charges,86% of total billed charges,730.85,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,886.15,97,,,percent of total billed charges,97% of total billed charges,822.2,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.15,97,,,percent of total billed charges,97% of total billed charges,849.61,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,886.15,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288,1818.76,
97608 Negative Pressure Wound Therapy Non DME >50 Sq Cm,3351843,CDM,761,RC,97608,HCPCS,Outpatient,,,902.65,451.33,,812.39,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,722.12,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,812.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,875.57,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,830.44,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,812.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,631.86,70,,,percent of total billed charges,70% of total billed charges,812.39,90,,,percent of total billed charges,90% of total billed charges,857.52,95,,,percent of total billed charges,95% of total billed charges,857.52,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,776.28,86,,,percent of total billed charges,86% of total billed charges,722.12,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,875.57,97,,,percent of total billed charges,97% of total billed charges,812.39,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,875.57,97,,,percent of total billed charges,97% of total billed charges,839.46,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,875.57,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288,1818.76,
97750 Physical Perf Test/Meas w/ Reprt Ea 15 Min,4305640,CDM,761,RC,97750,HCPCS,Outpatient,,,199.73,99.87,,179.76,90,,,percent of total billed charges,90% of total Billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,159.78,80,,,Percent of total Billed charges,80% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,193.74,97,,,Percent of total billed charges,97% of total billed charges,31.65,100,,,Fee Schedule,100% of CMS OPPS Rate,183.75,92,,,Percent of total billed charges,92% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,128.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.67,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,145.36,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,179.76,90,,,percent of total billed charges,90% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,139.81,70,,,percent of total billed charges,70% of total billed charges,179.76,90,,,percent of total billed charges,90% of total billed charges,189.74,95,,,percent of total billed charges,95% of total billed charges,189.74,95,,,percent of total billed charges,95% of total billed charges,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,171.77,86,,,percent of total billed charges,86% of total billed charges,159.78,80,,,percent of total billed charges,80% of total billed charges,36.87,111,,,Fee Schedule,111% of CMS OPPS Rate,193.74,97,,,percent of total billed charges,97% of total billed charges,179.76,90,,,percent of total billed charges,90% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.74,97,,,percent of total billed charges,97% of total billed charges,185.75,93,,,percent of total billed charges,93% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,193.74,97,,,percent of total billed charges,97% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.7,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.95,193.74,
97760 Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,3436091,CDM,761,RC,97760,HCPCS,Outpatient,,,120.87,60.44,,108.78,90,,,percent of total billed charges,90% of total Billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,96.7,80,,,Percent of total Billed charges,80% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.24,97,,,Percent of total billed charges,97% of total billed charges,44.71,100,,,Fee Schedule,100% of CMS OPPS Rate,111.2,92,,,Percent of total billed charges,92% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,181.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,205.24,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,108.78,90,,,percent of total billed charges,90% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,84.61,70,,,percent of total billed charges,70% of total billed charges,108.78,90,,,percent of total billed charges,90% of total billed charges,114.83,95,,,percent of total billed charges,95% of total billed charges,114.83,95,,,percent of total billed charges,95% of total billed charges,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,103.95,86,,,percent of total billed charges,86% of total billed charges,96.7,80,,,percent of total billed charges,80% of total billed charges,51.24,111,,,Fee Schedule,111% of CMS OPPS Rate,117.24,97,,,percent of total billed charges,97% of total billed charges,108.78,90,,,percent of total billed charges,90% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.24,97,,,percent of total billed charges,97% of total billed charges,112.41,93,,,percent of total billed charges,93% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.24,97,,,percent of total billed charges,97% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.05,221.22,
97761- Prosthetic train/UE/LE/ea 15 min,3435932,CDM,510,RC,97761,HCPCS,Outpatient,,,104.27,52.14,,93.84,90,,,percent of total billed charges,90% of total Billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,83.42,80,,,Percent of total Billed charges,80% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,101.14,97,,,Percent of total billed charges,97% of total billed charges,38.89,100,,,Fee Schedule,100% of CMS OPPS Rate,95.93,92,,,Percent of total billed charges,92% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,157.93,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,178.51,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,93.84,90,,,percent of total billed charges,90% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,72.99,70,,,percent of total billed charges,70% of total billed charges,93.84,90,,,percent of total billed charges,90% of total billed charges,99.06,95,,,percent of total billed charges,95% of total billed charges,99.06,95,,,percent of total billed charges,95% of total billed charges,38.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,77.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,89.67,86,,,percent of total billed charges,86% of total billed charges,83.42,80,,,percent of total billed charges,80% of total billed charges,44.02,111,,,Fee Schedule,111% of CMS OPPS Rate,101.14,97,,,percent of total billed charges,97% of total billed charges,93.84,90,,,percent of total billed charges,90% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.14,97,,,percent of total billed charges,97% of total billed charges,96.97,93,,,percent of total billed charges,93% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,101.14,97,,,percent of total billed charges,97% of total billed charges,38.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,33.09,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33.09,192.4,
97763 Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,3436092,CDM,761,RC,97763,HCPCS,Outpatient,,,133.23,66.62,,119.91,90,,,percent of total billed charges,90% of total Billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,106.58,80,,,Percent of total Billed charges,80% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.23,97,,,Percent of total billed charges,97% of total billed charges,48.7,100,,,Fee Schedule,100% of CMS OPPS Rate,122.57,92,,,Percent of total billed charges,92% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,197.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,223.54,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,119.91,90,,,percent of total billed charges,90% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,93.26,70,,,percent of total billed charges,70% of total billed charges,119.91,90,,,percent of total billed charges,90% of total billed charges,126.57,95,,,percent of total billed charges,95% of total billed charges,126.57,95,,,percent of total billed charges,95% of total billed charges,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,114.58,86,,,percent of total billed charges,86% of total billed charges,106.58,80,,,percent of total billed charges,80% of total billed charges,54.56,111,,,Fee Schedule,111% of CMS OPPS Rate,129.23,97,,,percent of total billed charges,97% of total billed charges,119.91,90,,,percent of total billed charges,90% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,129.23,97,,,percent of total billed charges,97% of total billed charges,123.9,93,,,percent of total billed charges,93% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,129.23,97,,,percent of total billed charges,97% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.75,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,41.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.44,240.94,
97804- Med nutri tx/re-asses/2 or>/30 min,3435563,CDM,510,RC,97804,HCPCS,Outpatient,,,43.06,21.53,,38.75,90,,,percent of total billed charges,90% of total Billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,34.45,80,,,Percent of total Billed charges,80% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.77,97,,,Percent of total billed charges,97% of total billed charges,14.68,100,,,Fee Schedule,100% of CMS OPPS Rate,39.62,92,,,Percent of total billed charges,92% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,59.71,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,14.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.75,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,67.5,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,38.75,90,,,percent of total billed charges,90% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,30.14,70,,,percent of total billed charges,70% of total billed charges,38.75,90,,,percent of total billed charges,90% of total billed charges,40.91,95,,,percent of total billed charges,95% of total billed charges,40.91,95,,,percent of total billed charges,95% of total billed charges,14.72,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.03,86,,,percent of total billed charges,86% of total billed charges,34.45,80,,,percent of total billed charges,80% of total billed charges,17.03,111,,,Fee Schedule,111% of CMS OPPS Rate,41.77,97,,,percent of total billed charges,97% of total billed charges,38.75,90,,,percent of total billed charges,90% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.77,97,,,percent of total billed charges,97% of total billed charges,40.05,93,,,percent of total billed charges,93% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,41.77,97,,,percent of total billed charges,97% of total billed charges,14.72,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.72,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,12.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.51,72.75,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,510,RC,98925,HCPCS,Outpatient,,,61.75,30.88,,55.58,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,49.4,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.9,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.81,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,55.58,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,43.23,70,,,percent of total billed charges,70% of total billed charges,55.58,90,,,percent of total billed charges,90% of total billed charges,58.66,95,,,percent of total billed charges,95% of total billed charges,58.66,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,53.11,86,,,percent of total billed charges,86% of total billed charges,49.4,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,59.9,97,,,percent of total billed charges,97% of total billed charges,55.58,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.9,97,,,percent of total billed charges,97% of total billed charges,57.43,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,59.9,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,510,RC,98925,HCPCS,Outpatient,,,80.71,40.36,,72.64,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,64.57,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.29,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,74.25,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.64,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,56.5,70,,,percent of total billed charges,70% of total billed charges,72.64,90,,,percent of total billed charges,90% of total billed charges,76.67,95,,,percent of total billed charges,95% of total billed charges,76.67,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.41,86,,,percent of total billed charges,86% of total billed charges,64.57,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.29,97,,,percent of total billed charges,97% of total billed charges,72.64,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.29,97,,,percent of total billed charges,97% of total billed charges,75.06,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,78.29,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,761,RC,98926,HCPCS,Outpatient,,,82.01,41.01,,73.81,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,65.61,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,79.55,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,75.45,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,73.81,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,57.41,70,,,percent of total billed charges,70% of total billed charges,73.81,90,,,percent of total billed charges,90% of total billed charges,77.91,95,,,percent of total billed charges,95% of total billed charges,77.91,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,70.53,86,,,percent of total billed charges,86% of total billed charges,65.61,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,79.55,97,,,percent of total billed charges,97% of total billed charges,73.81,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,79.55,97,,,percent of total billed charges,97% of total billed charges,76.27,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,79.55,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,510,RC,98927,HCPCS,Outpatient,,,121.51,60.76,,109.36,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,97.21,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,117.86,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,111.79,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,109.36,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,85.06,70,,,percent of total billed charges,70% of total billed charges,109.36,90,,,percent of total billed charges,90% of total billed charges,115.43,95,,,percent of total billed charges,95% of total billed charges,115.43,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,104.5,86,,,percent of total billed charges,86% of total billed charges,97.21,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,117.86,97,,,percent of total billed charges,97% of total billed charges,109.36,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.86,97,,,percent of total billed charges,97% of total billed charges,113,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.86,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,510,RC,98927,HCPCS,Outpatient,,,149.13,74.57,,134.22,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,119.3,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,144.66,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,137.2,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,134.22,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,104.39,70,,,percent of total billed charges,70% of total billed charges,134.22,90,,,percent of total billed charges,90% of total billed charges,141.67,95,,,percent of total billed charges,95% of total billed charges,141.67,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,128.25,86,,,percent of total billed charges,86% of total billed charges,119.3,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,144.66,97,,,percent of total billed charges,97% of total billed charges,134.22,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.66,97,,,percent of total billed charges,97% of total billed charges,138.69,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,144.66,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,144.66,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,510,RC,98928,HCPCS,Outpatient,,,153.82,76.91,,138.44,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,123.06,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,149.21,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,141.51,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,138.44,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,107.67,70,,,percent of total billed charges,70% of total billed charges,138.44,90,,,percent of total billed charges,90% of total billed charges,146.13,95,,,percent of total billed charges,95% of total billed charges,146.13,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,132.29,86,,,percent of total billed charges,86% of total billed charges,123.06,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,149.21,97,,,percent of total billed charges,97% of total billed charges,138.44,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.21,97,,,percent of total billed charges,97% of total billed charges,143.05,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,149.21,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,149.21,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,510,RC,98928,HCPCS,Outpatient,,,183.81,91.91,,165.43,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,147.05,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,178.3,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,169.11,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,165.43,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,128.67,70,,,percent of total billed charges,70% of total billed charges,165.43,90,,,percent of total billed charges,90% of total billed charges,174.62,95,,,percent of total billed charges,95% of total billed charges,174.62,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,158.08,86,,,percent of total billed charges,86% of total billed charges,147.05,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,178.3,97,,,percent of total billed charges,97% of total billed charges,165.43,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.3,97,,,percent of total billed charges,97% of total billed charges,170.94,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,178.3,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,178.3,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,510,RC,98929,HCPCS,Outpatient,,,185.36,92.68,,166.82,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,148.29,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.8,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,170.53,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,166.82,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,129.75,70,,,percent of total billed charges,70% of total billed charges,166.82,90,,,percent of total billed charges,90% of total billed charges,176.09,95,,,percent of total billed charges,95% of total billed charges,176.09,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,159.41,86,,,percent of total billed charges,86% of total billed charges,148.29,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,179.8,97,,,percent of total billed charges,97% of total billed charges,166.82,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.8,97,,,percent of total billed charges,97% of total billed charges,172.38,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,179.8,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,179.8,
98960 - Education Training for self-mgmt,4323185,CDM,761,RC,98960,HCPCS,Outpatient,,,52.56,26.28,,47.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,42.05,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,48.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.79,70,,,percent of total billed charges,70% of total billed charges,47.3,90,,,percent of total billed charges,90% of total billed charges,49.93,95,,,percent of total billed charges,95% of total billed charges,49.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.2,86,,,percent of total billed charges,86% of total billed charges,42.05,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,50.98,97,,,percent of total billed charges,97% of total billed charges,47.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50.98,97,,,percent of total billed charges,97% of total billed charges,48.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.79,50.98,
98966- Phone assess/nonMD/est pt/5-10 min,3437859,CDM,983,RC,98966,HCPCS,Outpatient,,,33.58,16.79,,30.22,90,,,percent of total billed charges,90% of total Billed charges,23.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.86,155,,,Fee Schedule,155% of CMS OPPS Rate,10.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.07,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,15.86,145,,,Fee Schedule,145% of CMS OPPS Rate,10.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.16,145,,,Fee Schedule,145% of CMS OPPS Rate,15.86,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.38,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,23.38,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.07,85,
98967- Phone assess/nonMD/est pt/11-20min,3437860,CDM,983,RC,98967,HCPCS,Outpatient,,,62.44,31.22,,56.2,90,,,percent of total billed charges,90% of total Billed charges,45.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.31,155,,,Fee Schedule,155% of CMS OPPS Rate,21.59,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,21.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.04,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,18.73,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,31.31,145,,,Fee Schedule,145% of CMS OPPS Rate,21.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.34,145,,,Fee Schedule,145% of CMS OPPS Rate,31.31,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,21.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,45.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.73,85,
98968- Phone assess/nonMD/est pt/21-30min,3437861,CDM,983,RC,98968,HCPCS,Outpatient,,,89.22,44.61,,80.3,90,,,percent of total billed charges,90% of total Billed charges,64.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,30.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,155,,,Fee Schedule,155% of CMS OPPS Rate,30.64,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.77,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,35.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,58.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,58.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.64,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85,100,,,Case rate,pays based on per visit rate,42.95,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,44.43,145,,,Fee Schedule,145% of CMS OPPS Rate,30.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.08,145,,,Fee Schedule,145% of CMS OPPS Rate,44.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,30.64,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.14,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,66.14,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26.77,93.08,
99000- Handle/convey/specimen/office-lab,3437863,CDM,983,RC,99000,HCPCS,Outpatient,,,63.82,31.91,,57.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,6.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,8.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,8.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.15,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.38,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.18,57.44,
99070- Supply/mat over & above for OV,3430564,CDM,960,RC,99070,HCPCS,Outpatient,,,13.29,6.65,,11.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.99,11.96,
99080- Special Reports Physical Form,3437877,CDM,983,RC,99080,HCPCS,Outpatient,,,39.89,19.95,,35.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.97,35.9,
99091- Clin data/dig transmit/interp/30mi,3437879,CDM,983,RC,99091,HCPCS,Outpatient,,,145.9,72.95,,131.31,90,,,percent of total billed charges,90% of total Billed charges,107.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.76,155,,,Fee Schedule,155% of CMS OPPS Rate,52.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,71.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,71.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,86.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,86.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,43.77,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.76,145,,,Fee Schedule,145% of CMS OPPS Rate,52.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.31,145,,,Fee Schedule,145% of CMS OPPS Rate,76.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,94.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,94.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,43.77,156.31,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,370,RC,99152,HCPCS,Outpatient,,,123.74,61.87,,111.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,98.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,111.37,90,,,Percent of total Billed charges,90% of total billed charges,10.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,120.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,113.84,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,86.62,70,,,percent of total billed charges,70% of total billed charges,111.37,90,,,percent of total billed charges,90% of total billed charges,117.55,95,,,percent of total billed charges,95% of total billed charges,117.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.42,86,,,percent of total billed charges,86% of total billed charges,98.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,120.03,97,,,percent of total billed charges,97% of total billed charges,111.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.03,97,,,percent of total billed charges,97% of total billed charges,115.08,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,120.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,120.03,
99153 - MOD SED SAME PHYS/QHP EA,3997220,CDM,370,RC,99153,HCPCS,Outpatient,,,25.91,12.96,,23.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,20.73,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,23.32,90,,,Percent of total Billed charges,90% of total billed charges,9.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,25.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.84,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.14,70,,,percent of total billed charges,70% of total billed charges,23.32,90,,,percent of total billed charges,90% of total billed charges,24.61,95,,,percent of total billed charges,95% of total billed charges,24.61,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.28,86,,,percent of total billed charges,86% of total billed charges,20.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,25.13,97,,,percent of total billed charges,97% of total billed charges,23.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.13,97,,,percent of total billed charges,97% of total billed charges,24.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,25.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.33,25.13,
Sedation Each Additional 15 Minutes,3428519,CDM,981,RC,99156,HCPCS,Outpatient,,,203.29,101.65,,182.96,90,,,percent of total billed charges,90% of total Billed charges,152.01,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,61.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.59,155,,,Fee Schedule,155% of CMS OPPS Rate,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,72.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,118.94,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,118.94,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,64.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,107.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,89.5,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,109.59,145,,,Fee Schedule,145% of CMS OPPS Rate,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.41,145,,,Fee Schedule,145% of CMS OPPS Rate,109.59,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.01,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.1,220.41,
Sedation First 30 Minutes,3428520,CDM,981,RC,99157,HCPCS,Outpatient,,,163.51,81.76,,147.16,90,,,percent of total billed charges,90% of total Billed charges,122.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,46.31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,88.12,155,,,Fee Schedule,155% of CMS OPPS Rate,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,95.55,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,95.55,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.81,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,85.99,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,69.65,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,88.12,145,,,Fee Schedule,145% of CMS OPPS Rate,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.25,145,,,Fee Schedule,145% of CMS OPPS Rate,88.12,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.31,177.25,
99173 Vision Screening,3435573,CDM,510,RC,99173,HCPCS,Outpatient,,,13.29,6.65,,11.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.63,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,11.96,90,,,Percent of total Billed charges,90% of total billed charges,6.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.3,70,,,percent of total billed charges,70% of total billed charges,11.96,90,,,percent of total billed charges,90% of total billed charges,12.63,95,,,percent of total billed charges,95% of total billed charges,12.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.43,86,,,percent of total billed charges,86% of total billed charges,10.63,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.89,97,,,percent of total billed charges,97% of total billed charges,11.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.89,97,,,percent of total billed charges,97% of total billed charges,12.36,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,12.89,
Vision Testing POC,3444212,CDM,920,RC,99173,HCPCS,Outpatient,,,6.65,3.33,,5.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,5.32,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.99,90,,,Percent of total Billed charges,90% of total billed charges,6.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4.66,70,,,percent of total billed charges,70% of total billed charges,5.99,90,,,percent of total billed charges,90% of total billed charges,6.32,95,,,percent of total billed charges,95% of total billed charges,6.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.72,86,,,percent of total billed charges,86% of total billed charges,5.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,6.45,97,,,percent of total billed charges,97% of total billed charges,5.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6.45,97,,,percent of total billed charges,97% of total billed charges,6.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.66,6.6,
99183 Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,3436093,CDM,761,RC,99183,HCPCS,Outpatient,,,283.33,141.67,,255,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,226.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,255,90,,,Percent of total Billed charges,90% of total billed charges,117.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,274.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,260.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,255,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.33,70,,,percent of total billed charges,70% of total billed charges,255,90,,,percent of total billed charges,90% of total billed charges,269.16,95,,,percent of total billed charges,95% of total billed charges,269.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.66,86,,,percent of total billed charges,86% of total billed charges,226.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,274.83,97,,,percent of total billed charges,97% of total billed charges,255,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,274.83,97,,,percent of total billed charges,97% of total billed charges,263.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,274.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,274.83,
99190- Assem/op pump/O2 or heat exch/60mi,3437890,CDM,983,RC,99190,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,623.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,701.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,701.43,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,606.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,606.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,701.43,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3726908,CDM,983,RC,99202,HCPCS,Outpatient,,,334.16,167.08,,300.74,90,,,percent of total billed charges,90% of total Billed charges,116.06,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108.23,90,,,Percent of total Billed charges,90% of total billed charges,35.33,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,67.99,155,,,Fee Schedule,155% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,58.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,75.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.03,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,93.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.89,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.66,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,67.99,145,,,Fee Schedule,145% of CMS OPPS Rate,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.29,145,,,Fee Schedule,145% of CMS OPPS Rate,67.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.89,100,,,Fee Schedule,100% of CMS OPPS Rate ,108,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,108,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35.33,300.74,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,334.16,167.08,,300.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,267.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,300.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,324.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,307.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,233.91,70,,,percent of total billed charges,70% of total billed charges,300.74,90,,,percent of total billed charges,90% of total billed charges,317.45,95,,,percent of total billed charges,95% of total billed charges,317.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,287.38,86,,,percent of total billed charges,86% of total billed charges,267.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,324.14,97,,,percent of total billed charges,97% of total billed charges,300.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,324.14,97,,,percent of total billed charges,97% of total billed charges,310.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,324.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.91,324.14,
99203 Office Outpt visit new Low or 30 to 44 mins,3726914,CDM,983,RC,99203,HCPCS,Outpatient,,,404.84,202.42,,364.36,90,,,percent of total billed charges,90% of total Billed charges,188.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.1,90,,,Percent of total Billed charges,90% of total billed charges,54.25,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.91,155,,,Fee Schedule,155% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,113.03,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,101.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.91,145,,,Fee Schedule,145% of CMS OPPS Rate,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.85,145,,,Fee Schedule,145% of CMS OPPS Rate,117.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,108.1,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,156.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.25,364.36,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,404.84,202.42,,364.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,323.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,364.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,392.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,372.45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,364.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,283.39,70,,,percent of total billed charges,70% of total billed charges,364.36,90,,,percent of total billed charges,90% of total billed charges,384.6,95,,,percent of total billed charges,95% of total billed charges,384.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.16,86,,,percent of total billed charges,86% of total billed charges,323.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,392.69,97,,,percent of total billed charges,97% of total billed charges,364.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,392.69,97,,,percent of total billed charges,97% of total billed charges,376.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,392.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.39,392.69,
99204 Office Outpt visit new Mod or 45 to 59 mins,3726901,CDM,983,RC,99204,HCPCS,Outpatient,,,508.59,254.30,,457.73,90,,,percent of total billed charges,90% of total Billed charges,291.41,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.94,90,,,Percent of total Billed charges,90% of total billed charges,90.37,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,188.96,155,,,Fee Schedule,155% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,150.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,150.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,193.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,260.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,173.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,144,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,188.96,145,,,Fee Schedule,145% of CMS OPPS Rate,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.54,145,,,Fee Schedule,145% of CMS OPPS Rate,188.96,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,160.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,130.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,240,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,90.37,457.73,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,508.59,254.30,,457.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,406.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,457.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,493.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,467.9,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,356.01,70,,,percent of total billed charges,70% of total billed charges,457.73,90,,,percent of total billed charges,90% of total billed charges,483.16,95,,,percent of total billed charges,95% of total billed charges,483.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,437.39,86,,,percent of total billed charges,86% of total billed charges,406.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,493.33,97,,,percent of total billed charges,97% of total billed charges,457.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,493.33,97,,,percent of total billed charges,97% of total billed charges,472.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,356.01,493.33,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,605.71,302.86,,545.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,484.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,545.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,587.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,557.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,545.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,424,70,,,percent of total billed charges,70% of total billed charges,545.14,90,,,percent of total billed charges,90% of total billed charges,575.42,95,,,percent of total billed charges,95% of total billed charges,575.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,520.91,86,,,percent of total billed charges,86% of total billed charges,484.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,587.54,97,,,percent of total billed charges,97% of total billed charges,545.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,587.54,97,,,percent of total billed charges,97% of total billed charges,563.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,587.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424,587.54,
99205 Office Outpt visit new High 60 to 74 mins,3726920,CDM,983,RC,99205,HCPCS,Outpatient,,,605.71,302.86,,545.14,90,,,percent of total billed charges,90% of total Billed charges,390.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.45,90,,,Percent of total Billed charges,90% of total billed charges,117.54,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,256.33,155,,,Fee Schedule,155% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,175.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,196.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.97,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,252.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,353.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,226.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,187.31,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,256.33,145,,,Fee Schedule,145% of CMS OPPS Rate,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,565.7,145,,,Fee Schedule,145% of CMS OPPS Rate,256.33,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,200.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,176.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,297.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.54,565.7,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,255.89,127.95,,230.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,204.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,230.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,235.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,230.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.12,70,,,percent of total billed charges,70% of total billed charges,230.3,90,,,percent of total billed charges,90% of total billed charges,243.1,95,,,percent of total billed charges,95% of total billed charges,243.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.07,86,,,percent of total billed charges,86% of total billed charges,204.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.21,97,,,percent of total billed charges,97% of total billed charges,230.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.21,97,,,percent of total billed charges,97% of total billed charges,237.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,248.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.12,248.21,
99211 Office Outpt visit Est nursing visit only,3726926,CDM,983,RC,99211,HCPCS,Outpatient,,,255.89,127.95,,230.3,90,,,percent of total billed charges,90% of total Billed charges,29.75,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,12.41,155,,,Fee Schedule,155% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,13.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,9.21,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.74,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,12.41,145,,,Fee Schedule,145% of CMS OPPS Rate,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.14,145,,,Fee Schedule,145% of CMS OPPS Rate,12.41,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.56,230.3,
99212 Office Outpt visit Est Straightforward 10 to 19 mins,3726932,CDM,983,RC,99212,HCPCS,Outpatient,,,309.78,154.89,,278.8,90,,,percent of total billed charges,90% of total Billed charges,88.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.06,90,,,Percent of total Billed charges,90% of total billed charges,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,50.37,155,,,Fee Schedule,155% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,30.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.77,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,50.37,145,,,Fee Schedule,145% of CMS OPPS Rate,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.02,145,,,Fee Schedule,145% of CMS OPPS Rate,50.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,45.48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,34.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,278.8,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,309.78,154.89,,278.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,247.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,278.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,300.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,285,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,216.85,70,,,percent of total billed charges,70% of total billed charges,278.8,90,,,percent of total billed charges,90% of total billed charges,294.29,95,,,percent of total billed charges,95% of total billed charges,294.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.41,86,,,percent of total billed charges,86% of total billed charges,247.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,300.49,97,,,percent of total billed charges,97% of total billed charges,278.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,300.49,97,,,percent of total billed charges,97% of total billed charges,288.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,216.85,300.49,
99213 Office Outpt visit Est Low 20 to 29 mins,3726938,CDM,983,RC,99213,HCPCS,Outpatient,,,371.28,185.64,,334.15,90,,,percent of total billed charges,90% of total Billed charges,150.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.95,90,,,Percent of total Billed charges,90% of total billed charges,35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,93.34,155,,,Fee Schedule,155% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,59.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,59.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,76.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,51.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,128.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,68.82,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,56.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,93.34,145,,,Fee Schedule,145% of CMS OPPS Rate,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,218.82,145,,,Fee Schedule,145% of CMS OPPS Rate,93.34,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,74.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,64.37,100,,,Fee Schedule,100% of CMS OPPS Rate ,104.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,104.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,35,334.15,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,371.28,185.64,,334.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,297.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,334.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,360.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,341.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,334.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,259.9,70,,,percent of total billed charges,70% of total billed charges,334.15,90,,,percent of total billed charges,90% of total billed charges,352.72,95,,,percent of total billed charges,95% of total billed charges,352.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.3,86,,,percent of total billed charges,86% of total billed charges,297.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,360.14,97,,,percent of total billed charges,97% of total billed charges,334.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,360.14,97,,,percent of total billed charges,97% of total billed charges,345.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259.9,360.14,
99214 Office Outpt visit Est Moderate 30 to 39 mins,3726944,CDM,983,RC,99214,HCPCS,Outpatient,,,434.18,217.09,,390.76,90,,,percent of total billed charges,90% of total Billed charges,217.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,155.69,90,,,Percent of total Billed charges,90% of total billed charges,54.42,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,137.69,155,,,Fee Schedule,155% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.7,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.89,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,117.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,79.25,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,189.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,105.65,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,85.53,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,137.69,145,,,Fee Schedule,145% of CMS OPPS Rate,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.87,145,,,Fee Schedule,145% of CMS OPPS Rate,137.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,104.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,94.96,100,,,Fee Schedule,100% of CMS OPPS Rate ,154,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,154,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,54.42,390.76,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,434.18,217.09,,390.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,347.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,390.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,421.15,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,399.45,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,390.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,303.93,70,,,percent of total billed charges,70% of total billed charges,390.76,90,,,percent of total billed charges,90% of total billed charges,412.47,95,,,percent of total billed charges,95% of total billed charges,412.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,373.39,86,,,percent of total billed charges,86% of total billed charges,347.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,421.15,97,,,percent of total billed charges,97% of total billed charges,390.76,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,421.15,97,,,percent of total billed charges,97% of total billed charges,403.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,421.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,303.93,421.15,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,528.99,264.50,,476.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,423.19,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,476.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,513.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,486.67,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,476.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.29,70,,,percent of total billed charges,70% of total billed charges,476.09,90,,,percent of total billed charges,90% of total billed charges,502.54,95,,,percent of total billed charges,95% of total billed charges,502.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.93,86,,,percent of total billed charges,86% of total billed charges,423.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,513.12,97,,,percent of total billed charges,97% of total billed charges,476.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,513.12,97,,,percent of total billed charges,97% of total billed charges,491.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.29,513.12,
99215 Office Outpt vist Est High 40 to 54 mins,3726950,CDM,983,RC,99215,HCPCS,Outpatient,,,528.99,264.50,,476.09,90,,,percent of total billed charges,90% of total Billed charges,312.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,209.9,90,,,Percent of total Billed charges,90% of total billed charges,78.05,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,202,155,,,Fee Schedule,155% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,129.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,129.8,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,165.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,111.93,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,278.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.07,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,120.54,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,202,145,,,Fee Schedule,145% of CMS OPPS Rate,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.28,145,,,Fee Schedule,145% of CMS OPPS Rate,202,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,139.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,207.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,207.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,78.05,476.09,
99288- Direct advanced life support,3437955,CDM,983,RC,99288,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,205,
Direct Advanced Life Support,3428415,CDM,981,RC,99288,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,205,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,205,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.5,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,205,
99341- Home visit new patient,3437990,CDM,983,RC,99341,HCPCS,Outpatient,,,137.94,68.97,,124.15,90,,,percent of total billed charges,90% of total Billed charges,99.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.53,155,,,Fee Schedule,155% of CMS OPPS Rate,47.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.33,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.33,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.38,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.28,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.53,145,,,Fee Schedule,145% of CMS OPPS Rate,47.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.74,145,,,Fee Schedule,145% of CMS OPPS Rate,68.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,71.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,80,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,143.74,
99342- Home visit new patient,3437991,CDM,983,RC,99342,HCPCS,Outpatient,,,197.67,98.84,,177.9,90,,,percent of total billed charges,90% of total Billed charges,150.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,75.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,110.13,155,,,Fee Schedule,155% of CMS OPPS Rate,75.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,75.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.3,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.38,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.13,145,,,Fee Schedule,145% of CMS OPPS Rate,75.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.89,145,,,Fee Schedule,145% of CMS OPPS Rate,110.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,75.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.17,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,75.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,116.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,217.89,
99344- Home visit new patient,3437993,CDM,983,RC,99344,HCPCS,Outpatient,,,461.65,230.83,,415.49,90,,,percent of total billed charges,90% of total Billed charges,313.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.93,155,,,Fee Schedule,155% of CMS OPPS Rate,139.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,188.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,139.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,212.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,212.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,269.73,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,269.73,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,138.5,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,279.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,242.76,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.93,145,,,Fee Schedule,145% of CMS OPPS Rate,139.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,454.63,145,,,Fee Schedule,145% of CMS OPPS Rate,202.93,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,139.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,177.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,139.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,267,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,267,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,138.5,454.63,
99345- Home visit new patient,3437994,CDM,983,RC,99345,HCPCS,Outpatient,,,559.66,279.83,,503.69,90,,,percent of total billed charges,90% of total Billed charges,406.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,196.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.37,155,,,Fee Schedule,155% of CMS OPPS Rate,196.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,258.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,328.46,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,328.46,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,167.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,392.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,295.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,284.37,145,,,Fee Schedule,145% of CMS OPPS Rate,196.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.53,145,,,Fee Schedule,145% of CMS OPPS Rate,284.37,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,196.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,218.32,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,196.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,320,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,320,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,167.9,589.53,
99347- Home visit est patient,3437995,CDM,983,RC,99347,HCPCS,Outpatient,,,139.4,69.70,,125.46,90,,,percent of total billed charges,90% of total Billed charges,95.69,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,21,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.76,155,,,Fee Schedule,155% of CMS OPPS Rate,43.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,41.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.76,145,,,Fee Schedule,145% of CMS OPPS Rate,43.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.75,145,,,Fee Schedule,145% of CMS OPPS Rate,62.76,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,55.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,81,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,21,138.75,
99348- Home visit est patient,3437996,CDM,983,RC,99348,HCPCS,Outpatient,,,212.72,106.36,,191.45,90,,,percent of total billed charges,90% of total Billed charges,153.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,106.98,155,,,Fee Schedule,155% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.66,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.66,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,123.93,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,123.93,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.82,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,147.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.98,145,,,Fee Schedule,145% of CMS OPPS Rate,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,222.95,145,,,Fee Schedule,145% of CMS OPPS Rate,106.98,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,73.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,123,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,123,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,26,222.95,
99349- Home visit est patient,3437997,CDM,983,RC,99349,HCPCS,Outpatient,,,326.99,163.50,,294.29,90,,,percent of total billed charges,90% of total Billed charges,246.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,179.48,155,,,Fee Schedule,155% of CMS OPPS Rate,123.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,123.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,149.58,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.58,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,189.2,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,189.2,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.1,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,247.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,170.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.48,145,,,Fee Schedule,145% of CMS OPPS Rate,123.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.76,145,,,Fee Schedule,145% of CMS OPPS Rate,179.48,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,123.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.21,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,123.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,186.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,186.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31,357.76,
99350- Home visit est patient,3437998,CDM,983,RC,99350,HCPCS,Outpatient,,,455.15,227.58,,409.64,90,,,percent of total billed charges,90% of total Billed charges,351.94,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,180.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,262.16,155,,,Fee Schedule,155% of CMS OPPS Rate,180.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,180.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,208.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,208.51,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,264.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,264.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,136.55,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,361.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,238.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.16,145,,,Fee Schedule,145% of CMS OPPS Rate,180.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.31,145,,,Fee Schedule,145% of CMS OPPS Rate,262.16,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,180.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,259.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36,510.31,
99360- Phys Standby Svc Prolng Phys Attn Ea 30 Min,3438009,CDM,983,RC,99360,HCPCS,Outpatient,,,134.29,67.15,,120.86,90,,,percent of total billed charges,90% of total Billed charges,116.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,52.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,82.75,155,,,Fee Schedule,155% of CMS OPPS Rate,57.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,57.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.39,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.39,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,40.29,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,83.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,67.49,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,82.75,145,,,Fee Schedule,145% of CMS OPPS Rate,57.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.78,145,,,Fee Schedule,145% of CMS OPPS Rate,82.75,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,57.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,67.57,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,57.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,90.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,40.29,168.78,
99363- Anticoagulant Mgmt Outpatient Init 90 Days,3438012,CDM,983,RC,99363,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,181,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,181,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,181,
99364- Anticoagulant Mgmt Outpatient Ea Sbsq 90 Days,3438013,CDM,983,RC,99364,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,62,
99374- Home health care supervision,3438021,CDM,983,RC,99374,HCPCS,Outpatient,,,132.97,66.49,,119.67,90,,,percent of total billed charges,90% of total Billed charges,118.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.57,155,,,Fee Schedule,155% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66.34,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.34,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.89,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.57,145,,,Fee Schedule,145% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.48,145,,,Fee Schedule,145% of CMS OPPS Rate,76.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,101,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,101,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,39.89,172.48,
99375- Home health care supervision,3438022,CDM,983,RC,99375,HCPCS,Outpatient,,,43.88,21.94,,39.49,90,,,percent of total billed charges,90% of total Billed charges,87.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.63,155,,,Fee Schedule,155% of CMS OPPS Rate,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,104.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,133.52,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,133.52,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,13.16,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,87.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.88,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,97.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,63.63,145,,,Fee Schedule,145% of CMS OPPS Rate,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.25,145,,,Fee Schedule,145% of CMS OPPS Rate,63.63,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.36,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,43.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,151.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,13.16,151.5,
99377- Hospice care supervision,3438023,CDM,983,RC,99377,HCPCS,Outpatient,,,187.48,93.74,,168.73,90,,,percent of total billed charges,90% of total Billed charges,118.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.57,155,,,Fee Schedule,155% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,69.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,85.11,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,56.24,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.59,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.8,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,76.57,145,,,Fee Schedule,145% of CMS OPPS Rate,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,172.48,145,,,Fee Schedule,145% of CMS OPPS Rate,76.57,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,57.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,101,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,101,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.81,172.48,
99381- Initial Comp Preventive Med less than 1 year New,3438027,CDM,510,RC,99381,HCPCS,Outpatient,,,281.89,140.95,,253.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,225.51,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,253.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,273.43,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,259.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,197.32,70,,,percent of total billed charges,70% of total billed charges,253.7,90,,,percent of total billed charges,90% of total billed charges,267.8,95,,,percent of total billed charges,95% of total billed charges,267.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.43,86,,,percent of total billed charges,86% of total billed charges,225.51,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,273.43,97,,,percent of total billed charges,97% of total billed charges,253.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,273.43,97,,,percent of total billed charges,97% of total billed charges,262.16,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,273.43,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.32,273.43,
99382- Initial Comp Preventive Med 1 to 4 years New,3438028,CDM,510,RC,99382,HCPCS,Outpatient,,,295.19,147.60,,265.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,236.15,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,265.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,286.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,271.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,206.63,70,,,percent of total billed charges,70% of total billed charges,265.67,90,,,percent of total billed charges,90% of total billed charges,280.43,95,,,percent of total billed charges,95% of total billed charges,280.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.86,86,,,percent of total billed charges,86% of total billed charges,236.15,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,286.33,97,,,percent of total billed charges,97% of total billed charges,265.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,286.33,97,,,percent of total billed charges,97% of total billed charges,274.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,286.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.63,286.33,
99383- Initial Comp Preventive Med 5 to 11 years New,3438029,CDM,510,RC,99383,HCPCS,Outpatient,,,307.16,153.58,,276.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,245.73,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,276.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,297.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,282.59,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,215.01,70,,,percent of total billed charges,70% of total billed charges,276.44,90,,,percent of total billed charges,90% of total billed charges,291.8,95,,,percent of total billed charges,95% of total billed charges,291.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,264.16,86,,,percent of total billed charges,86% of total billed charges,245.73,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,297.95,97,,,percent of total billed charges,97% of total billed charges,276.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,297.95,97,,,percent of total billed charges,97% of total billed charges,285.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,297.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.01,297.95,
99384- Initial Comp Preventive Med 12 to 17 years New,3438030,CDM,983,RC,99384,HCPCS,Outpatient,,,340.95,170.48,,306.86,90,,,percent of total billed charges,90% of total Billed charges,224.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.27,155,,,Fee Schedule,155% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.27,145,,,Fee Schedule,145% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.08,145,,,Fee Schedule,145% of CMS OPPS Rate,138.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,126.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,326.08,
99385- Initial Comp Preventive Med 18 to 39 years New,3438031,CDM,983,RC,99385,HCPCS,Outpatient,,,329.86,164.93,,296.87,90,,,percent of total billed charges,90% of total Billed charges,217.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,91.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,133.07,155,,,Fee Schedule,155% of CMS OPPS Rate,91.77,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,91.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.79,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,148.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,148.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,99.86,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,183.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,133.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,108.99,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,133.07,145,,,Fee Schedule,145% of CMS OPPS Rate,91.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,314.97,145,,,Fee Schedule,145% of CMS OPPS Rate,133.07,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,91.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.34,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,91.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,159.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,314.97,
99386- Initial Comp Preventive Med 40 to 64 years New,3438032,CDM,983,RC,99386,HCPCS,Outpatient,,,384.62,192.31,,346.16,90,,,percent of total billed charges,90% of total Billed charges,256.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,111.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,161.23,155,,,Fee Schedule,155% of CMS OPPS Rate,111.19,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,111.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,140.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,140.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,180.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,180.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,121.17,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,222.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,162.03,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,132.09,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,161.23,145,,,Fee Schedule,145% of CMS OPPS Rate,111.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.39,145,,,Fee Schedule,145% of CMS OPPS Rate,161.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,111.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,146.88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,111.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,185.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,185.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,372.39,
99387- Initial Comp Preventive Med 65+ yrs New,3438033,CDM,983,RC,99387,HCPCS,Outpatient,,,514,257.00,,462.6,90,,,percent of total billed charges,90% of total Billed charges,277.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,119.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,173.97,155,,,Fee Schedule,155% of CMS OPPS Rate,119.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,151.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,151.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,194.06,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,194.06,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,130.54,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,239.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,174.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,143.64,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,173.97,145,,,Fee Schedule,145% of CMS OPPS Rate,119.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,402.01,145,,,Fee Schedule,145% of CMS OPPS Rate,173.97,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,119.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,162.49,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,119.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,205,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,205,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,462.6,
99391- Periodic Comp Preventive Med less than 1 year Est,3438035,CDM,983,RC,99391,HCPCS,Outpatient,,,248.64,124.32,,223.78,90,,,percent of total billed charges,90% of total Billed charges,159.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,94.69,155,,,Fee Schedule,155% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,82.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,82.82,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,106.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,106.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.46,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,78.32,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,94.69,145,,,Fee Schedule,145% of CMS OPPS Rate,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.17,145,,,Fee Schedule,145% of CMS OPPS Rate,94.69,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,96.53,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,115.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,231.17,
99392- Periodic Comp Preventive Med 1 to 4 years Est,3438037,CDM,983,RC,99392,HCPCS,Outpatient,,,265.93,132.97,,239.34,90,,,percent of total billed charges,90% of total Billed charges,172.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.43,155,,,Fee Schedule,155% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.43,145,,,Fee Schedule,145% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.59,145,,,Fee Schedule,145% of CMS OPPS Rate,104.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,128.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,249.59,
99393- Periodic Comp Preventive Med 5 to 11 years Est,3438038,CDM,983,RC,99393,HCPCS,Outpatient,,,276.58,138.29,,248.92,90,,,percent of total billed charges,90% of total Billed charges,171.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,104.43,155,,,Fee Schedule,155% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,72.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,144.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.98,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,84.45,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,104.43,145,,,Fee Schedule,145% of CMS OPPS Rate,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,249.17,145,,,Fee Schedule,145% of CMS OPPS Rate,104.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,101.64,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,72.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,128,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,249.17,
99394- Periodic Comp Preventive Med 12 to 17 years Est,3438039,CDM,983,RC,99394,HCPCS,Outpatient,,,291.19,145.60,,262.07,90,,,percent of total billed charges,90% of total Billed charges,190.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,81.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,117.64,155,,,Fee Schedule,155% of CMS OPPS Rate,81.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,81.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.18,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,102.18,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,130.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,130.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,88.1,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,117.86,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,96,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,117.64,145,,,Fee Schedule,145% of CMS OPPS Rate,81.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.46,145,,,Fee Schedule,145% of CMS OPPS Rate,117.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,81.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111.54,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,81.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,140,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,140,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,276.46,
99397- Periodic Comp Preventive Med 65+ years Est,3438042,CDM,983,RC,99397,HCPCS,Outpatient,,,341.72,170.86,,307.55,90,,,percent of total billed charges,90% of total Billed charges,225.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.27,155,,,Fee Schedule,155% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.27,145,,,Fee Schedule,145% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.51,145,,,Fee Schedule,145% of CMS OPPS Rate,138.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,173,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,326.51,
"99397- Prev Visit, Est, 65 & Over",3438043,CDM,983,RC,99397,HCPCS,Outpatient,,,341.72,170.86,,307.55,90,,,percent of total billed charges,90% of total Billed charges,225.18,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,138.27,155,,,Fee Schedule,155% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,120.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,104.15,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,139.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,114.04,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,138.27,145,,,Fee Schedule,145% of CMS OPPS Rate,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,326.51,145,,,Fee Schedule,145% of CMS OPPS Rate,138.27,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,136.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,95.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,173,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,173,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20,326.51,
99411- Prev Med Counsel+Risk Factor Redj Grp Spx 30 Min,3438064,CDM,983,RC,99411,HCPCS,Outpatient,,,53.19,26.60,,47.87,90,,,percent of total billed charges,90% of total Billed charges,26.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.53,155,,,Fee Schedule,155% of CMS OPPS Rate,7.26,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.54,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,9.54,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.58,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.58,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,15.96,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.42,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,8.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,10.53,145,,,Fee Schedule,145% of CMS OPPS Rate,7.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.02,145,,,Fee Schedule,145% of CMS OPPS Rate,10.53,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,23,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,23,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.26,47.87,
99412- Prev Med Counsel+Risk Factor Redj Grp Spx 60 Min,3438066,CDM,983,RC,99412,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,35.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,12.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.75,155,,,Fee Schedule,155% of CMS OPPS Rate,12.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,19.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.94,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,17.57,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,14.44,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,17.75,145,,,Fee Schedule,145% of CMS OPPS Rate,12.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.16,145,,,Fee Schedule,145% of CMS OPPS Rate,17.75,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,19.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,12.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,30,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,30,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,12.24,59.83,
99417 - Prolonged outpatient E/M Service - ea addl 15 min,3640926,CDM,983,RC,99417,HCPCS,Outpatient,,,91,45.50,,81.9,90,,,percent of total billed charges,90% of total Billed charges,60.57,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,155,,,Fee Schedule,155% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.6,145,,,Fee Schedule,145% of CMS OPPS Rate,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.83,145,,,Fee Schedule,145% of CMS OPPS Rate,42.6,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.3,87.83,
ONLINE E/M PHYS CULM 7 DAYS 21+MIN,3527890,CDM,960,RC,99423,HCPCS,Outpatient,,,123.18,61.59,,110.86,90,,,percent of total billed charges,90% of total Billed charges,85.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.99,155,,,Fee Schedule,155% of CMS OPPS Rate,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,43.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,64.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,64.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,36.95,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,57.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,48.36,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,56.99,145,,,Fee Schedule,145% of CMS OPPS Rate,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.15,145,,,Fee Schedule,145% of CMS OPPS Rate,56.99,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,53.78,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,39.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.95,124.15,
99429- Unlisted Preventive Medicine Service,3438069,CDM,983,RC,99429,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
99439- Chrnc Care Mgmt Svc Ea Addl,3918991,CDM,982,RC,99439,HCPCS,Outpatient,,,121.26,60.63,,109.13,90,,,percent of total billed charges,90% of total Billed charges,79.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,155,,,Fee Schedule,155% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.38,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,145,,,Fee Schedule,145% of CMS OPPS Rate,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,115.23,145,,,Fee Schedule,145% of CMS OPPS Rate,49.13,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.88,115.23,
99444- Online e/m by phys/qhp,3438077,CDM,983,RC,99444,HCPCS,Outpatient,,,119.67,59.84,,107.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.9,107.7,
99450- Basic life disability exam,3438088,CDM,983,RC,99450,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,50,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,50,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,85.59,
99455- Work Related/Med Dblt Xm Treating Phys,3438090,CDM,983,RC,99455,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,117.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,117.12,
99456- Work Related/Med Dblt Xm Oth/Thn Treating Phys,3438092,CDM,983,RC,99456,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,135.14,
"99487- Complex chronic care management, 60 minutes",3431351,CDM,960,RC,99487,HCPCS,Outpatient,,,181.62,90.81,,163.46,90,,,percent of total billed charges,90% of total Billed charges,213.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.09,155,,,Fee Schedule,155% of CMS OPPS Rate,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,45.4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,54.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,176.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,69.9,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,55.58,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,128.09,145,,,Fee Schedule,145% of CMS OPPS Rate,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.91,145,,,Fee Schedule,145% of CMS OPPS Rate,128.09,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.96,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,88.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.37,309.91,
99489- Com chronic care mngt/add 30 min,3431072,CDM,510,RC,99489,HCPCS,Outpatient,,,176.33,88.17,,158.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,141.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,158.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,171.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,162.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,123.43,70,,,percent of total billed charges,70% of total billed charges,158.7,90,,,percent of total billed charges,90% of total billed charges,167.51,95,,,percent of total billed charges,95% of total billed charges,167.51,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.64,86,,,percent of total billed charges,86% of total billed charges,141.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,171.04,97,,,percent of total billed charges,97% of total billed charges,158.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,171.04,97,,,percent of total billed charges,97% of total billed charges,163.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,123.43,171.04,
99489- Complx chron care addl30 min,3438134,CDM,983,RC,99489,HCPCS,Outpatient,,,176.33,88.17,,158.7,90,,,percent of total billed charges,90% of total Billed charges,115.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.8,155,,,Fee Schedule,155% of CMS OPPS Rate,48.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.91,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,22.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,38.37,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,38.37,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,52.9,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,34.53,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,27.43,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,70.8,145,,,Fee Schedule,145% of CMS OPPS Rate,48.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.94,145,,,Fee Schedule,145% of CMS OPPS Rate,70.8,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,49.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.91,166.94,
99490 Chronic Care Management,3438180,CDM,983,RC,99490,HCPCS,Outpatient,,,161.34,80.67,,145.21,90,,,percent of total billed charges,90% of total Billed charges,109.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,49.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.24,155,,,Fee Schedule,155% of CMS OPPS Rate,49.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,48,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,48,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,48.4,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,98.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,35.37,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,71.24,145,,,Fee Schedule,145% of CMS OPPS Rate,49.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.2,145,,,Fee Schedule,145% of CMS OPPS Rate,71.24,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,49.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,49.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.82,159.2,
99495- Trans care mgmt 14 day disch,3438135,CDM,510,RC,99495,HCPCS,Outpatient,,,372.33,186.17,,335.1,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,297.86,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,361.16,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,342.54,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,335.1,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,260.63,70,,,percent of total billed charges,70% of total billed charges,335.1,90,,,percent of total billed charges,90% of total billed charges,353.71,95,,,percent of total billed charges,95% of total billed charges,353.71,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,320.2,86,,,percent of total billed charges,86% of total billed charges,297.86,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,361.16,97,,,percent of total billed charges,97% of total billed charges,335.1,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,361.16,97,,,percent of total billed charges,97% of total billed charges,346.27,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,361.16,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
99496- Trans care mgmt 7 day disch,3438136,CDM,510,RC,99496,HCPCS,Outpatient,,,503.97,251.99,,453.57,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,403.18,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,488.85,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,463.65,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,453.57,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,352.78,70,,,percent of total billed charges,70% of total billed charges,453.57,90,,,percent of total billed charges,90% of total billed charges,478.77,95,,,percent of total billed charges,95% of total billed charges,478.77,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,433.41,86,,,percent of total billed charges,86% of total billed charges,403.18,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,488.85,97,,,percent of total billed charges,97% of total billed charges,453.57,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.85,97,,,percent of total billed charges,97% of total billed charges,468.69,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,488.85,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
99500 Home visit prenatal,3430565,CDM,960,RC,99500,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
99606 Mtms by pharm est 15 min,3430567,CDM,960,RC,99606,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
0001A - ADM SARSCOV2 30MCG/0.3ML 1ST,3999148,CDM,771,RC,0001A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0002A - ADM SARSCOV2 30MCG/0.3ML 2ND,3997221,CDM,771,RC,0002A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0003A - ADM SARSCOV2 30MCG/0.3ML 3RD,3997222,CDM,771,RC,0003A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0004A - ADM SARSCOV2 30MCG/0.3ML BST,3999149,CDM,771,RC,0004A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0011A - ADM SARSCOV2 100MCG/0.5ML1ST,3997223,CDM,771,RC,0011A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0012A - ADM SARSCOV2 100MCG/0.5ML2ND,3997224,CDM,771,RC,0012A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0013A - ADM SARSCOV2 100MCG/0.5ML3RD,3997225,CDM,771,RC,0013A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0031A - ADM SARSCOV2 VAC AD26 .5ML,3999150,CDM,771,RC,0031A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0034A - ADM SARSCOV2 VAC AD26 .5ML B,3999151,CDM,771,RC,0034A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0041A - IMM ADMN SARSCOV2 5 MCG/0.5 ML 1ST DOSE,4037470,CDM,771,RC,0041A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,77.3,80,,,Percent of total Billed charges,80% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,88.89,92,,,Percent of total billed charges,92% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100.23,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,202.41,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,86.96,90,,,percent of total billed charges,90% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.04,202.41,
ADM SARSCV2 30MCG TRS-SUCR 1,4227161,CDM,771,RC,0051A,HCPCS,Outpatient,,,80.03,40.02,,72.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.02,70,,,percent of total billed charges,70% of total billed charges,72.03,90,,,percent of total billed charges,90% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.83,86,,,percent of total billed charges,86% of total billed charges,64.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.02,77.63,
ADM SARSCV2 30MCG TRS-SUCR 2,4227162,CDM,771,RC,0052A,HCPCS,Outpatient,,,80.03,40.02,,72.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.02,70,,,percent of total billed charges,70% of total billed charges,72.03,90,,,percent of total billed charges,90% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.83,86,,,percent of total billed charges,86% of total billed charges,64.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.02,77.63,
ADM SARSCV2 30MCG TRS-SUCR 3,4227163,CDM,771,RC,0053A,HCPCS,Outpatient,,,80.03,40.02,,72.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,73.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.02,70,,,percent of total billed charges,70% of total billed charges,72.03,90,,,percent of total billed charges,90% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.83,86,,,percent of total billed charges,86% of total billed charges,64.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.02,77.63,
0064A - ADM SARSCOV2 50MCG/0.25MLBST,3997226,CDM,771,RC,0064A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0071A - ADM SARSCV2 10MCG TRS-SUCR 1,3997227,CDM,771,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
Admin PED Covid: First Dose: Pfizer PED 0071A,3867236,CDM,771,RC,0071A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0072A - ADM SARSCV2 10MCG TRS-SUCR 2,3997228,CDM,771,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
Admin Ped Covid: Second Dose: Pfizer PED 0072A,3867235,CDM,771,RC,0072A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0073A - Adm Sarscv2 10 mcg Trs-Sucr 3,4169605,CDM,983,RC,0073A,HCPCS,Outpatient,,,94.98,47.49,,85.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.49,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.49,85.48,
Third Dose: Pfizer PED 0073A,4037366,CDM,771,RC,0073A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
First Dose: Pfizer 6m-4y 0081A,4061289,CDM,771,RC,0081A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
Second Dose: Pfizer 6m-4y 0082A,4061288,CDM,771,RC,0082A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
Third Dose: Pfizer 6m-4y 0083A,4061287,CDM,771,RC,0083A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
0124A - Adm SARSCV2 BVL 30mcg/.3ML Booster,4189301,CDM,983,RC,0124A,HCPCS,Outpatient,,,100.39,50.20,,90.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.12,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.12,90.35,
Bivalent Booster: Pfizer 0124A,4179748,CDM,771,RC,0124A,HCPCS,Outpatient,,,100.39,50.20,,90.35,90,,,percent of total billed charges,90% of total Billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,80.31,80,,,Percent of total Billed charges,80% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,97.38,97,,,Percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,92.36,92,,,Percent of total billed charges,92% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100.23,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,202.41,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,90.35,90,,,percent of total billed charges,90% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,70.27,70,,,percent of total billed charges,70% of total billed charges,90.35,90,,,percent of total billed charges,90% of total billed charges,95.37,95,,,percent of total billed charges,95% of total billed charges,95.37,95,,,percent of total billed charges,95% of total billed charges,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,86.34,86,,,percent of total billed charges,86% of total billed charges,80.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,97.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,97.38,97,,,percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.04,202.41,
ADM SARSCV2 30MCG TRS-SUCR B,4227179,CDM,771,RC,0154A,HCPCS,Outpatient,,,80.03,40.02,,72.03,90,,,percent of total billed charges,90% of total Billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,64.02,80,,,Percent of total Billed charges,80% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,Percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,73.63,92,,,Percent of total billed charges,92% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,100.23,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,159.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,202.41,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.03,90,,,percent of total billed charges,90% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,56.02,70,,,percent of total billed charges,70% of total billed charges,72.03,90,,,percent of total billed charges,90% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,76.03,95,,,percent of total billed charges,95% of total billed charges,37.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,75.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,68.83,86,,,percent of total billed charges,86% of total billed charges,64.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.63,97,,,percent of total billed charges,97% of total billed charges,37.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.04,202.41,
ADM SARSCV2 BVL 10MCG/2ML Booster,4223275,CDM,983,RC,0154A,HCPCS,Outpatient,,,80.03,40.02,,72.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.01,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.01,72.03,
0296T CardioKey Application,3575069,CDM,960,RC,0296T,HCPCS,Outpatient,,,28.08,14.04,,25.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,36.22,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.22,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,15.84,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,15.84,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,8.42,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.11,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.42,36.22,
0298T CardioKey Interpretation,3575070,CDM,960,RC,0298T,HCPCS,Outpatient,,,64.91,32.46,,58.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,37.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,36.62,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.62,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,19.47,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.85,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.47,58.42,
0500F- Initial preventive physical exam (IPPE),3428311,CDM,983,RC,0500F,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
TCAT Rmv/Debulk ICAR Mas Perq,4223276,CDM,960,RC,0644T,HCPCS,Outpatient,,,212,106.00,,190.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.6,190.8,
3354F - CLIN SIGN DEP SYMP BY STAND DEP ASSESS TOOL,3999152,CDM,510,RC,3354F,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
541PEP Pre employment Physical,3438253,CDM,510,RC,541PEP,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,79.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,89.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,91.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.8,70,,,percent of total billed charges,70% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.76,86,,,percent of total billed charges,86% of total billed charges,79.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,92.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.8,96.73,
561OM DOT Physicial,3438252,CDM,510,RC,561OM,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,79.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,89.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,91.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.8,70,,,percent of total billed charges,70% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.76,86,,,percent of total billed charges,86% of total billed charges,79.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,92.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.8,96.73,
611C Drug Screen Collection,3435567,CDM,510,RC,611C,HCPCS,Outpatient,,,30.58,15.29,,27.52,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.52,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.13,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.41,70,,,percent of total billed charges,70% of total billed charges,27.52,90,,,percent of total billed charges,90% of total billed charges,29.05,95,,,percent of total billed charges,95% of total billed charges,29.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.3,86,,,percent of total billed charges,86% of total billed charges,24.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.66,97,,,percent of total billed charges,97% of total billed charges,27.52,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.66,97,,,percent of total billed charges,97% of total billed charges,28.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,29.66,
611D DOT Drug Screen,3435568,CDM,510,RC,611D,HCPCS,Outpatient,,,59.84,29.92,,53.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,47.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,53.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,55.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.89,70,,,percent of total billed charges,70% of total billed charges,53.86,90,,,percent of total billed charges,90% of total billed charges,56.85,95,,,percent of total billed charges,95% of total billed charges,56.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.46,86,,,percent of total billed charges,86% of total billed charges,47.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,53.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,55.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.89,58.04,
611HR Hair Specimen,3435569,CDM,510,RC,611HR,HCPCS,Outpatient,,,126.32,63.16,,113.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,101.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,113.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,116.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.42,70,,,percent of total billed charges,70% of total billed charges,113.69,90,,,percent of total billed charges,90% of total billed charges,120,95,,,percent of total billed charges,95% of total billed charges,120,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.64,86,,,percent of total billed charges,86% of total billed charges,101.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,122.53,97,,,percent of total billed charges,97% of total billed charges,113.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.53,97,,,percent of total billed charges,97% of total billed charges,117.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.42,122.53,
611N Non DOT Drug Screen,3435570,CDM,510,RC,611N,HCPCS,Outpatient,,,59.84,29.92,,53.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,47.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,53.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,55.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,41.89,70,,,percent of total billed charges,70% of total billed charges,53.86,90,,,percent of total billed charges,90% of total billed charges,56.85,95,,,percent of total billed charges,95% of total billed charges,56.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.46,86,,,percent of total billed charges,86% of total billed charges,47.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,53.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,55.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.89,58.04,
BLS MILEAGE,3527830,CDM,981,RC,A0380,HCPCS,Outpatient,,,8.78,4.39,,7.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,4,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,4,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,7.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,7.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2.63,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,7.9,
ALS MILEAGE,3527832,CDM,981,RC,A0390,HCPCS,Outpatient,,,8.78,4.39,,7.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,7.43,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,7.43,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2.63,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.63,7.9,
ALS-1 NON EMERGENCY,3527831,CDM,981,RC,A0426,HCPCS,Outpatient,,,263.42,131.71,,237.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,258.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.03,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,375.46,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.03,375.46,
BLS-NON EMERGENCY,3527829,CDM,981,RC,A0428,HCPCS,Outpatient,,,219.52,109.76,,197.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,215.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,215.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,215.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.86,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,312.89,125,,,Fee Schedule,125% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.31,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.86,312.89,
"A4561- Pessary rubber, any type",3431438,CDM,450,RC,A4561,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"A4562- Pessary, non rubber,any type",3431439,CDM,450,RC,A4562,HCPCS,Outpatient,,,343.71,171.86,,309.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,274.97,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,309.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,333.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,316.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,309.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,240.6,70,,,percent of total billed charges,70% of total billed charges,309.34,90,,,percent of total billed charges,90% of total billed charges,326.52,95,,,percent of total billed charges,95% of total billed charges,326.52,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,295.59,86,,,percent of total billed charges,86% of total billed charges,274.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,333.4,97,,,percent of total billed charges,97% of total billed charges,309.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,333.4,97,,,percent of total billed charges,97% of total billed charges,319.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,333.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240.6,333.4,
A6197-KERRACEL AG 4X5IN,3436119,CDM,279,RC,A6197,HCPCS,Outpatient,,,35.12,17.56,,31.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,31.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,32.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.58,70,,,percent of total billed charges,70% of total billed charges,31.61,90,,,percent of total billed charges,90% of total billed charges,33.36,95,,,percent of total billed charges,95% of total billed charges,33.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.2,86,,,percent of total billed charges,86% of total billed charges,28.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,34.07,97,,,percent of total billed charges,97% of total billed charges,31.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.07,97,,,percent of total billed charges,97% of total billed charges,32.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.58,34.07,
A6235-DUODERM XTHIN 6X6IN,3436129,CDM,279,RC,A6235,HCPCS,Outpatient,,,15.05,7.53,,13.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.04,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.54,70,,,percent of total billed charges,70% of total billed charges,13.55,90,,,percent of total billed charges,90% of total billed charges,14.3,95,,,percent of total billed charges,95% of total billed charges,14.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.94,86,,,percent of total billed charges,86% of total billed charges,12.04,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.6,97,,,percent of total billed charges,97% of total billed charges,13.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.6,97,,,percent of total billed charges,97% of total billed charges,14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.54,14.6,
A9500-NM Isotope Sesamibi Add-on,4263189,CDM,343,RC,A9500,HCPCS,Outpatient,,,506.78,253.39,,456.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,405.42,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,456.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,491.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,466.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,456.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,354.75,70,,,percent of total billed charges,70% of total billed charges,456.1,90,,,percent of total billed charges,90% of total billed charges,481.44,95,,,percent of total billed charges,95% of total billed charges,481.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,435.83,86,,,percent of total billed charges,86% of total billed charges,405.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,491.58,97,,,percent of total billed charges,97% of total billed charges,456.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,491.58,97,,,percent of total billed charges,97% of total billed charges,471.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,491.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,354.75,491.58,
"A9606- Radium RA-223 dichloride, therapeutic, per microcurie",3435846,CDM,450,RC,A9606,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,419.74,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,157.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.15,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,847.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,156.46,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,134.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,847.58,
DOTPE  Self-Pay DOT Exam,3438189,CDM,999,RC,DOTPE,HCPCS,Outpatient,,,120,60.00,,108,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,108,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,116.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,110.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,84,70,,,percent of total billed charges,70% of total billed charges,108,90,,,percent of total billed charges,90% of total billed charges,114,95,,,percent of total billed charges,95% of total billed charges,114,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.2,86,,,percent of total billed charges,86% of total billed charges,96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,116.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84,116.4,
Single Tip Cane,3428523,CDM,981,RC,E0100,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,17.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,17.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.91,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,18.91,
E0114 - Crutch Underarm Pair No Wood,4189318,CDM,983,RC,E0114,HCPCS,Outpatient,,,151.96,75.98,,136.76,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,35.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,35.62,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.59,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.62,136.76,
Folding Walker W/Wheels,3428430,CDM,981,RC,E0149,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,170.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.83,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.9,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,229.9,
Flexibility Evaluation,4199643,CDM,978,RC,FLEX,HCPCS,Outpatient,,,31.8,15.90,,28.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.54,28.62,
G0008 - Flu vaccine admin,3574864,CDM,960,RC,G0008,HCPCS,Outpatient,,,70.47,35.24,,63.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,23.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,20.86,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,63.42,
Medicare G0008,3444227,CDM,771,RC,G0008,HCPCS,Outpatient,,,70.47,35.24,,63.42,90,,,percent of total billed charges,90% of total Billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,56.38,80,,,Percent of total Billed charges,80% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.42,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,68.36,97,,,Percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,64.83,92,,,Percent of total billed charges,92% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.42,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,49.33,70,,,percent of total billed charges,70% of total billed charges,63.42,90,,,percent of total billed charges,90% of total billed charges,66.95,95,,,percent of total billed charges,95% of total billed charges,66.95,95,,,percent of total billed charges,95% of total billed charges,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.6,86,,,percent of total billed charges,86% of total billed charges,56.38,80,,,percent of total billed charges,80% of total billed charges,39.39,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.36,97,,,percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11,206.55,
ADMIN PNEUMOCOCCAL VACCINE,3435725,CDM,771,RC,G0009,HCPCS,Outpatient,,,239.98,119.99,,215.98,90,,,percent of total billed charges,90% of total Billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,191.98,80,,,Percent of total Billed charges,80% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,215.98,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,232.78,97,,,Percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,220.78,92,,,Percent of total billed charges,92% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,102.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,163.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,206.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,215.98,90,,,percent of total billed charges,90% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,167.99,70,,,percent of total billed charges,70% of total billed charges,215.98,90,,,percent of total billed charges,90% of total billed charges,227.98,95,,,percent of total billed charges,95% of total billed charges,227.98,95,,,percent of total billed charges,95% of total billed charges,38.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,76.95,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,206.38,86,,,percent of total billed charges,86% of total billed charges,191.98,80,,,percent of total billed charges,80% of total billed charges,39.39,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,232.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,232.78,97,,,percent of total billed charges,97% of total billed charges,38.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.47,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,32.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11,232.78,
G0009 Pneumococcal admin,3574862,CDM,960,RC,G0009,HCPCS,Outpatient,,,239.88,119.94,,215.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,23.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,71.96,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,16.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,215.89,
G0010 - Hep B admin,3574863,CDM,960,RC,G0010,HCPCS,Outpatient,,,70.47,35.24,,63.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.8,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,23.39,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,23.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,20.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,36.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,21.14,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.72,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.72,63.42,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,510,RC,G0101,HCPCS,Outpatient,,,99.99,50.00,,89.99,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,79.99,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.99,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,91.99,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,89.99,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,69.99,70,,,percent of total billed charges,70% of total billed charges,89.99,90,,,percent of total billed charges,90% of total billed charges,94.99,95,,,percent of total billed charges,95% of total billed charges,94.99,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,85.99,86,,,percent of total billed charges,86% of total billed charges,79.99,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,96.99,97,,,percent of total billed charges,97% of total billed charges,89.99,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.99,97,,,percent of total billed charges,97% of total billed charges,92.99,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,96.99,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,369.77,
"G0179- Home health re-certification, physician",3435919,CDM,510,RC,G0179,HCPCS,Outpatient,,,101.88,50.94,,91.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,81.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,91.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,93.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,65.06,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,80.13,78.65,,,percent of total billed charges,78.65% of total billed charges,91.01,89.33,,,percent of total billed charges,89.33% of total billed charges,91.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,71.32,70,,,percent of total billed charges,70% of total billed charges,91.69,90,,,percent of total billed charges,90% of total billed charges,96.79,95,,,percent of total billed charges,95% of total billed charges,96.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.62,86,,,percent of total billed charges,86% of total billed charges,81.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,98.82,97,,,percent of total billed charges,97% of total billed charges,91.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.82,97,,,percent of total billed charges,97% of total billed charges,94.75,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,98.82,
"G0182- Hospice, care plan oversite, by physician, 30 min",3435921,CDM,510,RC,G0182,HCPCS,Outpatient,,,270.82,135.41,,243.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,216.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,243.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,262.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,249.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,172.95,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,213.01,78.65,,,percent of total billed charges,78.65% of total billed charges,241.93,89.33,,,percent of total billed charges,89.33% of total billed charges,243.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,189.57,70,,,percent of total billed charges,70% of total billed charges,243.74,90,,,percent of total billed charges,90% of total billed charges,257.28,95,,,percent of total billed charges,95% of total billed charges,257.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.91,86,,,percent of total billed charges,86% of total billed charges,216.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,262.7,97,,,percent of total billed charges,97% of total billed charges,243.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,262.7,97,,,percent of total billed charges,97% of total billed charges,251.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.95,262.7,
BREATHING RETRAINING,3435727,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,21.37,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.99,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.62,70,,,percent of total billed charges,70% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.42,86,,,percent of total billed charges,86% of total billed charges,18.99,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.03,97,,,percent of total billed charges,97% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.03,97,,,percent of total billed charges,97% of total billed charges,22.08,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.03,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.62,121.67,
Breathing Retraining Outpatient,634103,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,21.37,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.99,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.62,70,,,percent of total billed charges,70% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.42,86,,,percent of total billed charges,86% of total billed charges,18.99,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.03,97,,,percent of total billed charges,97% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.03,97,,,percent of total billed charges,97% of total billed charges,22.08,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.03,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.62,121.67,
Pulmonary Rehab Breathing Retraining,651868,CDM,410,RC,G0237,HCPCS,Outpatient,,,23.74,11.87,,21.37,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.99,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.62,70,,,percent of total billed charges,70% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.42,86,,,percent of total billed charges,86% of total billed charges,18.99,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.03,97,,,percent of total billed charges,97% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.03,97,,,percent of total billed charges,97% of total billed charges,22.08,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.03,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.62,121.67,
Therapeutic Procedure to Improve Respiratory Function; Per 1,4109132,CDM,410,RC,G0238,HCPCS,Outpatient,,,23.74,11.87,,21.37,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,18.99,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.03,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,21.84,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,16.62,70,,,percent of total billed charges,70% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.55,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,20.42,86,,,percent of total billed charges,86% of total billed charges,18.99,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,23.03,97,,,percent of total billed charges,97% of total billed charges,21.37,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.03,97,,,percent of total billed charges,97% of total billed charges,22.08,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.03,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.62,121.67,
Home Management Training,634106,CDM,410,RC,G0239,HCPCS,Outpatient,,,30.32,15.16,,27.29,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,24.26,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.41,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,27.89,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,27.29,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,21.22,70,,,percent of total billed charges,70% of total billed charges,27.29,90,,,percent of total billed charges,90% of total billed charges,28.8,95,,,percent of total billed charges,95% of total billed charges,28.8,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.08,86,,,percent of total billed charges,86% of total billed charges,24.26,80,,,percent of total billed charges,80% of total billed charges,34.55,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,29.41,97,,,percent of total billed charges,97% of total billed charges,27.29,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.41,97,,,percent of total billed charges,97% of total billed charges,28.2,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.41,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.22,165.55,
G0248- Demonstrate use home iINR monitor,3430574,CDM,450,RC,G0248,HCPCS,Outpatient,,,152.06,76.03,,136.85,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,121.65,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.85,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,147.5,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,139.9,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,136.85,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,106.44,70,,,percent of total billed charges,70% of total billed charges,136.85,90,,,percent of total billed charges,90% of total billed charges,144.46,95,,,percent of total billed charges,95% of total billed charges,144.46,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,130.77,86,,,percent of total billed charges,86% of total billed charges,121.65,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,147.5,97,,,percent of total billed charges,97% of total billed charges,136.85,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.5,97,,,percent of total billed charges,97% of total billed charges,141.42,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,147.5,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,80.74,40.37,,72.67,90,,,percent of total billed charges,90% of total Billed charges,56.22,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.51,155,,,Fee Schedule,155% of CMS OPPS Rate,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.22,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,37.51,145,,,Fee Schedule,145% of CMS OPPS Rate,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.52,145,,,Fee Schedule,145% of CMS OPPS Rate,37.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,23.02,81.52,
"G0277 HBOT, Full Body Chamber, 30 Minutes",3436143,CDM,761,RC,G0277,HCPCS,Outpatient,,,917.05,458.53,,825.35,90,,,percent of total billed charges,90% of total Billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,733.64,80,,,Percent of total Billed charges,80% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,825.35,90,,,Percent of total Billed charges,90% of total billed charges,48.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,889.54,97,,,Percent of total billed charges,97% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,843.69,92,,,Percent of total billed charges,92% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,301.95,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,113.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,609.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,825.35,90,,,percent of total billed charges,90% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,641.94,70,,,percent of total billed charges,70% of total billed charges,825.35,90,,,percent of total billed charges,90% of total billed charges,871.2,95,,,percent of total billed charges,95% of total billed charges,871.2,95,,,percent of total billed charges,95% of total billed charges,113.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,788.66,86,,,percent of total billed charges,86% of total billed charges,733.64,80,,,percent of total billed charges,80% of total billed charges,118.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,889.54,97,,,percent of total billed charges,97% of total billed charges,825.35,90,,,percent of total billed charges,90% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,889.54,97,,,percent of total billed charges,97% of total billed charges,852.86,93,,,percent of total billed charges,93% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,889.54,97,,,percent of total billed charges,97% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.59,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,96.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.89,889.54,
"G0279 - TOMOSYNTHESIS, MAMMO",3999153,CDM,983,RC,G0279,HCPCS,Outpatient,,,55.27,27.64,,49.74,90,,,percent of total billed charges,90% of total Billed charges,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.42,155,,,Fee Schedule,155% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,16.58,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.42,145,,,Fee Schedule,145% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.55,145,,,Fee Schedule,145% of CMS OPPS Rate,30.42,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.58,97.88,
WHFMT MA Diagnostic TOMO,3610993,CDM,972,RC,G0279,HCPCS,Outpatient,,,132.28,66.14,,119.05,90,,,percent of total billed charges,90% of total Billed charges,41.76,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,43.51,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,30.42,155,,,Fee Schedule,155% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.88,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,97.88,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,77.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,39.68,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,29.22,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.42,145,,,Fee Schedule,145% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.55,145,,,Fee Schedule,145% of CMS OPPS Rate,30.42,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,59.52,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.98,119.05,
Occult Blood Screening (FIT test),3334727,CDM,300,RC,G0328,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,85.71,80,,,Percent of total Billed charges,80% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.43,90,,,Percent of total Billed charges,90% of total billed charges,20.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.93,97,,,Percent of total billed charges,97% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,98.57,92,,,Percent of total billed charges,92% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,73.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,82.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.43,90,,,percent of total billed charges,90% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,75,70,,,percent of total billed charges,70% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,18.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.14,86,,,percent of total billed charges,86% of total billed charges,85.71,80,,,percent of total billed charges,80% of total billed charges,20.03,111,,,Fee Schedule,111% of CMS OPPS Rate,103.93,97,,,percent of total billed charges,97% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.93,97,,,percent of total billed charges,97% of total billed charges,99.64,93,,,percent of total billed charges,93% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.93,97,,,percent of total billed charges,97% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,15.34,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.34,103.93,
Occult Blood Screening (FIT test) X 3,3334916,CDM,300,RC,G0328,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,85.71,80,,,Percent of total Billed charges,80% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.43,90,,,Percent of total Billed charges,90% of total billed charges,20.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.93,97,,,Percent of total billed charges,97% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,98.57,92,,,Percent of total billed charges,92% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,73.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,18.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,82.76,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.43,90,,,percent of total billed charges,90% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,75,70,,,percent of total billed charges,70% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,18.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,36.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.14,86,,,percent of total billed charges,86% of total billed charges,85.71,80,,,percent of total billed charges,80% of total billed charges,20.03,111,,,Fee Schedule,111% of CMS OPPS Rate,103.93,97,,,percent of total billed charges,97% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.93,97,,,percent of total billed charges,97% of total billed charges,99.64,93,,,percent of total billed charges,93% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.93,97,,,percent of total billed charges,97% of total billed charges,18.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,15.34,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.34,103.93,
G0372- Phys Srv Req For Pwr Mob Device,3435923,CDM,510,RC,G0372,HCPCS,Outpatient,,,23.06,11.53,,20.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,18.45,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,20.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.37,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.22,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.14,70,,,percent of total billed charges,70% of total billed charges,20.75,90,,,percent of total billed charges,90% of total billed charges,21.91,95,,,percent of total billed charges,95% of total billed charges,21.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.83,86,,,percent of total billed charges,86% of total billed charges,18.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.37,97,,,percent of total billed charges,97% of total billed charges,20.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.37,97,,,percent of total billed charges,97% of total billed charges,21.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.37,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.14,22.37,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,1038.8,519.40,,934.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,831.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,934.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1007.64,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,955.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,934.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,727.16,70,,,percent of total billed charges,70% of total billed charges,934.92,90,,,percent of total billed charges,90% of total billed charges,986.86,95,,,percent of total billed charges,95% of total billed charges,986.86,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,893.37,86,,,percent of total billed charges,86% of total billed charges,831.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1007.64,97,,,percent of total billed charges,97% of total billed charges,934.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1007.64,97,,,percent of total billed charges,97% of total billed charges,966.08,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1007.64,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,1007.64,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,1524.25,762.13,,1371.83,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1219.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1371.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1478.52,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.31,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1371.83,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.98,70,,,percent of total billed charges,70% of total billed charges,1371.83,90,,,percent of total billed charges,90% of total billed charges,1448.04,95,,,percent of total billed charges,95% of total billed charges,1448.04,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1310.86,86,,,percent of total billed charges,86% of total billed charges,1219.4,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1478.52,97,,,percent of total billed charges,97% of total billed charges,1371.83,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1478.52,97,,,percent of total billed charges,97% of total billed charges,1417.55,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1478.52,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,143.02,1478.52,
G0402Initial Wellness Visit ''Welcome to Medicare'',3442036,CDM,983,RC,G0402,HCPCS,Outpatient,,,426.2,213.10,,383.58,90,,,percent of total billed charges,90% of total Billed charges,288.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.43,155,,,Fee Schedule,155% of CMS OPPS Rate,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.86,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.43,145,,,Fee Schedule,145% of CMS OPPS Rate,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,417.8,145,,,Fee Schedule,145% of CMS OPPS Rate,185.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,270.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83.63,417.8,
IPPE-Welcome to Medicare G0402,3428471,CDM,983,RC,G0402,HCPCS,Outpatient,,,426.2,213.10,,383.58,90,,,percent of total billed charges,90% of total Billed charges,288.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.43,155,,,Fee Schedule,155% of CMS OPPS Rate,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,127.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,116.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,116.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,187.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,187.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,127.86,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,255.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,168.87,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,133.17,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,185.43,145,,,Fee Schedule,145% of CMS OPPS Rate,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,417.8,145,,,Fee Schedule,145% of CMS OPPS Rate,185.43,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,83.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,127.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,270.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,83.63,417.8,
G0403- Ekg For Init Preventive Exam,3428455,CDM,983,RC,G0403,HCPCS,Outpatient,,,36.01,18.01,,32.41,90,,,percent of total billed charges,90% of total Billed charges,27.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,155,,,Fee Schedule,155% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.47,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.15,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,24.15,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,24,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,10.8,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,21.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.73,145,,,Fee Schedule,145% of CMS OPPS Rate,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.37,145,,,Fee Schedule,145% of CMS OPPS Rate,19.73,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18.58,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,29.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,10.8,39.37,
G0404- EKG tracing for IPPE,3428456,CDM,983,RC,G0404,HCPCS,Outpatient,,,14.52,7.26,,13.07,90,,,percent of total billed charges,90% of total Billed charges,11.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,155,,,Fee Schedule,155% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,11.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.36,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.21,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.22,145,,,Fee Schedule,145% of CMS OPPS Rate,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.14,145,,,Fee Schedule,145% of CMS OPPS Rate,8.22,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,5.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,4.36,16.14,
G0405- EKG interpret & report for IPPE,3428457,CDM,983,RC,G0405,HCPCS,Outpatient,,,21.49,10.75,,19.34,90,,,percent of total billed charges,90% of total Billed charges,16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.5,155,,,Fee Schedule,155% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.07,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,12.07,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,12.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,6.45,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,11.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,9.02,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,11.5,145,,,Fee Schedule,145% of CMS OPPS Rate,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.2,145,,,Fee Schedule,145% of CMS OPPS Rate,11.5,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7.62,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.26,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,14.26,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.45,23.2,
G0429 - dermal filler injection,3572730,CDM,983,RC,G0429,HCPCS,Outpatient,,,9346.96,4673.48,,8412.26,90,,,percent of total billed charges,90% of total Billed charges,157.93,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.51,155,,,Fee Schedule,155% of CMS OPPS Rate,65.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.48,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,86.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,103.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,103.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,2804.09,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,93.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,76.51,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,95.51,145,,,Fee Schedule,145% of CMS OPPS Rate,65.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,229,145,,,Fee Schedule,145% of CMS OPPS Rate,95.51,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,90.41,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,149.39,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,149.39,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.87,8412.26,
G0438 AWV w/PPS initial visit,3428458,CDM,510,RC,G0438,HCPCS,Outpatient,,,426.2,213.10,,383.58,90,,,percent of total billed charges,90% of total Billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,340.96,80,,,Percent of total Billed charges,80% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,383.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,413.41,97,,,Percent of total billed charges,97% of total billed charges,157.05,100,,,Fee Schedule,100% of CMS OPPS Rate,392.1,92,,,Percent of total billed charges,92% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,640.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,157.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.39,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,724.04,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,383.58,90,,,percent of total billed charges,90% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,298.34,70,,,percent of total billed charges,70% of total billed charges,383.58,90,,,percent of total billed charges,90% of total billed charges,404.89,95,,,percent of total billed charges,95% of total billed charges,404.89,95,,,percent of total billed charges,95% of total billed charges,157.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,366.53,86,,,percent of total billed charges,86% of total billed charges,340.96,80,,,percent of total billed charges,80% of total billed charges,180.39,111,,,Fee Schedule,111% of CMS OPPS Rate,413.41,97,,,percent of total billed charges,97% of total billed charges,383.58,90,,,percent of total billed charges,90% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.41,97,,,percent of total billed charges,97% of total billed charges,396.37,93,,,percent of total billed charges,93% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,413.41,97,,,percent of total billed charges,97% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,134.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.22,780.39,
"G0438- Ppps, Initial Visit",3435669,CDM,510,RC,G0438,HCPCS,Outpatient,,,426.2,213.10,,383.58,90,,,percent of total billed charges,90% of total Billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,340.96,80,,,Percent of total Billed charges,80% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,383.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,413.41,97,,,Percent of total billed charges,97% of total billed charges,157.05,100,,,Fee Schedule,100% of CMS OPPS Rate,392.1,92,,,Percent of total billed charges,92% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,640.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,157.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,780.39,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,724.04,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,383.58,90,,,percent of total billed charges,90% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,298.34,70,,,percent of total billed charges,70% of total billed charges,383.58,90,,,percent of total billed charges,90% of total billed charges,404.89,95,,,percent of total billed charges,95% of total billed charges,404.89,95,,,percent of total billed charges,95% of total billed charges,157.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,315.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,366.53,86,,,percent of total billed charges,86% of total billed charges,340.96,80,,,percent of total billed charges,80% of total billed charges,180.39,111,,,Fee Schedule,111% of CMS OPPS Rate,413.41,97,,,percent of total billed charges,97% of total billed charges,383.58,90,,,percent of total billed charges,90% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.41,97,,,percent of total billed charges,97% of total billed charges,396.37,93,,,percent of total billed charges,93% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,413.41,97,,,percent of total billed charges,97% of total billed charges,157.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,134.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,134.22,780.39,
G0439 AWV w/PPS subsequent visit,3428459,CDM,510,RC,G0439,HCPCS,Outpatient,,,330.95,165.48,,297.86,90,,,percent of total billed charges,90% of total Billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,264.76,80,,,Percent of total Billed charges,80% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,321.02,97,,,Percent of total billed charges,97% of total billed charges,122.1,100,,,Fee Schedule,100% of CMS OPPS Rate,304.47,92,,,Percent of total billed charges,92% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,497.59,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,122.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,562.45,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,297.86,90,,,percent of total billed charges,90% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,231.67,70,,,percent of total billed charges,70% of total billed charges,297.86,90,,,percent of total billed charges,90% of total billed charges,314.4,95,,,percent of total billed charges,95% of total billed charges,314.4,95,,,percent of total billed charges,95% of total billed charges,122.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.62,86,,,percent of total billed charges,86% of total billed charges,264.76,80,,,percent of total billed charges,80% of total billed charges,121.57,111,,,Fee Schedule,111% of CMS OPPS Rate,321.02,97,,,percent of total billed charges,97% of total billed charges,297.86,90,,,percent of total billed charges,90% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.02,97,,,percent of total billed charges,97% of total billed charges,307.78,93,,,percent of total billed charges,93% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.02,97,,,percent of total billed charges,97% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,104.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,104.26,606.22,
"G0439- Ppps, Subseq Visit",3435670,CDM,510,RC,G0439,HCPCS,Outpatient,,,330.95,165.48,,297.86,90,,,percent of total billed charges,90% of total Billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,264.76,80,,,Percent of total Billed charges,80% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,321.02,97,,,Percent of total billed charges,97% of total billed charges,122.1,100,,,Fee Schedule,100% of CMS OPPS Rate,304.47,92,,,Percent of total billed charges,92% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,497.59,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,122.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,606.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,562.45,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,297.86,90,,,percent of total billed charges,90% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,231.67,70,,,percent of total billed charges,70% of total billed charges,297.86,90,,,percent of total billed charges,90% of total billed charges,314.4,95,,,percent of total billed charges,95% of total billed charges,314.4,95,,,percent of total billed charges,95% of total billed charges,122.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,245.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,284.62,86,,,percent of total billed charges,86% of total billed charges,264.76,80,,,percent of total billed charges,80% of total billed charges,121.57,111,,,Fee Schedule,111% of CMS OPPS Rate,321.02,97,,,percent of total billed charges,97% of total billed charges,297.86,90,,,percent of total billed charges,90% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,321.02,97,,,percent of total billed charges,97% of total billed charges,307.78,93,,,percent of total billed charges,93% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,321.02,97,,,percent of total billed charges,97% of total billed charges,122.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,104.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,104.26,606.22,
G0463 - EST PATIENT LVL 1,3717121,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0463 OCC EYE CLINIC VISIT,3686903,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,370,RC,G0500,HCPCS,Outpatient,,,133.78,66.89,,120.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,107.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,120.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,123.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.65,70,,,percent of total billed charges,70% of total billed charges,120.4,90,,,percent of total billed charges,90% of total billed charges,127.09,95,,,percent of total billed charges,95% of total billed charges,127.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.05,86,,,percent of total billed charges,86% of total billed charges,107.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,129.77,97,,,percent of total billed charges,97% of total billed charges,120.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,129.77,97,,,percent of total billed charges,97% of total billed charges,124.42,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.65,129.77,
G2212 - Prolonged OP E/M Service-beyond the maximum (ea addl 15 min),3623709,CDM,510,RC,G2212,HCPCS,Outpatient,,,99.72,49.86,,89.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,79.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,89.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,91.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,69.8,70,,,percent of total billed charges,70% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,94.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.76,86,,,percent of total billed charges,86% of total billed charges,79.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,89.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,92.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,96.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.8,96.73,
G6002-GUIDANCE FOR RADIAJ TX DLVR,3400484,CDM,983,RC,G6002,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,94.37,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,56.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.64,155,,,Fee Schedule,155% of CMS OPPS Rate,47.34,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,129.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,145.57,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,145.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,37.52,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,94.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.49,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.64,145,,,Fee Schedule,145% of CMS OPPS Rate,47.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.84,145,,,Fee Schedule,145% of CMS OPPS Rate,68.64,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,47.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,56.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.89,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,47.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.52,145.57,
G8431 Positive Depression Screen w/follow up plan documented,3438182,CDM,983,RC,G8431,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
G9299- No Eval Risk Venus thromboembolic Card risk Prior to procedure,3430584,CDM,960,RC,G9299,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Intensive Outpatient Treatment,3438168,CDM,983,RC,H0015,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
H0019- BH Intensive Residential Treatment Services,3438158,CDM,960,RC,H0019,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
H0032- BH Individual Treatment Plan Update/Review,3438161,CDM,960,RC,H0032,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,88.2,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,88.2,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,96,
H0035- Partial Hospitalization - Age 18 and Older,3438162,CDM,983,RC,H0035,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,40,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,40,
H2010 -Comprehensive med svc 15 min,3430585,CDM,960,RC,H2010,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMB EPINEPHrine Charge:0.3 mg EPINEPHrine Inj,3444289,CDM,636,RC,J0171,HCPCS,Outpatient,,,40.39,20.20,,36.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.31,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.27,70,,,percent of total billed charges,70% of total billed charges,36.35,90,,,percent of total billed charges,90% of total billed charges,38.37,95,,,percent of total billed charges,95% of total billed charges,38.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,86,,,percent of total billed charges,86% of total billed charges,32.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,36.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,37.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.31,39.18,
AMB EPINEPHrine Charge:0.5 mg EPINEPHrine Inj,3444290,CDM,636,RC,J0171,HCPCS,Outpatient,,,40.39,20.20,,36.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.31,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,37.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.27,70,,,percent of total billed charges,70% of total billed charges,36.35,90,,,percent of total billed charges,90% of total billed charges,38.37,95,,,percent of total billed charges,95% of total billed charges,38.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.74,86,,,percent of total billed charges,86% of total billed charges,32.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,36.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,37.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.18,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.31,39.18,
AMB alprostadil Charge:10 mcg  alprostadil  Inj,3444240,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,717.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.2,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,717.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,733.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,558.25,70,,,percent of total billed charges,70% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.85,86,,,percent of total billed charges,86% of total billed charges,638,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,741.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,773.58,
AMB alprostadil Charge:2.5 mcg  alprostadil  Inj,3444238,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,717.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.2,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,717.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,733.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,558.25,70,,,percent of total billed charges,70% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.85,86,,,percent of total billed charges,86% of total billed charges,638,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,741.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,773.58,
AMB alprostadil Charge:5 mcg  alprostadil  Inj,3444239,CDM,636,RC,J0270,HCPCS,Outpatient,,,797.5,398.75,,717.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.2,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,717.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,733.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,558.25,70,,,percent of total billed charges,70% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,757.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,685.85,86,,,percent of total billed charges,86% of total billed charges,638,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,717.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,741.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,773.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,773.58,
AMB amiodarone Charge:150 mg amiodarone Inj,3444242,CDM,636,RC,J0282,HCPCS,Outpatient,,,5.4,2.70,,4.86,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.65,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.78,70,,,percent of total billed charges,70% of total billed charges,4.86,90,,,percent of total billed charges,90% of total billed charges,5.13,95,,,percent of total billed charges,95% of total billed charges,5.13,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.64,86,,,percent of total billed charges,86% of total billed charges,4.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.24,97,,,percent of total billed charges,97% of total billed charges,4.86,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.24,97,,,percent of total billed charges,97% of total billed charges,5.02,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.65,5.24,
AMB atropine Charge:0.4 mg atropine Inj,3444243,CDM,636,RC,J0461,HCPCS,Outpatient,,,0.07,0.04,,0.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.06,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.05,70,,,percent of total billed charges,70% of total billed charges,0.06,90,,,percent of total billed charges,90% of total billed charges,0.07,95,,,percent of total billed charges,95% of total billed charges,0.07,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.06,86,,,percent of total billed charges,86% of total billed charges,0.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.07,97,,,percent of total billed charges,97% of total billed charges,0.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.07,97,,,percent of total billed charges,97% of total billed charges,0.07,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,0.11,
AMB benralizumab Charge:300 mg benralizumab Inj,3444247,CDM,636,RC,J0517,HCPCS,Outpatient,,,14447.38,7223.69,,13002.64,90,,,percent of total billed charges,90% of total Billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,262.86,150,,,Fee Schedule,150% of Fee Schedule Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,13002.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14013.96,97,,,Percent of total billed charges,97% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,13291.59,92,,,Percent of total billed charges,92% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,453.36,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,170.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,722.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,915.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,13002.64,90,,,percent of total billed charges,90% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,10113.17,70,,,percent of total billed charges,70% of total billed charges,13002.64,90,,,percent of total billed charges,90% of total billed charges,13725.01,95,,,percent of total billed charges,95% of total billed charges,13725.01,95,,,percent of total billed charges,95% of total billed charges,170.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,341.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12424.75,86,,,percent of total billed charges,86% of total billed charges,11557.9,80,,,percent of total billed charges,80% of total billed charges,188.82,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,14013.96,97,,,percent of total billed charges,97% of total billed charges,13002.64,90,,,percent of total billed charges,90% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,14013.96,97,,,percent of total billed charges,97% of total billed charges,13436.06,93,,,percent of total billed charges,93% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,14013.96,97,,,percent of total billed charges,97% of total billed charges,170.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,144.97,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,144.97,14013.96,
AMB onabotulinumtoxinA Charge -> 100 unit Botox Inj,3616873,CDM,636,RC,J0585,HCPCS,Outpatient,,,3804,1902.00,,3423.6,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3423.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3689.88,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,3499.68,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3423.6,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,2662.8,70,,,percent of total billed charges,70% of total billed charges,3423.6,90,,,percent of total billed charges,90% of total billed charges,3613.8,95,,,percent of total billed charges,95% of total billed charges,3613.8,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3271.44,86,,,percent of total billed charges,86% of total billed charges,3043.2,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3689.88,97,,,percent of total billed charges,97% of total billed charges,3423.6,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,3689.88,97,,,percent of total billed charges,97% of total billed charges,3537.72,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3689.88,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,3689.88,
AMB onabotulinumtoxinA Charge -> 200 unit Botox Inj,3616872,CDM,636,RC,J0585,HCPCS,Outpatient,,,7608,3804.00,,6847.2,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6847.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7379.76,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6999.36,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6847.2,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,5325.6,70,,,percent of total billed charges,70% of total billed charges,6847.2,90,,,percent of total billed charges,90% of total billed charges,7227.6,95,,,percent of total billed charges,95% of total billed charges,7227.6,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6542.88,86,,,percent of total billed charges,86% of total billed charges,6086.4,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7379.76,97,,,percent of total billed charges,97% of total billed charges,6847.2,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,7379.76,97,,,percent of total billed charges,97% of total billed charges,7075.44,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7379.76,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,7379.76,
"J0585 - Injection, onabotulinumtoxinA, 1 unit",3430587,CDM,636,RC,J0585,HCPCS,Outpatient,,,16.8,8.40,,15.12,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,15.46,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15.12,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,11.76,70,,,percent of total billed charges,70% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14.45,86,,,percent of total billed charges,86% of total billed charges,13.44,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16.3,97,,,percent of total billed charges,97% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.3,97,,,percent of total billed charges,97% of total billed charges,15.62,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,33.97,
J0585-OCC EYE BOTOX SUPPLY PER UNIT,3536987,CDM,636,RC,J0585,HCPCS,Outpatient,,,38,19.00,,34.2,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.86,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,34.96,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.2,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.6,70,,,percent of total billed charges,70% of total billed charges,34.2,90,,,percent of total billed charges,90% of total billed charges,36.1,95,,,percent of total billed charges,95% of total billed charges,36.1,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.68,86,,,percent of total billed charges,86% of total billed charges,30.4,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36.86,97,,,percent of total billed charges,97% of total billed charges,34.2,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.86,97,,,percent of total billed charges,97% of total billed charges,35.34,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.86,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,36.86,
onabotulinumtoxinA,,,636,RC,J0585,HCPCS,Outpatient,,,1622.7,811.35,,1460.43,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1460.43,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1574.02,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1492.88,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1460.43,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,1135.89,70,,,percent of total billed charges,70% of total billed charges,1460.43,90,,,percent of total billed charges,90% of total billed charges,1541.57,95,,,percent of total billed charges,95% of total billed charges,1541.57,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1395.52,86,,,percent of total billed charges,86% of total billed charges,1298.16,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1574.02,97,,,percent of total billed charges,97% of total billed charges,1460.43,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,1574.02,97,,,percent of total billed charges,97% of total billed charges,1509.11,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1574.02,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,1574.02,
J0587 - Botox - 100 units,3918949,CDM,636,RC,J0587,HCPCS,Outpatient,,,1393.28,696.64,,1253.95,90,,,percent of total billed charges,90% of total Billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,18.71,150,,,Fee Schedule,150% of Fee Schedule Rate,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,1253.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1351.48,97,,,Percent of total billed charges,97% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,1281.82,92,,,Percent of total billed charges,92% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,34.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.25,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,69.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1253.95,90,,,percent of total billed charges,90% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,975.3,70,,,percent of total billed charges,70% of total billed charges,1253.95,90,,,percent of total billed charges,90% of total billed charges,1323.62,95,,,percent of total billed charges,95% of total billed charges,1323.62,95,,,percent of total billed charges,95% of total billed charges,13.04,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1198.22,86,,,percent of total billed charges,86% of total billed charges,1114.62,80,,,percent of total billed charges,80% of total billed charges,13.24,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1351.48,97,,,percent of total billed charges,97% of total billed charges,1253.95,90,,,percent of total billed charges,90% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.48,97,,,percent of total billed charges,97% of total billed charges,1295.75,93,,,percent of total billed charges,93% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1351.48,97,,,percent of total billed charges,97% of total billed charges,13.04,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.04,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.08,1351.48,
AMB incobotulinumtoxinA Charge:25unit Xeomin Inj,3444320,CDM,636,RC,J0588,HCPCS,Outpatient,,,5.63,2.82,,5.07,90,,,percent of total billed charges,90% of total Billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,7.89,150,,,Fee Schedule,150% of Fee Schedule Rate,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.46,97,,,Percent of total billed charges,97% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,92,,,Percent of total billed charges,92% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5.07,90,,,percent of total billed charges,90% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,70,,,percent of total billed charges,70% of total billed charges,5.07,90,,,percent of total billed charges,90% of total billed charges,5.35,95,,,percent of total billed charges,95% of total billed charges,5.35,95,,,percent of total billed charges,95% of total billed charges,5.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4.84,86,,,percent of total billed charges,86% of total billed charges,4.5,80,,,percent of total billed charges,80% of total billed charges,5.57,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5.46,97,,,percent of total billed charges,97% of total billed charges,5.07,90,,,percent of total billed charges,90% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.46,97,,,percent of total billed charges,97% of total billed charges,5.24,93,,,percent of total billed charges,93% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.46,97,,,percent of total billed charges,97% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.94,27.85,
AMB incobotulinumtoxinA Charge:50unit Xeomin Inj,3444321,CDM,636,RC,J0588,HCPCS,Outpatient,,,5.63,2.82,,5.07,90,,,percent of total billed charges,90% of total Billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,7.89,150,,,Fee Schedule,150% of Fee Schedule Rate,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.46,97,,,Percent of total billed charges,97% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.18,92,,,Percent of total billed charges,92% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,13.79,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5.07,90,,,percent of total billed charges,90% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,3.94,70,,,percent of total billed charges,70% of total billed charges,5.07,90,,,percent of total billed charges,90% of total billed charges,5.35,95,,,percent of total billed charges,95% of total billed charges,5.35,95,,,percent of total billed charges,95% of total billed charges,5.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4.84,86,,,percent of total billed charges,86% of total billed charges,4.5,80,,,percent of total billed charges,80% of total billed charges,5.57,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5.46,97,,,percent of total billed charges,97% of total billed charges,5.07,90,,,percent of total billed charges,90% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.46,97,,,percent of total billed charges,97% of total billed charges,5.24,93,,,percent of total billed charges,93% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5.46,97,,,percent of total billed charges,97% of total billed charges,5.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.94,27.85,
AMB canakinumab Charge:150 mg canakinumab Inj,3444252,CDM,636,RC,J0638,HCPCS,Outpatient,,,46234.04,23117.02,,41610.64,90,,,percent of total billed charges,90% of total Billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate,173.18,150,,,Fee Schedule,150% of Fee Schedule Rate,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,41610.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44847.02,97,,,Percent of total billed charges,97% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate,42535.32,92,,,Percent of total billed charges,92% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate,324.45,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,122.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,517.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,655.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,41610.64,90,,,percent of total billed charges,90% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate,32363.83,70,,,percent of total billed charges,70% of total billed charges,41610.64,90,,,percent of total billed charges,90% of total billed charges,43922.34,95,,,percent of total billed charges,95% of total billed charges,43922.34,95,,,percent of total billed charges,95% of total billed charges,122.06,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,244.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,39761.27,86,,,percent of total billed charges,86% of total billed charges,36987.23,80,,,percent of total billed charges,80% of total billed charges,125.69,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,44847.02,97,,,percent of total billed charges,97% of total billed charges,41610.64,90,,,percent of total billed charges,90% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,44847.02,97,,,percent of total billed charges,97% of total billed charges,42997.66,93,,,percent of total billed charges,93% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44847.02,97,,,percent of total billed charges,97% of total billed charges,122.06,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.06,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,103.75,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.75,44847.02,
AMB cefTRIAXone Charge:1000 mg cefTRIAXone Inj,3444253,CDM,636,RC,J0696,HCPCS,Outpatient,,,103.39,51.70,,93.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,93.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,100.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,95.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.37,70,,,percent of total billed charges,70% of total billed charges,93.05,90,,,percent of total billed charges,90% of total billed charges,98.22,95,,,percent of total billed charges,95% of total billed charges,98.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88.92,86,,,percent of total billed charges,86% of total billed charges,82.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,100.29,97,,,percent of total billed charges,97% of total billed charges,93.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,100.29,97,,,percent of total billed charges,97% of total billed charges,96.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,100.29,
AMB cefTRIAXone Charge:250 mg cefTRIAXone Inj,3444255,CDM,636,RC,J0696,HCPCS,Outpatient,,,2.03,1.02,,1.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.42,70,,,percent of total billed charges,70% of total billed charges,1.83,90,,,percent of total billed charges,90% of total billed charges,1.93,95,,,percent of total billed charges,95% of total billed charges,1.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.75,86,,,percent of total billed charges,86% of total billed charges,1.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1.97,97,,,percent of total billed charges,97% of total billed charges,1.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.97,97,,,percent of total billed charges,97% of total billed charges,1.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,1.97,
AMB cefTRIAXone Charge:500 mg cefTRIAXone Inj,3444254,CDM,636,RC,J0696,HCPCS,Outpatient,,,60.41,30.21,,54.37,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.6,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,55.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.29,70,,,percent of total billed charges,70% of total billed charges,54.37,90,,,percent of total billed charges,90% of total billed charges,57.39,95,,,percent of total billed charges,95% of total billed charges,57.39,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.95,86,,,percent of total billed charges,86% of total billed charges,48.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,58.6,97,,,percent of total billed charges,97% of total billed charges,54.37,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.6,97,,,percent of total billed charges,97% of total billed charges,56.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.6,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,58.6,
J0696 - Ceftriaxone - 250mg,3918950,CDM,636,RC,J0696,HCPCS,Outpatient,,,45.92,22.96,,41.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,41.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.14,70,,,percent of total billed charges,70% of total billed charges,41.33,90,,,percent of total billed charges,90% of total billed charges,43.62,95,,,percent of total billed charges,95% of total billed charges,43.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,86,,,percent of total billed charges,86% of total billed charges,36.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,41.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,42.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.84,44.54,
AMB betamethasone Charge:12 mg betamethasone Inj,3444251,CDM,636,RC,J0702,HCPCS,Outpatient,,,56.61,28.31,,50.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.85,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,52.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.63,70,,,percent of total billed charges,70% of total billed charges,50.95,90,,,percent of total billed charges,90% of total billed charges,53.78,95,,,percent of total billed charges,95% of total billed charges,53.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.68,86,,,percent of total billed charges,86% of total billed charges,45.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,50.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,52.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,54.91,
AMB betamethasone Charge:6 mg betamethasone Inj,3444249,CDM,636,RC,J0702,HCPCS,Outpatient,,,28.3,14.15,,25.47,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.85,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,26.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.81,70,,,percent of total billed charges,70% of total billed charges,25.47,90,,,percent of total billed charges,90% of total billed charges,26.89,95,,,percent of total billed charges,95% of total billed charges,26.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.34,86,,,percent of total billed charges,86% of total billed charges,22.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.45,97,,,percent of total billed charges,97% of total billed charges,25.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.45,97,,,percent of total billed charges,97% of total billed charges,26.32,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,27.45,
AMB betamethasone Charge:9 mg betamethasone Inj,3444250,CDM,636,RC,J0702,HCPCS,Outpatient,,,56.61,28.31,,50.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.85,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,50.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,52.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.63,70,,,percent of total billed charges,70% of total billed charges,50.95,90,,,percent of total billed charges,90% of total billed charges,53.78,95,,,percent of total billed charges,95% of total billed charges,53.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.68,86,,,percent of total billed charges,86% of total billed charges,45.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,50.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,52.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.85,54.91,
AMB certolizumab Charge:400 mg certolizumab Inj,3444256,CDM,636,RC,J0717,HCPCS,Outpatient,,,26004.02,13002.01,,23403.62,90,,,percent of total billed charges,90% of total Billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.51,150,,,Fee Schedule,150% of Fee Schedule Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,23403.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25223.9,97,,,Percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,23923.7,92,,,Percent of total billed charges,92% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.3,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23403.62,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,18202.81,70,,,percent of total billed charges,70% of total billed charges,23403.62,90,,,percent of total billed charges,90% of total billed charges,24703.82,95,,,percent of total billed charges,95% of total billed charges,24703.82,95,,,percent of total billed charges,95% of total billed charges,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22363.46,86,,,percent of total billed charges,86% of total billed charges,20803.22,80,,,percent of total billed charges,80% of total billed charges,9.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25223.9,97,,,percent of total billed charges,97% of total billed charges,23403.62,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,25223.9,97,,,percent of total billed charges,97% of total billed charges,24183.74,93,,,percent of total billed charges,93% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25223.9,97,,,percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.16,25223.9,
J0717 - Cimza - 1mg,3918953,CDM,636,RC,J0717,HCPCS,Outpatient,,,8.95,4.48,,8.06,90,,,percent of total billed charges,90% of total Billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.51,150,,,Fee Schedule,150% of Fee Schedule Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.68,97,,,Percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,92,,,Percent of total billed charges,92% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.3,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8.06,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,70,,,percent of total billed charges,70% of total billed charges,8.06,90,,,percent of total billed charges,90% of total billed charges,8.5,95,,,percent of total billed charges,95% of total billed charges,8.5,95,,,percent of total billed charges,95% of total billed charges,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7.7,86,,,percent of total billed charges,86% of total billed charges,7.16,80,,,percent of total billed charges,80% of total billed charges,9.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8.68,97,,,percent of total billed charges,97% of total billed charges,8.06,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.68,97,,,percent of total billed charges,97% of total billed charges,8.32,93,,,percent of total billed charges,93% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.68,97,,,percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.16,26.3,
"J0717 - Injection, certolizumab pegol, 1 mg",3918952,CDM,636,RC,J0717,HCPCS,Outpatient,,,8.95,4.48,,8.06,90,,,percent of total billed charges,90% of total Billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,12.51,150,,,Fee Schedule,150% of Fee Schedule Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.68,97,,,Percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,8.23,92,,,Percent of total billed charges,92% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,13.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,26.3,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8.06,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,70,,,percent of total billed charges,70% of total billed charges,8.06,90,,,percent of total billed charges,90% of total billed charges,8.5,95,,,percent of total billed charges,95% of total billed charges,8.5,95,,,percent of total billed charges,95% of total billed charges,4.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7.7,86,,,percent of total billed charges,86% of total billed charges,7.16,80,,,percent of total billed charges,80% of total billed charges,9.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8.68,97,,,percent of total billed charges,97% of total billed charges,8.06,90,,,percent of total billed charges,90% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.68,97,,,percent of total billed charges,97% of total billed charges,8.32,93,,,percent of total billed charges,93% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8.68,97,,,percent of total billed charges,97% of total billed charges,4.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4.16,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.16,26.3,
AMB collagenase clostridium Charge:0.58 mg Xiaflex Inj,3444259,CDM,636,RC,J0775,HCPCS,Outpatient,,,36596.35,18298.18,,32936.72,90,,,percent of total billed charges,90% of total Billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate,76.07,150,,,Fee Schedule,150% of Fee Schedule Rate,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,32936.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35498.46,97,,,Percent of total billed charges,97% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate,33668.64,92,,,Percent of total billed charges,92% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate,180.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,287.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,363.65,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,32936.72,90,,,percent of total billed charges,90% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate,25617.45,70,,,percent of total billed charges,70% of total billed charges,32936.72,90,,,percent of total billed charges,90% of total billed charges,34766.53,95,,,percent of total billed charges,95% of total billed charges,34766.53,95,,,percent of total billed charges,95% of total billed charges,67.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,135.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,31472.86,86,,,percent of total billed charges,86% of total billed charges,29277.08,80,,,percent of total billed charges,80% of total billed charges,58.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,35498.46,97,,,percent of total billed charges,97% of total billed charges,32936.72,90,,,percent of total billed charges,90% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,35498.46,97,,,percent of total billed charges,97% of total billed charges,34034.61,93,,,percent of total billed charges,93% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,35498.46,97,,,percent of total billed charges,97% of total billed charges,67.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.75,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,57.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.58,35498.46,
10 mg prochlorperazine Inj,4241578,CDM,636,RC,J0780,HCPCS,Outpatient,,,49.95,24.98,,44.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,15.12,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges,44.96,90,,,percent of total billed charges,90% of total billed charges,47.45,95,,,percent of total billed charges,95% of total billed charges,47.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,86,,,percent of total billed charges,86% of total billed charges,39.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,44.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,46.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48.45,
5 mg prochlorperazine Inj,4241579,CDM,636,RC,J0780,HCPCS,Outpatient,,,49.95,24.98,,44.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,15.12,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.97,70,,,percent of total billed charges,70% of total billed charges,44.96,90,,,percent of total billed charges,90% of total billed charges,47.45,95,,,percent of total billed charges,95% of total billed charges,47.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.96,86,,,percent of total billed charges,86% of total billed charges,39.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,44.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,46.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,48.45,
AMB Denosumab Charge:120 mg denosumab Inj,3444270,CDM,636,RC,J0897,HCPCS,Outpatient,,,17264.75,8632.38,,15538.28,90,,,percent of total billed charges,90% of total Billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,150,,,Fee Schedule,150% of Fee Schedule Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,15538.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16746.81,97,,,Percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,15883.57,92,,,Percent of total billed charges,92% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,130,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15538.28,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12085.33,70,,,percent of total billed charges,70% of total billed charges,15538.28,90,,,percent of total billed charges,90% of total billed charges,16401.51,95,,,percent of total billed charges,95% of total billed charges,16401.51,95,,,percent of total billed charges,95% of total billed charges,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14847.69,86,,,percent of total billed charges,86% of total billed charges,13811.8,80,,,percent of total billed charges,80% of total billed charges,22.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16746.81,97,,,percent of total billed charges,97% of total billed charges,15538.28,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,16746.81,97,,,percent of total billed charges,97% of total billed charges,16056.22,93,,,percent of total billed charges,93% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,16746.81,97,,,percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,20.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.58,16746.81,
AMB Denosumab Charge:60 mg denosumab Inj,3444269,CDM,636,RC,J0897,HCPCS,Outpatient,,,9385.85,4692.93,,8447.27,90,,,percent of total billed charges,90% of total Billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,150,,,Fee Schedule,150% of Fee Schedule Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,8447.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9104.27,97,,,Percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,8634.98,92,,,Percent of total billed charges,92% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,130,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8447.27,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,6570.1,70,,,percent of total billed charges,70% of total billed charges,8447.27,90,,,percent of total billed charges,90% of total billed charges,8916.56,95,,,percent of total billed charges,95% of total billed charges,8916.56,95,,,percent of total billed charges,95% of total billed charges,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8071.83,86,,,percent of total billed charges,86% of total billed charges,7508.68,80,,,percent of total billed charges,80% of total billed charges,22.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9104.27,97,,,percent of total billed charges,97% of total billed charges,8447.27,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,9104.27,97,,,percent of total billed charges,97% of total billed charges,8728.84,93,,,percent of total billed charges,93% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9104.27,97,,,percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,20.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.58,9104.27,
"J0897 - Injection, denosumab, 1 mg",3918954,CDM,636,RC,J0897,HCPCS,Outpatient,,,2979.56,1489.78,,2681.6,90,,,percent of total billed charges,90% of total Billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,150,,,Fee Schedule,150% of Fee Schedule Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2681.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2890.17,97,,,Percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2741.2,92,,,Percent of total billed charges,92% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,130,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2681.6,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2085.69,70,,,percent of total billed charges,70% of total billed charges,2681.6,90,,,percent of total billed charges,90% of total billed charges,2830.58,95,,,percent of total billed charges,95% of total billed charges,2830.58,95,,,percent of total billed charges,95% of total billed charges,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2562.42,86,,,percent of total billed charges,86% of total billed charges,2383.65,80,,,percent of total billed charges,80% of total billed charges,22.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2890.17,97,,,percent of total billed charges,97% of total billed charges,2681.6,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2890.17,97,,,percent of total billed charges,97% of total billed charges,2770.99,93,,,percent of total billed charges,93% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2890.17,97,,,percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,20.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.58,2890.17,
J0897 - Prolia - 1mg,3918955,CDM,636,RC,J0897,HCPCS,Outpatient,,,2979.56,1489.78,,2681.6,90,,,percent of total billed charges,90% of total Billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,30.08,150,,,Fee Schedule,150% of Fee Schedule Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2681.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2890.17,97,,,Percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2741.2,92,,,Percent of total billed charges,92% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,64.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,102.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,130,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2681.6,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2085.69,70,,,percent of total billed charges,70% of total billed charges,2681.6,90,,,percent of total billed charges,90% of total billed charges,2830.58,95,,,percent of total billed charges,95% of total billed charges,2830.58,95,,,percent of total billed charges,95% of total billed charges,24.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,48.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2562.42,86,,,percent of total billed charges,86% of total billed charges,2383.65,80,,,percent of total billed charges,80% of total billed charges,22.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2890.17,97,,,percent of total billed charges,97% of total billed charges,2681.6,90,,,percent of total billed charges,90% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2890.17,97,,,percent of total billed charges,97% of total billed charges,2770.99,93,,,percent of total billed charges,93% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2890.17,97,,,percent of total billed charges,97% of total billed charges,24.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,20.58,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20.58,2890.17,
80mg DEPO-Medrol Inj,3444357,CDM,636,RC,J1010,HCPCS,Outpatient,,,44.06,22.03,,39.65,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,35.25,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.65,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,40.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.84,70,,,percent of total billed charges,70% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,41.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.89,86,,,percent of total billed charges,86% of total billed charges,35.25,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.74,97,,,percent of total billed charges,97% of total billed charges,39.65,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.74,97,,,percent of total billed charges,97% of total billed charges,40.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.84,42.74,
AMB MethylPREDNISolone Charge:40 mg DEPO-Medrol Inj,3444356,CDM,636,RC,J1010,HCPCS,Outpatient,,,30.69,15.35,,27.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.55,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,27.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.77,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.48,70,,,percent of total billed charges,70% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,29.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.39,86,,,percent of total billed charges,86% of total billed charges,24.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.77,97,,,percent of total billed charges,97% of total billed charges,27.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.77,97,,,percent of total billed charges,97% of total billed charges,28.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.77,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.48,29.77,
AMB MethylPREDNISolone Charge:40 mg DEPO-Medrol Inj,3711090,CDM,636,RC,J1010,HCPCS,Outpatient,,,15.35,7.68,,13.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.89,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,14.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.75,70,,,percent of total billed charges,70% of total billed charges,13.82,90,,,percent of total billed charges,90% of total billed charges,14.58,95,,,percent of total billed charges,95% of total billed charges,14.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.2,86,,,percent of total billed charges,86% of total billed charges,12.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.89,97,,,percent of total billed charges,97% of total billed charges,13.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.89,97,,,percent of total billed charges,97% of total billed charges,14.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.75,14.89,
"J1010-RHM DEPOMEDROL,40MG",3430593,CDM,636,RC,J1010,HCPCS,Outpatient,,,16.8,8.40,,15.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,13.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,15.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.76,70,,,percent of total billed charges,70% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,86,,,percent of total billed charges,86% of total billed charges,13.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,15.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,16.3,
"J1030 - Injection, methylprednisolone acetate, 40 mg",3918956,CDM,636,RC,J1010,HCPCS,Outpatient,,,45.92,22.96,,41.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,36.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,41.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,42.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.14,70,,,percent of total billed charges,70% of total billed charges,41.33,90,,,percent of total billed charges,90% of total billed charges,43.62,95,,,percent of total billed charges,95% of total billed charges,43.62,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.49,86,,,percent of total billed charges,86% of total billed charges,36.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,41.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,42.71,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.14,44.54,
J1030 - RHM DepoMedrol - 40mg,3918957,CDM,636,RC,J1010,HCPCS,Outpatient,,,16.8,8.40,,15.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,13.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,15.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.76,70,,,percent of total billed charges,70% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,15.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.45,86,,,percent of total billed charges,86% of total billed charges,13.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,15.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,15.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.76,16.3,
"J1040 - Methylprednisolone, 80 mg",3918958,CDM,636,RC,J1010,HCPCS,Outpatient,,,57.12,28.56,,51.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,45.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,51.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.41,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,52.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,39.98,70,,,percent of total billed charges,70% of total billed charges,51.41,90,,,percent of total billed charges,90% of total billed charges,54.26,95,,,percent of total billed charges,95% of total billed charges,54.26,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.12,86,,,percent of total billed charges,86% of total billed charges,45.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,55.41,97,,,percent of total billed charges,97% of total billed charges,51.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,55.41,97,,,percent of total billed charges,97% of total billed charges,53.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.41,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.98,55.41,
AMB medroxyPROGESTERone Charge:150 mg DEPO-Provera Inj,3444350,CDM,636,RC,J1050,HCPCS,Outpatient,,,230.4,115.20,,207.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.87,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,207.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.28,70,,,percent of total billed charges,70% of total billed charges,207.36,90,,,percent of total billed charges,90% of total billed charges,218.88,95,,,percent of total billed charges,95% of total billed charges,218.88,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.14,86,,,percent of total billed charges,86% of total billed charges,184.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.49,97,,,percent of total billed charges,97% of total billed charges,207.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.49,97,,,percent of total billed charges,97% of total billed charges,214.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,223.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,223.49,
100 mg Depo-Testosterone Inj,3616862,CDM,636,RC,J1071,HCPCS,Outpatient,,,63,31.50,,56.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,56.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.11,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,57.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.1,70,,,percent of total billed charges,70% of total billed charges,56.7,90,,,percent of total billed charges,90% of total billed charges,59.85,95,,,percent of total billed charges,95% of total billed charges,59.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.18,86,,,percent of total billed charges,86% of total billed charges,50.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.11,97,,,percent of total billed charges,97% of total billed charges,56.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.11,97,,,percent of total billed charges,97% of total billed charges,58.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.11,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,61.11,
150 mg Depo-Testosterone Inj,4215708,CDM,636,RC,J1071,HCPCS,Outpatient,,,94.5,47.25,,85.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,85.05,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,91.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,86.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.15,70,,,percent of total billed charges,70% of total billed charges,85.05,90,,,percent of total billed charges,90% of total billed charges,89.78,95,,,percent of total billed charges,95% of total billed charges,89.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.27,86,,,percent of total billed charges,86% of total billed charges,75.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,91.67,97,,,percent of total billed charges,97% of total billed charges,85.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,91.67,97,,,percent of total billed charges,97% of total billed charges,87.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,91.67,
250 mg Depo-Testosterone Inj,4215715,CDM,636,RC,J1071,HCPCS,Outpatient,,,157.5,78.75,,141.75,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,141.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,152.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,144.9,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,110.25,70,,,percent of total billed charges,70% of total billed charges,141.75,90,,,percent of total billed charges,90% of total billed charges,149.63,95,,,percent of total billed charges,95% of total billed charges,149.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.45,86,,,percent of total billed charges,86% of total billed charges,126,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,152.78,97,,,percent of total billed charges,97% of total billed charges,141.75,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,152.78,97,,,percent of total billed charges,97% of total billed charges,146.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,152.78,
50 mg Depo-Testosterone Inj,3616863,CDM,636,RC,J1071,HCPCS,Outpatient,,,31.5,15.75,,28.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,28.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.05,70,,,percent of total billed charges,70% of total billed charges,28.35,90,,,percent of total billed charges,90% of total billed charges,29.93,95,,,percent of total billed charges,95% of total billed charges,29.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.09,86,,,percent of total billed charges,86% of total billed charges,25.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.56,97,,,percent of total billed charges,97% of total billed charges,28.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.56,97,,,percent of total billed charges,97% of total billed charges,29.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,30.56,
AMB Testosterone Charge:1000 mg Aveed Inj,3444413,CDM,636,RC,J1071,HCPCS,Outpatient,,,5607.36,2803.68,,5046.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,5046.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5439.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5158.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5046.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3925.15,70,,,percent of total billed charges,70% of total billed charges,5046.62,90,,,percent of total billed charges,90% of total billed charges,5326.99,95,,,percent of total billed charges,95% of total billed charges,5326.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4822.33,86,,,percent of total billed charges,86% of total billed charges,4485.89,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5439.14,97,,,percent of total billed charges,97% of total billed charges,5046.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5439.14,97,,,percent of total billed charges,97% of total billed charges,5214.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5439.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,5439.14,
AMB Testosterone Charge:200 mg Depo-Testosterone Inj,3444410,CDM,636,RC,J1071,HCPCS,Outpatient,,,126,63.00,,113.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,113.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,115.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.2,70,,,percent of total billed charges,70% of total billed charges,113.4,90,,,percent of total billed charges,90% of total billed charges,119.7,95,,,percent of total billed charges,95% of total billed charges,119.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.36,86,,,percent of total billed charges,86% of total billed charges,100.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,122.22,97,,,percent of total billed charges,97% of total billed charges,113.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.22,97,,,percent of total billed charges,97% of total billed charges,117.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,122.22,
AMB Testosterone Charge:300mg Depo-Testosterone Inj,3444411,CDM,636,RC,J1071,HCPCS,Outpatient,,,189,94.50,,170.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,170.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,183.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,173.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,132.3,70,,,percent of total billed charges,70% of total billed charges,170.1,90,,,percent of total billed charges,90% of total billed charges,179.55,95,,,percent of total billed charges,95% of total billed charges,179.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162.54,86,,,percent of total billed charges,86% of total billed charges,151.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,183.33,97,,,percent of total billed charges,97% of total billed charges,170.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,183.33,97,,,percent of total billed charges,97% of total billed charges,175.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,183.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,183.33,
AMB Testosterone Charge:500mg Depo-Testosterone Inj,3444412,CDM,636,RC,J1071,HCPCS,Outpatient,,,315,157.50,,283.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,283.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.55,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,289.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,220.5,70,,,percent of total billed charges,70% of total billed charges,283.5,90,,,percent of total billed charges,90% of total billed charges,299.25,95,,,percent of total billed charges,95% of total billed charges,299.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.9,86,,,percent of total billed charges,86% of total billed charges,252,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,305.55,97,,,percent of total billed charges,97% of total billed charges,283.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.55,97,,,percent of total billed charges,97% of total billed charges,292.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.55,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,305.55,
AMB Testosterone Charge:750 mg Aveed Inj,3444414,CDM,636,RC,J1071,HCPCS,Outpatient,,,4205.52,2102.76,,3784.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,3784.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4079.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3869.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3784.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2943.86,70,,,percent of total billed charges,70% of total billed charges,3784.97,90,,,percent of total billed charges,90% of total billed charges,3995.24,95,,,percent of total billed charges,95% of total billed charges,3995.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3616.75,86,,,percent of total billed charges,86% of total billed charges,3364.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4079.35,97,,,percent of total billed charges,97% of total billed charges,3784.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4079.35,97,,,percent of total billed charges,97% of total billed charges,3911.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4079.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,4079.35,
J1071 - Testosterone - 1mg,3918959,CDM,636,RC,J1071,HCPCS,Outpatient,,,43.7,21.85,,39.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.03,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,39.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.39,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,40.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.59,70,,,percent of total billed charges,70% of total billed charges,39.33,90,,,percent of total billed charges,90% of total billed charges,41.52,95,,,percent of total billed charges,95% of total billed charges,41.52,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.58,86,,,percent of total billed charges,86% of total billed charges,34.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.39,97,,,percent of total billed charges,97% of total billed charges,39.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.39,97,,,percent of total billed charges,97% of total billed charges,40.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.39,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.03,42.39,
AMB dexamethasone Charge -> 8 mg dexamethasone Inj,3444272,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.16,0.08,,0.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.23,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.11,70,,,percent of total billed charges,70% of total billed charges,0.14,90,,,percent of total billed charges,90% of total billed charges,0.15,95,,,percent of total billed charges,95% of total billed charges,0.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,86,,,percent of total billed charges,86% of total billed charges,0.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,0.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,0.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,0.23,
AMB dexamethasone Charge:4 mg dexamethasone Inj,3444271,CDM,636,RC,J1100,HCPCS,Outpatient,,,0.16,0.08,,0.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.23,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.11,70,,,percent of total billed charges,70% of total billed charges,0.14,90,,,percent of total billed charges,90% of total billed charges,0.15,95,,,percent of total billed charges,95% of total billed charges,0.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.14,86,,,percent of total billed charges,86% of total billed charges,0.13,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,0.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,0.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,0.23,
J1100 - Dexamethasone - 1mg,3918960,CDM,636,RC,J1100,HCPCS,Outpatient,,,1.48,0.74,,1.33,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.23,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.04,70,,,percent of total billed charges,70% of total billed charges,1.33,90,,,percent of total billed charges,90% of total billed charges,1.41,95,,,percent of total billed charges,95% of total billed charges,1.41,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.27,86,,,percent of total billed charges,86% of total billed charges,1.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1.44,97,,,percent of total billed charges,97% of total billed charges,1.33,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.44,97,,,percent of total billed charges,97% of total billed charges,1.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.23,1.44,
J1200 - Benadryl - upto 50mg,3918961,CDM,636,RC,J1200,HCPCS,Outpatient,,,1.66,0.83,,1.49,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.41,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.49,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.61,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.16,70,,,percent of total billed charges,70% of total billed charges,1.49,90,,,percent of total billed charges,90% of total billed charges,1.58,95,,,percent of total billed charges,95% of total billed charges,1.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.43,86,,,percent of total billed charges,86% of total billed charges,1.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1.61,97,,,percent of total billed charges,97% of total billed charges,1.49,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.61,97,,,percent of total billed charges,97% of total billed charges,1.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.61,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.16,1.61,
AMB dimethyl sulfoxide Charge:50 mL Rimso-50 Inj,3444275,CDM,636,RC,J1212,HCPCS,Outpatient,,,3971.35,1985.68,,3574.22,90,,,percent of total billed charges,90% of total Billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,914.96,150,,,Fee Schedule,150% of Fee Schedule Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3574.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3852.21,97,,,Percent of total billed charges,97% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,3653.64,92,,,Percent of total billed charges,92% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1812.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,681.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2888.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3659.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3574.22,90,,,percent of total billed charges,90% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,2779.95,70,,,percent of total billed charges,70% of total billed charges,3574.22,90,,,percent of total billed charges,90% of total billed charges,3772.78,95,,,percent of total billed charges,95% of total billed charges,3772.78,95,,,percent of total billed charges,95% of total billed charges,681.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3415.36,86,,,percent of total billed charges,86% of total billed charges,3177.08,80,,,percent of total billed charges,80% of total billed charges,705.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3852.21,97,,,percent of total billed charges,97% of total billed charges,3574.22,90,,,percent of total billed charges,90% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,3852.21,97,,,percent of total billed charges,97% of total billed charges,3693.36,93,,,percent of total billed charges,93% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3852.21,97,,,percent of total billed charges,97% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,579.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,579.47,3852.21,
284 mg inclisiran (Leqvio) Inj,4081125,CDM,636,RC,J1306,HCPCS,Outpatient,,,8775,4387.50,,7897.5,90,,,percent of total billed charges,90% of total Billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,7020,80,,,Percent of total Billed charges,80% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,7897.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8511.75,97,,,Percent of total billed charges,97% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,8073,92,,,Percent of total billed charges,92% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,64.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7897.5,90,,,percent of total billed charges,90% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,6142.5,70,,,percent of total billed charges,70% of total billed charges,7897.5,90,,,percent of total billed charges,90% of total billed charges,8336.25,95,,,percent of total billed charges,95% of total billed charges,8336.25,95,,,percent of total billed charges,95% of total billed charges,12.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7546.5,86,,,percent of total billed charges,86% of total billed charges,7020,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8511.75,97,,,percent of total billed charges,97% of total billed charges,7897.5,90,,,percent of total billed charges,90% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,8511.75,97,,,percent of total billed charges,97% of total billed charges,8160.75,93,,,percent of total billed charges,93% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8511.75,97,,,percent of total billed charges,97% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.21,8511.75,
"J1306 - Injection, inclisiran, 1 mg",4209176,CDM,636,RC,J1306,HCPCS,Outpatient,,,38.45,19.23,,34.61,90,,,percent of total billed charges,90% of total Billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,30.76,80,,,Percent of total Billed charges,80% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,37.3,97,,,Percent of total billed charges,97% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,35.37,92,,,Percent of total billed charges,92% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,31.95,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,64.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.61,90,,,percent of total billed charges,90% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,26.92,70,,,percent of total billed charges,70% of total billed charges,34.61,90,,,percent of total billed charges,90% of total billed charges,36.53,95,,,percent of total billed charges,95% of total billed charges,36.53,95,,,percent of total billed charges,95% of total billed charges,12.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,24.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,33.07,86,,,percent of total billed charges,86% of total billed charges,30.76,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,37.3,97,,,percent of total billed charges,97% of total billed charges,34.61,90,,,percent of total billed charges,90% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.3,97,,,percent of total billed charges,97% of total billed charges,35.76,93,,,percent of total billed charges,93% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.3,97,,,percent of total billed charges,97% of total billed charges,12.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.21,64.51,
AMB gentamicin Charge:80 mg gentamincin Inj,3444299,CDM,636,RC,J1580,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.99,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,13.1,
AMB glucagon Charge:1 mg glucagon Inj,3444300,CDM,636,RC,J1610,HCPCS,Outpatient,,,223.87,111.94,,201.48,90,,,percent of total billed charges,90% of total Billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,310.86,150,,,Fee Schedule,150% of Fee Schedule Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,217.15,97,,,Percent of total billed charges,97% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,205.96,92,,,Percent of total billed charges,92% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,498.39,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,794.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1006.41,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.48,90,,,percent of total billed charges,90% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,156.71,70,,,percent of total billed charges,70% of total billed charges,201.48,90,,,percent of total billed charges,90% of total billed charges,212.68,95,,,percent of total billed charges,95% of total billed charges,212.68,95,,,percent of total billed charges,95% of total billed charges,187.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.53,86,,,percent of total billed charges,86% of total billed charges,179.1,80,,,percent of total billed charges,80% of total billed charges,235.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,217.15,97,,,percent of total billed charges,97% of total billed charges,201.48,90,,,percent of total billed charges,90% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.15,97,,,percent of total billed charges,97% of total billed charges,208.2,93,,,percent of total billed charges,93% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,217.15,97,,,percent of total billed charges,97% of total billed charges,187.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,156.71,1006.41,
"40,000 units heparin Inj",4207118,CDM,636,RC,J1644,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.32,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,13.1,
"AMB heparin Charge -> 10,000 units heparin Inj",3626983,CDM,636,RC,J1644,HCPCS,Outpatient,,,15.78,7.89,,14.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.32,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,14.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,14.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.05,70,,,percent of total billed charges,70% of total billed charges,14.2,90,,,percent of total billed charges,90% of total billed charges,14.99,95,,,percent of total billed charges,95% of total billed charges,14.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.57,86,,,percent of total billed charges,86% of total billed charges,12.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.31,97,,,percent of total billed charges,97% of total billed charges,14.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.31,97,,,percent of total billed charges,97% of total billed charges,14.68,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.32,15.31,
AMB hydrocortisone  Charge:100 mg hydrocortisone Inj,3444317,CDM,636,RC,J1720,HCPCS,Outpatient,,,14.45,7.23,,13.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,20.13,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13.29,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.12,70,,,percent of total billed charges,70% of total billed charges,13.01,90,,,percent of total billed charges,90% of total billed charges,13.73,95,,,percent of total billed charges,95% of total billed charges,13.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.43,86,,,percent of total billed charges,86% of total billed charges,11.56,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.02,97,,,percent of total billed charges,97% of total billed charges,13.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.02,97,,,percent of total billed charges,97% of total billed charges,13.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.12,20.13,
AMB HYDROXYprogesterone Charge:250 mg HYDROXYprogesterone Inj,3444318,CDM,636,RC,J1726,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,150,,,Fee Schedule,150% of Fee Schedule Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,36.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,74.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,17.62,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.74,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,74.17,
AMB HYDROXYprogesterone Charge:275 mg HYDROXYprogesterone Inj,3444319,CDM,636,RC,J1726,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,44.18,150,,,Fee Schedule,150% of Fee Schedule Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,92,,,Percent of total billed charges,92% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,36.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,58.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,74.17,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,0.01,90,,,percent of total billed charges,90% of total billed charges,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,17.62,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.82,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.74,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,0.01,74.17,
AMB ketorolac Charge:30 mg ketorolac Inj,3444330,CDM,636,RC,J1885,HCPCS,Outpatient,,,30.38,15.19,,27.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.78,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,27.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.27,70,,,percent of total billed charges,70% of total billed charges,27.34,90,,,percent of total billed charges,90% of total billed charges,28.86,95,,,percent of total billed charges,95% of total billed charges,28.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.13,86,,,percent of total billed charges,86% of total billed charges,24.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,27.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,28.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,29.47,
AMB ketorolac Charge;60 mg ketorolac Inj,3444331,CDM,636,RC,J1885,HCPCS,Outpatient,,,30.38,15.19,,27.34,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.78,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,27.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.27,70,,,percent of total billed charges,70% of total billed charges,27.34,90,,,percent of total billed charges,90% of total billed charges,28.86,95,,,percent of total billed charges,95% of total billed charges,28.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.13,86,,,percent of total billed charges,86% of total billed charges,24.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,27.34,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,28.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,29.47,
"J1885 - Injection, ketorolac tromethamine, per 15 mg",3918962,CDM,636,RC,J1885,HCPCS,Outpatient,,,11.46,5.73,,10.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.78,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,10.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.02,70,,,percent of total billed charges,70% of total billed charges,10.31,90,,,percent of total billed charges,90% of total billed charges,10.89,95,,,percent of total billed charges,95% of total billed charges,10.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,86,,,percent of total billed charges,86% of total billed charges,9.17,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,10.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,10.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,11.12,
J1885 - Ketorolac  15mg,3918963,CDM,636,RC,J1885,HCPCS,Outpatient,,,11.46,5.73,,10.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.78,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,10.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.02,70,,,percent of total billed charges,70% of total billed charges,10.31,90,,,percent of total billed charges,90% of total billed charges,10.89,95,,,percent of total billed charges,95% of total billed charges,10.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.86,86,,,percent of total billed charges,86% of total billed charges,9.17,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,10.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,10.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.78,11.12,
AMB furosemide Charge:20 mg furosemide Inj,3444297,CDM,636,RC,J1940,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,13.1,
AMB furosemide Charge:40 mg furosemide Inj,3444298,CDM,636,RC,J1940,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,13.1,
J1940 - LASIX-20 mg furosemide Inj,4178536,CDM,636,RC,J1940,HCPCS,Outpatient,,,33.6,16.80,,30.24,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,30.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.52,70,,,percent of total billed charges,70% of total billed charges,30.24,90,,,percent of total billed charges,90% of total billed charges,31.92,95,,,percent of total billed charges,95% of total billed charges,31.92,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.9,86,,,percent of total billed charges,86% of total billed charges,26.88,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.59,97,,,percent of total billed charges,97% of total billed charges,30.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.59,97,,,percent of total billed charges,97% of total billed charges,31.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,32.59,
J1940 - LASIX-40 mg furosemide Inj,4178537,CDM,636,RC,J1940,HCPCS,Outpatient,,,67.2,33.60,,60.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.18,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.04,70,,,percent of total billed charges,70% of total billed charges,60.48,90,,,percent of total billed charges,90% of total billed charges,63.84,95,,,percent of total billed charges,95% of total billed charges,63.84,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.79,86,,,percent of total billed charges,86% of total billed charges,53.76,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,65.18,97,,,percent of total billed charges,97% of total billed charges,60.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,65.18,97,,,percent of total billed charges,97% of total billed charges,62.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.18,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.08,65.18,
11.25 mg leuprolide IM Inj,3444334,CDM,636,RC,J1950,HCPCS,Outpatient,,,21407.75,10703.88,,19266.98,90,,,percent of total billed charges,90% of total Billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1980,150,,,Fee Schedule,150% of Fee Schedule Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,19266.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20765.52,97,,,Percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,19695.13,92,,,Percent of total billed charges,92% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4051.87,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6459.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8181.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,19266.98,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,14985.43,70,,,percent of total billed charges,70% of total billed charges,19266.98,90,,,percent of total billed charges,90% of total billed charges,20337.36,95,,,percent of total billed charges,95% of total billed charges,20337.36,95,,,percent of total billed charges,95% of total billed charges,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3048.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,18410.67,86,,,percent of total billed charges,86% of total billed charges,17126.2,80,,,percent of total billed charges,80% of total billed charges,1495.79,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20765.52,97,,,percent of total billed charges,97% of total billed charges,19266.98,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,20765.52,97,,,percent of total billed charges,97% of total billed charges,19909.21,93,,,percent of total billed charges,93% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,20765.52,97,,,percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.34,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1295.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1295.68,20765.52,
3.75 mg leuprolide IM Inj,3444336,CDM,636,RC,J1950,HCPCS,Outpatient,,,9801.95,4900.98,,8821.76,90,,,percent of total billed charges,90% of total Billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1980,150,,,Fee Schedule,150% of Fee Schedule Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,8821.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9507.89,97,,,Percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,9017.79,92,,,Percent of total billed charges,92% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4051.87,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6459.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8181.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8821.76,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,6861.37,70,,,percent of total billed charges,70% of total billed charges,8821.76,90,,,percent of total billed charges,90% of total billed charges,9311.85,95,,,percent of total billed charges,95% of total billed charges,9311.85,95,,,percent of total billed charges,95% of total billed charges,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3048.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8429.68,86,,,percent of total billed charges,86% of total billed charges,7841.56,80,,,percent of total billed charges,80% of total billed charges,1495.79,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9507.89,97,,,percent of total billed charges,97% of total billed charges,8821.76,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,9507.89,97,,,percent of total billed charges,97% of total billed charges,9115.81,93,,,percent of total billed charges,93% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9507.89,97,,,percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.34,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1295.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1295.68,9507.89,
"J1950 - Injection, leuprolide acetate (for depot suspension)",4169302,CDM,636,RC,J1950,HCPCS,Outpatient,,,7718.65,3859.33,,6946.79,90,,,percent of total billed charges,90% of total Billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1980,150,,,Fee Schedule,150% of Fee Schedule Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,6946.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7487.09,97,,,Percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,7101.16,92,,,Percent of total billed charges,92% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,4051.87,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6459.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8181.96,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6946.79,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,5403.06,70,,,percent of total billed charges,70% of total billed charges,6946.79,90,,,percent of total billed charges,90% of total billed charges,7332.72,95,,,percent of total billed charges,95% of total billed charges,7332.72,95,,,percent of total billed charges,95% of total billed charges,1524.34,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3048.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6638.04,86,,,percent of total billed charges,86% of total billed charges,6174.92,80,,,percent of total billed charges,80% of total billed charges,1495.79,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7487.09,97,,,percent of total billed charges,97% of total billed charges,6946.79,90,,,percent of total billed charges,90% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,7487.09,97,,,percent of total billed charges,97% of total billed charges,7178.34,93,,,percent of total billed charges,93% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7487.09,97,,,percent of total billed charges,97% of total billed charges,1524.34,100,,,Fee Schedule,100% of CMS OPPS Rate ,1524.34,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1295.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1295.68,8181.96,
AMB bupivacaine Charge -> 10 mL bupivacaine Inj,3626948,CDM,636,RC,J2001,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,13.1,
AMB epinephrine-lidocaine Charge -> 10mL lidocaine w/epi Inj,3444292,CDM,636,RC,J2001,HCPCS,Outpatient,,,36.45,18.23,,32.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,32.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,33.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.52,70,,,percent of total billed charges,70% of total billed charges,32.81,90,,,percent of total billed charges,90% of total billed charges,34.63,95,,,percent of total billed charges,95% of total billed charges,34.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.35,86,,,percent of total billed charges,86% of total billed charges,29.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,35.36,97,,,percent of total billed charges,97% of total billed charges,32.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.36,97,,,percent of total billed charges,97% of total billed charges,33.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,35.36,
AMB epinephrine-lidocaine Charge -> 20 mL lidocaine w/epi Inj,3444293,CDM,636,RC,J2001,HCPCS,Outpatient,,,72.9,36.45,,65.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,70.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,67.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.03,70,,,percent of total billed charges,70% of total billed charges,65.61,90,,,percent of total billed charges,90% of total billed charges,69.26,95,,,percent of total billed charges,95% of total billed charges,69.26,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.69,86,,,percent of total billed charges,86% of total billed charges,58.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,70.71,97,,,percent of total billed charges,97% of total billed charges,65.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,70.71,97,,,percent of total billed charges,97% of total billed charges,67.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,70.71,
AMB epinephrine-lidocaine Charge -> 5mL lidocaine w/epi Inj,3444291,CDM,636,RC,J2001,HCPCS,Outpatient,,,18.23,9.12,,16.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.76,70,,,percent of total billed charges,70% of total billed charges,16.41,90,,,percent of total billed charges,90% of total billed charges,17.32,95,,,percent of total billed charges,95% of total billed charges,17.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.68,86,,,percent of total billed charges,86% of total billed charges,14.58,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,97,,,percent of total billed charges,97% of total billed charges,16.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.68,97,,,percent of total billed charges,97% of total billed charges,16.95,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.05,17.68,
AMB mepolizumab Charge:100 mg Nucala Inj,3444355,CDM,636,RC,J2182,HCPCS,Outpatient,,,32.21,16.11,,28.99,90,,,percent of total billed charges,90% of total Billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,46.37,150,,,Fee Schedule,150% of Fee Schedule Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31.24,97,,,Percent of total billed charges,97% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,29.63,92,,,Percent of total billed charges,92% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,80.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.84,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,161.93,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,28.99,90,,,percent of total billed charges,90% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,22.55,70,,,percent of total billed charges,70% of total billed charges,28.99,90,,,percent of total billed charges,90% of total billed charges,30.6,95,,,percent of total billed charges,95% of total billed charges,30.6,95,,,percent of total billed charges,95% of total billed charges,30.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,27.7,86,,,percent of total billed charges,86% of total billed charges,25.77,80,,,percent of total billed charges,80% of total billed charges,31.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31.24,97,,,percent of total billed charges,97% of total billed charges,28.99,90,,,percent of total billed charges,90% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.24,97,,,percent of total billed charges,97% of total billed charges,29.96,93,,,percent of total billed charges,93% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.24,97,,,percent of total billed charges,97% of total billed charges,30.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,25.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.55,161.93,
AMB nalbuphine Charge:10mg Nubain Inj,3444369,CDM,636,RC,J2300,HCPCS,Outpatient,,,25.76,12.88,,23.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.95,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,23.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.03,70,,,percent of total billed charges,70% of total billed charges,23.18,90,,,percent of total billed charges,90% of total billed charges,24.47,95,,,percent of total billed charges,95% of total billed charges,24.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.15,86,,,percent of total billed charges,86% of total billed charges,20.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.99,97,,,percent of total billed charges,97% of total billed charges,23.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.99,97,,,percent of total billed charges,97% of total billed charges,23.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,24.99,
AMB nalbuphine Charge:5 mg Nubain Inj,3444368,CDM,636,RC,J2300,HCPCS,Outpatient,,,12.88,6.44,,11.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.95,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,11.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,11.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.02,70,,,percent of total billed charges,70% of total billed charges,11.59,90,,,percent of total billed charges,90% of total billed charges,12.24,95,,,percent of total billed charges,95% of total billed charges,12.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.08,86,,,percent of total billed charges,86% of total billed charges,10.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.49,97,,,percent of total billed charges,97% of total billed charges,11.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.49,97,,,percent of total billed charges,97% of total billed charges,11.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.95,12.49,
AMB naloxone Charge:0.2 mg Narcan Inj,3444371,CDM,636,RC,J2310,HCPCS,Outpatient,,,13.84,6.92,,12.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,23.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.69,70,,,percent of total billed charges,70% of total billed charges,12.46,90,,,percent of total billed charges,90% of total billed charges,13.15,95,,,percent of total billed charges,95% of total billed charges,13.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,86,,,percent of total billed charges,86% of total billed charges,11.07,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,12.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,12.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.69,23.84,
AMB naloxone Charge:0.4 mg Narcan Inj,3444370,CDM,636,RC,J2310,HCPCS,Outpatient,,,13.84,6.92,,12.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,23.84,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.69,70,,,percent of total billed charges,70% of total billed charges,12.46,90,,,percent of total billed charges,90% of total billed charges,13.15,95,,,percent of total billed charges,95% of total billed charges,13.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.9,86,,,percent of total billed charges,86% of total billed charges,11.07,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,12.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,12.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.42,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.69,23.84,
210 mg tezepelumab Inj,4199400,CDM,636,RC,J2356,HCPCS,Outpatient,,,9766.4,4883.20,,8789.76,90,,,percent of total billed charges,90% of total Billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,7813.12,80,,,Percent of total Billed charges,80% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,8789.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9473.41,97,,,Percent of total billed charges,97% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8985.09,92,,,Percent of total billed charges,92% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,49.38,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,18.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,99.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8789.76,90,,,percent of total billed charges,90% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,6836.48,70,,,percent of total billed charges,70% of total billed charges,8789.76,90,,,percent of total billed charges,90% of total billed charges,9278.08,95,,,percent of total billed charges,95% of total billed charges,9278.08,95,,,percent of total billed charges,95% of total billed charges,18.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8399.1,86,,,percent of total billed charges,86% of total billed charges,7813.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9473.41,97,,,percent of total billed charges,97% of total billed charges,8789.76,90,,,percent of total billed charges,90% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,9473.41,97,,,percent of total billed charges,97% of total billed charges,9082.75,93,,,percent of total billed charges,93% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,9473.41,97,,,percent of total billed charges,97% of total billed charges,18.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,15.79,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,15.79,9473.41,
AMB omalizumab Charge:150 mg Xolair Inj,3444375,CDM,636,RC,J2357,HCPCS,Outpatient,,,41.61,20.81,,37.45,90,,,percent of total billed charges,90% of total Billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,57.38,150,,,Fee Schedule,150% of Fee Schedule Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,40.36,97,,,Percent of total billed charges,97% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,38.28,92,,,Percent of total billed charges,92% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,103.9,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,39.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,209.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.45,90,,,percent of total billed charges,90% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.13,70,,,percent of total billed charges,70% of total billed charges,37.45,90,,,percent of total billed charges,90% of total billed charges,39.53,95,,,percent of total billed charges,95% of total billed charges,39.53,95,,,percent of total billed charges,95% of total billed charges,39.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.78,86,,,percent of total billed charges,86% of total billed charges,33.29,80,,,percent of total billed charges,80% of total billed charges,41.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,40.36,97,,,percent of total billed charges,97% of total billed charges,37.45,90,,,percent of total billed charges,90% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.36,97,,,percent of total billed charges,97% of total billed charges,38.7,93,,,percent of total billed charges,93% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.36,97,,,percent of total billed charges,97% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,33.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.13,209.81,
AMB omalizumab Charge:300 mg Xolair Inj,3444376,CDM,636,RC,J2357,HCPCS,Outpatient,,,41.61,20.81,,37.45,90,,,percent of total billed charges,90% of total Billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,57.38,150,,,Fee Schedule,150% of Fee Schedule Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,40.36,97,,,Percent of total billed charges,97% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,38.28,92,,,Percent of total billed charges,92% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,103.9,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,39.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,165.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,209.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,37.45,90,,,percent of total billed charges,90% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,29.13,70,,,percent of total billed charges,70% of total billed charges,37.45,90,,,percent of total billed charges,90% of total billed charges,39.53,95,,,percent of total billed charges,95% of total billed charges,39.53,95,,,percent of total billed charges,95% of total billed charges,39.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.18,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,35.78,86,,,percent of total billed charges,86% of total billed charges,33.29,80,,,percent of total billed charges,80% of total billed charges,41.84,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,40.36,97,,,percent of total billed charges,97% of total billed charges,37.45,90,,,percent of total billed charges,90% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.36,97,,,percent of total billed charges,97% of total billed charges,38.7,93,,,percent of total billed charges,93% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,40.36,97,,,percent of total billed charges,97% of total billed charges,39.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,33.22,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.13,209.81,
AMB orphenadrine Charge:60 mg orphenadrine Inj,3444381,CDM,636,RC,J2360,HCPCS,Outpatient,,,8.64,4.32,,7.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,7.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6.05,70,,,percent of total billed charges,70% of total billed charges,7.78,90,,,percent of total billed charges,90% of total billed charges,8.21,95,,,percent of total billed charges,95% of total billed charges,8.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,86,,,percent of total billed charges,86% of total billed charges,6.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,7.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,8.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.05,10.05,
J2360 - Norflex - upto 60mg,3918964,CDM,636,RC,J2360,HCPCS,Outpatient,,,8.64,4.32,,7.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.05,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,7.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6.05,70,,,percent of total billed charges,70% of total billed charges,7.78,90,,,percent of total billed charges,90% of total billed charges,8.21,95,,,percent of total billed charges,95% of total billed charges,8.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,86,,,percent of total billed charges,86% of total billed charges,6.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,7.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,8.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.05,10.05,
AMB ondansetron:4mg ondansetron INJ,3444380,CDM,636,RC,J2405,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.17,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,13.1,
J2405 - Zofran - 1mg,3918965,CDM,636,RC,J2405,HCPCS,Outpatient,,,0.82,0.41,,0.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.17,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.75,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.57,70,,,percent of total billed charges,70% of total billed charges,0.74,90,,,percent of total billed charges,90% of total billed charges,0.78,95,,,percent of total billed charges,95% of total billed charges,0.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.71,86,,,percent of total billed charges,86% of total billed charges,0.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,97,,,percent of total billed charges,97% of total billed charges,0.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.8,97,,,percent of total billed charges,97% of total billed charges,0.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.8,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.17,0.8,
AMB promethazine Charge:12.5 mg Phenergan Inj,3444389,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.15,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,13.1,
AMB promethazine Charge:25 mg Phenergan Inj,3444390,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.15,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,13.1,
AMB promethazine Charge:50 mg Phenergan Inj,3444391,CDM,636,RC,J2550,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.15,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,13.1,
J2550 - Phenergan - upto 50mg,3918966,CDM,636,RC,J2550,HCPCS,Outpatient,,,26.88,13.44,,24.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.15,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,24.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,24.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.82,70,,,percent of total billed charges,70% of total billed charges,24.19,90,,,percent of total billed charges,90% of total billed charges,25.54,95,,,percent of total billed charges,95% of total billed charges,25.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.12,86,,,percent of total billed charges,86% of total billed charges,21.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,26.07,97,,,percent of total billed charges,97% of total billed charges,24.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.07,97,,,percent of total billed charges,97% of total billed charges,25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.15,26.07,
0.4 mg regadenoson Inj,4241444,CDM,636,RC,J2785,HCPCS,Outpatient,,,695.95,347.98,,626.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,92.39,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,626.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,675.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,640.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,626.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,487.17,70,,,percent of total billed charges,70% of total billed charges,626.36,90,,,percent of total billed charges,90% of total billed charges,661.15,95,,,percent of total billed charges,95% of total billed charges,661.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,598.52,86,,,percent of total billed charges,86% of total billed charges,556.76,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,675.07,97,,,percent of total billed charges,97% of total billed charges,626.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,675.07,97,,,percent of total billed charges,97% of total billed charges,647.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,675.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.39,675.07,
AMB RHo (D) immune globulin Charge:300 mcg RhoGAM Inj,3444392,CDM,636,RC,J2790,HCPCS,Outpatient,,,635,317.50,,571.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,124.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,571.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,615.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,584.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,571.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,444.5,70,,,percent of total billed charges,70% of total billed charges,571.5,90,,,percent of total billed charges,90% of total billed charges,603.25,95,,,percent of total billed charges,95% of total billed charges,603.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,546.1,86,,,percent of total billed charges,86% of total billed charges,508,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,615.95,97,,,percent of total billed charges,97% of total billed charges,571.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,615.95,97,,,percent of total billed charges,97% of total billed charges,590.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,615.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.11,615.95,
AMB RHo (D) immune globulin Charge:300 mcg RhoGAM Inj,3563024,CDM,636,RC,J2790,HCPCS,Outpatient,,,172.48,86.24,,155.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,124.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,158.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.74,70,,,percent of total billed charges,70% of total billed charges,155.23,90,,,percent of total billed charges,90% of total billed charges,163.86,95,,,percent of total billed charges,95% of total billed charges,163.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.33,86,,,percent of total billed charges,86% of total billed charges,137.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,155.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,160.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.74,167.31,
"J2790 - Injection, Rho D immune globulin, human, full dose,",3918967,CDM,636,RC,J2790,HCPCS,Outpatient,,,172.48,86.24,,155.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,124.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,155.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,158.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,120.74,70,,,percent of total billed charges,70% of total billed charges,155.23,90,,,percent of total billed charges,90% of total billed charges,163.86,95,,,percent of total billed charges,95% of total billed charges,163.86,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.33,86,,,percent of total billed charges,86% of total billed charges,137.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,155.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,160.41,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.74,167.31,
J2790 - Rhogam - 300mcg (1500 IU),3918968,CDM,636,RC,J2790,HCPCS,Outpatient,,,17.9,8.95,,16.11,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,124.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,16.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.53,70,,,percent of total billed charges,70% of total billed charges,16.11,90,,,percent of total billed charges,90% of total billed charges,17.01,95,,,percent of total billed charges,95% of total billed charges,17.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.39,86,,,percent of total billed charges,86% of total billed charges,14.32,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,17.36,97,,,percent of total billed charges,97% of total billed charges,16.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.36,97,,,percent of total billed charges,97% of total billed charges,16.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.53,124.11,
AMB RHo (D) immune globulin Charge -> 300 mcg Rhophylac Inj,4339403,CDM,636,RC,J2791,HCPCS,Outpatient,,,962.3,481.15,,866.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7.43,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,866.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,933.43,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,885.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,866.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,673.61,70,,,percent of total billed charges,70% of total billed charges,866.07,90,,,percent of total billed charges,90% of total billed charges,914.19,95,,,percent of total billed charges,95% of total billed charges,914.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,827.58,86,,,percent of total billed charges,86% of total billed charges,769.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,933.43,97,,,percent of total billed charges,97% of total billed charges,866.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,933.43,97,,,percent of total billed charges,97% of total billed charges,894.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,933.43,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.43,933.43,
AMB ropivacaine Charge -> 10 mL ropivacaine Inj,3627011,CDM,636,RC,J2795,HCPCS,Outpatient,,,22.4,11.20,,20.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,20.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.68,70,,,percent of total billed charges,70% of total billed charges,20.16,90,,,percent of total billed charges,90% of total billed charges,21.28,95,,,percent of total billed charges,95% of total billed charges,21.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.26,86,,,percent of total billed charges,86% of total billed charges,17.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,21.73,97,,,percent of total billed charges,97% of total billed charges,20.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.73,97,,,percent of total billed charges,97% of total billed charges,20.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,21.73,
AMB ropivacaine Charge -> 5 mL ropivacaine Inj,3627010,CDM,636,RC,J2795,HCPCS,Outpatient,,,11.2,5.60,,10.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.11,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,10.3,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.84,70,,,percent of total billed charges,70% of total billed charges,10.08,90,,,percent of total billed charges,90% of total billed charges,10.64,95,,,percent of total billed charges,95% of total billed charges,10.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.63,86,,,percent of total billed charges,86% of total billed charges,8.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,10.86,97,,,percent of total billed charges,97% of total billed charges,10.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.86,97,,,percent of total billed charges,97% of total billed charges,10.42,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.11,10.86,
AMB MethylPREDNISolone Charge:125 mg SOLU-Medrol Inj,3444359,CDM,636,RC,J2919,HCPCS,Outpatient,,,27.47,13.74,,24.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,21.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,25.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.23,70,,,percent of total billed charges,70% of total billed charges,24.72,90,,,percent of total billed charges,90% of total billed charges,26.1,95,,,percent of total billed charges,95% of total billed charges,26.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.62,86,,,percent of total billed charges,86% of total billed charges,21.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,26.65,97,,,percent of total billed charges,97% of total billed charges,24.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.65,97,,,percent of total billed charges,97% of total billed charges,25.55,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.23,26.65,
AMB MethylPREDNISolone Charge:40 mg SOLU-Medrol Inj,3444358,CDM,636,RC,J2919,HCPCS,Outpatient,,,16.24,8.12,,14.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.75,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,14.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.37,70,,,percent of total billed charges,70% of total billed charges,14.62,90,,,percent of total billed charges,90% of total billed charges,15.43,95,,,percent of total billed charges,95% of total billed charges,15.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.97,86,,,percent of total billed charges,86% of total billed charges,12.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.75,97,,,percent of total billed charges,97% of total billed charges,14.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.75,97,,,percent of total billed charges,97% of total billed charges,15.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.75,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.37,15.75,
METHYLPREDNISOLONE INJ,3435737,CDM,636,RC,J2919,HCPCS,Outpatient,,,13.44,6.72,,12.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.41,70,,,percent of total billed charges,70% of total billed charges,12.1,90,,,percent of total billed charges,90% of total billed charges,12.77,95,,,percent of total billed charges,95% of total billed charges,12.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,86,,,percent of total billed charges,86% of total billed charges,10.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,12.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,12.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.41,13.04,
AMB romosozumab Charge -> 105 mg romosozumab Inj,3563077,CDM,636,RC,J3111,HCPCS,Outpatient,,,2763.06,1381.53,,2486.75,90,,,percent of total billed charges,90% of total Billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,13.97,150,,,Fee Schedule,150% of Fee Schedule Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2486.75,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2680.17,97,,,Percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,2542.02,92,,,Percent of total billed charges,92% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,27.51,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.85,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,55.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2486.75,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1934.14,70,,,percent of total billed charges,70% of total billed charges,2486.75,90,,,percent of total billed charges,90% of total billed charges,2624.91,95,,,percent of total billed charges,95% of total billed charges,2624.91,95,,,percent of total billed charges,95% of total billed charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2376.23,86,,,percent of total billed charges,86% of total billed charges,2210.45,80,,,percent of total billed charges,80% of total billed charges,10,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2680.17,97,,,percent of total billed charges,97% of total billed charges,2486.75,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,2680.17,97,,,percent of total billed charges,97% of total billed charges,2569.65,93,,,percent of total billed charges,93% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2680.17,97,,,percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.77,2680.17,
AMB romosozumab Charge -> 210 mg romosozumab Inj,3563076,CDM,636,RC,J3111,HCPCS,Outpatient,,,5525.87,2762.94,,4973.28,90,,,percent of total billed charges,90% of total Billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,13.97,150,,,Fee Schedule,150% of Fee Schedule Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,4973.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5360.09,97,,,Percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,5083.8,92,,,Percent of total billed charges,92% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,27.51,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.85,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,55.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4973.28,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3868.11,70,,,percent of total billed charges,70% of total billed charges,4973.28,90,,,percent of total billed charges,90% of total billed charges,5249.58,95,,,percent of total billed charges,95% of total billed charges,5249.58,95,,,percent of total billed charges,95% of total billed charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4752.25,86,,,percent of total billed charges,86% of total billed charges,4420.7,80,,,percent of total billed charges,80% of total billed charges,10,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5360.09,97,,,percent of total billed charges,97% of total billed charges,4973.28,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,5360.09,97,,,percent of total billed charges,97% of total billed charges,5139.06,93,,,percent of total billed charges,93% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,5360.09,97,,,percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.77,5360.09,
J3111 - Evenity - 1mg,3918971,CDM,636,RC,J3111,HCPCS,Outpatient,,,4584.63,2292.32,,4126.17,90,,,percent of total billed charges,90% of total Billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,13.97,150,,,Fee Schedule,150% of Fee Schedule Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,4126.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4447.09,97,,,Percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,4217.86,92,,,Percent of total billed charges,92% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,27.51,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.85,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,55.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4126.17,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3209.24,70,,,percent of total billed charges,70% of total billed charges,4126.17,90,,,percent of total billed charges,90% of total billed charges,4355.4,95,,,percent of total billed charges,95% of total billed charges,4355.4,95,,,percent of total billed charges,95% of total billed charges,10.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3942.78,86,,,percent of total billed charges,86% of total billed charges,3667.7,80,,,percent of total billed charges,80% of total billed charges,10,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4447.09,97,,,percent of total billed charges,97% of total billed charges,4126.17,90,,,percent of total billed charges,90% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,4447.09,97,,,percent of total billed charges,97% of total billed charges,4263.71,93,,,percent of total billed charges,93% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4447.09,97,,,percent of total billed charges,97% of total billed charges,10.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8.77,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.77,4447.09,
162 mg tocilizumab Inj,3877034,CDM,636,RC,J3262,HCPCS,Outpatient,,,2336.68,1168.34,,2103.01,90,,,percent of total billed charges,90% of total Billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,7.74,150,,,Fee Schedule,150% of Fee Schedule Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,2103.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2266.58,97,,,Percent of total billed charges,97% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,2149.75,92,,,Percent of total billed charges,92% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,16.45,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2103.01,90,,,percent of total billed charges,90% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,1635.68,70,,,percent of total billed charges,70% of total billed charges,2103.01,90,,,percent of total billed charges,90% of total billed charges,2219.85,95,,,percent of total billed charges,95% of total billed charges,2219.85,95,,,percent of total billed charges,95% of total billed charges,6.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2009.54,86,,,percent of total billed charges,86% of total billed charges,1869.34,80,,,percent of total billed charges,80% of total billed charges,5.99,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2266.58,97,,,percent of total billed charges,97% of total billed charges,2103.01,90,,,percent of total billed charges,90% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,2266.58,97,,,percent of total billed charges,97% of total billed charges,2173.11,93,,,percent of total billed charges,93% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2266.58,97,,,percent of total billed charges,97% of total billed charges,6.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.26,2266.58,
10 mg Kenalog Inj,4305698,CDM,636,RC,J3301,HCPCS,Outpatient,,,14.51,7.26,,13.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.46,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,13.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.16,70,,,percent of total billed charges,70% of total billed charges,13.06,90,,,percent of total billed charges,90% of total billed charges,13.78,95,,,percent of total billed charges,95% of total billed charges,13.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.48,86,,,percent of total billed charges,86% of total billed charges,11.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.07,97,,,percent of total billed charges,97% of total billed charges,13.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.07,97,,,percent of total billed charges,97% of total billed charges,13.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,14.07,
AMB triamcinolone Charge:40 mg Kenalog Inj,3444415,CDM,636,RC,J3301,HCPCS,Outpatient,,,22.95,11.48,,20.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.46,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.11,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.07,70,,,percent of total billed charges,70% of total billed charges,20.66,90,,,percent of total billed charges,90% of total billed charges,21.8,95,,,percent of total billed charges,95% of total billed charges,21.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.74,86,,,percent of total billed charges,86% of total billed charges,18.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.26,97,,,percent of total billed charges,97% of total billed charges,20.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.26,97,,,percent of total billed charges,97% of total billed charges,21.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,22.26,
"J3301 - Injection, triamcinolone acetonide, not otherwise sp",3918972,CDM,636,RC,J3301,HCPCS,Outpatient,,,7.46,3.73,,6.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.46,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.22,70,,,percent of total billed charges,70% of total billed charges,6.71,90,,,percent of total billed charges,90% of total billed charges,7.09,95,,,percent of total billed charges,95% of total billed charges,7.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,86,,,percent of total billed charges,86% of total billed charges,5.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,6.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,6.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,7.24,
J3301 - Kenalog 10 MG,3918973,CDM,636,RC,J3301,HCPCS,Outpatient,,,7.46,3.73,,6.71,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.46,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.22,70,,,percent of total billed charges,70% of total billed charges,6.71,90,,,percent of total billed charges,90% of total billed charges,7.09,95,,,percent of total billed charges,95% of total billed charges,7.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.42,86,,,percent of total billed charges,86% of total billed charges,5.97,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,6.71,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,6.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.46,7.24,
AMB triptorelin Charge:3.75 mg Trelstar,3444416,CDM,636,RC,J3315,HCPCS,Outpatient,,,4879.45,2439.73,,4391.51,90,,,percent of total billed charges,90% of total Billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,403.64,150,,,Fee Schedule,150% of Fee Schedule Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,4391.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4733.07,97,,,Percent of total billed charges,97% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,4489.09,92,,,Percent of total billed charges,92% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,1067.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,401.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1702.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2156.41,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4391.51,90,,,percent of total billed charges,90% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,3415.62,70,,,percent of total billed charges,70% of total billed charges,4391.51,90,,,percent of total billed charges,90% of total billed charges,4635.48,95,,,percent of total billed charges,95% of total billed charges,4635.48,95,,,percent of total billed charges,95% of total billed charges,401.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,803.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4196.33,86,,,percent of total billed charges,86% of total billed charges,3903.56,80,,,percent of total billed charges,80% of total billed charges,428.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4733.07,97,,,percent of total billed charges,97% of total billed charges,4391.51,90,,,percent of total billed charges,90% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,4733.07,97,,,percent of total billed charges,97% of total billed charges,4537.89,93,,,percent of total billed charges,93% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4733.07,97,,,percent of total billed charges,97% of total billed charges,401.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.75,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,341.48,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,341.48,4733.07,
AMB ustekinumab Charge:45 mg Stelera Inj,3444419,CDM,636,RC,J3358,HCPCS,Outpatient,,,13.29,6.65,,11.96,90,,,percent of total billed charges,90% of total Billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,18.78,150,,,Fee Schedule,150% of Fee Schedule Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.89,97,,,Percent of total billed charges,97% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.23,92,,,Percent of total billed charges,92% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,33.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.47,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,67.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11.96,90,,,percent of total billed charges,90% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,9.3,70,,,percent of total billed charges,70% of total billed charges,11.96,90,,,percent of total billed charges,90% of total billed charges,12.63,95,,,percent of total billed charges,95% of total billed charges,12.63,95,,,percent of total billed charges,95% of total billed charges,12.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.43,86,,,percent of total billed charges,86% of total billed charges,10.63,80,,,percent of total billed charges,80% of total billed charges,13.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12.89,97,,,percent of total billed charges,97% of total billed charges,11.96,90,,,percent of total billed charges,90% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.89,97,,,percent of total billed charges,97% of total billed charges,12.36,93,,,percent of total billed charges,93% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12.89,97,,,percent of total billed charges,97% of total billed charges,12.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,10.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.3,67.73,
AMB cyanocobalamin Charge:1000mcg cyanocobalamin Inj,3444262,CDM,636,RC,J3420,HCPCS,Outpatient,,,18.66,9.33,,16.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,17.17,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.06,70,,,percent of total billed charges,70% of total billed charges,16.79,90,,,percent of total billed charges,90% of total billed charges,17.73,95,,,percent of total billed charges,95% of total billed charges,17.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.05,86,,,percent of total billed charges,86% of total billed charges,14.93,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,18.1,97,,,percent of total billed charges,97% of total billed charges,16.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.1,97,,,percent of total billed charges,97% of total billed charges,17.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,18.1,
AMB cyanocobalamin Charge:500mcg cyanocobalamin Inj,3444263,CDM,636,RC,J3420,HCPCS,Outpatient,,,18.65,9.33,,16.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.09,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,17.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.06,70,,,percent of total billed charges,70% of total billed charges,16.79,90,,,percent of total billed charges,90% of total billed charges,17.72,95,,,percent of total billed charges,95% of total billed charges,17.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.04,86,,,percent of total billed charges,86% of total billed charges,14.92,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,18.09,97,,,percent of total billed charges,97% of total billed charges,16.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.09,97,,,percent of total billed charges,97% of total billed charges,17.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.09,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,18.09,
J3420 - B12 - upto 1000 mcg,3918974,CDM,636,RC,J3420,HCPCS,Outpatient,,,30.24,15.12,,27.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,27.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.17,70,,,percent of total billed charges,70% of total billed charges,27.22,90,,,percent of total billed charges,90% of total billed charges,28.73,95,,,percent of total billed charges,95% of total billed charges,28.73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.01,86,,,percent of total billed charges,86% of total billed charges,24.19,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,29.33,97,,,percent of total billed charges,97% of total billed charges,27.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.33,97,,,percent of total billed charges,97% of total billed charges,28.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.94,29.33,
J3420-MSA VITAMIN B-12 INJ,3430597,CDM,636,RC,J3420,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,2.94,
AMB hyaluronidase Charge:200 unit hyaluronidase Inj,3444316,CDM,636,RC,J3470,HCPCS,Outpatient,,,183.46,91.73,,165.11,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,85.38,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,165.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,168.78,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,165.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,128.42,70,,,percent of total billed charges,70% of total billed charges,165.11,90,,,percent of total billed charges,90% of total billed charges,174.29,95,,,percent of total billed charges,95% of total billed charges,174.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.78,86,,,percent of total billed charges,86% of total billed charges,146.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,177.96,97,,,percent of total billed charges,97% of total billed charges,165.11,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,177.96,97,,,percent of total billed charges,97% of total billed charges,170.62,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.38,177.96,
AMB potassium chloride Charge -> 20 mEq KCl Inj,3626977,CDM,636,RC,J3480,HCPCS,Outpatient,,,10.08,5.04,,9.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.21,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,9.07,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,9.27,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.06,70,,,percent of total billed charges,70% of total billed charges,9.07,90,,,percent of total billed charges,90% of total billed charges,9.58,95,,,percent of total billed charges,95% of total billed charges,9.58,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.67,86,,,percent of total billed charges,86% of total billed charges,8.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,9.78,97,,,percent of total billed charges,97% of total billed charges,9.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.78,97,,,percent of total billed charges,97% of total billed charges,9.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,9.78,
AMB bupivacaine Charge -> 15 mL bupivacaine Inj,3626949,CDM,636,RC,J3490,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,13.1,
AMB bupivacaine Charge -> 20 mL bupivacaine Inj,3626950,CDM,636,RC,J3490,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.45,13.1,
AMB dupilumab Charge:200 mg duplimab Inj,3444286,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMB dupilumab Charge:300 mg duplimab Inj,3444288,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMB dupilumab Charge:400 mg duplimab Inj,3444285,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
AMB dupilumab Charge:600 mg duplimab Inj,3444287,CDM,636,RC,J3590,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
J3590 Axiofill 250mg + Q4186 Epifix 14mm,4205140,CDM,636,RC,J3590,HCPCS,Outpatient,,,6036,3018.00,,5432.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4828.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5432.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5854.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5553.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5432.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4225.2,70,,,percent of total billed charges,70% of total billed charges,5432.4,90,,,percent of total billed charges,90% of total billed charges,5734.2,95,,,percent of total billed charges,95% of total billed charges,5734.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5190.96,86,,,percent of total billed charges,86% of total billed charges,4828.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5854.92,97,,,percent of total billed charges,97% of total billed charges,5432.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5854.92,97,,,percent of total billed charges,97% of total billed charges,5613.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5854.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4225.2,5854.92,
J3590 Axiofill 500mg + Q4186 Epifix 14mm,4205141,CDM,636,RC,J3590,HCPCS,Outpatient,,,8861,4430.50,,7974.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7088.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,7974.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8595.17,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8152.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7974.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6202.7,70,,,percent of total billed charges,70% of total billed charges,7974.9,90,,,percent of total billed charges,90% of total billed charges,8417.95,95,,,percent of total billed charges,95% of total billed charges,8417.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7620.46,86,,,percent of total billed charges,86% of total billed charges,7088.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8595.17,97,,,percent of total billed charges,97% of total billed charges,7974.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8595.17,97,,,percent of total billed charges,97% of total billed charges,8240.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8595.17,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6202.7,8595.17,
AMB sodium chloride Charge -> 40 mL Sodium Chloride Inj,3626966,CDM,636,RC,J7030,HCPCS,Outpatient,,,15.66,7.83,,14.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.77,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,14.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.19,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,14.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.96,70,,,percent of total billed charges,70% of total billed charges,14.09,90,,,percent of total billed charges,90% of total billed charges,14.88,95,,,percent of total billed charges,95% of total billed charges,14.88,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.47,86,,,percent of total billed charges,86% of total billed charges,12.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,15.19,97,,,percent of total billed charges,97% of total billed charges,14.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.19,97,,,percent of total billed charges,97% of total billed charges,14.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.19,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,15.19,
AMB sodium chloride Charge -> 5 mL Sodium Chloride Inj,3626965,CDM,636,RC,J7030,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.77,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,13.1,
AMB sodium chloride Charge -> 60 mL Sodium Chloride Inj,3626967,CDM,636,RC,J7030,HCPCS,Outpatient,,,23.48,11.74,,21.13,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.77,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,21.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.44,70,,,percent of total billed charges,70% of total billed charges,21.13,90,,,percent of total billed charges,90% of total billed charges,22.31,95,,,percent of total billed charges,95% of total billed charges,22.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.19,86,,,percent of total billed charges,86% of total billed charges,18.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.78,97,,,percent of total billed charges,97% of total billed charges,21.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.78,97,,,percent of total billed charges,97% of total billed charges,21.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,22.78,
AMB sodium chloride Charge:2 mL Sodium Chloride Inj,3444400,CDM,636,RC,J7030,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3.77,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.77,13.1,
AMB Levonorgestrel Charge:19.5 mg Kyleena Implant,3444338,CDM,636,RC,J7296,HCPCS,Outpatient,,,2832.95,1416.48,,2549.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1430.27,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2549.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2606.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2549.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1983.07,70,,,percent of total billed charges,70% of total billed charges,2549.66,90,,,percent of total billed charges,90% of total billed charges,2691.3,95,,,percent of total billed charges,95% of total billed charges,2691.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2436.34,86,,,percent of total billed charges,86% of total billed charges,2266.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,2549.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,2634.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.27,2747.96,
J7296 - Kyleena  (Levonorgestrel-releasing intrauterine cont,3918975,CDM,636,RC,J7296,HCPCS,Outpatient,,,2135.84,1067.92,,1922.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1430.27,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1922.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1964.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1495.09,70,,,percent of total billed charges,70% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.82,86,,,percent of total billed charges,86% of total billed charges,1708.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1986.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.27,2071.76,
AMB Levonorgestrel Charge:52 mg Liletta Implant,3444339,CDM,636,RC,J7297,HCPCS,Outpatient,,,2281.77,1140.89,,2053.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1124.1,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2053.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2213.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2099.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2053.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1597.24,70,,,percent of total billed charges,70% of total billed charges,2053.59,90,,,percent of total billed charges,90% of total billed charges,2167.68,95,,,percent of total billed charges,95% of total billed charges,2167.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1962.32,86,,,percent of total billed charges,86% of total billed charges,1825.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2213.32,97,,,percent of total billed charges,97% of total billed charges,2053.59,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2213.32,97,,,percent of total billed charges,97% of total billed charges,2122.05,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2213.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.1,2213.32,
Levonorgestrel 52 mg Liletta Implant,4171307,CDM,636,RC,J7297,HCPCS,Outpatient,,,2135.84,1067.92,,1922.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1124.1,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1922.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1964.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1495.09,70,,,percent of total billed charges,70% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.82,86,,,percent of total billed charges,86% of total billed charges,1708.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1986.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.1,2071.76,
AMB Levonorgestrel Charge:52 mg Mirena Implant,3444340,CDM,636,RC,J7298,HCPCS,Outpatient,,,2832.95,1416.48,,2549.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1430.27,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2549.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2606.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2549.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1983.07,70,,,percent of total billed charges,70% of total billed charges,2549.66,90,,,percent of total billed charges,90% of total billed charges,2691.3,95,,,percent of total billed charges,95% of total billed charges,2691.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2436.34,86,,,percent of total billed charges,86% of total billed charges,2266.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,2549.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,2634.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2747.96,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.27,2747.96,
J7298 - Levonorgestrel-releasing intrauterine contraceptive,3918976,CDM,636,RC,J7298,HCPCS,Outpatient,,,2135.84,1067.92,,1922.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1430.27,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1922.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1964.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1495.09,70,,,percent of total billed charges,70% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,2029.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1836.82,86,,,percent of total billed charges,86% of total billed charges,1708.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1922.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,1986.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2071.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1430.27,2071.76,
AMB copper IUD Charge:Paragard Implant,3444260,CDM,636,RC,J7300,HCPCS,Outpatient,,,2182.95,1091.48,,1964.66,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1212.75,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1964.66,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2117.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2008.31,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1964.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1528.07,70,,,percent of total billed charges,70% of total billed charges,1964.66,90,,,percent of total billed charges,90% of total billed charges,2073.8,95,,,percent of total billed charges,95% of total billed charges,2073.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1877.34,86,,,percent of total billed charges,86% of total billed charges,1746.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2117.46,97,,,percent of total billed charges,97% of total billed charges,1964.66,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2117.46,97,,,percent of total billed charges,97% of total billed charges,2030.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2117.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.75,2117.46,
J7300 - Intrauterine copper contraceptive,3918977,CDM,636,RC,J7300,HCPCS,Outpatient,,,1827.84,913.92,,1645.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1212.75,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1645.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1773,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1681.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1645.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1279.49,70,,,percent of total billed charges,70% of total billed charges,1645.06,90,,,percent of total billed charges,90% of total billed charges,1736.45,95,,,percent of total billed charges,95% of total billed charges,1736.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1571.94,86,,,percent of total billed charges,86% of total billed charges,1462.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1773,97,,,percent of total billed charges,97% of total billed charges,1645.06,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1773,97,,,percent of total billed charges,97% of total billed charges,1699.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1773,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1212.75,1773,
AMB Levonorgestrel Charge:17.5 mg Skyla Implant,3444341,CDM,636,RC,J7301,HCPCS,Outpatient,,,2358.9,1179.45,,2123.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1190.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2123.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2288.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2170.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2123.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1651.23,70,,,percent of total billed charges,70% of total billed charges,2123.01,90,,,percent of total billed charges,90% of total billed charges,2240.96,95,,,percent of total billed charges,95% of total billed charges,2240.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2028.65,86,,,percent of total billed charges,86% of total billed charges,1887.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2288.13,97,,,percent of total billed charges,97% of total billed charges,2123.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2288.13,97,,,percent of total billed charges,97% of total billed charges,2193.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2288.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.94,2288.13,
Levonorgestrel 13.5 mg Skyla Implant,4171308,CDM,636,RC,J7301,HCPCS,Outpatient,,,1778.56,889.28,,1600.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1190.94,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1600.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1725.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1636.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1600.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1244.99,70,,,percent of total billed charges,70% of total billed charges,1600.7,90,,,percent of total billed charges,90% of total billed charges,1689.63,95,,,percent of total billed charges,95% of total billed charges,1689.63,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1529.56,86,,,percent of total billed charges,86% of total billed charges,1422.85,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1725.2,97,,,percent of total billed charges,97% of total billed charges,1600.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1725.2,97,,,percent of total billed charges,97% of total billed charges,1654.06,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1725.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1190.94,1725.2,
AMB Nexplanon 68mg Charge:68 mg Nexplanon Implant,3444372,CDM,636,RC,J7307,HCPCS,Outpatient,,,2949.71,1474.86,,2654.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1402.23,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,2654.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2861.22,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2713.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2654.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2064.8,70,,,percent of total billed charges,70% of total billed charges,2654.74,90,,,percent of total billed charges,90% of total billed charges,2802.22,95,,,percent of total billed charges,95% of total billed charges,2802.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2536.75,86,,,percent of total billed charges,86% of total billed charges,2359.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2861.22,97,,,percent of total billed charges,97% of total billed charges,2654.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2861.22,97,,,percent of total billed charges,97% of total billed charges,2743.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2861.22,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1402.23,2861.22,
"J7307 - Etonogestrel (contraceptive) implant system, includi",3918978,CDM,636,RC,J7307,HCPCS,Outpatient,,,2094.4,1047.20,,1884.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1402.23,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1884.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2031.57,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1926.85,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1884.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1466.08,70,,,percent of total billed charges,70% of total billed charges,1884.96,90,,,percent of total billed charges,90% of total billed charges,1989.68,95,,,percent of total billed charges,95% of total billed charges,1989.68,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1801.18,86,,,percent of total billed charges,86% of total billed charges,1675.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2031.57,97,,,percent of total billed charges,97% of total billed charges,1884.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2031.57,97,,,percent of total billed charges,97% of total billed charges,1947.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2031.57,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1402.23,2031.57,
AMB sodium hyaluronate Charge:20 mg Durolane Inj,3444401,CDM,636,RC,J7318,HCPCS,Outpatient,,,2040.64,1020.32,,1836.58,90,,,percent of total billed charges,90% of total Billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,24.87,150,,,Fee Schedule,150% of Fee Schedule Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1836.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1979.42,97,,,Percent of total billed charges,97% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1877.39,92,,,Percent of total billed charges,92% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,16.66,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.65,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1836.58,90,,,percent of total billed charges,90% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,1428.45,70,,,percent of total billed charges,70% of total billed charges,1836.58,90,,,percent of total billed charges,90% of total billed charges,1938.61,95,,,percent of total billed charges,95% of total billed charges,1938.61,95,,,percent of total billed charges,95% of total billed charges,6.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1754.95,86,,,percent of total billed charges,86% of total billed charges,1632.51,80,,,percent of total billed charges,80% of total billed charges,19.12,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1979.42,97,,,percent of total billed charges,97% of total billed charges,1836.58,90,,,percent of total billed charges,90% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,1979.42,97,,,percent of total billed charges,97% of total billed charges,1897.8,93,,,percent of total billed charges,93% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1979.42,97,,,percent of total billed charges,97% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.32,1979.42,
J7318 - Durolane - 1mg,3918979,CDM,636,RC,J7318,HCPCS,Outpatient,,,102.03,51.02,,91.83,90,,,percent of total billed charges,90% of total Billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,24.87,150,,,Fee Schedule,150% of Fee Schedule Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.97,97,,,Percent of total billed charges,97% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,93.87,92,,,Percent of total billed charges,92% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,16.66,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.65,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,91.83,90,,,percent of total billed charges,90% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,71.42,70,,,percent of total billed charges,70% of total billed charges,91.83,90,,,percent of total billed charges,90% of total billed charges,96.93,95,,,percent of total billed charges,95% of total billed charges,96.93,95,,,percent of total billed charges,95% of total billed charges,6.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,87.75,86,,,percent of total billed charges,86% of total billed charges,81.62,80,,,percent of total billed charges,80% of total billed charges,19.12,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,98.97,97,,,percent of total billed charges,97% of total billed charges,91.83,90,,,percent of total billed charges,90% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,97,,,percent of total billed charges,97% of total billed charges,94.89,93,,,percent of total billed charges,93% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.97,97,,,percent of total billed charges,97% of total billed charges,6.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.27,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.32,98.97,
AMB sodium hyaluronate Charge:25 mg Supartz Inj,3444403,CDM,636,RC,J7321,HCPCS,Outpatient,,,808.48,404.24,,727.63,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,127.25,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,727.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,784.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,743.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,727.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,565.94,70,,,percent of total billed charges,70% of total billed charges,727.63,90,,,percent of total billed charges,90% of total billed charges,768.06,95,,,percent of total billed charges,95% of total billed charges,768.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,695.29,86,,,percent of total billed charges,86% of total billed charges,646.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,784.23,97,,,percent of total billed charges,97% of total billed charges,727.63,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,784.23,97,,,percent of total billed charges,97% of total billed charges,751.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,784.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127.25,784.23,
AMB sodium hyaluronate Charge:20 mg Euflexxa Inj,3444402,CDM,636,RC,J7323,HCPCS,Outpatient,,,2049.6,1024.80,,1844.64,90,,,percent of total billed charges,90% of total Billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,226.32,150,,,Fee Schedule,150% of Fee Schedule Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1844.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1988.11,97,,,Percent of total billed charges,97% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1885.63,92,,,Percent of total billed charges,92% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,327.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,123.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,521.79,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,660.95,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1844.64,90,,,percent of total billed charges,90% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,1434.72,70,,,percent of total billed charges,70% of total billed charges,1844.64,90,,,percent of total billed charges,90% of total billed charges,1947.12,95,,,percent of total billed charges,95% of total billed charges,1947.12,95,,,percent of total billed charges,95% of total billed charges,123.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,246.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1762.66,86,,,percent of total billed charges,86% of total billed charges,1639.68,80,,,percent of total billed charges,80% of total billed charges,155.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1988.11,97,,,percent of total billed charges,97% of total billed charges,1844.64,90,,,percent of total billed charges,90% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,1988.11,97,,,percent of total billed charges,97% of total billed charges,1906.13,93,,,percent of total billed charges,93% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1988.11,97,,,percent of total billed charges,97% of total billed charges,123.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,123.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,104.66,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,104.66,1988.11,
AMB sodium hyaluronate Charge:30 mg Orthovisc Inj,3444404,CDM,636,RC,J7324,HCPCS,Outpatient,,,600.32,300.16,,540.29,90,,,percent of total billed charges,90% of total Billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,223.7,150,,,Fee Schedule,150% of Fee Schedule Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,540.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,582.31,97,,,Percent of total billed charges,97% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,552.29,92,,,Percent of total billed charges,92% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,362.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,136.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,577.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,731.38,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,540.29,90,,,percent of total billed charges,90% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,420.22,70,,,percent of total billed charges,70% of total billed charges,540.29,90,,,percent of total billed charges,90% of total billed charges,570.3,95,,,percent of total billed charges,95% of total billed charges,570.3,95,,,percent of total billed charges,95% of total billed charges,136.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,516.28,86,,,percent of total billed charges,86% of total billed charges,480.26,80,,,percent of total billed charges,80% of total billed charges,142.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,582.31,97,,,percent of total billed charges,97% of total billed charges,540.29,90,,,percent of total billed charges,90% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,582.31,97,,,percent of total billed charges,97% of total billed charges,558.3,93,,,percent of total billed charges,93% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,582.31,97,,,percent of total billed charges,97% of total billed charges,136.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,136.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,115.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,115.82,731.38,
AMB Synvisc Charge:16 mg Synvisc Inj,3444405,CDM,636,RC,J7325,HCPCS,Outpatient,,,12.32,6.16,,11.09,90,,,percent of total billed charges,90% of total Billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.81,150,,,Fee Schedule,150% of Fee Schedule Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.95,97,,,Percent of total billed charges,97% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,92,,,Percent of total billed charges,92% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,23.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.15,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,47.07,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11.09,90,,,percent of total billed charges,90% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,70,,,percent of total billed charges,70% of total billed charges,11.09,90,,,percent of total billed charges,90% of total billed charges,11.7,95,,,percent of total billed charges,95% of total billed charges,11.7,95,,,percent of total billed charges,95% of total billed charges,8.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10.6,86,,,percent of total billed charges,86% of total billed charges,9.86,80,,,percent of total billed charges,80% of total billed charges,11.34,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11.95,97,,,percent of total billed charges,97% of total billed charges,11.09,90,,,percent of total billed charges,90% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.95,97,,,percent of total billed charges,97% of total billed charges,11.46,93,,,percent of total billed charges,93% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.95,97,,,percent of total billed charges,97% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.45,47.07,
AMB Synvisc Charge:48 mg Synvisc Inj,3444406,CDM,636,RC,J7325,HCPCS,Outpatient,,,12.32,6.16,,11.09,90,,,percent of total billed charges,90% of total Billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,17.81,150,,,Fee Schedule,150% of Fee Schedule Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11.95,97,,,Percent of total billed charges,97% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,11.33,92,,,Percent of total billed charges,92% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,23.31,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.15,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,47.07,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11.09,90,,,percent of total billed charges,90% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,70,,,percent of total billed charges,70% of total billed charges,11.09,90,,,percent of total billed charges,90% of total billed charges,11.7,95,,,percent of total billed charges,95% of total billed charges,11.7,95,,,percent of total billed charges,95% of total billed charges,8.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10.6,86,,,percent of total billed charges,86% of total billed charges,9.86,80,,,percent of total billed charges,80% of total billed charges,11.34,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11.95,97,,,percent of total billed charges,97% of total billed charges,11.09,90,,,percent of total billed charges,90% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.95,97,,,percent of total billed charges,97% of total billed charges,11.46,93,,,percent of total billed charges,93% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11.95,97,,,percent of total billed charges,97% of total billed charges,8.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.45,47.07,
AMB levalbuterol Charge:levalbuterol Neb Soln,3444337,CDM,636,RC,J7611,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.3,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.3,13.1,
ALBUTEROL IPRATROP NON-COMP,3435726,CDM,250,RC,J7620,HCPCS,Outpatient,,,8.4,4.20,,7.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.21,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.15,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,7.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.88,70,,,percent of total billed charges,70% of total billed charges,7.56,90,,,percent of total billed charges,90% of total billed charges,7.98,95,,,percent of total billed charges,95% of total billed charges,7.98,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.22,86,,,percent of total billed charges,86% of total billed charges,6.72,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8.15,97,,,percent of total billed charges,97% of total billed charges,7.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8.15,97,,,percent of total billed charges,97% of total billed charges,7.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.15,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,8.15,
AMB albuterol Charge:albuterol Neb Soln,3444236,CDM,636,RC,J7620,HCPCS,Outpatient,,,13.5,6.75,,12.15,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.21,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.42,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.45,70,,,percent of total billed charges,70% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,12.83,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,86,,,percent of total billed charges,86% of total billed charges,10.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.15,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,12.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.1,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,13.1,
AMB DuoNeb Charge:DuoNeb Neb Soln,3444284,CDM,636,RC,J7620,HCPCS,Outpatient,,,25.2,12.60,,22.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.21,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,22.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.64,70,,,percent of total billed charges,70% of total billed charges,22.68,90,,,percent of total billed charges,90% of total billed charges,23.94,95,,,percent of total billed charges,95% of total billed charges,23.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.67,86,,,percent of total billed charges,86% of total billed charges,20.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.44,97,,,percent of total billed charges,97% of total billed charges,22.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.44,97,,,percent of total billed charges,97% of total billed charges,23.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.21,24.44,
AMB ipratropium Charge:ipratropium Neb Soln,3444327,CDM,636,RC,J7645,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.08,
IPRATROPIUM BROMIDE COMP,3435736,CDM,636,RC,J7645,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.08,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.08,
16.7 mg BCG Inj,4017340,CDM,636,RC,J9030,HCPCS,Outpatient,,,314.76,157.38,,283.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.4,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,283.28,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.32,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,289.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,220.33,70,,,percent of total billed charges,70% of total billed charges,283.28,90,,,percent of total billed charges,90% of total billed charges,299.02,95,,,percent of total billed charges,95% of total billed charges,299.02,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,270.69,86,,,percent of total billed charges,86% of total billed charges,251.81,80,,,percent of total billed charges,80% of total billed charges,3.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,305.32,97,,,percent of total billed charges,97% of total billed charges,283.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,305.32,97,,,percent of total billed charges,97% of total billed charges,292.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.32,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,305.32,
25 mg BCG Inj,4017341,CDM,636,RC,J9030,HCPCS,Outpatient,,,471.2,235.60,,424.08,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.4,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,424.08,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,457.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,433.5,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,424.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,329.84,70,,,percent of total billed charges,70% of total billed charges,424.08,90,,,percent of total billed charges,90% of total billed charges,447.64,95,,,percent of total billed charges,95% of total billed charges,447.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,405.23,86,,,percent of total billed charges,86% of total billed charges,376.96,80,,,percent of total billed charges,80% of total billed charges,3.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,457.06,97,,,percent of total billed charges,97% of total billed charges,424.08,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,457.06,97,,,percent of total billed charges,97% of total billed charges,438.22,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,457.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,457.06,
AMB BCG Charge:50 mg BCG Inj,3444246,CDM,636,RC,J9030,HCPCS,Outpatient,,,942.4,471.20,,848.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.4,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,848.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,914.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,867.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,848.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,659.68,70,,,percent of total billed charges,70% of total billed charges,848.16,90,,,percent of total billed charges,90% of total billed charges,895.28,95,,,percent of total billed charges,95% of total billed charges,895.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810.46,86,,,percent of total billed charges,86% of total billed charges,753.92,80,,,percent of total billed charges,80% of total billed charges,3.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,914.13,97,,,percent of total billed charges,97% of total billed charges,848.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,914.13,97,,,percent of total billed charges,97% of total billed charges,876.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,914.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,914.13,
AMB degarelix Charge:120 mg degarelix Inj,3444266,CDM,636,RC,J9155,HCPCS,Outpatient,,,4572.55,2286.28,,4115.3,90,,,percent of total billed charges,90% of total Billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,6.18,150,,,Fee Schedule,150% of Fee Schedule Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4115.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4435.37,97,,,Percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4206.75,92,,,Percent of total billed charges,92% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4115.3,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,3200.79,70,,,percent of total billed charges,70% of total billed charges,4115.3,90,,,percent of total billed charges,90% of total billed charges,4343.92,95,,,percent of total billed charges,95% of total billed charges,4343.92,95,,,percent of total billed charges,95% of total billed charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3932.39,86,,,percent of total billed charges,86% of total billed charges,3658.04,80,,,percent of total billed charges,80% of total billed charges,4.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4435.37,97,,,percent of total billed charges,97% of total billed charges,4115.3,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4435.37,97,,,percent of total billed charges,97% of total billed charges,4252.47,93,,,percent of total billed charges,93% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4435.37,97,,,percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.13,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.51,4435.37,
AMB degarelix Charge:240 mg degarelix Inj,3444265,CDM,636,RC,J9155,HCPCS,Outpatient,,,9145.1,4572.55,,8230.59,90,,,percent of total billed charges,90% of total Billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,6.18,150,,,Fee Schedule,150% of Fee Schedule Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,8230.59,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8870.75,97,,,Percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,8413.49,92,,,Percent of total billed charges,92% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8230.59,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,6401.57,70,,,percent of total billed charges,70% of total billed charges,8230.59,90,,,percent of total billed charges,90% of total billed charges,8687.85,95,,,percent of total billed charges,95% of total billed charges,8687.85,95,,,percent of total billed charges,95% of total billed charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7864.79,86,,,percent of total billed charges,86% of total billed charges,7316.08,80,,,percent of total billed charges,80% of total billed charges,4.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8870.75,97,,,percent of total billed charges,97% of total billed charges,8230.59,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,8870.75,97,,,percent of total billed charges,97% of total billed charges,8504.94,93,,,percent of total billed charges,93% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8870.75,97,,,percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.13,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.51,8870.75,
AMB degarelix Charge:80 mg degarelix Inj,3444267,CDM,636,RC,J9155,HCPCS,Outpatient,,,3048.37,1524.19,,2743.53,90,,,percent of total billed charges,90% of total Billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,6.18,150,,,Fee Schedule,150% of Fee Schedule Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2743.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2956.92,97,,,Percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2804.5,92,,,Percent of total billed charges,92% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,10.97,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,22.16,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2743.53,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,2133.86,70,,,percent of total billed charges,70% of total billed charges,2743.53,90,,,percent of total billed charges,90% of total billed charges,2895.95,95,,,percent of total billed charges,95% of total billed charges,2895.95,95,,,percent of total billed charges,95% of total billed charges,4.13,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2621.6,86,,,percent of total billed charges,86% of total billed charges,2438.7,80,,,percent of total billed charges,80% of total billed charges,4.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2956.92,97,,,percent of total billed charges,97% of total billed charges,2743.53,90,,,percent of total billed charges,90% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,2956.92,97,,,percent of total billed charges,97% of total billed charges,2834.98,93,,,percent of total billed charges,93% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2956.92,97,,,percent of total billed charges,97% of total billed charges,4.13,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.13,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.51,2956.92,
2000 mg gemcitabine Inj,4267412,CDM,636,RC,J9201,HCPCS,Outpatient,,,244.62,122.31,,220.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7.8,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,220.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.28,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,225.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,220.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,171.23,70,,,percent of total billed charges,70% of total billed charges,220.16,90,,,percent of total billed charges,90% of total billed charges,232.39,95,,,percent of total billed charges,95% of total billed charges,232.39,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.37,86,,,percent of total billed charges,86% of total billed charges,195.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,237.28,97,,,percent of total billed charges,97% of total billed charges,220.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,237.28,97,,,percent of total billed charges,97% of total billed charges,227.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.28,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.8,237.28,
AMB interferon alfa-2b Charge:1 MUnit Intron A Inj,3444326,CDM,636,RC,J9214,HCPCS,Outpatient,,,12817.8,6408.90,,11536.02,90,,,percent of total billed charges,90% of total Billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,53.42,150,,,Fee Schedule,150% of Fee Schedule Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,11536.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12433.27,97,,,Percent of total billed charges,97% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,11792.38,92,,,Percent of total billed charges,92% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,86.57,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,32.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,138.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,174.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11536.02,90,,,percent of total billed charges,90% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,8972.46,70,,,percent of total billed charges,70% of total billed charges,11536.02,90,,,percent of total billed charges,90% of total billed charges,12176.91,95,,,percent of total billed charges,95% of total billed charges,12176.91,95,,,percent of total billed charges,95% of total billed charges,32.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,65.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11023.31,86,,,percent of total billed charges,86% of total billed charges,10254.24,80,,,percent of total billed charges,80% of total billed charges,38.11,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12433.27,97,,,percent of total billed charges,97% of total billed charges,11536.02,90,,,percent of total billed charges,90% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,12433.27,97,,,percent of total billed charges,97% of total billed charges,11920.55,93,,,percent of total billed charges,93% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12433.27,97,,,percent of total billed charges,97% of total billed charges,32.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.68,12433.27,
22.5 mg leuprolide IM Inj,5801840,CDM,636,RC,J9217,HCPCS,Outpatient,,,35041.55,17520.78,,31537.4,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,31537.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33990.3,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,32238.23,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,31537.4,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,24529.09,70,,,percent of total billed charges,70% of total billed charges,31537.4,90,,,percent of total billed charges,90% of total billed charges,33289.47,95,,,percent of total billed charges,95% of total billed charges,33289.47,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,30135.73,86,,,percent of total billed charges,86% of total billed charges,28033.24,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33990.3,97,,,percent of total billed charges,97% of total billed charges,31537.4,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,33990.3,97,,,percent of total billed charges,97% of total billed charges,32588.64,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,33990.3,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,33990.3,
22.5 mg leuprolide SubCu Inj,3867205,CDM,636,RC,J9217,HCPCS,Outpatient,,,8130.4,4065.20,,7317.36,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,7317.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7886.49,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,7479.97,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7317.36,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,5691.28,70,,,percent of total billed charges,70% of total billed charges,7317.36,90,,,percent of total billed charges,90% of total billed charges,7723.88,95,,,percent of total billed charges,95% of total billed charges,7723.88,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6992.14,86,,,percent of total billed charges,86% of total billed charges,6504.32,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7886.49,97,,,percent of total billed charges,97% of total billed charges,7317.36,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,7886.49,97,,,percent of total billed charges,97% of total billed charges,7561.27,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7886.49,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,7886.49,
30 mg leuprolide IM Inj,3444333,CDM,636,RC,J9217,HCPCS,Outpatient,,,46722.2,23361.10,,42049.98,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,42049.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45320.53,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,42984.42,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,42049.98,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,32705.54,70,,,percent of total billed charges,70% of total billed charges,42049.98,90,,,percent of total billed charges,90% of total billed charges,44386.09,95,,,percent of total billed charges,95% of total billed charges,44386.09,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,40181.09,86,,,percent of total billed charges,86% of total billed charges,37377.76,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,45320.53,97,,,percent of total billed charges,97% of total billed charges,42049.98,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,45320.53,97,,,percent of total billed charges,97% of total billed charges,43451.65,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45320.53,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,45320.53,
30 mg leuprolide SubCu Inj,3867204,CDM,636,RC,J9217,HCPCS,Outpatient,,,10840.55,5420.28,,9756.5,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,9756.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10515.33,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,9973.31,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9756.5,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,7588.39,70,,,percent of total billed charges,70% of total billed charges,9756.5,90,,,percent of total billed charges,90% of total billed charges,10298.52,95,,,percent of total billed charges,95% of total billed charges,10298.52,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9322.87,86,,,percent of total billed charges,86% of total billed charges,8672.44,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10515.33,97,,,percent of total billed charges,97% of total billed charges,9756.5,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,10515.33,97,,,percent of total billed charges,97% of total billed charges,10081.71,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,10515.33,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,10515.33,
45 mg leuprolide SubCu Inj,3867203,CDM,636,RC,J9217,HCPCS,Outpatient,,,16260.8,8130.40,,14634.72,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,14634.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15772.98,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,14959.94,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14634.72,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,11382.56,70,,,percent of total billed charges,70% of total billed charges,14634.72,90,,,percent of total billed charges,90% of total billed charges,15447.76,95,,,percent of total billed charges,95% of total billed charges,15447.76,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13984.29,86,,,percent of total billed charges,86% of total billed charges,13008.64,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15772.98,97,,,percent of total billed charges,97% of total billed charges,14634.72,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,15772.98,97,,,percent of total billed charges,97% of total billed charges,15122.54,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15772.98,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,15772.98,
7.5 mg leuprolide IM Inj,3444335,CDM,636,RC,J9217,HCPCS,Outpatient,,,11680.55,5840.28,,10512.5,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,10512.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11330.13,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,10746.11,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10512.5,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,8176.39,70,,,percent of total billed charges,70% of total billed charges,10512.5,90,,,percent of total billed charges,90% of total billed charges,11096.52,95,,,percent of total billed charges,95% of total billed charges,11096.52,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10045.27,86,,,percent of total billed charges,86% of total billed charges,9344.44,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11330.13,97,,,percent of total billed charges,97% of total billed charges,10512.5,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,11330.13,97,,,percent of total billed charges,97% of total billed charges,10862.91,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11330.13,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,11330.13,
7.5 mg leuprolide SubCu Inj,3867202,CDM,636,RC,J9217,HCPCS,Outpatient,,,2710.15,1355.08,,2439.14,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2439.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2628.85,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,2493.34,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2439.14,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,1897.11,70,,,percent of total billed charges,70% of total billed charges,2439.14,90,,,percent of total billed charges,90% of total billed charges,2574.64,95,,,percent of total billed charges,95% of total billed charges,2574.64,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2330.73,86,,,percent of total billed charges,86% of total billed charges,2168.12,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2628.85,97,,,percent of total billed charges,97% of total billed charges,2439.14,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,2628.85,97,,,percent of total billed charges,97% of total billed charges,2520.44,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2628.85,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,141.68,2628.85,
J9217 - Eligard 7.5 MG,3918980,CDM,636,RC,J9217,HCPCS,Outpatient,,,102.03,51.02,,91.83,90,,,percent of total billed charges,90% of total Billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,350.54,150,,,Fee Schedule,150% of Fee Schedule Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.97,97,,,Percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,93.87,92,,,Percent of total billed charges,92% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,443.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,894.71,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,91.83,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,71.42,70,,,percent of total billed charges,70% of total billed charges,91.83,90,,,percent of total billed charges,90% of total billed charges,96.93,95,,,percent of total billed charges,95% of total billed charges,96.93,95,,,percent of total billed charges,95% of total billed charges,166.69,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,333.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,87.75,86,,,percent of total billed charges,86% of total billed charges,81.62,80,,,percent of total billed charges,80% of total billed charges,249.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,98.97,97,,,percent of total billed charges,97% of total billed charges,91.83,90,,,percent of total billed charges,90% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.97,97,,,percent of total billed charges,97% of total billed charges,94.89,93,,,percent of total billed charges,93% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,98.97,97,,,percent of total billed charges,97% of total billed charges,166.69,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.69,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,141.68,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,71.42,894.71,
AMB mitoMYcin Charge:20mg mitoMYcin Instillation,3444363,CDM,636,RC,J9280,HCPCS,Outpatient,,,3539.1,1769.55,,3185.19,90,,,percent of total billed charges,90% of total Billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,150,,,Fee Schedule,150% of Fee Schedule Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,3185.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3432.93,97,,,Percent of total billed charges,97% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,3255.97,92,,,Percent of total billed charges,92% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,254.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.15,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,513.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3185.19,90,,,percent of total billed charges,90% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,2477.37,70,,,percent of total billed charges,70% of total billed charges,3185.19,90,,,percent of total billed charges,90% of total billed charges,3362.15,95,,,percent of total billed charges,95% of total billed charges,3362.15,95,,,percent of total billed charges,95% of total billed charges,95.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3043.63,86,,,percent of total billed charges,86% of total billed charges,2831.28,80,,,percent of total billed charges,80% of total billed charges,55.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3432.93,97,,,percent of total billed charges,97% of total billed charges,3185.19,90,,,percent of total billed charges,90% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,3432.93,97,,,percent of total billed charges,97% of total billed charges,3291.36,93,,,percent of total billed charges,93% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3432.93,97,,,percent of total billed charges,97% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,81.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55.36,3432.93,
AMB mitoMYcin Charge:40mg mitoMYcin Instillation,3617068,CDM,636,RC,J9280,HCPCS,Outpatient,,,7078.2,3539.10,,6370.38,90,,,percent of total billed charges,90% of total Billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,136.89,150,,,Fee Schedule,150% of Fee Schedule Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,6370.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6865.85,97,,,Percent of total billed charges,97% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,6511.94,92,,,Percent of total billed charges,92% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,254.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,405.15,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,513.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6370.38,90,,,percent of total billed charges,90% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,4954.74,70,,,percent of total billed charges,70% of total billed charges,6370.38,90,,,percent of total billed charges,90% of total billed charges,6724.29,95,,,percent of total billed charges,95% of total billed charges,6724.29,95,,,percent of total billed charges,95% of total billed charges,95.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,191.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6087.25,86,,,percent of total billed charges,86% of total billed charges,5662.56,80,,,percent of total billed charges,80% of total billed charges,55.36,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6865.85,97,,,percent of total billed charges,97% of total billed charges,6370.38,90,,,percent of total billed charges,90% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,6865.85,97,,,percent of total billed charges,97% of total billed charges,6582.73,93,,,percent of total billed charges,93% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6865.85,97,,,percent of total billed charges,97% of total billed charges,95.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,81.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55.36,6865.85,
Cervical Collar Flex/Foam,3428407,CDM,981,RC,L0120,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,20.03,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.03,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,23.66,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,23.66,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,39.29,
Cerv Collar Semirig 2 pc,3428406,CDM,981,RC,L0172,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,100.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.12,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,196.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,196.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,118.27,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,118.27,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,196.49,
Cerv Clr Semirg 2pc W/Ext,3428405,CDM,981,RC,L0174,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,196.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,196.69,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,386,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,386,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,221.27,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,232.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,232.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,386,
Rib Belt,3428516,CDM,981,RC,L0220,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,100.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,198.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,198.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.59,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,119.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,119.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,198.17,
"Lumbar Orthosis, Flexible",3428484,CDM,981,RC,L0625,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,41.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,41.16,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,80.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,80.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,48.62,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.62,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,80.78,
"KO, Elas w/Condyl Pad & Jnts",3428477,CDM,981,RC,L1820,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,109.25,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,109.25,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,214.38,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,214.38,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121.54,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.87,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,129.05,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,129.05,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,214.38,
KO Adj Joint Rigid,3428475,CDM,981,RC,L1832,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,506.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,506.37,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,993.74,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,993.74,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,513.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,551,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,598.18,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,598.18,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,993.74,
KO Rgd w/o Jnt Prefab,3428476,CDM,981,RC,L1836,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,99.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,99.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,195.72,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,195.72,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,117.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,117.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,195.72,
AFO Ankle Gauntlet,3428381,CDM,981,RC,L1902,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,66.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,66.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,131,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,131,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.63,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,78.85,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,78.85,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,131,
AFO Mltigmnts Support,3428382,CDM,981,RC,L1906,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,86.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,86.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.59,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.69,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,101.71,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,101.71,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,168.98,
AFO Adjustble,3428380,CDM,981,RC,L1930,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,169.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,169.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,332.4,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,332.4,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,266.45,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,200.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,332.4,
Ankl Cntrl Stirp Rigid,3428384,CDM,981,RC,L1932,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,666.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,666.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,666.92,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1308.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1308.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,810.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.14,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,787.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,787.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,1308.83,
AFO Plastic Rehab,3428383,CDM,981,RC,L1951,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,627.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,627.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,627.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,1231.79,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,1231.79,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,762.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,706.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,741.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,741.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,1231.79,
L3260 Ambulatory Surgical Boot Ea,3436153,CDM,279,RC,L3260,HCPCS,Outpatient,,,12.86,6.43,,11.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,11.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,11.83,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,8.21,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,10.11,78.65,,,percent of total billed charges,78.65% of total billed charges,11.49,89.33,,,percent of total billed charges,89.33% of total billed charges,11.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9,70,,,percent of total billed charges,70% of total billed charges,11.57,90,,,percent of total billed charges,90% of total billed charges,12.22,95,,,percent of total billed charges,95% of total billed charges,12.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.06,86,,,percent of total billed charges,86% of total billed charges,10.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.47,97,,,percent of total billed charges,97% of total billed charges,11.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12.47,97,,,percent of total billed charges,97% of total billed charges,11.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.21,12.47,
Surgical Boot/Shoe Ea,3428526,CDM,981,RC,L3260,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,17.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,243.74,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,243.74,
Shoulder Orthsis Figure 8,3428522,CDM,981,RC,L3650,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,47.61,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.61,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,93.44,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,93.44,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.81,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,56.24,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,56.24,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,93.44,
Shoulder Orthsis Clavicle,3428521,CDM,981,RC,L3670,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,95.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,95.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,186.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,186.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97.06,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.55,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,112.42,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,112.42,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,186.75,
SO Single Shoulder Prefab,3428525,CDM,981,RC,L3678,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
Thmb Spica/Wrist Fx Brace,3428529,CDM,981,RC,L3809,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,170.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,170.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,170.08,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,333.78,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,333.78,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,206.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.8,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,333.78,
WHO Wrist Extension,3428541,CDM,981,RC,L3908,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,47.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,47.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,92.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,92.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.53,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.28,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,,,,,Other,Not Separately reimbursable,55.68,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,55.68,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,92.49,
Humeral Fracture Brace,3428464,CDM,981,RC,L3980,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,224.35,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,224.35,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,440.28,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,440.28,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.02,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.02,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,440.28,
Radius/Ulna Fx Brace,3428513,CDM,981,RC,L3982,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,261.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,513.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,513.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,513.3,
Ulnar Gutter Splint,3428536,CDM,981,RC,L3982,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,261.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,,,,,Other,Not Separately reimbursable,261.56,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,261.56,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,513.3,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,513.3,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.97,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,308.97,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,0.01,513.3,
Musculoskeletal Screening,4199644,CDM,978,RC,MS,HCPCS,Outpatient,,,75,37.50,,67.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.5,67.5,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,510,RC,Q0091,HCPCS,Outpatient,,,106.37,53.19,,95.73,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,85.1,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,103.18,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,97.86,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,95.73,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,74.46,70,,,percent of total billed charges,70% of total billed charges,95.73,90,,,percent of total billed charges,90% of total billed charges,101.05,95,,,percent of total billed charges,95% of total billed charges,101.05,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,91.48,86,,,percent of total billed charges,86% of total billed charges,85.1,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,103.18,97,,,percent of total billed charges,97% of total billed charges,95.73,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.18,97,,,percent of total billed charges,97% of total billed charges,98.92,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,103.18,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.26,121.67,
Q0111 Wet mounts w preparations,3428512,CDM,510,RC,Q0111,HCPCS,Outpatient,,,15.48,7.74,,13.93,90,,,percent of total billed charges,90% of total Billed charges,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,12.38,80,,,Percent of total Billed charges,80% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.93,90,,,Percent of total Billed charges,90% of total billed charges,6.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15.02,97,,,Percent of total billed charges,97% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,14.24,92,,,Percent of total billed charges,92% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,70.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,79.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,13.93,90,,,percent of total billed charges,90% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,10.84,70,,,percent of total billed charges,70% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,14.71,95,,,percent of total billed charges,95% of total billed charges,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13.31,86,,,percent of total billed charges,86% of total billed charges,12.38,80,,,percent of total billed charges,80% of total billed charges,16.78,111,,,Fee Schedule,111% of CMS OPPS Rate,15.02,97,,,percent of total billed charges,97% of total billed charges,13.93,90,,,percent of total billed charges,90% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.02,97,,,percent of total billed charges,97% of total billed charges,14.4,93,,,percent of total billed charges,93% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15.02,97,,,percent of total billed charges,97% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.31,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.96,85.55,
AMB ondansetron:4 mg ondansetron Tab,3444379,CDM,636,RC,Q0162,HCPCS,Outpatient,,,50.15,25.08,,45.14,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,40.12,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,45.14,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,46.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,35.11,70,,,percent of total billed charges,70% of total billed charges,45.14,90,,,percent of total billed charges,90% of total billed charges,47.64,95,,,percent of total billed charges,95% of total billed charges,47.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.13,86,,,percent of total billed charges,86% of total billed charges,40.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.65,97,,,percent of total billed charges,97% of total billed charges,45.14,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.65,97,,,percent of total billed charges,97% of total billed charges,46.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.11,48.65,
"Q4106 Dermagraft (38), Per sq cm",3783110,CDM,278,RC,Q4106,HCPCS,Outpatient,,,65.79,32.90,,59.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.63,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,59.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,60.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,46.05,70,,,percent of total billed charges,70% of total billed charges,59.21,90,,,percent of total billed charges,90% of total billed charges,62.5,95,,,percent of total billed charges,95% of total billed charges,62.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.58,86,,,percent of total billed charges,86% of total billed charges,52.63,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.82,97,,,percent of total billed charges,97% of total billed charges,59.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.82,97,,,percent of total billed charges,97% of total billed charges,61.18,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.05,63.82,
Q4121 Theraskin 1.75x1.75cm (3) per sq cm,4351234,CDM,278,RC,Q4121,HCPCS,Outpatient,,,3538,1769.00,,3184.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2830.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3184.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3431.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3254.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3184.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2476.6,70,,,percent of total billed charges,70% of total billed charges,3184.2,90,,,percent of total billed charges,90% of total billed charges,3361.1,95,,,percent of total billed charges,95% of total billed charges,3361.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3042.68,86,,,percent of total billed charges,86% of total billed charges,2830.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3431.86,97,,,percent of total billed charges,97% of total billed charges,3184.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3431.86,97,,,percent of total billed charges,97% of total billed charges,3290.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3431.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2476.6,3431.86,
Q4121 Theraskin 2.5x2.5cm (6) per sq cm,4351235,CDM,278,RC,Q4121,HCPCS,Outpatient,,,1972,986.00,,1774.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1577.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1774.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1912.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1814.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1774.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1380.4,70,,,percent of total billed charges,70% of total billed charges,1774.8,90,,,percent of total billed charges,90% of total billed charges,1873.4,95,,,percent of total billed charges,95% of total billed charges,1873.4,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1695.92,86,,,percent of total billed charges,86% of total billed charges,1577.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1912.84,97,,,percent of total billed charges,97% of total billed charges,1774.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1912.84,97,,,percent of total billed charges,97% of total billed charges,1833.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1912.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380.4,1912.84,
Q4121 Theraskin 2.5x5.1cm (13) per sq cm,4351236,CDM,278,RC,Q4121,HCPCS,Outpatient,,,928,464.00,,835.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,742.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,835.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,900.16,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,853.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,835.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,649.6,70,,,percent of total billed charges,70% of total billed charges,835.2,90,,,percent of total billed charges,90% of total billed charges,881.6,95,,,percent of total billed charges,95% of total billed charges,881.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,798.08,86,,,percent of total billed charges,86% of total billed charges,742.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,900.16,97,,,percent of total billed charges,97% of total billed charges,835.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,900.16,97,,,percent of total billed charges,97% of total billed charges,863.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,900.16,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.6,900.16,
Q4121 Theraskin 4x6.5cm (26) per sq cm,4351237,CDM,278,RC,Q4121,HCPCS,Outpatient,,,525,262.50,,472.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,420,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,472.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,509.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,483,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,367.5,70,,,percent of total billed charges,70% of total billed charges,472.5,90,,,percent of total billed charges,90% of total billed charges,498.75,95,,,percent of total billed charges,95% of total billed charges,498.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,451.5,86,,,percent of total billed charges,86% of total billed charges,420,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,509.25,97,,,percent of total billed charges,97% of total billed charges,472.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,509.25,97,,,percent of total billed charges,97% of total billed charges,488.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,509.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,367.5,509.25,
"Q4121 Theraskin 5.1cm x 7.6cm (39), Per sq cm",3984938,CDM,278,RC,Q4121,HCPCS,Outpatient,,,400,200.00,,360,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,320,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,360,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,368,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,280,70,,,percent of total billed charges,70% of total billed charges,360,90,,,percent of total billed charges,90% of total billed charges,380,95,,,percent of total billed charges,95% of total billed charges,380,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344,86,,,percent of total billed charges,86% of total billed charges,320,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,388,97,,,percent of total billed charges,97% of total billed charges,360,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388,97,,,percent of total billed charges,97% of total billed charges,372,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280,388,
Q4121 Theraskin 7.6x15.24cm (116) per sq cm,4351238,CDM,278,RC,Q4121,HCPCS,Outpatient,,,349,174.50,,314.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,279.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,314.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,338.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,321.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,244.3,70,,,percent of total billed charges,70% of total billed charges,314.1,90,,,percent of total billed charges,90% of total billed charges,331.55,95,,,percent of total billed charges,95% of total billed charges,331.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,300.14,86,,,percent of total billed charges,86% of total billed charges,279.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,338.53,97,,,percent of total billed charges,97% of total billed charges,314.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,338.53,97,,,percent of total billed charges,97% of total billed charges,324.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.3,338.53,
"Q4158 Kerecis Omega3 1.75cm x 1.75cm (4), Per sq cm",3984950,CDM,278,RC,Q4158,HCPCS,Outpatient,,,1591,795.50,,1431.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1272.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1431.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1463.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1113.7,70,,,percent of total billed charges,70% of total billed charges,1431.9,90,,,percent of total billed charges,90% of total billed charges,1511.45,95,,,percent of total billed charges,95% of total billed charges,1511.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.26,86,,,percent of total billed charges,86% of total billed charges,1272.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,1431.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,1479.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.7,1543.27,
"Q4158 Kerecis Omega3 3cm x 3.5cm (11), Per sq cm",3984956,CDM,278,RC,Q4158,HCPCS,Outpatient,,,796,398.00,,716.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,636.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,716.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,772.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,732.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,557.2,70,,,percent of total billed charges,70% of total billed charges,716.4,90,,,percent of total billed charges,90% of total billed charges,756.2,95,,,percent of total billed charges,95% of total billed charges,756.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,684.56,86,,,percent of total billed charges,86% of total billed charges,636.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,772.12,97,,,percent of total billed charges,97% of total billed charges,716.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,772.12,97,,,percent of total billed charges,97% of total billed charges,740.28,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,772.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,557.2,772.12,
"Q4158 Kerecis Omega3 3cm x 7cm (21), Per sq cm",3984962,CDM,278,RC,Q4158,HCPCS,Outpatient,,,666,333.00,,599.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,532.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,599.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,646.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,612.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,599.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,466.2,70,,,percent of total billed charges,70% of total billed charges,599.4,90,,,percent of total billed charges,90% of total billed charges,632.7,95,,,percent of total billed charges,95% of total billed charges,632.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,572.76,86,,,percent of total billed charges,86% of total billed charges,532.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,646.02,97,,,percent of total billed charges,97% of total billed charges,599.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,646.02,97,,,percent of total billed charges,97% of total billed charges,619.38,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,646.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,466.2,646.02,
"Q4158 Kerecis Omega3 5cm x 7cm (35), Per sq cm",3984968,CDM,278,RC,Q4158,HCPCS,Outpatient,,,492,246.00,,442.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,393.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,442.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,477.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,452.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,442.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,344.4,70,,,percent of total billed charges,70% of total billed charges,442.8,90,,,percent of total billed charges,90% of total billed charges,467.4,95,,,percent of total billed charges,95% of total billed charges,467.4,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.12,86,,,percent of total billed charges,86% of total billed charges,393.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,477.24,97,,,percent of total billed charges,97% of total billed charges,442.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,477.24,97,,,percent of total billed charges,97% of total billed charges,457.56,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.4,477.24,
"Q4158 Kerecis Omega3 7cm x 10cm (70), Per sq cm",3991161,CDM,278,RC,Q4158,HCPCS,Outpatient,,,574,287.00,,516.6,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,459.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,516.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.78,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,528.08,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,516.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,401.8,70,,,percent of total billed charges,70% of total billed charges,516.6,90,,,percent of total billed charges,90% of total billed charges,545.3,95,,,percent of total billed charges,95% of total billed charges,545.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,493.64,86,,,percent of total billed charges,86% of total billed charges,459.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,556.78,97,,,percent of total billed charges,97% of total billed charges,516.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,556.78,97,,,percent of total billed charges,97% of total billed charges,533.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,556.78,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,401.8,556.78,
"Q4158 Kerecis Omega3 7cm x 7cm (49), Per sq cm",3984974,CDM,278,RC,Q4158,HCPCS,Outpatient,,,401,200.50,,360.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,320.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,360.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,368.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,360.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,280.7,70,,,percent of total billed charges,70% of total billed charges,360.9,90,,,percent of total billed charges,90% of total billed charges,380.95,95,,,percent of total billed charges,95% of total billed charges,380.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.86,86,,,percent of total billed charges,86% of total billed charges,320.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,388.97,97,,,percent of total billed charges,97% of total billed charges,360.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,388.97,97,,,percent of total billed charges,97% of total billed charges,372.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,388.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.7,388.97,
"Q4158 Kerecis Omega3 Micro 19cm2 (19), Per sq cm",3984992,CDM,278,RC,Q4158,HCPCS,Outpatient,,,662,331.00,,595.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,529.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,595.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,642.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,609.04,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,595.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,463.4,70,,,percent of total billed charges,70% of total billed charges,595.8,90,,,percent of total billed charges,90% of total billed charges,628.9,95,,,percent of total billed charges,95% of total billed charges,628.9,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,569.32,86,,,percent of total billed charges,86% of total billed charges,529.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,642.14,97,,,percent of total billed charges,97% of total billed charges,595.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,642.14,97,,,percent of total billed charges,97% of total billed charges,615.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,642.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,463.4,642.14,
"Q4158 Kerecis Omega3 Micro 4cm2 (4), Per sq cm",3984976,CDM,278,RC,Q4158,HCPCS,Outpatient,,,1591,795.50,,1431.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1272.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1431.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1463.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1431.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1113.7,70,,,percent of total billed charges,70% of total billed charges,1431.9,90,,,percent of total billed charges,90% of total billed charges,1511.45,95,,,percent of total billed charges,95% of total billed charges,1511.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1368.26,86,,,percent of total billed charges,86% of total billed charges,1272.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,1431.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,1479.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1543.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1113.7,1543.27,
"Q4158 Kerecis Omega3 Micro 8cm2 (8), Per sq cm",3984986,CDM,278,RC,Q4158,HCPCS,Outpatient,,,939,469.50,,845.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,751.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,845.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,910.83,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,863.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,845.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,657.3,70,,,percent of total billed charges,70% of total billed charges,845.1,90,,,percent of total billed charges,90% of total billed charges,892.05,95,,,percent of total billed charges,95% of total billed charges,892.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,807.54,86,,,percent of total billed charges,86% of total billed charges,751.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,910.83,97,,,percent of total billed charges,97% of total billed charges,845.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,910.83,97,,,percent of total billed charges,97% of total billed charges,873.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,910.83,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,657.3,910.83,
"Q4159 Affinity fresh amniotic 2.5x2.5cm (7), Per sq cm",4223263,CDM,278,RC,Q4159,HCPCS,Outpatient,,,2567,1283.50,,2310.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2053.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2310.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2489.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2361.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2310.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1796.9,70,,,percent of total billed charges,70% of total billed charges,2310.3,90,,,percent of total billed charges,90% of total billed charges,2438.65,95,,,percent of total billed charges,95% of total billed charges,2438.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2207.62,86,,,percent of total billed charges,86% of total billed charges,2053.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2489.99,97,,,percent of total billed charges,97% of total billed charges,2310.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2489.99,97,,,percent of total billed charges,97% of total billed charges,2387.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2489.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1796.9,2489.99,
Q4160 Nushield 1.6cm disc (3) per sq cm,4351239,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1578,789.00,,1420.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1262.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1420.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1530.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1451.76,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1420.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1104.6,70,,,percent of total billed charges,70% of total billed charges,1420.2,90,,,percent of total billed charges,90% of total billed charges,1499.1,95,,,percent of total billed charges,95% of total billed charges,1499.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1357.08,86,,,percent of total billed charges,86% of total billed charges,1262.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1530.66,97,,,percent of total billed charges,97% of total billed charges,1420.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1530.66,97,,,percent of total billed charges,97% of total billed charges,1467.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1530.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1104.6,1530.66,
Q4160 Nushield 2x3cm (6) per sq cm,4351240,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1588,794.00,,1429.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1270.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1429.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1540.36,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1460.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1429.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1111.6,70,,,percent of total billed charges,70% of total billed charges,1429.2,90,,,percent of total billed charges,90% of total billed charges,1508.6,95,,,percent of total billed charges,95% of total billed charges,1508.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1365.68,86,,,percent of total billed charges,86% of total billed charges,1270.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1540.36,97,,,percent of total billed charges,97% of total billed charges,1429.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1540.36,97,,,percent of total billed charges,97% of total billed charges,1476.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1540.36,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1111.6,1540.36,
Q4160 Nushield 2x4cm (8) per sq cm,4351241,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1423,711.50,,1280.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1138.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1280.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1380.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1309.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1280.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,996.1,70,,,percent of total billed charges,70% of total billed charges,1280.7,90,,,percent of total billed charges,90% of total billed charges,1351.85,95,,,percent of total billed charges,95% of total billed charges,1351.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1223.78,86,,,percent of total billed charges,86% of total billed charges,1138.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1380.31,97,,,percent of total billed charges,97% of total billed charges,1280.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1380.31,97,,,percent of total billed charges,97% of total billed charges,1323.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1380.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,996.1,1380.31,
Q4160 Nushield 3x4cm (12 ) per sq cm,4351242,CDM,278,RC,Q4160,HCPCS,Outpatient,,,1373,686.50,,1235.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1098.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1235.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1331.81,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1263.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1235.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,961.1,70,,,percent of total billed charges,70% of total billed charges,1235.7,90,,,percent of total billed charges,90% of total billed charges,1304.35,95,,,percent of total billed charges,95% of total billed charges,1304.35,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1180.78,86,,,percent of total billed charges,86% of total billed charges,1098.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1331.81,97,,,percent of total billed charges,97% of total billed charges,1235.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1331.81,97,,,percent of total billed charges,97% of total billed charges,1276.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1331.81,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,961.1,1331.81,
"Q4186 Epifix 14mm (2), Per sq cm",3984998,CDM,278,RC,Q4186,HCPCS,Outpatient,,,299.5,149.75,,269.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,239.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,269.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,290.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,275.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,269.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.65,70,,,percent of total billed charges,70% of total billed charges,269.55,90,,,percent of total billed charges,90% of total billed charges,284.53,95,,,percent of total billed charges,95% of total billed charges,284.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.57,86,,,percent of total billed charges,86% of total billed charges,239.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,290.52,97,,,percent of total billed charges,97% of total billed charges,269.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,290.52,97,,,percent of total billed charges,97% of total billed charges,278.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.65,290.52,
"Q4186 Epifix 14mm (2), Per sq cm",4205142,CDM,278,RC,Q4186,HCPCS,Outpatient,,,1023.68,511.84,,921.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,818.94,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,921.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,992.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,941.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,921.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,716.58,70,,,percent of total billed charges,70% of total billed charges,921.31,90,,,percent of total billed charges,90% of total billed charges,972.5,95,,,percent of total billed charges,95% of total billed charges,972.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,880.36,86,,,percent of total billed charges,86% of total billed charges,818.94,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,992.97,97,,,percent of total billed charges,97% of total billed charges,921.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,992.97,97,,,percent of total billed charges,97% of total billed charges,952.02,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,992.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,716.58,992.97,
"Q4186 Epifix 18mm (3), Per sq cm",3732918,CDM,278,RC,Q4186,HCPCS,Outpatient,,,457,228.50,,411.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,365.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,411.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,443.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,420.44,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,411.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,319.9,70,,,percent of total billed charges,70% of total billed charges,411.3,90,,,percent of total billed charges,90% of total billed charges,434.15,95,,,percent of total billed charges,95% of total billed charges,434.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,393.02,86,,,percent of total billed charges,86% of total billed charges,365.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,443.29,97,,,percent of total billed charges,97% of total billed charges,411.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,443.29,97,,,percent of total billed charges,97% of total billed charges,425.01,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.9,443.29,
"Q4186 Epifix 2cm x 2cm (4), Per sq cm",3732917,CDM,278,RC,Q4186,HCPCS,Outpatient,,,492.75,246.38,,443.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,394.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,443.48,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,477.97,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,453.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,443.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,344.93,70,,,percent of total billed charges,70% of total billed charges,443.48,90,,,percent of total billed charges,90% of total billed charges,468.11,95,,,percent of total billed charges,95% of total billed charges,468.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,423.77,86,,,percent of total billed charges,86% of total billed charges,394.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,477.97,97,,,percent of total billed charges,97% of total billed charges,443.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,477.97,97,,,percent of total billed charges,97% of total billed charges,458.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,477.97,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,344.93,477.97,
"Q4186 Epifix 2cm x 3cm (6), Per sq cm",3985004,CDM,278,RC,Q4186,HCPCS,Outpatient,,,381.5,190.75,,343.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,305.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,343.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,350.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.05,70,,,percent of total billed charges,70% of total billed charges,343.35,90,,,percent of total billed charges,90% of total billed charges,362.43,95,,,percent of total billed charges,95% of total billed charges,362.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.09,86,,,percent of total billed charges,86% of total billed charges,305.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,343.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,354.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.05,370.06,
"Q4186 Epifix 2cm x 4cm (8), Per sq cm",3732919,CDM,278,RC,Q4186,HCPCS,Outpatient,,,321.25,160.63,,289.13,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,257,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,311.61,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,295.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,224.88,70,,,percent of total billed charges,70% of total billed charges,289.13,90,,,percent of total billed charges,90% of total billed charges,305.19,95,,,percent of total billed charges,95% of total billed charges,305.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.28,86,,,percent of total billed charges,86% of total billed charges,257,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,311.61,97,,,percent of total billed charges,97% of total billed charges,289.13,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,311.61,97,,,percent of total billed charges,97% of total billed charges,298.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.61,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,224.88,311.61,
"Q4186 Epifix 3cm x 4cm (12), Per sq cm",3985010,CDM,278,RC,Q4186,HCPCS,Outpatient,,,381.5,190.75,,343.35,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,305.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,343.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,350.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,343.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.05,70,,,percent of total billed charges,70% of total billed charges,343.35,90,,,percent of total billed charges,90% of total billed charges,362.43,95,,,percent of total billed charges,95% of total billed charges,362.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,328.09,86,,,percent of total billed charges,86% of total billed charges,305.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,343.35,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,354.8,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,370.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,267.05,370.06,
"Q4186 Epifix 4cm x 4cm (16), Per sq cm",3985016,CDM,278,RC,Q4186,HCPCS,Outpatient,,,374.44,187.22,,337,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,299.55,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,337,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,363.21,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,344.48,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,337,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,262.11,70,,,percent of total billed charges,70% of total billed charges,337,90,,,percent of total billed charges,90% of total billed charges,355.72,95,,,percent of total billed charges,95% of total billed charges,355.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.02,86,,,percent of total billed charges,86% of total billed charges,299.55,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,363.21,97,,,percent of total billed charges,97% of total billed charges,337,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,363.21,97,,,percent of total billed charges,97% of total billed charges,348.23,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.21,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,262.11,363.21,
"Q4186 Epifix 5cm x 6cm (30), Per sq cm",3985022,CDM,278,RC,Q4186,HCPCS,Outpatient,,,379.7,189.85,,341.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,303.76,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,341.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,368.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,349.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,265.79,70,,,percent of total billed charges,70% of total billed charges,341.73,90,,,percent of total billed charges,90% of total billed charges,360.72,95,,,percent of total billed charges,95% of total billed charges,360.72,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.54,86,,,percent of total billed charges,86% of total billed charges,303.76,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,368.31,97,,,percent of total billed charges,97% of total billed charges,341.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,368.31,97,,,percent of total billed charges,97% of total billed charges,353.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.79,368.31,
"Q4186 Epifix 7cm x 7cm (49), Per sq cm",3985028,CDM,278,RC,Q4186,HCPCS,Outpatient,,,379.41,189.71,,341.47,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,303.53,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,341.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,368.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,349.06,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,341.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,265.59,70,,,percent of total billed charges,70% of total billed charges,341.47,90,,,percent of total billed charges,90% of total billed charges,360.44,95,,,percent of total billed charges,95% of total billed charges,360.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,326.29,86,,,percent of total billed charges,86% of total billed charges,303.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,368.03,97,,,percent of total billed charges,97% of total billed charges,341.47,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,368.03,97,,,percent of total billed charges,97% of total billed charges,352.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,368.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,265.59,368.03,
"Q4186 Epifix Mesh 2cm x 3cm (4), Per sq cm",3985034,CDM,278,RC,Q4186,HCPCS,Outpatient,,,572.25,286.13,,515.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,457.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,515.03,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,555.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,526.47,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,515.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,400.58,70,,,percent of total billed charges,70% of total billed charges,515.03,90,,,percent of total billed charges,90% of total billed charges,543.64,95,,,percent of total billed charges,95% of total billed charges,543.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,492.14,86,,,percent of total billed charges,86% of total billed charges,457.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,555.08,97,,,percent of total billed charges,97% of total billed charges,515.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,555.08,97,,,percent of total billed charges,97% of total billed charges,532.19,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,555.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.58,555.08,
"Q4186 Epifix Mesh 3.5cm x 3.5cm (8), Per sq cm",3985040,CDM,278,RC,Q4186,HCPCS,Outpatient,,,298.63,149.32,,268.77,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,238.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,268.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,274.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,268.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.04,70,,,percent of total billed charges,70% of total billed charges,268.77,90,,,percent of total billed charges,90% of total billed charges,283.7,95,,,percent of total billed charges,95% of total billed charges,283.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,256.82,86,,,percent of total billed charges,86% of total billed charges,238.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,289.67,97,,,percent of total billed charges,97% of total billed charges,268.77,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,289.67,97,,,percent of total billed charges,97% of total billed charges,277.73,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,289.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.04,289.67,
"Q4186 Epifix Mesh 4cm x 4.5cm (11), Per sq cm",3732920,CDM,278,RC,Q4186,HCPCS,Outpatient,,,235.36,117.68,,211.82,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,188.29,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,211.82,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,216.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,211.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.75,70,,,percent of total billed charges,70% of total billed charges,211.82,90,,,percent of total billed charges,90% of total billed charges,223.59,95,,,percent of total billed charges,95% of total billed charges,223.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.41,86,,,percent of total billed charges,86% of total billed charges,188.29,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,228.3,97,,,percent of total billed charges,97% of total billed charges,211.82,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.3,97,,,percent of total billed charges,97% of total billed charges,218.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.75,228.3,
Q4196 Nushield 4x4cm (16) per sq cm,4351243,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1067,533.50,,960.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,853.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,960.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1034.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,981.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,960.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,746.9,70,,,percent of total billed charges,70% of total billed charges,960.3,90,,,percent of total billed charges,90% of total billed charges,1013.65,95,,,percent of total billed charges,95% of total billed charges,1013.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,917.62,86,,,percent of total billed charges,86% of total billed charges,853.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1034.99,97,,,percent of total billed charges,97% of total billed charges,960.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1034.99,97,,,percent of total billed charges,97% of total billed charges,992.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1034.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,746.9,1034.99,
Q4196 Nushield 4x6cm (24) per sq cm,4351244,CDM,278,RC,Q4196,HCPCS,Outpatient,,,936,468.00,,842.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,748.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,842.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.92,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,861.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,842.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,655.2,70,,,percent of total billed charges,70% of total billed charges,842.4,90,,,percent of total billed charges,90% of total billed charges,889.2,95,,,percent of total billed charges,95% of total billed charges,889.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,804.96,86,,,percent of total billed charges,86% of total billed charges,748.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,907.92,97,,,percent of total billed charges,97% of total billed charges,842.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.92,97,,,percent of total billed charges,97% of total billed charges,870.48,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.92,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,655.2,907.92,
Q4196 puraply am 1.6 disc (3) per sq cm,4351245,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1797,898.50,,1617.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1437.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1617.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1743.09,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1653.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1617.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.9,70,,,percent of total billed charges,70% of total billed charges,1617.3,90,,,percent of total billed charges,90% of total billed charges,1707.15,95,,,percent of total billed charges,95% of total billed charges,1707.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1545.42,86,,,percent of total billed charges,86% of total billed charges,1437.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1743.09,97,,,percent of total billed charges,97% of total billed charges,1617.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1743.09,97,,,percent of total billed charges,97% of total billed charges,1671.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1743.09,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.9,1743.09,
Q4196 puraply am 2x2cm (4) per sq cm,4351246,CDM,278,RC,Q4196,HCPCS,Outpatient,,,2246,1123.00,,2021.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1796.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2021.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2178.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2066.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2021.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1572.2,70,,,percent of total billed charges,70% of total billed charges,2021.4,90,,,percent of total billed charges,90% of total billed charges,2133.7,95,,,percent of total billed charges,95% of total billed charges,2133.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1931.56,86,,,percent of total billed charges,86% of total billed charges,1796.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2178.62,97,,,percent of total billed charges,97% of total billed charges,2021.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2178.62,97,,,percent of total billed charges,97% of total billed charges,2088.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2178.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1572.2,2178.62,
Q4196 puraply am 2x4cm (8) per sq cm,4351247,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1348,674.00,,1213.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1078.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1213.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1307.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1240.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1213.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,943.6,70,,,percent of total billed charges,70% of total billed charges,1213.2,90,,,percent of total billed charges,90% of total billed charges,1280.6,95,,,percent of total billed charges,95% of total billed charges,1280.6,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1159.28,86,,,percent of total billed charges,86% of total billed charges,1078.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1307.56,97,,,percent of total billed charges,97% of total billed charges,1213.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1307.56,97,,,percent of total billed charges,97% of total billed charges,1253.64,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1307.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,943.6,1307.56,
"Q4196 Puraply AM 3x4 (12), per sq cm",4281267,CDM,278,RC,Q4196,HCPCS,Outpatient,,,1318,659.00,,1186.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1054.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1186.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1278.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1212.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1186.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,922.6,70,,,percent of total billed charges,70% of total billed charges,1186.2,90,,,percent of total billed charges,90% of total billed charges,1252.1,95,,,percent of total billed charges,95% of total billed charges,1252.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1133.48,86,,,percent of total billed charges,86% of total billed charges,1054.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1278.46,97,,,percent of total billed charges,97% of total billed charges,1186.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1278.46,97,,,percent of total billed charges,97% of total billed charges,1225.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1278.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,922.6,1278.46,
"Q4196 PuraplyAM 4x4cm  (16), per sq cm",4231174,CDM,278,RC,Q4196,HCPCS,Outpatient,,,216,108.00,,194.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,198.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,151.2,70,,,percent of total billed charges,70% of total billed charges,194.4,90,,,percent of total billed charges,90% of total billed charges,205.2,95,,,percent of total billed charges,95% of total billed charges,205.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.76,86,,,percent of total billed charges,86% of total billed charges,172.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,209.52,97,,,percent of total billed charges,97% of total billed charges,194.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.52,97,,,percent of total billed charges,97% of total billed charges,200.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,209.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.2,209.52,
"Q4196 PuraplyAMXT 4.91cm x 4.91cm (25), Per sq cm",3985046,CDM,278,RC,Q4196,HCPCS,Outpatient,,,272,136.00,,244.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,217.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,244.8,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,263.84,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,250.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,190.4,70,,,percent of total billed charges,70% of total billed charges,244.8,90,,,percent of total billed charges,90% of total billed charges,258.4,95,,,percent of total billed charges,95% of total billed charges,258.4,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,233.92,86,,,percent of total billed charges,86% of total billed charges,217.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,263.84,97,,,percent of total billed charges,97% of total billed charges,244.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,263.84,97,,,percent of total billed charges,97% of total billed charges,252.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.84,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.4,263.84,
"CL Definity Contrast , per mL",3632862,CDM,636,RC,Q9957,HCPCS,Outpatient,,,241.92,120.96,,217.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,193.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,222.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,169.34,70,,,percent of total billed charges,70% of total billed charges,217.73,90,,,percent of total billed charges,90% of total billed charges,229.82,95,,,percent of total billed charges,95% of total billed charges,229.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.05,86,,,percent of total billed charges,86% of total billed charges,193.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,217.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,224.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.34,234.66,
"Definity Contrast , per mL",867985,CDM,636,RC,Q9957,HCPCS,Outpatient,,,241.92,120.96,,217.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,193.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,217.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,222.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,217.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,169.34,70,,,percent of total billed charges,70% of total billed charges,217.73,90,,,percent of total billed charges,90% of total billed charges,229.82,95,,,percent of total billed charges,95% of total billed charges,229.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.05,86,,,percent of total billed charges,86% of total billed charges,193.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,217.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,224.99,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,234.66,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.34,234.66,
ROTC,4199642,CDM,978,RC,ROTC,HCPCS,Outpatient,,,111.3,55.65,,100.17,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.39,100.17,
150 mg testosterone Pellet,4041269,CDM,250,RC,S0189,HCPCS,Outpatient,,,376.32,188.16,,338.69,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,301.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,338.69,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,365.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,346.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,338.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,263.42,70,,,percent of total billed charges,70% of total billed charges,338.69,90,,,percent of total billed charges,90% of total billed charges,357.5,95,,,percent of total billed charges,95% of total billed charges,357.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.64,86,,,percent of total billed charges,86% of total billed charges,301.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,365.03,97,,,percent of total billed charges,97% of total billed charges,338.69,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,365.03,97,,,percent of total billed charges,97% of total billed charges,349.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,365.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,263.42,365.03,
300 mg testosterone Pellet,4041270,CDM,250,RC,S0189,HCPCS,Outpatient,,,752.64,376.32,,677.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,602.11,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,677.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.06,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,692.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,526.85,70,,,percent of total billed charges,70% of total billed charges,677.38,90,,,percent of total billed charges,90% of total billed charges,715.01,95,,,percent of total billed charges,95% of total billed charges,715.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.27,86,,,percent of total billed charges,86% of total billed charges,602.11,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,730.06,97,,,percent of total billed charges,97% of total billed charges,677.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.06,97,,,percent of total billed charges,97% of total billed charges,699.96,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.06,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,526.85,730.06,
75 mg testosterone Pellet,4041268,CDM,250,RC,S0189,HCPCS,Outpatient,,,168.75,84.38,,151.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,135,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,151.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,163.69,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,155.25,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,118.13,70,,,percent of total billed charges,70% of total billed charges,151.88,90,,,percent of total billed charges,90% of total billed charges,160.31,95,,,percent of total billed charges,95% of total billed charges,160.31,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.13,86,,,percent of total billed charges,86% of total billed charges,135,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,163.69,97,,,percent of total billed charges,97% of total billed charges,151.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,163.69,97,,,percent of total billed charges,97% of total billed charges,156.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163.69,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,118.13,163.69,
S0610 Annual gynecological examina,3428517,CDM,920,RC,S0610,HCPCS,Outpatient,,,327.11,163.56,,294.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,261.69,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,294.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,317.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,300.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,294.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,228.98,70,,,percent of total billed charges,70% of total billed charges,294.4,90,,,percent of total billed charges,90% of total billed charges,310.75,95,,,percent of total billed charges,95% of total billed charges,310.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,281.31,86,,,percent of total billed charges,86% of total billed charges,261.69,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,317.3,97,,,percent of total billed charges,97% of total billed charges,294.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,317.3,97,,,percent of total billed charges,97% of total billed charges,304.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,317.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.98,317.3,
S0612 Annual gynecological examina,3428518,CDM,510,RC,S0612,HCPCS,Outpatient,,,361.67,180.84,,325.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,289.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,325.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,350.82,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,332.74,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,325.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,253.17,70,,,percent of total billed charges,70% of total billed charges,325.5,90,,,percent of total billed charges,90% of total billed charges,343.59,95,,,percent of total billed charges,95% of total billed charges,343.59,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,311.04,86,,,percent of total billed charges,86% of total billed charges,289.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,350.82,97,,,percent of total billed charges,97% of total billed charges,325.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,350.82,97,,,percent of total billed charges,97% of total billed charges,336.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,350.82,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,253.17,350.82,
S2900- Surgical techniques requiring use of robotic surgical system (list separately in addition to,3566799,CDM,510,RC,S2900,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
S8185 Flutter device,3621406,CDM,510,RC,S8185,HCPCS,Outpatient,,,132.97,66.49,,119.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,106.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,119.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,128.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,122.33,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.08,70,,,percent of total billed charges,70% of total billed charges,119.67,90,,,percent of total billed charges,90% of total billed charges,126.32,95,,,percent of total billed charges,95% of total billed charges,126.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.35,86,,,percent of total billed charges,86% of total billed charges,106.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,128.98,97,,,percent of total billed charges,97% of total billed charges,119.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,128.98,97,,,percent of total billed charges,97% of total billed charges,123.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.08,128.98,
"S9455- Diabetic Management Program,Group Session",3435930,CDM,510,RC,S9455,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
S9484- BH Crisis Assessment & Intervention,3438171,CDM,960,RC,S9484,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"S9981- Medical Rec Copying Fee,Admin",3435931,CDM,510,RC,S9981,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"T2022- Case Management, Monthly",3438178,CDM,983,RC,T2022,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
T2023- Targeted Case Management Contact,3438179,CDM,983,RC,T2023,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"V2799- Vision item or service, miscellaneous",3435630,CDM,510,RC,V2799,HCPCS,Outpatient,,,0.01,0.01,,0.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,86,,,percent of total billed charges,86% of total billed charges,0.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.01,0.01,
"10005 - Fine needle aspiration biopsy, including ultrasound",3572795,CDM,510,RC,10005,HCPCS,Outpatient,,,153.17,76.59,,137.85,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,122.54,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.85,90,,,Percent of total Billed charges,90% of total billed charges,65.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,148.57,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,140.92,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,137.85,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,107.22,70,,,percent of total billed charges,70% of total billed charges,137.85,90,,,percent of total billed charges,90% of total billed charges,145.51,95,,,percent of total billed charges,95% of total billed charges,145.51,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,131.73,86,,,percent of total billed charges,86% of total billed charges,122.54,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,148.57,97,,,percent of total billed charges,97% of total billed charges,137.85,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.57,97,,,percent of total billed charges,97% of total billed charges,142.45,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.57,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.78,3163.8,
SCSN US Exam,4345737,CDM,402,RC,10005,HCPCS,Outpatient,,,3244.85,1622.43,,2920.37,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2595.88,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2920.37,90,,,Percent of total Billed charges,90% of total billed charges,65.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3147.5,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.26,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2920.37,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.4,70,,,percent of total billed charges,70% of total billed charges,2920.37,90,,,percent of total billed charges,90% of total billed charges,3082.61,95,,,percent of total billed charges,95% of total billed charges,3082.61,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2790.57,86,,,percent of total billed charges,86% of total billed charges,2595.88,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3147.5,97,,,percent of total billed charges,97% of total billed charges,2920.37,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3147.5,97,,,percent of total billed charges,97% of total billed charges,3017.71,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3147.5,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.78,3163.8,
SCSN US Exam,4345739,CDM,402,RC,10005,HCPCS,Outpatient,,,3244.85,1622.43,,2920.37,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2595.88,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2920.37,90,,,Percent of total Billed charges,90% of total billed charges,65.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3147.5,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2985.26,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2920.37,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2271.4,70,,,percent of total billed charges,70% of total billed charges,2920.37,90,,,percent of total billed charges,90% of total billed charges,3082.61,95,,,percent of total billed charges,95% of total billed charges,3082.61,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2790.57,86,,,percent of total billed charges,86% of total billed charges,2595.88,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3147.5,97,,,percent of total billed charges,97% of total billed charges,2920.37,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3147.5,97,,,percent of total billed charges,97% of total billed charges,3017.71,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3147.5,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.78,3163.8,
10006-MSA FNA BIOPSY W/ ULTSND GD ADD LES,3428647,CDM,361,RC,10006,HCPCS,Outpatient,,,1402.79,701.40,,1262.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1122.23,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1262.51,90,,,Percent of total Billed charges,90% of total billed charges,44.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1360.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1290.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1262.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,981.95,70,,,percent of total billed charges,70% of total billed charges,1262.51,90,,,percent of total billed charges,90% of total billed charges,1332.65,95,,,percent of total billed charges,95% of total billed charges,1332.65,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1206.4,86,,,percent of total billed charges,86% of total billed charges,1122.23,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1360.71,97,,,percent of total billed charges,97% of total billed charges,1262.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1360.71,97,,,percent of total billed charges,97% of total billed charges,1304.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1360.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.71,1360.71,
10007-MSA FNA BIOPSY W/ FLUORO GD 1ST LES,3428648,CDM,361,RC,10007,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,84.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.66,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.74,3446.32,
10008-MSA FNA BIOPSY W/ FLUORO GD ADD LES,3428649,CDM,361,RC,10008,HCPCS,Outpatient,,,418,209.00,,376.2,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,334.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,376.2,90,,,Percent of total Billed charges,90% of total billed charges,55.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,405.46,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,384.56,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,376.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,292.6,70,,,percent of total billed charges,70% of total billed charges,376.2,90,,,percent of total billed charges,90% of total billed charges,397.1,95,,,percent of total billed charges,95% of total billed charges,397.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,359.48,86,,,percent of total billed charges,86% of total billed charges,334.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,405.46,97,,,percent of total billed charges,97% of total billed charges,376.2,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,405.46,97,,,percent of total billed charges,97% of total billed charges,388.74,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,405.46,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50.01,405.46,
10021- Fine needle asp w/o image guide,3431472,CDM,761,RC,10021,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,68.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.24,1953.17,
"10035 Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radio",3621199,CDM,510,RC,10035,HCPCS,Outpatient,,,702.75,351.38,,632.48,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,562.2,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,632.48,90,,,Percent of total Billed charges,90% of total billed charges,77.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,681.67,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,646.53,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,632.48,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,491.93,70,,,percent of total billed charges,70% of total billed charges,632.48,90,,,percent of total billed charges,90% of total billed charges,667.61,95,,,percent of total billed charges,95% of total billed charges,667.61,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,604.37,86,,,percent of total billed charges,86% of total billed charges,562.2,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,681.67,97,,,percent of total billed charges,97% of total billed charges,632.48,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.67,97,,,percent of total billed charges,97% of total billed charges,653.56,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,681.67,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.26,3163.8,
10040- Acne surgery,3431474,CDM,761,RC,10040,HCPCS,Outpatient,,,885.98,442.99,,797.38,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,708.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.38,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,859.4,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,815.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,797.38,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,620.19,70,,,percent of total billed charges,70% of total billed charges,797.38,90,,,percent of total billed charges,90% of total billed charges,841.68,95,,,percent of total billed charges,95% of total billed charges,841.68,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,761.94,86,,,percent of total billed charges,86% of total billed charges,708.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,859.4,97,,,percent of total billed charges,97% of total billed charges,797.38,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,859.4,97,,,percent of total billed charges,97% of total billed charges,823.96,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,859.4,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,880.35,
10060- Abscess/simple/single/I  & D,3431475,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,980.65,
10060 Incision & Drainage Abscess Simple/Single,3436008,CDM,761,RC,10060,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,980.65,
"10061- I&D ,Abscess, Complex or S",3428656,CDM,761,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1953.17,
10061 Incision & Drainage Abscess Complicated/Multiple,3436009,CDM,761,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1953.17,
"10061- Incision and Drainage, Complex",3428467,CDM,510,RC,10061,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1953.17,
"10080- Incision and Drainage( IND) Pilonidal Cyst, Simple",3428657,CDM,510,RC,10080,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,3446.32,
10081- I & D/pilonidal cyst/complicated,3431476,CDM,761,RC,10081,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,123.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.5,3446.32,
10120- Incision/rmv FB/SQ tis/simple,3431477,CDM,761,RC,10120,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,1953.17,
10121- Incision/rmv FB/SQ tis/complicat,3431478,CDM,761,RC,10121,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,7941.56,
"10140- Incision and Drainage of hematoma, seroma or fluid collection",4346598,CDM,510,RC,10140,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,25.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.5,7941.56,
10160- Punc asp/abscess/hema/bulla/cyst,3428658,CDM,761,RC,10160,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,1953.17,
10180 Incision & Drainage Complex PO Wound Infection,3436011,CDM,761,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,13918.49,
"10180- Incision and Drainage, Compex post-op wound infection",4346593,CDM,510,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,13918.49,
10180- Postop wound infection/complex/I&D,3431479,CDM,761,RC,10180,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,169.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.29,13918.49,
11000- Debrid ecz/inf skin up tp 10% body,3428659,CDM,510,RC,11000,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,32.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.3,3076.37,
11001 - DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF,4037472,CDM,510,RC,11001,HCPCS,Outpatient,,,1780.8,890.40,,1602.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1424.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1602.72,90,,,Percent of total Billed charges,90% of total billed charges,16.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1727.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1638.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1246.56,70,,,percent of total billed charges,70% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.49,86,,,percent of total billed charges,86% of total billed charges,1424.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1656.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1727.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.81,1727.38,
11011- Debride/rmv FB/open fx/skin/sq/mus,3431484,CDM,510,RC,11011,HCPCS,Outpatient,,,6552.91,3276.46,,5897.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,5242.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,5897.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6356.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,6028.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5897.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,4587.04,70,,,percent of total billed charges,70% of total billed charges,5897.62,90,,,percent of total billed charges,90% of total billed charges,6225.26,95,,,percent of total billed charges,95% of total billed charges,6225.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5635.5,86,,,percent of total billed charges,86% of total billed charges,5242.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6356.32,97,,,percent of total billed charges,97% of total billed charges,5897.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,6356.32,97,,,percent of total billed charges,97% of total billed charges,6094.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,6356.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,501.01,6356.32,
11042 Debridement Subcutaneous Tissue 20 Sq Cm/<,3436013,CDM,761,RC,11042,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1953.17,
11042-DEB SUBQ Tissue 20 SQ CM/<,3574980,CDM,510,RC,11042,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1953.17,
11043 Deb Musc Fascia 20 Sq Cm less than,3572727,CDM,510,RC,11043,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,3076.37,
11043 Debridement Muscle & Fascia 20 Sq Cm/<,3436016,CDM,761,RC,11043,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,3076.37,
11044 Debridement Bone Muscle & Fascia 20 Sq Cm/<,3436020,CDM,761,RC,11044,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,7941.56,
"11044 Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if p",3621458,CDM,510,RC,11044,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,7941.56,
11045 Dbrdmt Subcutaneous Tissue Ea Addl 20 Sq Cm,3436023,CDM,761,RC,11045,HCPCS,Outpatient,,,649.09,324.55,,584.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,519.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,584.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,597.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,454.36,70,,,percent of total billed charges,70% of total billed charges,584.18,90,,,percent of total billed charges,90% of total billed charges,616.64,95,,,percent of total billed charges,95% of total billed charges,616.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.22,86,,,percent of total billed charges,86% of total billed charges,519.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,584.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,603.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.36,629.62,
11045 Debride subq tiss ea add 20sq cm,3570187,CDM,510,RC,11045,HCPCS,Outpatient,,,649.09,324.55,,584.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,519.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,584.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,597.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,584.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,454.36,70,,,percent of total billed charges,70% of total billed charges,584.18,90,,,percent of total billed charges,90% of total billed charges,616.64,95,,,percent of total billed charges,95% of total billed charges,616.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,558.22,86,,,percent of total billed charges,86% of total billed charges,519.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,584.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,603.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,454.36,629.62,
11046 Deb Mus Fasica Add On,3550404,CDM,510,RC,11046,HCPCS,Outpatient,,,753.31,376.66,,677.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,602.65,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,677.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,693.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,527.32,70,,,percent of total billed charges,70% of total billed charges,677.98,90,,,percent of total billed charges,90% of total billed charges,715.64,95,,,percent of total billed charges,95% of total billed charges,715.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.85,86,,,percent of total billed charges,86% of total billed charges,602.65,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,677.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,700.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.32,730.71,
11046 Debridement Muscle & Fascia Ea Addl 20 Sq Cm,3436025,CDM,761,RC,11046,HCPCS,Outpatient,,,753.31,376.66,,677.98,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,602.65,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,677.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,693.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,677.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,527.32,70,,,percent of total billed charges,70% of total billed charges,677.98,90,,,percent of total billed charges,90% of total billed charges,715.64,95,,,percent of total billed charges,95% of total billed charges,715.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,647.85,86,,,percent of total billed charges,86% of total billed charges,602.65,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,677.98,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,700.58,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,730.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,527.32,730.71,
11047 Debridement Bone Each Additional 20 Sq Cm,3436026,CDM,761,RC,11047,HCPCS,Outpatient,,,2532.54,1266.27,,2279.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2026.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2279.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2329.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2279.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1772.78,70,,,percent of total billed charges,70% of total billed charges,2279.29,90,,,percent of total billed charges,90% of total billed charges,2405.91,95,,,percent of total billed charges,95% of total billed charges,2405.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2177.98,86,,,percent of total billed charges,86% of total billed charges,2026.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,2279.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,2355.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1772.78,2456.56,
11047- Debridement/bone/ea add 20 sq cm,3431488,CDM,761,RC,11047,HCPCS,Outpatient,,,2532.54,1266.27,,2279.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2026.03,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2279.29,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2329.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2279.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1772.78,70,,,percent of total billed charges,70% of total billed charges,2279.29,90,,,percent of total billed charges,90% of total billed charges,2405.91,95,,,percent of total billed charges,95% of total billed charges,2405.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2177.98,86,,,percent of total billed charges,86% of total billed charges,2026.03,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,2279.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,2355.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2456.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1772.78,2456.56,
11055- Trim hyperkeratotic lesion/sng,3431489,CDM,761,RC,11055,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,980.65,
11056- Trim hyperkeratotic lesion/2-4,3431490,CDM,761,RC,11056,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,32.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.68,980.65,
11057- Trim hyperkeratotic lesion/>4,3431491,CDM,761,RC,11057,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,42.83,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.94,980.65,
11102 Shave Biopsy,3428674,CDM,761,RC,11102,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,35.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32.23,980.65,
11103 Additional Shave Biopsy,3428675,CDM,761,RC,11103,HCPCS,Outpatient,,,126.24,63.12,,113.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,100.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,113.62,90,,,Percent of total Billed charges,90% of total billed charges,20.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,122.45,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,116.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,88.37,70,,,percent of total billed charges,70% of total billed charges,113.62,90,,,percent of total billed charges,90% of total billed charges,119.93,95,,,percent of total billed charges,95% of total billed charges,119.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.57,86,,,percent of total billed charges,86% of total billed charges,100.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,122.45,97,,,percent of total billed charges,97% of total billed charges,113.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.45,97,,,percent of total billed charges,97% of total billed charges,117.4,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,122.45,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,122.45,
11104 Punch Biopsy with Suture,3428676,CDM,761,RC,11104,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,44.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.43,1953.17,
11105 Add'l Punch Biospy with suture,3428677,CDM,761,RC,11105,HCPCS,Outpatient,,,429.95,214.98,,386.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,343.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,386.96,90,,,Percent of total Billed charges,90% of total billed charges,24.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,417.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,395.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,386.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,300.97,70,,,percent of total billed charges,70% of total billed charges,386.96,90,,,percent of total billed charges,90% of total billed charges,408.45,95,,,percent of total billed charges,95% of total billed charges,408.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,369.76,86,,,percent of total billed charges,86% of total billed charges,343.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,417.05,97,,,percent of total billed charges,97% of total billed charges,386.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,417.05,97,,,percent of total billed charges,97% of total billed charges,399.85,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,417.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.05,417.05,
11106 Wedge Biopsy with Suture,3428678,CDM,761,RC,11106,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,54.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.21,3076.37,
11107 Add'l Wedge Biopsy with suture,3428679,CDM,761,RC,11107,HCPCS,Outpatient,,,175.38,87.69,,157.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,140.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,157.84,90,,,Percent of total Billed charges,90% of total billed charges,28.92,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,170.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,161.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,122.77,70,,,percent of total billed charges,70% of total billed charges,157.84,90,,,percent of total billed charges,90% of total billed charges,166.61,95,,,percent of total billed charges,95% of total billed charges,166.61,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,150.83,86,,,percent of total billed charges,86% of total billed charges,140.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,170.12,97,,,percent of total billed charges,97% of total billed charges,157.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,170.12,97,,,percent of total billed charges,97% of total billed charges,163.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,170.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,170.12,
11200- Remove skin tags </= 15,3431493,CDM,761,RC,11200,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,34.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31,980.65,
11201- Remove skin tags/ea add 10 lesions,3431494,CDM,761,RC,11201,HCPCS,Outpatient,,,47.68,23.84,,42.91,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,38.14,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,42.91,90,,,Percent of total Billed charges,90% of total billed charges,16.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,46.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,43.87,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.38,70,,,percent of total billed charges,70% of total billed charges,42.91,90,,,percent of total billed charges,90% of total billed charges,45.3,95,,,percent of total billed charges,95% of total billed charges,45.3,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41,86,,,percent of total billed charges,86% of total billed charges,38.14,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,46.25,97,,,percent of total billed charges,97% of total billed charges,42.91,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,46.25,97,,,percent of total billed charges,97% of total billed charges,44.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.57,46.25,
"11300- Shave Skin Lesion,0.5Cm Or Less",3431495,CDM,761,RC,11300,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,27.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25,1953.17,
"11301- Shave Skin Lesion,0.6-1.0Cm",3431496,CDM,761,RC,11301,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,980.65,
"11302- Shave Skin Lesion,1.1-2.0Cm",3431497,CDM,761,RC,11302,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,980.65,
11303- Shave epi/derm sng lesion/trunk/arm/leg/>2.0cm,3431498,CDM,761,RC,11303,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,51.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47,1953.17,
"11305- Shave Skin Lesion, .5Cm Or Less",3431499,CDM,761,RC,11305,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,980.65,
"11306- Shave Skin Lesion,0.6-1.0 Cm",3431500,CDM,761,RC,11306,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,980.65,
"11307- Shave Skin Lesion,1.1-2.0 Cm",3431501,CDM,761,RC,11307,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,980.65,
11308- Shave epi/derm sng lesion/scalp/neck/hnd/ft/genit/>2.0cm,3431502,CDM,761,RC,11308,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1953.17,
11310- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.5cm or <,3431503,CDM,761,RC,11310,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,35.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,32,980.65,
11311- Shave epi/derm sng lesion/face/ear/lid/nose/lip/0.6-1.0cm,3431504,CDM,761,RC,11311,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,41.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38,980.65,
11312- Shave epi/derm sng lesion/face/ear/lid/nose/lip/1.1-2.0cm,3431505,CDM,761,RC,11312,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,50,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50,1953.17,
11313- Shave epi/derm sng lesion/face/ear/lid/nose/lip/>2.0cm,3431506,CDM,761,RC,11313,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,69.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63,1953.17,
11400- Exc Tr-Ext Benign+Marg 0.5 < Cm,3431507,CDM,761,RC,11400,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,3446.32,
11401- Exc tr-ext benign+marg 0.6-1 cm,3431508,CDM,761,RC,11401,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1953.17,
11402- Exc tr-ext benign+marg 1.1-2 cm,3431509,CDM,761,RC,11402,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,59.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54,3446.32,
11403- Exc tr-ext bengin+marg 2.1-3cm,3431510,CDM,761,RC,11403,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,71.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65,3446.32,
11404- Exc tr-ext benign+marg 3.1-4 cm,3431511,CDM,761,RC,11404,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,88.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.5,7941.56,
11406- Exc tr-ext bengin+marg >4.0 cm,3431512,CDM,761,RC,11406,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,129.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.5,7941.56,
11420- Exc h-f-nk-sp benign+marg 0.5/<,3431513,CDM,761,RC,11420,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,7941.56,
Clinic Excision Benign Lesion 0.5- 11420,4351219,CDM,761,RC,11420,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,7941.56,
11421- Exc h-f-nk-sp benign+marg 0.6-1,3431514,CDM,761,RC,11421,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,3446.32,
Clinic Excision Benign Lesion 0.6-1.0-  11421,4351220,CDM,761,RC,11421,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,3446.32,
11422- Exc h-f-nk-sp benign1.1-2,3431515,CDM,761,RC,11422,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,7941.56,
Clinic Excision Benign Lesion 1.1-2.0 - 11422,4351221,CDM,761,RC,11422,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,7941.56,
11423- Exc h-f-nk-sp benign+marg 2.1-3,3431516,CDM,761,RC,11423,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,7941.56,
Clinic Excision Benign Lesion 2.1-3.0 - 11423,4351222,CDM,761,RC,11423,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,39.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,36,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36,7941.56,
11424- Exc benign les/see area/3.1-4.0cm,3431517,CDM,761,RC,11424,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,7941.56,
Clinic Excision Benign Lesion 3.1-4.0 - 11424,4351223,CDM,761,RC,11424,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,95.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.5,7941.56,
11426- Exc h-f-nk-sp benign+marg >4 cm,3431518,CDM,761,RC,11426,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,133.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121,13918.49,
Clinic Excision Benign Lesion over 4.0 - 11426,4351224,CDM,761,RC,11426,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,133.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,121,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121,13918.49,
11440- Exc face-mm benign+marg 0.5 cm/<,3431519,CDM,761,RC,11440,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,59.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.5,3446.32,
11441- Exc face-mm benign+marg 0.6-1 cm,3431520,CDM,761,RC,11441,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,72.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.5,3446.32,
11442- Exc face-mm benign+marg 1.1-2 cm,3431521,CDM,761,RC,11442,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,86.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.5,3446.32,
11443- Exc face-mm benign+marg 2.1-3 cm,3431522,CDM,761,RC,11443,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,97.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89,7941.56,
11444- Exc/benign les/see area/3.1-4.0cm,3431523,CDM,761,RC,11444,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,128.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,117,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117,7941.56,
11446- Exc benign lesion/see area/>4.0cm,3431524,CDM,761,RC,11446,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,130.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118.5,13918.49,
11450- Exc/hidradenitis/axilla/smp/im rpr,3431525,CDM,761,RC,11450,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,201.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,183.24,13918.49,
11451- Exc/hidradenitis/axilla/comp rpr,3431526,CDM,761,RC,11451,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,277.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,252.67,13918.49,
11462- Exc/hidradenitis/ingun/smp/imt rpr,3431527,CDM,761,RC,11462,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,191.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.95,13918.49,
11463- Exc/hidradenitis/inguinal/comp rpr,3431528,CDM,761,RC,11463,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,283.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,257.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,257.76,13918.49,
11470- Exc hidradenit/perianal/neal/sp/in,3431529,CDM,761,RC,11470,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,234.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.98,13918.49,
11471- Exc hidradenitis/perianal/neal/com,3431530,CDM,761,RC,11471,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,305.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,278.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,278.14,13918.49,
11600- Exc/malig/trunk/arms/legs <0.5cm,3431531,CDM,761,RC,11600,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,3446.32,
11601- Exc malig/trunk/arm/leg 0.6-1.0cm,3431532,CDM,761,RC,11601,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,3446.32,
11602- Exc tr-ext mal+marg 1.1-2 cm,3431533,CDM,761,RC,11602,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,89.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,81,1953.17,
11603- Exc tr-ext mal+marg 2.1-3 cm,3431534,CDM,761,RC,11603,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,94.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85.5,3446.32,
11604- Exc tr-ext mal+marg 3.1-4 cm,3431535,CDM,761,RC,11604,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,138.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,125.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,125.5,3446.32,
11606- Exc tr-ext mal+marg >4 cm,3431536,CDM,761,RC,11606,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,270.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,246,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,246,7941.56,
11620- Exc/malig/see area/0.5cm or less,3431537,CDM,761,RC,11620,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,100.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.5,7941.56,
11621- Exc H-F-Nk-Sp Mlg+Marg 0.6-1.0 Cm,3431538,CDM,761,RC,11621,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,3446.32,
11622- Exc s/n/h/f/g mal+mrg 1.1-2,3431539,CDM,761,RC,11622,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,123.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,112,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112,3446.32,
11623- Exc H-F-Nk-Sp Mlg+Marg 2.1-3 Cm,3431540,CDM,761,RC,11623,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,7941.56,
11624- Exc s/n/h/f/g mal+mrg 3.1-4,3431541,CDM,761,RC,11624,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,207.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189,7941.56,
11626- Exc s/n/h/f/g mal+mrg >4 cm,3431542,CDM,761,RC,11626,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,264,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,240,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,240,13918.49,
11640- Exc/malg/fac/ear/lid/nos/lip<0.5cm,3431543,CDM,761,RC,11640,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,84.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,77,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77,3446.32,
11641- Exc f/e/e/n/l mal+mrg 0.6-1,3431544,CDM,761,RC,11641,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,3446.32,
11642- Exc Face-Mm Malig+Marg 1.1-2,3431545,CDM,761,RC,11642,HCPCS,Outpatient,,,3552.91,1776.46,,3197.62,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2842.33,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.62,90,,,Percent of total Billed charges,90% of total billed charges,148.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3446.32,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3268.68,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2487.04,70,,,percent of total billed charges,70% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,3375.26,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3055.5,86,,,percent of total billed charges,86% of total billed charges,2842.33,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3446.32,97,,,percent of total billed charges,97% of total billed charges,3197.62,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3446.32,97,,,percent of total billed charges,97% of total billed charges,3304.21,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,135,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3446.32,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,135,3446.32,
11643- Exc f/e/e/n/l mal+mrg 2.1-3,3431546,CDM,761,RC,11643,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,210.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,191.16,7941.56,
11644- Exc Face-Mm Malig+Marg 3.1-4.0,3431547,CDM,761,RC,11644,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,243.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,221,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,221,7941.56,
11646- Exc/malig/fac/ear/lid/nose/lip>4cm,3431548,CDM,761,RC,11646,HCPCS,Outpatient,,,14348.96,7174.48,,12914.06,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11479.17,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12914.06,90,,,Percent of total Billed charges,90% of total billed charges,281.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13918.49,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,13201.04,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,10044.27,70,,,percent of total billed charges,70% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,13631.51,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,12340.11,86,,,percent of total billed charges,86% of total billed charges,11479.17,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,13918.49,97,,,percent of total billed charges,97% of total billed charges,12914.06,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,13918.49,97,,,percent of total billed charges,97% of total billed charges,13344.53,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,256,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13918.49,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,256,13918.49,
11721 - DEB NAIL 6 OR MORE Profee,3435765,CDM,510,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,299.61,
11721- Debride/nails/any method/6 or more,3431551,CDM,761,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,299.61,
11721 Debridement Nail Any Method 6/>,3549202,CDM,761,RC,11721,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,299.61,
11730 - Nail avulsion; single,4023138,CDM,761,RC,11730,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
11730- Avulsion/nail plate/simple/single,3431552,CDM,761,RC,11730,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
11732 - Nail avulsion; each additional,4023139,CDM,761,RC,11732,HCPCS,Outpatient,,,395.34,197.67,,355.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,316.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,355.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,363.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,276.74,70,,,percent of total billed charges,70% of total billed charges,355.81,90,,,percent of total billed charges,90% of total billed charges,375.57,95,,,percent of total billed charges,95% of total billed charges,375.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.99,86,,,percent of total billed charges,86% of total billed charges,316.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,355.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,367.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.74,383.48,
11732- Avulsion/nail plate/simple/ea add,3431553,CDM,761,RC,11732,HCPCS,Outpatient,,,395.34,197.67,,355.81,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,316.27,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,355.81,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,363.71,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,355.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,276.74,70,,,percent of total billed charges,70% of total billed charges,355.81,90,,,percent of total billed charges,90% of total billed charges,375.57,95,,,percent of total billed charges,95% of total billed charges,375.57,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,339.99,86,,,percent of total billed charges,86% of total billed charges,316.27,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,355.81,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,367.67,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,383.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,276.74,383.48,
11750- Excise/nail/matrix/perm removal,3431555,CDM,761,RC,11750,HCPCS,Outpatient,,,141.35,70.68,,127.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,113.08,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,137.11,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,130.04,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,127.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,98.95,70,,,percent of total billed charges,70% of total billed charges,127.22,90,,,percent of total billed charges,90% of total billed charges,134.28,95,,,percent of total billed charges,95% of total billed charges,134.28,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,121.56,86,,,percent of total billed charges,86% of total billed charges,113.08,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,137.11,97,,,percent of total billed charges,97% of total billed charges,127.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.11,97,,,percent of total billed charges,97% of total billed charges,131.46,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,137.11,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.95,1818.76,
11900- Intralesional injection/</=7,3431563,CDM,761,RC,11900,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
11901- Inj/intralesional/> 7 lesions,3431564,CDM,761,RC,11901,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
11950 - Subcutaneous injection filling material,3572729,CDM,983,RC,11950,HCPCS,Outpatient,,,67.12,33.56,,60.41,90,,,percent of total billed charges,90% of total Billed charges,118.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,78.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.31,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,42.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,67.12,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,62.07,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,80.26,155,,,Fee Schedule,155% of CMS OPPS Rate,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.3,155,,,Fee Schedule,155% of CMS OPPS Rate,184.3,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.76,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,51.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,135.32,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,42.53,184.3,
11950- Subq inj/fill material/1cc or <,3431566,CDM,761,RC,11950,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.4,980.65,
11951- Subq inj/fill material/1.1-5.0 cc,3431567,CDM,761,RC,11951,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
11980- Hormone pellet implant/subq,3431570,CDM,510,RC,11980,HCPCS,Outpatient,,,2037.53,1018.77,,1833.78,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1630.02,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1833.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1976.4,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1874.53,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1833.78,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1426.27,70,,,percent of total billed charges,70% of total billed charges,1833.78,90,,,percent of total billed charges,90% of total billed charges,1935.65,95,,,percent of total billed charges,95% of total billed charges,1935.65,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1752.28,86,,,percent of total billed charges,86% of total billed charges,1630.02,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1976.4,97,,,percent of total billed charges,97% of total billed charges,1833.78,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1976.4,97,,,percent of total billed charges,97% of total billed charges,1894.9,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1976.4,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.49,1976.4,
11981- Insert/drug delivery implant,3431571,CDM,510,RC,11981,HCPCS,Outpatient,,,89.11,44.56,,80.2,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,71.29,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.2,90,,,Percent of total Billed charges,90% of total billed charges,83.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,86.44,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,80.2,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,62.38,70,,,percent of total billed charges,70% of total billed charges,80.2,90,,,percent of total billed charges,90% of total billed charges,84.65,95,,,percent of total billed charges,95% of total billed charges,84.65,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,76.63,86,,,percent of total billed charges,86% of total billed charges,71.29,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,86.44,97,,,percent of total billed charges,97% of total billed charges,80.2,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.44,97,,,percent of total billed charges,97% of total billed charges,82.87,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,86.44,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,62.38,566.05,
11982- Remove/drug delivery implant,3431572,CDM,510,RC,11982,HCPCS,Outpatient,,,1819.23,909.62,,1637.31,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1455.38,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1637.31,90,,,Percent of total Billed charges,90% of total billed charges,101.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1764.65,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1673.69,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1637.31,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1273.46,70,,,percent of total billed charges,70% of total billed charges,1637.31,90,,,percent of total billed charges,90% of total billed charges,1728.27,95,,,percent of total billed charges,95% of total billed charges,1728.27,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1564.54,86,,,percent of total billed charges,86% of total billed charges,1455.38,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1764.65,97,,,percent of total billed charges,97% of total billed charges,1637.31,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1764.65,97,,,percent of total billed charges,97% of total billed charges,1691.88,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1764.65,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92.33,1840.7,
12001 - SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/<,4037467,CDM,510,RC,12001,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,980.65,
12002- Rep Superfic Wound 2.6-7.5Cm,3431575,CDM,761,RC,12002,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,980.65,
12004- Rep Superific Wound 7.6-12.5 cm,3431576,CDM,761,RC,12004,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,980.65,
12005- Rep Superfic Wound 12.6-20.0Cm,3431577,CDM,761,RC,12005,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
"12006- Simple Repair, scalp/neck/axillae/trunk/genital/extrem, 2.5 - 7.5 cm",3428737,CDM,510,RC,12006,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
12007- Smpl rpr/scalp/neck/ax/ext genit/trnk/extrem/inc hnd/ft/>30cm,3431578,CDM,761,RC,12007,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,980.65,
12011-EYE RPR SPR WND FACE <2.5CM,3428738,CDM,510,RC,12011,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,980.65,
12011-OCC EYE RPR SPR WND FACE <2.5CM,3536972,CDM,983,RC,12011,HCPCS,Outpatient,,,790.68,395.34,,711.61,90,,,percent of total billed charges,90% of total Billed charges,162.81,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,88.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,63.33,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,111.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,74.35,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,86.21,155,,,Fee Schedule,155% of CMS OPPS Rate,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.36,155,,,Fee Schedule,155% of CMS OPPS Rate,252.36,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.61,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,55.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.16,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,212.16,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.5,711.61,
12013- Rep Superfic Wounds 2.6-5.0Cm,3431580,CDM,761,RC,12013,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,980.65,
12014 - Simple repair of superficial wound of eyelid,3428739,CDM,983,RC,12014,HCPCS,Outpatient,,,163.46,81.73,,147.11,90,,,percent of total billed charges,90% of total Billed charges,214.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.92,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,114.63,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,73.06,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,142.25,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,102.13,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,118.22,155,,,Fee Schedule,155% of CMS OPPS Rate,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,332.8,155,,,Fee Schedule,155% of CMS OPPS Rate,332.8,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,191.09,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,265.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,47.5,332.8,
12015- Rep Superfic Wounds 7.6-12.5Cm,3431581,CDM,761,RC,12015,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,980.65,
12016- Smp rp fac/ear/no/lip/lid 12.6-20,3428740,CDM,510,RC,12016,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
12018- Smpl rpr/face/ear/lid/nose/lip/>30.0cm,3431582,CDM,761,RC,12018,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,980.65,
12020 - Treatment of superficial wound dehiscence; simple cl,4231108,CDM,510,RC,12020,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,3076.37,
12020 -OCC CLOSURE OF SPLIT WOUND,3568838,CDM,983,RC,12020,HCPCS,Outpatient,,,273.19,136.60,,245.87,90,,,percent of total billed charges,90% of total Billed charges,455.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,251.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,282.93,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,282.93,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,281.66,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,150.64,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,364.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,273.19,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,218.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,282.66,155,,,Fee Schedule,155% of CMS OPPS Rate,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.1,155,,,Fee Schedule,155% of CMS OPPS Rate,706.1,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,217.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,182.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,544,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,544,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,94,706.1,
12020- Tx superfic wnd dehise/smp close,3431583,CDM,761,RC,12020,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,103.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,94,3076.37,
12021- Tx superficial wnd dehise/smp/pack,3431584,CDM,761,RC,12021,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,129.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,118,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,118,1953.17,
12031- Int rp scalp/ax/trunk/ext 2.5 or <,3428743,CDM,761,RC,12031,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,1953.17,
"12032- Intermed Rpr, Scalp, Axillae, Trunk, Extremities 2.6-7.5cm",3431585,CDM,761,RC,12032,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,36.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,33,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,33,1953.17,
12034- Itmed rpr/scalp/ax/trnk/extrem/exclu hnd/ft/7.6-12.5c,3431586,CDM,761,RC,12034,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1953.17,
12035- Int rp scalp/ax/trunk/ext 12.6-20,3428744,CDM,510,RC,12035,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
"12037 - Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands an",3715279,CDM,510,RC,12037,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,8932.64,
12041- Itmed rpr/neck/hand/ft/ext genit/2.5 cm or <,3431587,CDM,761,RC,12041,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,26.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.5,1953.17,
12042- Itmed rpr/neck/hand/ft/ext genit/2.6-7.5 cm,3431588,CDM,761,RC,12042,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,39.05,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35.5,1953.17,
12044- Int rp neck/hand/feet/gen 7.6-12.5,3428745,CDM,510,RC,12044,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,53.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.5,3076.37,
12045- Itmed rpr/neck/hnd/ft/ext genit/12.6-20.0cm,3431589,CDM,761,RC,12045,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,3076.37,
12046- Itmed rpr/neck/hnd/ft/ext genit/20.1-30.0cm,3431590,CDM,761,RC,12046,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,3076.37,
12047- Itmed rpr/neck/hnd/ft/ext genit/> 30.0 cm,3431591,CDM,761,RC,12047,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,8932.64,
12051- Itmed rpr/face/ear/lid/nose/lip/2.5 cm or<,3431592,CDM,761,RC,12051,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,1953.17,
12052- Itmed rpr/face/ear/lid/nose/lip/2.6-5.0 cm,3431593,CDM,761,RC,12052,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1953.17,
12053- Int rp fac/ear/lid/nos/lip 5.1-7.5,3428750,CDM,761,RC,12053,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,52.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.5,1953.17,
12054- In rp fac/ear/lid/nos/lip 7.6-12.5,3428751,CDM,510,RC,12054,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,67.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.5,1953.17,
12055- Itmed rpr/face 2.6-20.0cm,3428752,CDM,510,RC,12055,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
12056- Int rp fac/ear/lid/nos/lip 20.1-30,3428755,CDM,510,RC,12056,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
12057- Itmed rpr/face/ear/lid/nose/lip/>30.0cm,3431594,CDM,761,RC,12057,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,101.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,92,1953.17,
13101- Complex repair/trunk/2.6-7.5 cm,3431595,CDM,761,RC,13101,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
"13102 - Repair, complex, trunk; each additional 5 cm or less",4037473,CDM,510,RC,13102,HCPCS,Outpatient,,,1780.8,890.40,,1602.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1424.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1602.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1638.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1137.26,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1400.64,78.65,,,percent of total billed charges,78.65% of total billed charges,1590.82,89.33,,,percent of total billed charges,89.33% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1246.56,70,,,percent of total billed charges,70% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.49,86,,,percent of total billed charges,86% of total billed charges,1424.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1656.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.26,1727.38,
13120- Repair/comp/scalp/arm/leg/1.1-2.5c,3431596,CDM,761,RC,13120,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,66,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,60,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60,3076.37,
13121- Cmplx rpr s/a/l 2.6-7.5 cm,3431597,CDM,761,RC,13121,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
"13122 - Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in",3715283,CDM,510,RC,13122,HCPCS,Outpatient,,,1780.8,890.40,,1602.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1424.64,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1602.72,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1638.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1137.26,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1400.64,78.65,,,percent of total billed charges,78.65% of total billed charges,1590.82,89.33,,,percent of total billed charges,89.33% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1246.56,70,,,percent of total billed charges,70% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,1691.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.49,86,,,percent of total billed charges,86% of total billed charges,1424.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1602.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,1656.14,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1137.26,1727.38,
13131- Cmplx rpr f/c/c/m/n/ax/g/h/f; 1.1 cm to 2.5 cm,3431598,CDM,761,RC,13131,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,78.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,71,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,71,1953.17,
13132- Cmplx rpr f/c/c/m/n/ax/g/h/f; 2.6 cm to 7.5 cm,3431599,CDM,761,RC,13132,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
13151- Cmplx rpr e/n/e/l; 1.1-2.5 cm,3431601,CDM,761,RC,13151,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,194.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177,3076.37,
13152- Cmplx rpr e/n/e/l; 2.6-7.5 cm,3431602,CDM,761,RC,13152,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
13160- Secondary clos/surg wound/ext/comp,3431603,CDM,761,RC,13160,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,8932.64,
14001- Skin Tiss Transfer 10.1-30Sq Cm,3431604,CDM,761,RC,14001,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,290.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,264,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,264,8932.64,
14020- Skin Tissue Trnfr 10Sq Cm Less,3431605,CDM,761,RC,14020,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,165,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,150,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,150,8932.64,
14021- Skin Tissue Trnfr 10.1-30Sq Cm,3431606,CDM,761,RC,14021,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,249.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,226.5,8932.64,
14040- Tis trnfr f/c/c/m/n/a/g/h/f; defect 10 sq cm or less,3431607,CDM,761,RC,14040,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,195.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.5,8932.64,
14041- Adj tis trans/see area/10.1-30sqcm,3431608,CDM,761,RC,14041,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,305.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,277.5,8932.64,
14060- Tis trnfr e/n/e/l 10 sq cm/<,3431609,CDM,761,RC,14060,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,268.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,244,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,244,8932.64,
"15040 - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less",3715286,CDM,510,RC,15040,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15101- Skin Split Graft Addl 100Sq Cm,3431614,CDM,761,RC,15101,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15110- Epidrm Autogrft Trnk/Arm/Leg,3431615,CDM,761,RC,15110,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15111- Epiderm autograft/specified areas/ea add 100sq cm/ea add 1% body area infant/child,3431616,CDM,761,RC,15111,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15115- Epiderm autograft/specified areas/first 100sq cm or </1% body area/infant/child,3431617,CDM,761,RC,15115,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15120 - SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/,4037474,CDM,510,RC,15120,HCPCS,Outpatient,,,18116.78,9058.39,,16305.1,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14493.42,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,16305.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17573.28,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16667.44,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12681.75,70,,,percent of total billed charges,70% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15580.43,86,,,percent of total billed charges,86% of total billed charges,14493.42,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17573.28,97,,,percent of total billed charges,97% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,17573.28,97,,,percent of total billed charges,97% of total billed charges,16848.61,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17573.28,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2511.41,17573.28,
15200- Full thick graft/trunk/</=20 sq cm,3431619,CDM,761,RC,15200,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15220- Full thick gft/scalp/arm/leg/20sqcm or<,3431620,CDM,761,RC,15220,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15221- Full thick gft/scalp/arm/leg/add 20sqcm,3431621,CDM,761,RC,15221,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15240- Full Thick Graft w/close donor site face/neck/ax/genit/hnd/ft <=20sqcm,3431622,CDM,761,RC,15240,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15241- Skin Full Graft Add 20Sq Cm,3431623,CDM,761,RC,15241,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15260- Full thick gft/nose/ear/lid/lip/20sqcm or<,3431624,CDM,761,RC,15260,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15261- Skin Full Graft Add 20 Sq Cm,3431625,CDM,761,RC,15261,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15271 App Skn Sub Grft T/A/L Area/100 Sq Cm/<1st 25,3436028,CDM,761,RC,15271,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15272 App Skn Sub Grft T/A/L Area/100 Sq Cm Ea Adl 25sqc,3436030,CDM,761,RC,15272,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15273 App Skn Subgrft T/A/L Area 100 Sq Cm 1st 100 Sq Cm,3549201,CDM,761,RC,15273,HCPCS,Outpatient,,,18116.78,9058.39,,16305.1,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14493.42,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,16305.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17573.28,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16667.44,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12681.75,70,,,percent of total billed charges,70% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15580.43,86,,,percent of total billed charges,86% of total billed charges,14493.42,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17573.28,97,,,percent of total billed charges,97% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,17573.28,97,,,percent of total billed charges,97% of total billed charges,16848.61,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17573.28,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2511.41,17573.28,
15273- Skin Sub Grft Trnk Arm Lg Child,3431626,CDM,761,RC,15273,HCPCS,Outpatient,,,18116.78,9058.39,,16305.1,90,,,percent of total billed charges,90% of total Billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,14493.42,80,,,Percent of total Billed charges,80% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,16305.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17573.28,97,,,Percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,16667.44,92,,,Percent of total billed charges,92% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,7853.69,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12520.4,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15858.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,12681.75,70,,,percent of total billed charges,70% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,17210.94,95,,,percent of total billed charges,95% of total billed charges,2954.6,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5909.21,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15580.43,86,,,percent of total billed charges,86% of total billed charges,14493.42,80,,,percent of total billed charges,80% of total billed charges,3078.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17573.28,97,,,percent of total billed charges,97% of total billed charges,16305.1,90,,,percent of total billed charges,90% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,17573.28,97,,,percent of total billed charges,97% of total billed charges,16848.61,93,,,percent of total billed charges,93% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17573.28,97,,,percent of total billed charges,97% of total billed charges,2954.6,100,,,Fee Schedule,100% of CMS OPPS Rate ,2954.6,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2511.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2511.41,17573.28,
15274 App Skn Sub Grft T/A/L Area>=100sqc Adl 100sqc,3549034,CDM,761,RC,15274,HCPCS,Outpatient,,,9058.39,4529.20,,8152.55,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,7246.71,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8152.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8786.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,8333.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,5784.89,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,7124.62,78.65,,,percent of total billed charges,78.65% of total billed charges,8092,89.33,,,percent of total billed charges,89.33% of total billed charges,8152.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,6340.87,70,,,percent of total billed charges,70% of total billed charges,8152.55,90,,,percent of total billed charges,90% of total billed charges,8605.47,95,,,percent of total billed charges,95% of total billed charges,8605.47,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7790.22,86,,,percent of total billed charges,86% of total billed charges,7246.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,8786.64,97,,,percent of total billed charges,97% of total billed charges,8152.55,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8786.64,97,,,percent of total billed charges,97% of total billed charges,8424.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8786.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5784.89,8786.64,
"15275 Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genit",3621205,CDM,510,RC,15275,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15275 Sub Grft F/S/N/H/F/G/M/D <100 Sq Cm 1st 25 Sq Cm,3436032,CDM,761,RC,15275,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
15276 Sub Grft F/S/N/H/F/G/M/D<100 Sq Cm Ea Addl 25sqc,3436033,CDM,761,RC,15276,HCPCS,Outpatient,,,4604.46,2302.23,,4144.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3683.57,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4144.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4236.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2940.51,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3621.51,78.65,,,percent of total billed charges,78.65% of total billed charges,4113.24,89.33,,,percent of total billed charges,89.33% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3223.12,70,,,percent of total billed charges,70% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,4374.24,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3959.84,86,,,percent of total billed charges,86% of total billed charges,3683.57,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4144.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,4282.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4466.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2940.51,4466.33,
15760- Composite graft/pri close/don area,3431628,CDM,761,RC,15760,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,328.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,298.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,298.5,8932.64,
"15788 - Chemical peel, facial; epidermal",3715288,CDM,510,RC,15788,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.64,1953.17,
"15789 - Chemical peel, facial; dermal",3715293,CDM,510,RC,15789,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,448.49,3076.37,
"15792 -Chemical peel, nonfacial; epidermal",3715294,CDM,510,RC,15792,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,330.33,3076.37,
"15793 - Chemical peel, nonfacial; dermal",3715296,CDM,510,RC,15793,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,1953.17,
"15820 - Blepharoplasty, lower eyelid;",3712914,CDM,510,RC,15820,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
"15851 - Removal of sutures under anesthesia (other than local), other surgeon",3715463,CDM,510,RC,15851,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
16020- Dress/debride pt-thick burn/<5% BS,3431631,CDM,761,RC,16020,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,980.65,
16025- Dress/debride pt-tck burn/5-10% BS,3431632,CDM,761,RC,16025,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,110.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,100.55,980.65,
17000- Destruct premalig lesion/1st les,3431633,CDM,761,RC,17000,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,980.65,
17003- DERM DESTRUCT PREMALG LES 2-14,3514645,CDM,761,RC,17003,HCPCS,Outpatient,,,505.49,252.75,,454.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,404.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,454.94,90,,,Percent of total Billed charges,90% of total billed charges,4.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,490.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,465.05,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,322.82,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,397.58,78.65,,,percent of total billed charges,78.65% of total billed charges,451.56,89.33,,,percent of total billed charges,89.33% of total billed charges,454.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,353.84,70,,,percent of total billed charges,70% of total billed charges,454.94,90,,,percent of total billed charges,90% of total billed charges,480.22,95,,,percent of total billed charges,95% of total billed charges,480.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,434.72,86,,,percent of total billed charges,86% of total billed charges,404.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,490.33,97,,,percent of total billed charges,97% of total billed charges,454.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.33,97,,,percent of total billed charges,97% of total billed charges,470.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,490.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.25,490.33,
17004- Destroy premal lesions 15/>,3428770,CDM,510,RC,17004,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,128.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116.39,1953.17,
17110- Destruct benign lesion 1-14,3431075,CDM,761,RC,17110,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,980.65,
17111- Destruct lesion 15 or more,3431076,CDM,761,RC,17111,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,56.51,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.37,980.65,
17250 Chemical Cauterization if Granulation Tissue,3436034,CDM,761,RC,17250,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,28.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.82,980.65,
17250- Chemical cautery of granulated tissue,3431077,CDM,761,RC,17250,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,28.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.82,980.65,
17260- Destruction of skin lesions,3431078,CDM,761,RC,17260,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,56.58,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51.44,980.65,
17261- Destruction of skin lesions,3431079,CDM,761,RC,17261,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,980.65,
17262- Destruction of skin lesions,3431080,CDM,761,RC,17262,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,93.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,85,980.65,
17263- Destruction of skin lesions,3431081,CDM,761,RC,17263,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,108.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99,980.65,
17264- Destruction of skin lesions,3431082,CDM,761,RC,17264,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,121.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.56,1953.17,
17266- Destruction of skin lesions,3431083,CDM,761,RC,17266,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,141.47,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.61,1953.17,
17270- Destruction of skin lesions,3431084,CDM,761,RC,17270,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,62.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.1,980.65,
17271- Destruction of skin lesions,3431085,CDM,761,RC,17271,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,73.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.5,980.65,
17272- Destruction of skin lesions,3431086,CDM,761,RC,17272,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,112.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.26,980.65,
17273- Destruction of skin lesions,3431087,CDM,761,RC,17273,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,124.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,113.5,1953.17,
17274- Destruction of skin lesions,3431088,CDM,761,RC,17274,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,158.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,144.48,1953.17,
17276- Destruction of skin lesions,3431089,CDM,761,RC,17276,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,192.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,175.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,175.35,1953.17,
17280- Destruction of skin lesions,3431090,CDM,761,RC,17280,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,72.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.76,980.65,
17281- Destruction of skin lesions,3431091,CDM,761,RC,17281,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,102.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93,1953.17,
17282- Destruction of skin lesions,3431092,CDM,761,RC,17282,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,129.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.39,1953.17,
"17283- Destruct Skin Lesions,2.1-3.0 cm",3431634,CDM,761,RC,17283,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,162.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,147.67,1953.17,
17284- Destruction of skin lesions,3431093,CDM,761,RC,17284,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,194.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.23,3076.37,
17286- Destruction of skin lesions,3431094,CDM,761,RC,17286,HCPCS,Outpatient,,,3171.52,1585.76,,2854.37,90,,,percent of total billed charges,90% of total Billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2537.22,80,,,Percent of total Billed charges,80% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2854.37,90,,,Percent of total Billed charges,90% of total billed charges,267.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3076.37,97,,,Percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2917.8,92,,,Percent of total billed charges,92% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1402.56,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2235.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2832.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2220.06,70,,,percent of total billed charges,70% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,3012.94,95,,,percent of total billed charges,95% of total billed charges,527.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1055.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2727.51,86,,,percent of total billed charges,86% of total billed charges,2537.22,80,,,percent of total billed charges,80% of total billed charges,513.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3076.37,97,,,percent of total billed charges,97% of total billed charges,2854.37,90,,,percent of total billed charges,90% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,3076.37,97,,,percent of total billed charges,97% of total billed charges,2949.51,93,,,percent of total billed charges,93% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3076.37,97,,,percent of total billed charges,97% of total billed charges,527.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,527.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,448.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,242.78,3076.37,
"17999 Unlisted procedure, skin, mucous membrane and subcutan",3623321,CDM,510,RC,17999,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
19000- Drainage Of Breast Lesion,3431635,CDM,360,RC,19000,HCPCS,Outpatient,,,144.51,72.26,,130.06,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,115.61,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.06,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,140.17,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,132.95,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,130.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,101.16,70,,,percent of total billed charges,70% of total billed charges,130.06,90,,,percent of total billed charges,90% of total billed charges,137.28,95,,,percent of total billed charges,95% of total billed charges,137.28,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,124.28,86,,,percent of total billed charges,86% of total billed charges,115.61,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,140.17,97,,,percent of total billed charges,97% of total billed charges,130.06,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.17,97,,,percent of total billed charges,97% of total billed charges,134.39,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,140.17,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,3163.8,
19001- Punc asp breast cyst ea additional,3428771,CDM,360,RC,19001,HCPCS,Outpatient,,,13.43,6.72,,12.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,10.74,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,12.09,90,,,Percent of total Billed charges,90% of total billed charges,22.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,13.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,8.58,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,10.56,78.65,,,percent of total billed charges,78.65% of total billed charges,12,89.33,,,percent of total billed charges,89.33% of total billed charges,12.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.4,70,,,percent of total billed charges,70% of total billed charges,12.09,90,,,percent of total billed charges,90% of total billed charges,12.76,95,,,percent of total billed charges,95% of total billed charges,12.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.55,86,,,percent of total billed charges,86% of total billed charges,10.74,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.03,97,,,percent of total billed charges,97% of total billed charges,12.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.03,97,,,percent of total billed charges,97% of total billed charges,12.49,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,13.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.58,22.43,
19020-,3428772,CDM,361,RC,19020,HCPCS,Outpatient,,,383.74,191.87,,345.37,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,306.99,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,345.37,90,,,Percent of total Billed charges,90% of total billed charges,80.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,372.23,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,353.04,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,345.37,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,268.62,70,,,percent of total billed charges,70% of total billed charges,345.37,90,,,percent of total billed charges,90% of total billed charges,364.55,95,,,percent of total billed charges,95% of total billed charges,364.55,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,330.02,86,,,percent of total billed charges,86% of total billed charges,306.99,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,372.23,97,,,percent of total billed charges,97% of total billed charges,345.37,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,372.23,97,,,percent of total billed charges,97% of total billed charges,356.88,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,372.23,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,73,7310.49,
19081- Bx breast 1st lesion w/o US,3428775,CDM,320,RC,19081,HCPCS,Outpatient,,,7311.24,3655.62,,6580.12,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5848.99,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,6580.12,90,,,Percent of total Billed charges,90% of total billed charges,163.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7091.9,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6726.34,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6580.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5117.87,70,,,percent of total billed charges,70% of total billed charges,6580.12,90,,,percent of total billed charges,90% of total billed charges,6945.68,95,,,percent of total billed charges,95% of total billed charges,6945.68,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6287.67,86,,,percent of total billed charges,86% of total billed charges,5848.99,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7091.9,97,,,percent of total billed charges,97% of total billed charges,6580.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7091.9,97,,,percent of total billed charges,97% of total billed charges,6799.45,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7091.9,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.3,7310.49,
"19082 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), w",3621196,CDM,510,RC,19082,HCPCS,Outpatient,,,758.04,379.02,,682.24,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,606.43,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,682.24,90,,,Percent of total Billed charges,90% of total billed charges,77.42,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,735.3,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,697.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,484.1,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,596.22,78.65,,,percent of total billed charges,78.65% of total billed charges,677.17,89.33,,,percent of total billed charges,89.33% of total billed charges,682.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,530.63,70,,,percent of total billed charges,70% of total billed charges,682.24,90,,,percent of total billed charges,90% of total billed charges,720.14,95,,,percent of total billed charges,95% of total billed charges,720.14,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,651.91,86,,,percent of total billed charges,86% of total billed charges,606.43,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,735.3,97,,,percent of total billed charges,97% of total billed charges,682.24,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,735.3,97,,,percent of total billed charges,97% of total billed charges,704.98,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,735.3,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70.38,735.3,
19083- Biopsy/breast/1st lesion/US guide,3431636,CDM,401,RC,19083,HCPCS,Outpatient,,,867.8,433.90,,781.02,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,694.24,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,781.02,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,841.77,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,798.38,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,781.02,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,607.46,70,,,percent of total billed charges,70% of total billed charges,781.02,90,,,percent of total billed charges,90% of total billed charges,824.41,95,,,percent of total billed charges,95% of total billed charges,824.41,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,746.31,86,,,percent of total billed charges,86% of total billed charges,694.24,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,841.77,97,,,percent of total billed charges,97% of total billed charges,781.02,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,841.77,97,,,percent of total billed charges,97% of total billed charges,807.05,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,841.77,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
SCSN US Guided Mammotome Breast Biopsy,3370946,CDM,402,RC,19083,HCPCS,Outpatient,,,867.8,433.90,,781.02,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,694.24,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,781.02,90,,,Percent of total Billed charges,90% of total billed charges,152.78,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,841.77,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,798.38,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,781.02,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,607.46,70,,,percent of total billed charges,70% of total billed charges,781.02,90,,,percent of total billed charges,90% of total billed charges,824.41,95,,,percent of total billed charges,95% of total billed charges,824.41,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,746.31,86,,,percent of total billed charges,86% of total billed charges,694.24,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,841.77,97,,,percent of total billed charges,97% of total billed charges,781.02,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,841.77,97,,,percent of total billed charges,97% of total billed charges,807.05,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,841.77,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,138.89,7310.49,
"19084 Biopsy, breast, with placement of breast localization device(s)",3621149,CDM,510,RC,19084,HCPCS,Outpatient,,,761.19,380.60,,685.07,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,608.95,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,685.07,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,738.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,700.29,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,486.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,598.69,78.65,,,percent of total billed charges,78.65% of total billed charges,679.98,89.33,,,percent of total billed charges,89.33% of total billed charges,685.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,532.83,70,,,percent of total billed charges,70% of total billed charges,685.07,90,,,percent of total billed charges,90% of total billed charges,723.13,95,,,percent of total billed charges,95% of total billed charges,723.13,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,654.62,86,,,percent of total billed charges,86% of total billed charges,608.95,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,738.35,97,,,percent of total billed charges,97% of total billed charges,685.07,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,738.35,97,,,percent of total billed charges,97% of total billed charges,707.91,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,738.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.12,738.35,
19100- Bx breast percut w/o image,3428778,CDM,401,RC,19100,HCPCS,Outpatient,,,204.53,102.27,,184.08,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,163.62,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.08,90,,,Percent of total Billed charges,90% of total billed charges,67.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,198.39,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,188.17,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,184.08,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,143.17,70,,,percent of total billed charges,70% of total billed charges,184.08,90,,,percent of total billed charges,90% of total billed charges,194.3,95,,,percent of total billed charges,95% of total billed charges,194.3,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,175.9,86,,,percent of total billed charges,86% of total billed charges,163.62,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,198.39,97,,,percent of total billed charges,97% of total billed charges,184.08,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,198.39,97,,,percent of total billed charges,97% of total billed charges,190.21,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,198.39,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,61.25,7310.49,
"19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lac",3621652,CDM,510,RC,19110,HCPCS,Outpatient,,,333.21,166.61,,299.89,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,266.57,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.89,90,,,Percent of total Billed charges,90% of total billed charges,217.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,323.21,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,306.55,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,299.89,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,233.25,70,,,percent of total billed charges,70% of total billed charges,299.89,90,,,percent of total billed charges,90% of total billed charges,316.55,95,,,percent of total billed charges,95% of total billed charges,316.55,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,286.56,86,,,percent of total billed charges,86% of total billed charges,266.57,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,323.21,97,,,percent of total billed charges,97% of total billed charges,299.89,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,323.21,97,,,percent of total billed charges,97% of total billed charges,309.89,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,198,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,323.21,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,198,16759.7,
21011- Ex SQ tumor/face or scalp < 2 cm,3434682,CDM,510,RC,21011,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,208.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.16,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.16,7941.56,
21012- Ex SQ tumor/face or scalp 2 cm/>,3434683,CDM,510,RC,21012,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,285.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,259.78,7941.56,
21013- Exc IM tumor/face & scalp < 2 cm,3434684,CDM,510,RC,21013,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,336.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,305.52,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,305.52,7941.56,
21552- Exc SQ tum/neck/ant thorax 3cm/>,3434705,CDM,510,RC,21552,HCPCS,Outpatient,,,12446.68,6223.34,,11202.01,90,,,percent of total billed charges,90% of total Billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,9957.34,80,,,Percent of total Billed charges,80% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,11202.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,12073.28,97,,,Percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,11450.95,92,,,Percent of total billed charges,92% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,6236.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9942.49,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12593.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11202.01,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,8712.68,70,,,percent of total billed charges,70% of total billed charges,11202.01,90,,,percent of total billed charges,90% of total billed charges,11824.35,95,,,percent of total billed charges,95% of total billed charges,11824.35,95,,,percent of total billed charges,95% of total billed charges,2346.26,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4692.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10704.14,86,,,percent of total billed charges,86% of total billed charges,9957.34,80,,,percent of total billed charges,80% of total billed charges,2397.43,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12073.28,97,,,percent of total billed charges,97% of total billed charges,11202.01,90,,,percent of total billed charges,90% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,12073.28,97,,,percent of total billed charges,97% of total billed charges,11575.41,93,,,percent of total billed charges,93% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,12073.28,97,,,percent of total billed charges,97% of total billed charges,2346.26,100,,,Fee Schedule,100% of CMS OPPS Rate ,2346.26,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1994.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1994.32,12593.67,
24065 Biopsy arm/elbow soft tissue  (the CPT code is built without a description),3428318,CDM,360,RC,24065,HCPCS,Outpatient,,,223.48,111.74,,201.13,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,178.78,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.13,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,216.78,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,205.6,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,156.44,70,,,percent of total billed charges,70% of total billed charges,201.13,90,,,percent of total billed charges,90% of total billed charges,212.31,95,,,percent of total billed charges,95% of total billed charges,212.31,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.19,86,,,percent of total billed charges,86% of total billed charges,178.78,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,216.78,97,,,percent of total billed charges,97% of total billed charges,201.13,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.78,97,,,percent of total billed charges,97% of total billed charges,207.84,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,216.78,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
25075- Exc SQ tumor/forearm/wrist/<3cm,3434889,CDM,960,RC,25075,HCPCS,Outpatient,,,7225.17,3612.59,,6502.65,90,,,percent of total billed charges,90% of total Billed charges,804.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,117.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,506.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,506.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,469.05,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,311.23,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,615.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,553.47,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,370.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,477.35,155,,,Fee Schedule,155% of CMS OPPS Rate,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,1247.05,155,,,Fee Schedule,155% of CMS OPPS Rate,1247.05,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,396.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,307.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,943.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,943.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,117.5,6502.65,
26115- Exc hand les sc < 1.5 cm,3434907,CDM,960,RC,26115,HCPCS,Outpatient,,,530.61,265.31,,477.55,90,,,percent of total billed charges,90% of total Billed charges,842.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,37.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.68,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,486.63,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,333.49,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,644,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,530.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,374.98,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,499.1,155,,,Fee Schedule,155% of CMS OPPS Rate,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,1305.16,155,,,Fee Schedule,155% of CMS OPPS Rate,1305.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.18,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,322,100,,,Fee Schedule,100% of CMS OPPS Rate ,989.4,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,989.4,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.5,1305.16,
"27040 - Biopsy, soft tissue of pelvis and hip area; superficial",4037478,CDM,983,RC,27040,HCPCS,Outpatient,,,343.48,171.74,,309.13,90,,,percent of total billed charges,90% of total Billed charges,514.72,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,34.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,283.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,318.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,318.59,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,297.27,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,187.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,385.74,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,343.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,229.89,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,298.95,155,,,Fee Schedule,155% of CMS OPPS Rate,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,797.82,155,,,Fee Schedule,155% of CMS OPPS Rate,797.82,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.68,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,192.87,100,,,Fee Schedule,100% of CMS OPPS Rate ,663,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,663,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,34.5,797.82,
"27613 - Biopsy, soft tissue of leg or ankle area; superficial",3715297,CDM,510,RC,27613,HCPCS,Outpatient,,,222.7,111.35,,200.43,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,178.16,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.43,90,,,Percent of total Billed charges,90% of total billed charges,37.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,216.02,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,204.88,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,200.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,155.89,70,,,percent of total billed charges,70% of total billed charges,200.43,90,,,percent of total billed charges,90% of total billed charges,211.57,95,,,percent of total billed charges,95% of total billed charges,211.57,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,191.52,86,,,percent of total billed charges,86% of total billed charges,178.16,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,216.02,97,,,percent of total billed charges,97% of total billed charges,200.43,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.02,97,,,percent of total billed charges,97% of total billed charges,207.11,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,216.02,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.5,7310.49,
28190- Remove foreign body/foot/subq,3435165,CDM,360,RC,28190,HCPCS,Outpatient,,,263.75,131.88,,237.38,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,211,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.38,90,,,Percent of total Billed charges,90% of total billed charges,33.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,255.84,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,242.65,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,237.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,184.63,70,,,percent of total billed charges,70% of total billed charges,237.38,90,,,percent of total billed charges,90% of total billed charges,250.56,95,,,percent of total billed charges,95% of total billed charges,250.56,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,226.83,86,,,percent of total billed charges,86% of total billed charges,211,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,255.84,97,,,percent of total billed charges,97% of total billed charges,237.38,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,255.84,97,,,percent of total billed charges,97% of total billed charges,245.29,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,255.84,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.5,3163.8,
29260 Strapping Elbow/Wrist,4305638,CDM,761,RC,29260,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,34.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.38,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.38,299.61,
29280 Strapping Hand/Finger,4305639,CDM,761,RC,29280,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,34.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,34.56,299.61,
29405 Application Short Leg Cast Below Knee-Toe,3436035,CDM,761,RC,29405,HCPCS,Outpatient,,,1356.16,678.08,,1220.54,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.93,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.54,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1315.48,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.67,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,949.31,70,,,percent of total billed charges,70% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1166.3,86,,,percent of total billed charges,86% of total billed charges,1084.93,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1315.48,97,,,percent of total billed charges,97% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.48,97,,,percent of total billed charges,97% of total billed charges,1261.23,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1315.48,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,1315.48,
29425 Application Short Leg Cast Walking/Ambulatory,3549204,CDM,761,RC,29425,HCPCS,Outpatient,,,1356.16,678.08,,1220.54,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.93,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.54,90,,,Percent of total Billed charges,90% of total billed charges,57.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1315.48,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.67,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,949.31,70,,,percent of total billed charges,70% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1166.3,86,,,percent of total billed charges,86% of total billed charges,1084.93,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1315.48,97,,,percent of total billed charges,97% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.48,97,,,percent of total billed charges,97% of total billed charges,1261.23,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1315.48,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,52.5,1315.48,
29445 Application Rigid Total Contact Leg Cast,3436037,CDM,761,RC,29445,HCPCS,Outpatient,,,1356.16,678.08,,1220.54,90,,,percent of total billed charges,90% of total Billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1084.93,80,,,Percent of total Billed charges,80% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1220.54,90,,,Percent of total Billed charges,90% of total billed charges,111.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1315.48,97,,,Percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,1247.67,92,,,Percent of total billed charges,92% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,579.19,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,923.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1169.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,949.31,70,,,percent of total billed charges,70% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,1288.35,95,,,percent of total billed charges,95% of total billed charges,217.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,435.8,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1166.3,86,,,percent of total billed charges,86% of total billed charges,1084.93,80,,,percent of total billed charges,80% of total billed charges,237.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1315.48,97,,,percent of total billed charges,97% of total billed charges,1220.54,90,,,percent of total billed charges,90% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,1315.48,97,,,percent of total billed charges,97% of total billed charges,1261.23,93,,,percent of total billed charges,93% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,101.47,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1315.48,97,,,percent of total billed charges,97% of total billed charges,217.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,217.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,185.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,101.47,1315.48,
29540 Strapping Ankle &/Foot,3436039,CDM,761,RC,29540,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,771.82,
29580 Application of Paste Boot,3436042,CDM,761,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29580 Application of Paste Boot - Bilateral,3436041,CDM,761,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29580 Application of Unna Boot,4135334,CDM,510,RC,29580,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot,3436046,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29581 Appl Mltlayr Compres Leg Below Knee W/Ankle Foot - Bil,3436045,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29581- Apply multi-lay compres/lower leg,3436044,CDM,761,RC,29581,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
29584 Appl Mltlayr Compres Sys Uparm Lwarm Hand&Fing,4305637,CDM,761,RC,29584,HCPCS,Outpatient,,,795.69,397.85,,716.12,90,,,percent of total billed charges,90% of total Billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,636.55,80,,,Percent of total Billed charges,80% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,716.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,771.82,97,,,Percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,732.03,92,,,Percent of total billed charges,92% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,351.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,561,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,710.59,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,556.98,70,,,percent of total billed charges,70% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,755.91,95,,,percent of total billed charges,95% of total billed charges,132.38,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,684.29,86,,,percent of total billed charges,86% of total billed charges,636.55,80,,,percent of total billed charges,80% of total billed charges,138.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,771.82,97,,,percent of total billed charges,97% of total billed charges,716.12,90,,,percent of total billed charges,90% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,771.82,97,,,percent of total billed charges,97% of total billed charges,739.99,93,,,percent of total billed charges,93% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,771.82,97,,,percent of total billed charges,97% of total billed charges,132.38,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.38,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.52,771.82,
31231- Nasal endoscopy dx,3431300,CDM,510,RC,31231,HCPCS,Outpatient,,,131.25,65.63,,118.13,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,105,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,118.13,90,,,Percent of total Billed charges,90% of total billed charges,64.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,127.31,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,120.75,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,118.13,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,91.88,70,,,percent of total billed charges,70% of total billed charges,118.13,90,,,percent of total billed charges,90% of total billed charges,124.69,95,,,percent of total billed charges,95% of total billed charges,124.69,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.88,86,,,percent of total billed charges,86% of total billed charges,105,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,127.31,97,,,percent of total billed charges,97% of total billed charges,118.13,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.31,97,,,percent of total billed charges,97% of total billed charges,122.06,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127.31,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.86,871.42,
31254 - NASAL/SINUS NDSC W/PARTIAL ETHMOIDECTOMY,4037482,CDM,983,RC,31254,HCPCS,Outpatient,,,476.93,238.47,,429.24,90,,,percent of total billed charges,90% of total Billed charges,658.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,197,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,313.3,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,352.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,352.38,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,369.12,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,216.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,478.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,435.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,287.28,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,370.56,155,,,Fee Schedule,155% of CMS OPPS Rate,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1020.6,155,,,Fee Schedule,155% of CMS OPPS Rate,1020.6,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,197,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,239.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,574.6,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,574.6,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,197,1020.6,
31575 - DIAGNOSTIC LARYNGOSCOPY,3908940,CDM,761,RC,31575,HCPCS,Outpatient,,,812.13,406.07,,730.92,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,649.7,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,730.92,90,,,Percent of total Billed charges,90% of total billed charges,75.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,787.77,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,747.16,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,730.92,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,568.49,70,,,percent of total billed charges,70% of total billed charges,730.92,90,,,percent of total billed charges,90% of total billed charges,771.52,95,,,percent of total billed charges,95% of total billed charges,771.52,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,698.43,86,,,percent of total billed charges,86% of total billed charges,649.7,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,787.77,97,,,percent of total billed charges,97% of total billed charges,730.92,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,787.77,97,,,percent of total billed charges,97% of total billed charges,755.28,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,787.77,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69,871.42,
"31575 Laryngoscopy, flexible; diagnostic",3584895,CDM,510,RC,31575,HCPCS,Outpatient,,,713.51,356.76,,642.16,90,,,percent of total billed charges,90% of total Billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,570.81,80,,,Percent of total Billed charges,80% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,642.16,90,,,Percent of total Billed charges,90% of total billed charges,75.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,692.1,97,,,Percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,656.43,92,,,Percent of total billed charges,92% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,431.54,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,687.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,871.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,642.16,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,499.46,70,,,percent of total billed charges,70% of total billed charges,642.16,90,,,percent of total billed charges,90% of total billed charges,677.83,95,,,percent of total billed charges,95% of total billed charges,677.83,95,,,percent of total billed charges,95% of total billed charges,162.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,324.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,613.62,86,,,percent of total billed charges,86% of total billed charges,570.81,80,,,percent of total billed charges,80% of total billed charges,161.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,692.1,97,,,percent of total billed charges,97% of total billed charges,642.16,90,,,percent of total billed charges,90% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,692.1,97,,,percent of total billed charges,97% of total billed charges,663.56,93,,,percent of total billed charges,93% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,692.1,97,,,percent of total billed charges,97% of total billed charges,162.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,162.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,69,871.42,
"36010 - PF - Introduction of catheter, superior or inferior vena cava",3640894,CDM,510,RC,36010,HCPCS,Outpatient,,,1082.56,541.28,,974.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,866.05,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,974.3,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1050.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,995.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,691.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,851.46,78.65,,,percent of total billed charges,78.65% of total billed charges,967.07,89.33,,,percent of total billed charges,89.33% of total billed charges,974.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,757.79,70,,,percent of total billed charges,70% of total billed charges,974.3,90,,,percent of total billed charges,90% of total billed charges,1028.43,95,,,percent of total billed charges,95% of total billed charges,1028.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,931,86,,,percent of total billed charges,86% of total billed charges,866.05,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1050.08,97,,,percent of total billed charges,97% of total billed charges,974.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1050.08,97,,,percent of total billed charges,97% of total billed charges,1006.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1050.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1050.08,
"36012 - PF - Selective catheter placement, venous system; second order, or more selective, branch (e",3640913,CDM,510,RC,36012,HCPCS,Outpatient,,,1640.01,820.01,,1476.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1312.01,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1476.01,90,,,Percent of total Billed charges,90% of total billed charges,125.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1590.81,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1508.81,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1047.35,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1289.9,78.65,,,percent of total billed charges,78.65% of total billed charges,1465.05,89.33,,,percent of total billed charges,89.33% of total billed charges,1476.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1148.01,70,,,percent of total billed charges,70% of total billed charges,1476.01,90,,,percent of total billed charges,90% of total billed charges,1558.01,95,,,percent of total billed charges,95% of total billed charges,1558.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1410.41,86,,,percent of total billed charges,86% of total billed charges,1312.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1590.81,97,,,percent of total billed charges,97% of total billed charges,1476.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1590.81,97,,,percent of total billed charges,97% of total billed charges,1525.21,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1590.81,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.5,1590.81,
"36248 - (PF) Selective catheter placement, arterial system; additional second order, third order,",3634905,CDM,510,RC,36248,HCPCS,Outpatient,,,169.77,84.89,,152.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,135.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,152.79,90,,,Percent of total Billed charges,90% of total billed charges,53.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,164.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,156.19,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,108.42,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,133.53,78.65,,,percent of total billed charges,78.65% of total billed charges,151.66,89.33,,,percent of total billed charges,89.33% of total billed charges,152.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,118.84,70,,,percent of total billed charges,70% of total billed charges,152.79,90,,,percent of total billed charges,90% of total billed charges,161.28,95,,,percent of total billed charges,95% of total billed charges,161.28,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146,86,,,percent of total billed charges,86% of total billed charges,135.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,164.68,97,,,percent of total billed charges,97% of total billed charges,152.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,164.68,97,,,percent of total billed charges,97% of total billed charges,157.89,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,164.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.58,164.68,
36410 - Non-routine bl draw 3/> yrs,4241827,CDM,960,RC,36410,HCPCS,Outpatient,,,38.9,19.45,,35.01,90,,,percent of total billed charges,90% of total Billed charges,25.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,11.73,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,14.34,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,7.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,10.83,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,13.93,155,,,Fee Schedule,155% of CMS OPPS Rate,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.59,155,,,Fee Schedule,155% of CMS OPPS Rate,39.59,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,24.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.99,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,32.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,7.43,39.59,
36465 NJX Noncmpnd Sclerosant Single Incmptnt Vein,3436048,CDM,761,RC,36465,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
36466 NJX Noncmpnd Sclerosant Multiple Incmptnt Veins,3436049,CDM,761,RC,36466,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1332.4,8932.64,
36468 Tx of symptomatic spider veins sclerotherapy,4117375,CDM,761,RC,36468,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,180.64,1953.17,
36470 Injection Sclerosant Single Incmptnt Vein,3436050,CDM,761,RC,36470,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,10.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.35,1953.17,
36471 Injection Sclerosant Multiple Incmptnt Veins,3436052,CDM,761,RC,36471,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,100.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,91.12,1953.17,
36475 - Radiofrequency ablation vein,4023140,CDM,761,RC,36475,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,12876.92,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,15613.27,
36475- Endo abl/incom vein/ext/rad fre/#1,3430716,CDM,761,RC,36475,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,12876.92,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,15613.27,
36475 Endovenous rf 1st vein,3428319,CDM,510,RC,36475,HCPCS,Outpatient,,,1880.93,940.47,,1692.84,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1504.74,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1692.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1824.5,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1730.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1692.84,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1316.65,70,,,percent of total billed charges,70% of total billed charges,1692.84,90,,,percent of total billed charges,90% of total billed charges,1786.88,95,,,percent of total billed charges,95% of total billed charges,1786.88,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1617.6,86,,,percent of total billed charges,86% of total billed charges,1504.74,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1824.5,97,,,percent of total billed charges,97% of total billed charges,1692.84,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1824.5,97,,,percent of total billed charges,97% of total billed charges,1749.26,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1824.5,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1316.65,14522.85,
36478 Endoven AbltJ Incmptnt Vein XTR Laser 1st Vein,3436053,CDM,761,RC,36478,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,12876.92,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2299.82,15613.27,
36482 Endoven Ablti Ther Chem Adhesive 1st Vein,3549208,CDM,761,RC,36482,HCPCS,Outpatient,,,27750.38,13875.19,,24975.34,90,,,percent of total billed charges,90% of total Billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,22200.3,80,,,Percent of total Billed charges,80% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,24975.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26917.87,97,,,Percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,25530.35,92,,,Percent of total billed charges,92% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.07,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,24975.34,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,19425.27,70,,,percent of total billed charges,70% of total billed charges,24975.34,90,,,percent of total billed charges,90% of total billed charges,26362.86,95,,,percent of total billed charges,95% of total billed charges,26362.86,95,,,percent of total billed charges,95% of total billed charges,4668.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23865.33,86,,,percent of total billed charges,86% of total billed charges,22200.3,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,26917.87,97,,,percent of total billed charges,97% of total billed charges,24975.34,90,,,percent of total billed charges,90% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,26917.87,97,,,percent of total billed charges,97% of total billed charges,25807.85,93,,,percent of total billed charges,93% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26917.87,97,,,percent of total billed charges,97% of total billed charges,4668.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3967.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3967.99,26917.87,
36483 Endoven Ablti Ther Chem Adhesive Sbsq Vein,3549209,CDM,761,RC,36483,HCPCS,Outpatient,,,5019.1,2509.55,,4517.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4015.28,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4517.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4868.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4617.57,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3205.31,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3947.63,78.65,,,percent of total billed charges,78.65% of total billed charges,4483.64,89.33,,,percent of total billed charges,89.33% of total billed charges,4517.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3513.37,70,,,percent of total billed charges,70% of total billed charges,4517.19,90,,,percent of total billed charges,90% of total billed charges,4768.15,95,,,percent of total billed charges,95% of total billed charges,4768.15,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4316.43,86,,,percent of total billed charges,86% of total billed charges,4015.28,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4868.53,97,,,percent of total billed charges,97% of total billed charges,4517.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4868.53,97,,,percent of total billed charges,97% of total billed charges,4667.76,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4868.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3205.31,4868.53,
36561- Insert tunn CVC w/sub-q port 5yr>,3430722,CDM,510,RC,36561,HCPCS,Outpatient,,,1645.54,822.77,,1480.99,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1316.43,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1480.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1596.17,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1513.9,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1480.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1151.88,70,,,percent of total billed charges,70% of total billed charges,1480.99,90,,,percent of total billed charges,90% of total billed charges,1563.26,95,,,percent of total billed charges,95% of total billed charges,1563.26,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1415.16,86,,,percent of total billed charges,86% of total billed charges,1316.43,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1596.17,97,,,percent of total billed charges,97% of total billed charges,1480.99,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1596.17,97,,,percent of total billed charges,97% of total billed charges,1530.35,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1596.17,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1151.88,14522.85,
"36571 - (PF) Insertion of peripherally inserted central venous access device, with subcutaneous port",3634907,CDM,510,RC,36571,HCPCS,Outpatient,,,2415.42,1207.71,,2173.88,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1932.34,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2173.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2342.96,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2222.19,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2173.88,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1690.79,70,,,percent of total billed charges,70% of total billed charges,2173.88,90,,,percent of total billed charges,90% of total billed charges,2294.65,95,,,percent of total billed charges,95% of total billed charges,2294.65,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2077.26,86,,,percent of total billed charges,86% of total billed charges,1932.34,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2342.96,97,,,percent of total billed charges,97% of total billed charges,2173.88,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2342.96,97,,,percent of total billed charges,97% of total billed charges,2246.34,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2342.96,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1690.79,14522.85,
"36575 - (PF) Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous",3634908,CDM,510,RC,36575,HCPCS,Outpatient,,,281.09,140.55,,252.98,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,224.87,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,252.98,90,,,Percent of total Billed charges,90% of total billed charges,41.04,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,272.66,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,258.6,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,252.98,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,196.76,70,,,percent of total billed charges,70% of total billed charges,252.98,90,,,percent of total billed charges,90% of total billed charges,267.04,95,,,percent of total billed charges,95% of total billed charges,267.04,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,241.74,86,,,percent of total billed charges,86% of total billed charges,224.87,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,272.66,97,,,percent of total billed charges,97% of total billed charges,252.98,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,272.66,97,,,percent of total billed charges,97% of total billed charges,261.41,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,272.66,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.31,2820.25,
"36582 - (PF) Replacement, complete, of a tunneled centrally inserted central venous access device,",3634909,CDM,510,RC,36582,HCPCS,Outpatient,,,1499.5,749.75,,1349.55,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1199.6,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1349.55,90,,,Percent of total Billed charges,90% of total billed charges,301.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1454.52,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1379.54,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1349.55,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1049.65,70,,,percent of total billed charges,70% of total billed charges,1349.55,90,,,percent of total billed charges,90% of total billed charges,1424.53,95,,,percent of total billed charges,95% of total billed charges,1424.53,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1289.57,86,,,percent of total billed charges,86% of total billed charges,1199.6,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1454.52,97,,,percent of total billed charges,97% of total billed charges,1349.55,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1454.52,97,,,percent of total billed charges,97% of total billed charges,1394.54,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1454.52,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,274.21,14522.85,
36589- Rmv tunnel cent ven access cath,3430724,CDM,361,RC,36589,HCPCS,Outpatient,,,72.62,36.31,,65.36,90,,,percent of total billed charges,90% of total Billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,58.1,80,,,Percent of total Billed charges,80% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,70.44,97,,,Percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,66.81,92,,,Percent of total billed charges,92% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.26,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,65.36,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,50.83,70,,,percent of total billed charges,70% of total billed charges,65.36,90,,,percent of total billed charges,90% of total billed charges,68.99,95,,,percent of total billed charges,95% of total billed charges,68.99,95,,,percent of total billed charges,95% of total billed charges,525.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,62.45,86,,,percent of total billed charges,86% of total billed charges,58.1,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,70.44,97,,,percent of total billed charges,97% of total billed charges,65.36,90,,,percent of total billed charges,90% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.44,97,,,percent of total billed charges,97% of total billed charges,67.54,93,,,percent of total billed charges,93% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,70.44,97,,,percent of total billed charges,97% of total billed charges,525.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.83,2820.26,
36590- Rmv tun cen ven acces cath/SQ port,3430725,CDM,361,RC,36590,HCPCS,Outpatient,,,86.86,43.43,,78.17,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,69.49,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.17,90,,,Percent of total Billed charges,90% of total billed charges,202.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,84.25,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,79.91,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,78.17,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,60.8,70,,,percent of total billed charges,70% of total billed charges,78.17,90,,,percent of total billed charges,90% of total billed charges,82.52,95,,,percent of total billed charges,95% of total billed charges,82.52,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,74.7,86,,,percent of total billed charges,86% of total billed charges,69.49,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,84.25,97,,,percent of total billed charges,97% of total billed charges,78.17,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.25,97,,,percent of total billed charges,97% of total billed charges,80.78,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,84.25,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,60.8,7253.45,
"36595 Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venou",3621453,CDM,510,RC,36595,HCPCS,Outpatient,,,1033.6,516.80,,930.24,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,826.88,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,930.24,90,,,Percent of total Billed charges,90% of total billed charges,193.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1002.59,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,950.91,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,930.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,723.52,70,,,percent of total billed charges,70% of total billed charges,930.24,90,,,percent of total billed charges,90% of total billed charges,981.92,95,,,percent of total billed charges,95% of total billed charges,981.92,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,888.9,86,,,percent of total billed charges,86% of total billed charges,826.88,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1002.59,97,,,percent of total billed charges,97% of total billed charges,930.24,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1002.59,97,,,percent of total billed charges,97% of total billed charges,961.25,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1002.59,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,176.34,14522.85,
"36901 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640895,CDM,510,RC,36901,HCPCS,Outpatient,,,1331.29,665.65,,1198.16,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1065.03,80,,,Percent of total Billed charges,80% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1198.16,90,,,Percent of total Billed charges,90% of total billed charges,131.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1291.35,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1224.79,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1198.16,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,931.9,70,,,percent of total billed charges,70% of total billed charges,1198.16,90,,,percent of total billed charges,90% of total billed charges,1264.73,95,,,percent of total billed charges,95% of total billed charges,1264.73,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1144.91,86,,,percent of total billed charges,86% of total billed charges,1065.03,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1291.35,97,,,percent of total billed charges,97% of total billed charges,1198.16,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1291.35,97,,,percent of total billed charges,97% of total billed charges,1238.1,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1291.35,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.24,7253.45,
"36902 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640896,CDM,510,RC,36902,HCPCS,Outpatient,,,2402.79,1201.40,,2162.51,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1922.23,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2162.51,90,,,Percent of total Billed charges,90% of total billed charges,195.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2330.71,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2210.57,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2162.51,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1681.95,70,,,percent of total billed charges,70% of total billed charges,2162.51,90,,,percent of total billed charges,90% of total billed charges,2282.65,95,,,percent of total billed charges,95% of total billed charges,2282.65,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2066.4,86,,,percent of total billed charges,86% of total billed charges,1922.23,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2330.71,97,,,percent of total billed charges,97% of total billed charges,2162.51,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2330.71,97,,,percent of total billed charges,97% of total billed charges,2234.59,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2330.71,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,177.66,25425.73,
"36903 - PF - Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiogr",3640897,CDM,510,RC,36903,HCPCS,Outpatient,,,9908.01,4954.01,,8917.21,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7926.41,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8917.21,90,,,Percent of total Billed charges,90% of total billed charges,267.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9610.77,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9115.37,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8917.21,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6935.61,70,,,percent of total billed charges,70% of total billed charges,8917.21,90,,,percent of total billed charges,90% of total billed charges,9412.61,95,,,percent of total billed charges,95% of total billed charges,9412.61,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8520.89,86,,,percent of total billed charges,86% of total billed charges,7926.41,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9610.77,97,,,percent of total billed charges,97% of total billed charges,8917.21,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9610.77,97,,,percent of total billed charges,97% of total billed charges,9214.45,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,243.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9610.77,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,243.21,51750.98,
36904 - PERQ THRMBC/NFS DIALYSIS CIRCUIT IMG DX ANGRPH,4037512,CDM,983,RC,36904,HCPCS,Outpatient,,,3566.67,1783.34,,3210,90,,,percent of total billed charges,90% of total Billed charges,2070.83,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,280.06,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.01,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,617.49,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,617.49,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,577.65,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,299.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,726.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,681.62,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,456.9,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,562.87,155,,,Fee Schedule,155% of CMS OPPS Rate,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,3209.79,155,,,Fee Schedule,155% of CMS OPPS Rate,3209.79,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,280.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1869.07,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,363.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,280.06,3210,
"36905 - PF - Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dia",3640914,CDM,510,RC,36905,HCPCS,Outpatient,,,4572.63,2286.32,,4115.37,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3658.1,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4115.37,90,,,Percent of total Billed charges,90% of total billed charges,386.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4435.45,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,4206.82,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4115.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,3200.84,70,,,percent of total billed charges,70% of total billed charges,4115.37,90,,,percent of total billed charges,90% of total billed charges,4344,95,,,percent of total billed charges,95% of total billed charges,4344,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3932.46,86,,,percent of total billed charges,86% of total billed charges,3658.1,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4435.45,97,,,percent of total billed charges,97% of total billed charges,4115.37,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,4435.45,97,,,percent of total billed charges,97% of total billed charges,4252.55,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,351.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4435.45,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,351.53,51750.98,
36906 - PERQ THRMBC/NFS DIAL CIRCUIT TCAT PLMT IV STENT,4037522,CDM,983,RC,36906,HCPCS,Outpatient,,,12275.31,6137.66,,11047.78,90,,,percent of total billed charges,90% of total Billed charges,5627.92,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,410.24,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,854.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,854.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,799.67,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,438.77,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1006.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,943.6,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,631.21,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,779.88,155,,,Fee Schedule,155% of CMS OPPS Rate,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,8723.28,155,,,Fee Schedule,155% of CMS OPPS Rate,8723.28,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,410.24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7079.03,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,503.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.24,11047.78,
"36908 - (PF) Transcatheter placement of intravascular stent(s), central dialysis segment, performed",3634910,CDM,510,RC,36908,HCPCS,Outpatient,,,3015.52,1507.76,,2713.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2412.42,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2713.97,90,,,Percent of total Billed charges,90% of total billed charges,168.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2925.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,2774.28,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1925.78,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,2371.77,78.65,,,percent of total billed charges,78.65% of total billed charges,2693.81,89.33,,,percent of total billed charges,89.33% of total billed charges,2713.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2110.86,70,,,percent of total billed charges,70% of total billed charges,2713.97,90,,,percent of total billed charges,90% of total billed charges,2864.74,95,,,percent of total billed charges,95% of total billed charges,2864.74,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2593.35,86,,,percent of total billed charges,86% of total billed charges,2412.42,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2925.05,97,,,percent of total billed charges,97% of total billed charges,2713.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2925.05,97,,,percent of total billed charges,97% of total billed charges,2804.43,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2925.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153.46,2925.05,
"37222 - PF - Revascularization, endovascular, open or percutaneous, iliac artery, each additional ip",3640916,CDM,510,RC,37222,HCPCS,Outpatient,,,1065.19,532.60,,958.67,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,852.15,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,958.67,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1033.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,979.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,680.25,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,837.8,78.65,,,percent of total billed charges,78.65% of total billed charges,951.55,89.33,,,percent of total billed charges,89.33% of total billed charges,958.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,745.63,70,,,percent of total billed charges,70% of total billed charges,958.67,90,,,percent of total billed charges,90% of total billed charges,1011.93,95,,,percent of total billed charges,95% of total billed charges,1011.93,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,916.06,86,,,percent of total billed charges,86% of total billed charges,852.15,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1033.23,97,,,percent of total billed charges,97% of total billed charges,958.67,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1033.23,97,,,percent of total billed charges,97% of total billed charges,990.63,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1033.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,680.25,1033.23,
37226 - REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL,4037523,CDM,481,RC,37226,HCPCS,Outpatient,,,52157.48,26078.74,,46941.73,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,41725.98,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,46941.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,50592.76,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,47984.88,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,46941.73,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,36510.24,70,,,percent of total billed charges,70% of total billed charges,46941.73,90,,,percent of total billed charges,90% of total billed charges,49549.61,95,,,percent of total billed charges,95% of total billed charges,49549.61,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44855.43,86,,,percent of total billed charges,86% of total billed charges,41725.98,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,50592.76,97,,,percent of total billed charges,97% of total billed charges,46941.73,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,50592.76,97,,,percent of total billed charges,97% of total billed charges,48506.46,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,50592.76,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8195.23,51750.98,
37231 - REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL,4037542,CDM,481,RC,37231,HCPCS,Outpatient,,,83391.09,41695.55,,75051.98,90,,,percent of total billed charges,90% of total Billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,66712.87,80,,,Percent of total Billed charges,80% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,75051.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,80889.36,97,,,Percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,76719.8,92,,,Percent of total billed charges,92% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,41471.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,66113.71,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,83742.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,75051.98,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,58373.76,70,,,percent of total billed charges,70% of total billed charges,75051.98,90,,,percent of total billed charges,90% of total billed charges,79221.54,95,,,percent of total billed charges,95% of total billed charges,79221.54,95,,,percent of total billed charges,95% of total billed charges,15601.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,31203.44,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71716.34,86,,,percent of total billed charges,86% of total billed charges,66712.87,80,,,percent of total billed charges,80% of total billed charges,16479.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,80889.36,97,,,percent of total billed charges,97% of total billed charges,75051.98,90,,,percent of total billed charges,90% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,80889.36,97,,,percent of total billed charges,97% of total billed charges,77553.71,93,,,percent of total billed charges,93% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80889.36,97,,,percent of total billed charges,97% of total billed charges,15601.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,15601.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,13261.45,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13261.45,83742.97,
"37238 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640917,CDM,510,RC,37238,HCPCS,Outpatient,,,7785.55,3892.78,,7007,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,6228.44,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7007,90,,,Percent of total Billed charges,90% of total billed charges,294.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7551.98,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7162.71,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7007,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,5449.89,70,,,percent of total billed charges,70% of total billed charges,7007,90,,,percent of total billed charges,90% of total billed charges,7396.27,95,,,percent of total billed charges,95% of total billed charges,7396.27,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6695.57,86,,,percent of total billed charges,86% of total billed charges,6228.44,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7551.98,97,,,percent of total billed charges,97% of total billed charges,7007,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,7551.98,97,,,percent of total billed charges,97% of total billed charges,7240.56,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7551.98,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,267.48,51750.98,
"37239 - PF - Transcatheter placement of an intravascular stent(s), open or percutaneous, including r",3640918,CDM,510,RC,37239,HCPCS,Outpatient,,,3849.36,1924.68,,3464.42,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3079.49,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3464.42,90,,,Percent of total Billed charges,90% of total billed charges,137.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3733.88,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3541.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,2458.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,3027.61,78.65,,,percent of total billed charges,78.65% of total billed charges,3438.69,89.33,,,percent of total billed charges,89.33% of total billed charges,3464.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2694.55,70,,,percent of total billed charges,70% of total billed charges,3464.42,90,,,percent of total billed charges,90% of total billed charges,3656.89,95,,,percent of total billed charges,95% of total billed charges,3656.89,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3310.45,86,,,percent of total billed charges,86% of total billed charges,3079.49,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3733.88,97,,,percent of total billed charges,97% of total billed charges,3464.42,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3733.88,97,,,percent of total billed charges,97% of total billed charges,3579.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3733.88,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,124.74,3733.88,
"37241 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretati",3621881,CDM,510,RC,37241,HCPCS,Outpatient,,,10544.45,5272.23,,9490.01,90,,,percent of total billed charges,90% of total Billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8435.56,80,,,Percent of total Billed charges,80% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9490.01,90,,,Percent of total Billed charges,90% of total billed charges,402.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,10228.12,97,,,Percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9700.89,92,,,Percent of total billed charges,92% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,25628.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40856.56,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51750.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9490.01,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,7381.12,70,,,percent of total billed charges,70% of total billed charges,9490.01,90,,,percent of total billed charges,90% of total billed charges,10017.23,95,,,percent of total billed charges,95% of total billed charges,10017.23,95,,,percent of total billed charges,95% of total billed charges,9641.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19282.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,9068.23,86,,,percent of total billed charges,86% of total billed charges,8435.56,80,,,percent of total billed charges,80% of total billed charges,10244.13,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,10228.12,97,,,percent of total billed charges,97% of total billed charges,9490.01,90,,,percent of total billed charges,90% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,10228.12,97,,,percent of total billed charges,97% of total billed charges,9806.34,93,,,percent of total billed charges,93% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,366.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,10228.12,97,,,percent of total billed charges,97% of total billed charges,9641.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,9641.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,8195.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,366.22,51750.98,
37246 - PF - Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive dise,3640899,CDM,510,RC,37246,HCPCS,Outpatient,,,3689.07,1844.54,,3320.16,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2951.26,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3320.16,90,,,Percent of total Billed charges,90% of total billed charges,320.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3578.4,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,3393.94,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3320.16,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2582.35,70,,,percent of total billed charges,70% of total billed charges,3320.16,90,,,percent of total billed charges,90% of total billed charges,3504.62,95,,,percent of total billed charges,95% of total billed charges,3504.62,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3172.6,86,,,percent of total billed charges,86% of total billed charges,2951.26,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3578.4,97,,,percent of total billed charges,97% of total billed charges,3320.16,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,3578.4,97,,,percent of total billed charges,97% of total billed charges,3430.84,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,291.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3578.4,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.76,25425.73,
37247 Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occ,3621308,CDM,510,RC,37247,HCPCS,Outpatient,,,940.44,470.22,,846.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,752.35,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,846.4,90,,,Percent of total Billed charges,90% of total billed charges,159.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,912.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,865.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,600.59,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,739.68,78.65,,,percent of total billed charges,78.65% of total billed charges,840.11,89.33,,,percent of total billed charges,89.33% of total billed charges,846.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,658.31,70,,,percent of total billed charges,70% of total billed charges,846.4,90,,,percent of total billed charges,90% of total billed charges,893.42,95,,,percent of total billed charges,95% of total billed charges,893.42,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,808.78,86,,,percent of total billed charges,86% of total billed charges,752.35,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,912.23,97,,,percent of total billed charges,97% of total billed charges,846.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,912.23,97,,,percent of total billed charges,97% of total billed charges,874.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,912.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.67,912.23,
"37248 - PF - Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, inclu",3640900,CDM,510,RC,37248,HCPCS,Outpatient,,,2660.21,1330.11,,2394.19,90,,,percent of total billed charges,90% of total Billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2128.17,80,,,Percent of total Billed charges,80% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2394.19,90,,,Percent of total Billed charges,90% of total billed charges,275.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2580.4,97,,,Percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,2447.39,92,,,Percent of total billed charges,92% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,12591.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20073.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25425.73,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2394.19,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1862.15,70,,,percent of total billed charges,70% of total billed charges,2394.19,90,,,percent of total billed charges,90% of total billed charges,2527.2,95,,,percent of total billed charges,95% of total billed charges,2527.2,95,,,percent of total billed charges,95% of total billed charges,4736.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9473.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2287.78,86,,,percent of total billed charges,86% of total billed charges,2128.17,80,,,percent of total billed charges,80% of total billed charges,5121.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2580.4,97,,,percent of total billed charges,97% of total billed charges,2394.19,90,,,percent of total billed charges,90% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,2580.4,97,,,percent of total billed charges,97% of total billed charges,2474,93,,,percent of total billed charges,93% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,250.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2580.4,97,,,percent of total billed charges,97% of total billed charges,4736.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,4736.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,4026.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,250.89,25425.73,
37252 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640919,CDM,510,RC,37252,HCPCS,Outpatient,,,2136.68,1068.34,,1923.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1709.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1923.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2072.58,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1965.75,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1364.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1680.55,78.65,,,percent of total billed charges,78.65% of total billed charges,1908.73,89.33,,,percent of total billed charges,89.33% of total billed charges,1923.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1495.68,70,,,percent of total billed charges,70% of total billed charges,1923.01,90,,,percent of total billed charges,90% of total billed charges,2029.85,95,,,percent of total billed charges,95% of total billed charges,2029.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1837.54,86,,,percent of total billed charges,86% of total billed charges,1709.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,2072.58,97,,,percent of total billed charges,97% of total billed charges,1923.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2072.58,97,,,percent of total billed charges,97% of total billed charges,1987.11,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2072.58,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1364.53,2072.58,
37253 - PF - Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or thera,3640920,CDM,510,RC,37253,HCPCS,Outpatient,,,238.46,119.23,,214.61,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.77,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,152.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,187.55,78.65,,,percent of total billed charges,78.65% of total billed charges,213.02,89.33,,,percent of total billed charges,89.33% of total billed charges,214.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.92,70,,,percent of total billed charges,70% of total billed charges,214.61,90,,,percent of total billed charges,90% of total billed charges,226.54,95,,,percent of total billed charges,95% of total billed charges,226.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,205.08,86,,,percent of total billed charges,86% of total billed charges,190.77,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.31,97,,,percent of total billed charges,97% of total billed charges,214.61,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.31,97,,,percent of total billed charges,97% of total billed charges,221.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.29,231.31,
37609- Ligation/biopsy/temporal artery,3430918,CDM,761,RC,37609,HCPCS,Outpatient,,,266.9,133.45,,240.21,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,213.52,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.21,90,,,Percent of total Billed charges,90% of total billed charges,136.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,258.89,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,245.55,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,240.21,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,186.83,70,,,percent of total billed charges,70% of total billed charges,240.21,90,,,percent of total billed charges,90% of total billed charges,253.56,95,,,percent of total billed charges,95% of total billed charges,253.56,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,229.53,86,,,percent of total billed charges,86% of total billed charges,213.52,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,258.89,97,,,percent of total billed charges,97% of total billed charges,240.21,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,258.89,97,,,percent of total billed charges,97% of total billed charges,248.22,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,124,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,258.89,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,124,7310.49,
37765- Stab phlebectomy/1 ext/10-20 incis,3430749,CDM,360,RC,37765,HCPCS,Outpatient,,,388.48,194.24,,349.63,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,310.78,80,,,Percent of total Billed charges,80% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,349.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,376.83,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,357.4,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,349.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,271.94,70,,,percent of total billed charges,70% of total billed charges,349.63,90,,,percent of total billed charges,90% of total billed charges,369.06,95,,,percent of total billed charges,95% of total billed charges,369.06,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,334.09,86,,,percent of total billed charges,86% of total billed charges,310.78,80,,,percent of total billed charges,80% of total billed charges,2865.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,376.83,97,,,percent of total billed charges,97% of total billed charges,349.63,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,376.83,97,,,percent of total billed charges,97% of total billed charges,361.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,376.83,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,271.94,14522.85,
37799- Vasc Surg/Unlisted Procedure,3430751,CDM,360,RC,37799,HCPCS,Outpatient,,,2672.39,1336.20,,2405.15,90,,,percent of total billed charges,90% of total Billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2137.91,80,,,Percent of total Billed charges,80% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2405.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2592.22,97,,,Percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,2458.6,92,,,Percent of total billed charges,92% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2226.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2820.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2405.15,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1870.67,70,,,percent of total billed charges,70% of total billed charges,2405.15,90,,,percent of total billed charges,90% of total billed charges,2538.77,95,,,percent of total billed charges,95% of total billed charges,2538.77,95,,,percent of total billed charges,95% of total billed charges,525.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1050.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2298.26,86,,,percent of total billed charges,86% of total billed charges,2137.91,80,,,percent of total billed charges,80% of total billed charges,651.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2592.22,97,,,percent of total billed charges,97% of total billed charges,2405.15,90,,,percent of total billed charges,90% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,2592.22,97,,,percent of total billed charges,97% of total billed charges,2485.32,93,,,percent of total billed charges,93% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2592.22,97,,,percent of total billed charges,97% of total billed charges,525.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,525.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,446.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,446.6,2820.25,
38505 - BX/EXC LYMPH NODE NEEDLE SUPERFICIAL,4037465,CDM,510,RC,38505,HCPCS,Outpatient,,,199.52,99.76,,179.57,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,159.62,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.57,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,193.53,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,183.56,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,179.57,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,139.66,70,,,percent of total billed charges,70% of total billed charges,179.57,90,,,percent of total billed charges,90% of total billed charges,189.54,95,,,percent of total billed charges,95% of total billed charges,189.54,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,171.59,86,,,percent of total billed charges,86% of total billed charges,159.62,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,193.53,97,,,percent of total billed charges,97% of total billed charges,179.57,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.53,97,,,percent of total billed charges,97% of total billed charges,185.55,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,193.53,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
38505- Bx/exc lymph node/needle/superfic,3431451,CDM,320,RC,38505,HCPCS,Outpatient,,,223.47,111.74,,201.12,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,178.78,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.12,90,,,Percent of total Billed charges,90% of total billed charges,74.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,216.77,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,205.59,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,156.43,70,,,percent of total billed charges,70% of total billed charges,201.12,90,,,percent of total billed charges,90% of total billed charges,212.3,95,,,percent of total billed charges,95% of total billed charges,212.3,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.18,86,,,percent of total billed charges,86% of total billed charges,178.78,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,216.77,97,,,percent of total billed charges,97% of total billed charges,201.12,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.77,97,,,percent of total billed charges,97% of total billed charges,207.83,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,216.77,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,67.43,7310.49,
38525- Bx/exc lymph node/open/deep axilla,3431453,CDM,510,RC,38525,HCPCS,Outpatient,,,6857.27,3428.64,,6171.54,90,,,percent of total billed charges,90% of total Billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,5485.82,80,,,Percent of total Billed charges,80% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,6171.54,90,,,Percent of total Billed charges,90% of total billed charges,171.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6651.55,97,,,Percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,6308.69,92,,,Percent of total billed charges,92% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,8299.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13231.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,16759.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6171.54,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,4800.09,70,,,percent of total billed charges,70% of total billed charges,6171.54,90,,,percent of total billed charges,90% of total billed charges,6514.41,95,,,percent of total billed charges,95% of total billed charges,6514.41,95,,,percent of total billed charges,95% of total billed charges,3122.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6244.83,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5897.25,86,,,percent of total billed charges,86% of total billed charges,5485.82,80,,,percent of total billed charges,80% of total billed charges,3132.17,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6651.55,97,,,percent of total billed charges,97% of total billed charges,6171.54,90,,,percent of total billed charges,90% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,6651.55,97,,,percent of total billed charges,97% of total billed charges,6377.26,93,,,percent of total billed charges,93% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,156,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6651.55,97,,,percent of total billed charges,97% of total billed charges,3122.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,3122.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2654.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,156,16759.7,
38792- Lymphangiography/sentinel node,3431465,CDM,510,RC,38792,HCPCS,Outpatient,,,117.67,58.84,,105.9,90,,,percent of total billed charges,90% of total Billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,94.14,80,,,Percent of total Billed charges,80% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,114.14,97,,,Percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,108.26,92,,,Percent of total billed charges,92% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,938.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1495.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1894.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,105.9,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,82.37,70,,,percent of total billed charges,70% of total billed charges,105.9,90,,,percent of total billed charges,90% of total billed charges,111.79,95,,,percent of total billed charges,95% of total billed charges,111.79,95,,,percent of total billed charges,95% of total billed charges,353.02,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,706.04,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,101.2,86,,,percent of total billed charges,86% of total billed charges,94.14,80,,,percent of total billed charges,80% of total billed charges,380.6,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,114.14,97,,,percent of total billed charges,97% of total billed charges,105.9,90,,,percent of total billed charges,90% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.14,97,,,percent of total billed charges,97% of total billed charges,109.43,93,,,percent of total billed charges,93% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,114.14,97,,,percent of total billed charges,97% of total billed charges,353.02,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.02,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,300.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.37,1894.86,
43239- EGD w/biopsy/single/multiple,3431169,CDM,510,RC,43239,HCPCS,Outpatient,,,599.31,299.66,,539.38,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,479.45,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.38,90,,,Percent of total Billed charges,90% of total billed charges,163.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,581.33,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,551.37,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,539.38,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,419.52,70,,,percent of total billed charges,70% of total billed charges,539.38,90,,,percent of total billed charges,90% of total billed charges,569.34,95,,,percent of total billed charges,95% of total billed charges,569.34,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,515.41,86,,,percent of total billed charges,86% of total billed charges,479.45,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,581.33,97,,,percent of total billed charges,97% of total billed charges,539.38,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.33,97,,,percent of total billed charges,97% of total billed charges,557.36,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,581.33,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.58,4024.46,
43251- EGD/remove tumor/polyp/w snare,3431180,CDM,510,RC,43251,HCPCS,Outpatient,,,756.47,378.24,,680.82,90,,,percent of total billed charges,90% of total Billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,605.18,80,,,Percent of total Billed charges,80% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,680.82,90,,,Percent of total Billed charges,90% of total billed charges,208.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,733.78,97,,,Percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,695.95,92,,,Percent of total billed charges,92% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,4204.64,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6703.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8490.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,680.82,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,529.53,70,,,percent of total billed charges,70% of total billed charges,680.82,90,,,percent of total billed charges,90% of total billed charges,718.65,95,,,percent of total billed charges,95% of total billed charges,718.65,95,,,percent of total billed charges,95% of total billed charges,1581.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3163.63,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,650.56,86,,,percent of total billed charges,86% of total billed charges,605.18,80,,,percent of total billed charges,80% of total billed charges,1610.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,733.78,97,,,percent of total billed charges,97% of total billed charges,680.82,90,,,percent of total billed charges,90% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,733.78,97,,,percent of total billed charges,97% of total billed charges,703.52,93,,,percent of total billed charges,93% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,733.78,97,,,percent of total billed charges,97% of total billed charges,1581.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1581.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1344.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,189.35,8490.45,
43450- Dilate esoph/unguide sound/bougie,3431204,CDM,510,RC,43450,HCPCS,Outpatient,,,267.69,133.85,,240.92,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,214.15,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.92,90,,,Percent of total Billed charges,90% of total billed charges,64.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,259.66,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,246.27,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,240.92,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,187.38,70,,,percent of total billed charges,70% of total billed charges,240.92,90,,,percent of total billed charges,90% of total billed charges,254.31,95,,,percent of total billed charges,95% of total billed charges,254.31,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,230.21,86,,,percent of total billed charges,86% of total billed charges,214.15,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,259.66,97,,,percent of total billed charges,97% of total billed charges,240.92,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.66,97,,,percent of total billed charges,97% of total billed charges,248.95,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.66,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59,4024.46,
43762-MSA CHANGE GASTROSTOMY TUBE W/O REV,3429902,CDM,360,RC,43762,HCPCS,Outpatient,,,1312.82,656.41,,1181.54,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.26,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1181.54,90,,,Percent of total Billed charges,90% of total billed charges,34.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1273.44,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1207.79,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1181.54,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,918.97,70,,,percent of total billed charges,70% of total billed charges,1181.54,90,,,percent of total billed charges,90% of total billed charges,1247.18,95,,,percent of total billed charges,95% of total billed charges,1247.18,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1129.03,86,,,percent of total billed charges,86% of total billed charges,1050.26,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1273.44,97,,,percent of total billed charges,97% of total billed charges,1181.54,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1273.44,97,,,percent of total billed charges,97% of total billed charges,1220.92,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1273.44,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.1,1273.44,
Clinic Adjustment Gastric Band - S2083,4311851,CDM,510,RC,43999,HCPCS,Outpatient,,,3977.49,1988.75,,3579.74,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3181.99,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3579.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3858.17,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,3659.29,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3579.74,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,2784.24,70,,,percent of total billed charges,70% of total billed charges,3579.74,90,,,percent of total billed charges,90% of total billed charges,3778.62,95,,,percent of total billed charges,95% of total billed charges,3778.62,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3420.64,86,,,percent of total billed charges,86% of total billed charges,3181.99,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3858.17,97,,,percent of total billed charges,97% of total billed charges,3579.74,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,3858.17,97,,,percent of total billed charges,97% of total billed charges,3699.07,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,3858.17,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,637.29,4024.46,
"44380 - (PF) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing",3635066,CDM,510,RC,44380,HCPCS,Outpatient,,,341.91,170.96,,307.72,90,,,percent of total billed charges,90% of total Billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,273.53,80,,,Percent of total Billed charges,80% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,307.72,90,,,Percent of total Billed charges,90% of total billed charges,64.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,331.65,97,,,Percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,314.56,92,,,Percent of total billed charges,92% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,1992.99,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3177.24,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4024.46,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,307.72,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,239.34,70,,,percent of total billed charges,70% of total billed charges,307.72,90,,,percent of total billed charges,90% of total billed charges,324.81,95,,,percent of total billed charges,95% of total billed charges,324.81,95,,,percent of total billed charges,95% of total billed charges,749.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1499.55,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,294.04,86,,,percent of total billed charges,86% of total billed charges,273.53,80,,,percent of total billed charges,80% of total billed charges,812.54,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,331.65,97,,,percent of total billed charges,97% of total billed charges,307.72,90,,,percent of total billed charges,90% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,331.65,97,,,percent of total billed charges,97% of total billed charges,317.98,93,,,percent of total billed charges,93% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,331.65,97,,,percent of total billed charges,97% of total billed charges,749.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,749.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,637.29,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.58,4024.46,
"44388 - Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or wa",3572804,CDM,510,RC,44388,HCPCS,Outpatient,,,397.16,198.58,,357.44,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,317.73,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,357.44,90,,,Percent of total Billed charges,90% of total billed charges,160.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,385.25,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,365.39,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,357.44,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,278.01,70,,,percent of total billed charges,70% of total billed charges,357.44,90,,,percent of total billed charges,90% of total billed charges,377.3,95,,,percent of total billed charges,95% of total billed charges,377.3,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,341.56,86,,,percent of total billed charges,86% of total billed charges,317.73,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,385.25,97,,,percent of total billed charges,97% of total billed charges,357.44,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,385.25,97,,,percent of total billed charges,97% of total billed charges,369.36,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,385.25,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,145.53,4051.42,
"44394 - (PF) Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by",3635067,CDM,510,RC,44394,HCPCS,Outpatient,,,534.57,267.29,,481.11,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,427.66,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,481.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,518.53,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,491.8,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,481.11,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,374.2,70,,,percent of total billed charges,70% of total billed charges,481.11,90,,,percent of total billed charges,90% of total billed charges,507.84,95,,,percent of total billed charges,95% of total billed charges,507.84,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.73,86,,,percent of total billed charges,86% of total billed charges,427.66,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,518.53,97,,,percent of total billed charges,97% of total billed charges,481.11,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.53,97,,,percent of total billed charges,97% of total billed charges,497.15,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,518.53,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,374.2,5279.31,
44404 - COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION,4037561,CDM,983,RC,44404,HCPCS,Outpatient,,,626.14,313.07,,563.53,90,,,percent of total billed charges,90% of total Billed charges,572.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,145.53,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.26,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,234.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,234.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,261.98,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,139.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,309.13,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,201.38,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,259.52,155,,,Fee Schedule,155% of CMS OPPS Rate,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,886.72,155,,,Fee Schedule,155% of CMS OPPS Rate,886.72,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,453.94,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,167.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139.71,886.72,
"45300 - Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushin",3572805,CDM,510,RC,45300,HCPCS,Outpatient,,,196.6,98.30,,176.94,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,157.28,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,176.94,90,,,Percent of total Billed charges,90% of total billed charges,26.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,190.7,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,180.87,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,176.94,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,137.62,70,,,percent of total billed charges,70% of total billed charges,176.94,90,,,percent of total billed charges,90% of total billed charges,186.77,95,,,percent of total billed charges,95% of total billed charges,186.77,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,169.08,86,,,percent of total billed charges,86% of total billed charges,157.28,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,190.7,97,,,percent of total billed charges,97% of total billed charges,176.94,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,190.7,97,,,percent of total billed charges,97% of total billed charges,182.84,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.37,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,190.7,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24.37,4051.42,
"45303 - (PF) Proctosigmoidoscopy, rigid; with dilation",3635073,CDM,510,RC,45303,HCPCS,Outpatient,,,2149.32,1074.66,,1934.39,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1719.46,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,1934.39,90,,,Percent of total Billed charges,90% of total billed charges,31.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2084.84,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1977.37,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1934.39,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,1504.52,70,,,percent of total billed charges,70% of total billed charges,1934.39,90,,,percent of total billed charges,90% of total billed charges,2041.85,95,,,percent of total billed charges,95% of total billed charges,2041.85,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1848.42,86,,,percent of total billed charges,86% of total billed charges,1719.46,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2084.84,97,,,percent of total billed charges,97% of total billed charges,1934.39,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,2084.84,97,,,percent of total billed charges,97% of total billed charges,1998.87,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2084.84,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.31,5279.31,
"45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple",3621146,CDM,510,RC,45305,HCPCS,Outpatient,,,267.67,133.84,,240.9,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,214.14,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.9,90,,,Percent of total Billed charges,90% of total billed charges,58.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,259.64,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,246.26,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,240.9,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,187.37,70,,,percent of total billed charges,70% of total billed charges,240.9,90,,,percent of total billed charges,90% of total billed charges,254.29,95,,,percent of total billed charges,95% of total billed charges,254.29,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,230.2,86,,,percent of total billed charges,86% of total billed charges,214.14,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,259.64,97,,,percent of total billed charges,97% of total billed charges,240.9,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,259.64,97,,,percent of total billed charges,97% of total billed charges,248.93,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,259.64,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53,5279.31,
"45338 - (PF) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by",3635074,CDM,510,RC,45338,HCPCS,Outpatient,,,446.12,223.06,,401.51,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,356.9,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.51,90,,,Percent of total Billed charges,90% of total billed charges,134.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,432.74,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,410.43,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,401.51,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,312.28,70,,,percent of total billed charges,70% of total billed charges,401.51,90,,,percent of total billed charges,90% of total billed charges,423.81,95,,,percent of total billed charges,95% of total billed charges,423.81,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.66,86,,,percent of total billed charges,86% of total billed charges,356.9,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,432.74,97,,,percent of total billed charges,97% of total billed charges,401.51,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.74,97,,,percent of total billed charges,97% of total billed charges,414.89,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.95,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,432.74,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,121.95,5279.31,
"45381 COLONSCOPE, SUBMUCOUS INJ",3429965,CDM,510,RC,45381,HCPCS,Outpatient,,,608.8,304.40,,547.92,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,487.04,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,547.92,90,,,Percent of total Billed charges,90% of total billed charges,234.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,590.54,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,560.1,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,547.92,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,426.16,70,,,percent of total billed charges,70% of total billed charges,547.92,90,,,percent of total billed charges,90% of total billed charges,578.36,95,,,percent of total billed charges,95% of total billed charges,578.36,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,523.57,86,,,percent of total billed charges,86% of total billed charges,487.04,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,590.54,97,,,percent of total billed charges,97% of total billed charges,547.92,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,590.54,97,,,percent of total billed charges,97% of total billed charges,566.18,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,590.54,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,213.21,5279.31,
45385- Colonoscopy/snare rmv/tumor/polyp,3431250,CDM,510,RC,45385,HCPCS,Outpatient,,,503.75,251.88,,453.38,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,403,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,453.38,90,,,Percent of total Billed charges,90% of total billed charges,294.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,488.64,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,463.45,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,453.38,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,352.63,70,,,percent of total billed charges,70% of total billed charges,453.38,90,,,percent of total billed charges,90% of total billed charges,478.56,95,,,percent of total billed charges,95% of total billed charges,478.56,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,433.23,86,,,percent of total billed charges,86% of total billed charges,403,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,488.64,97,,,percent of total billed charges,97% of total billed charges,453.38,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,488.64,97,,,percent of total billed charges,97% of total billed charges,468.49,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.08,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,488.64,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,268.08,5279.31,
46050-MSA INCISION OF ANAL ABSCESS,3429979,CDM,361,RC,46050,HCPCS,Outpatient,,,332.42,166.21,,299.18,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,265.94,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.18,90,,,Percent of total Billed charges,90% of total billed charges,83.23,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,322.45,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,305.83,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,299.18,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,232.69,70,,,percent of total billed charges,70% of total billed charges,299.18,90,,,percent of total billed charges,90% of total billed charges,315.8,95,,,percent of total billed charges,95% of total billed charges,315.8,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,285.88,86,,,percent of total billed charges,86% of total billed charges,265.94,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,322.45,97,,,percent of total billed charges,97% of total billed charges,299.18,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,322.45,97,,,percent of total billed charges,97% of total billed charges,309.15,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,75.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,322.45,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75.66,4051.42,
"46080- Sphincterotomy, anal, division of sphincter (separate procedure)",3621307,CDM,510,RC,46080,HCPCS,Outpatient,,,319.02,159.51,,287.12,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,255.22,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,287.12,90,,,Percent of total Billed charges,90% of total billed charges,146.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,309.45,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,293.5,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,287.12,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,223.31,70,,,percent of total billed charges,70% of total billed charges,287.12,90,,,percent of total billed charges,90% of total billed charges,303.07,95,,,percent of total billed charges,95% of total billed charges,303.07,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,274.36,86,,,percent of total billed charges,86% of total billed charges,255.22,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,309.45,97,,,percent of total billed charges,97% of total billed charges,287.12,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,309.45,97,,,percent of total billed charges,97% of total billed charges,296.69,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,133,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,309.45,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,133,12526.48,
46083-Incise external hemorrhoid,3431258,CDM,510,RC,46083,HCPCS,Outpatient,,,1171.77,585.89,,1054.59,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,937.42,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1054.59,90,,,Percent of total Billed charges,90% of total billed charges,45.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1136.62,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1078.03,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1054.59,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,820.24,70,,,percent of total billed charges,70% of total billed charges,1054.59,90,,,percent of total billed charges,90% of total billed charges,1113.18,95,,,percent of total billed charges,95% of total billed charges,1113.18,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1007.72,86,,,percent of total billed charges,86% of total billed charges,937.42,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1136.62,97,,,percent of total billed charges,97% of total billed charges,1054.59,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1136.62,97,,,percent of total billed charges,97% of total billed charges,1089.75,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,41,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1136.62,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41,1136.62,
"46200- Fissurectomy, including sphincterotomy, when performed",3621646,CDM,510,RC,46200,HCPCS,Outpatient,,,337.95,168.98,,304.16,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,270.36,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.16,90,,,Percent of total Billed charges,90% of total billed charges,200.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,327.81,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,310.91,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,304.16,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,236.57,70,,,percent of total billed charges,70% of total billed charges,304.16,90,,,percent of total billed charges,90% of total billed charges,321.05,95,,,percent of total billed charges,95% of total billed charges,321.05,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,290.64,86,,,percent of total billed charges,86% of total billed charges,270.36,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,327.81,97,,,percent of total billed charges,97% of total billed charges,304.16,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.81,97,,,percent of total billed charges,97% of total billed charges,314.29,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,182,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,327.81,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,182,12526.48,
46220-HKBT EXC PERIANAL SKIN TAG,3435933,CDM,510,RC,46220,HCPCS,Outpatient,,,4568.35,2284.18,,4111.52,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3654.68,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,4111.52,90,,,Percent of total Billed charges,90% of total billed charges,88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,4431.3,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,4202.88,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4111.52,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,3197.85,70,,,percent of total billed charges,70% of total billed charges,4111.52,90,,,percent of total billed charges,90% of total billed charges,4339.93,95,,,percent of total billed charges,95% of total billed charges,4339.93,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3928.78,86,,,percent of total billed charges,86% of total billed charges,3654.68,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4431.3,97,,,percent of total billed charges,97% of total billed charges,4111.52,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,4431.3,97,,,percent of total billed charges,97% of total billed charges,4248.57,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,80,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,4431.3,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80,5279.31,
46221-Ligation of hemorrhoid(s),3431259,CDM,361,RC,46221,HCPCS,Outpatient,,,223.47,111.74,,201.12,90,,,percent of total billed charges,90% of total Billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,178.78,80,,,Percent of total Billed charges,80% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.12,90,,,Percent of total Billed charges,90% of total billed charges,50.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,216.77,97,,,Percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,205.59,92,,,Percent of total billed charges,92% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,2006.34,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3198.52,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4051.42,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,201.12,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,156.43,70,,,percent of total billed charges,70% of total billed charges,201.12,90,,,percent of total billed charges,90% of total billed charges,212.3,95,,,percent of total billed charges,95% of total billed charges,212.3,95,,,percent of total billed charges,95% of total billed charges,754.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1509.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,192.18,86,,,percent of total billed charges,86% of total billed charges,178.78,80,,,percent of total billed charges,80% of total billed charges,789.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,216.77,97,,,percent of total billed charges,97% of total billed charges,201.12,90,,,percent of total billed charges,90% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,216.77,97,,,percent of total billed charges,97% of total billed charges,207.83,93,,,percent of total billed charges,93% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,216.77,97,,,percent of total billed charges,97% of total billed charges,754.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,754.8,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,641.57,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46,4051.42,
"46255 - Hemorrhoidectomy, internal and external, single column/group;",3572807,CDM,510,RC,46255,HCPCS,Outpatient,,,360.98,180.49,,324.88,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,288.78,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,324.88,90,,,Percent of total Billed charges,90% of total billed charges,288.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,350.15,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,332.1,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,324.88,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,252.69,70,,,percent of total billed charges,70% of total billed charges,324.88,90,,,percent of total billed charges,90% of total billed charges,342.93,95,,,percent of total billed charges,95% of total billed charges,342.93,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,310.44,86,,,percent of total billed charges,86% of total billed charges,288.78,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,350.15,97,,,percent of total billed charges,97% of total billed charges,324.88,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,350.15,97,,,percent of total billed charges,97% of total billed charges,335.71,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,262.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,350.15,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,252.69,12526.48,
46270- Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous,3566791,CDM,510,RC,46270,HCPCS,Outpatient,,,599.01,299.51,,539.11,90,,,percent of total billed charges,90% of total Billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,479.21,80,,,Percent of total Billed charges,80% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,539.11,90,,,Percent of total Billed charges,90% of total billed charges,233.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,581.04,97,,,Percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,551.09,92,,,Percent of total billed charges,92% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,6203.37,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9889.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,12526.48,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,539.11,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,419.31,70,,,percent of total billed charges,70% of total billed charges,539.11,90,,,percent of total billed charges,90% of total billed charges,569.06,95,,,percent of total billed charges,95% of total billed charges,569.06,95,,,percent of total billed charges,95% of total billed charges,2333.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4667.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,515.15,86,,,percent of total billed charges,86% of total billed charges,479.21,80,,,percent of total billed charges,80% of total billed charges,2423.58,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,581.04,97,,,percent of total billed charges,97% of total billed charges,539.11,90,,,percent of total billed charges,90% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,581.04,97,,,percent of total billed charges,97% of total billed charges,557.08,93,,,percent of total billed charges,93% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,581.04,97,,,percent of total billed charges,97% of total billed charges,2333.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2333.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1983.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,212.5,12526.48,
46320-Removal of hemorrhoid clot,3431262,CDM,361,RC,46320,HCPCS,Outpatient,,,244.79,122.40,,220.31,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,195.83,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,220.31,90,,,Percent of total Billed charges,90% of total billed charges,44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,237.45,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,225.21,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,220.31,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,171.35,70,,,percent of total billed charges,70% of total billed charges,220.31,90,,,percent of total billed charges,90% of total billed charges,232.55,95,,,percent of total billed charges,95% of total billed charges,232.55,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,210.52,86,,,percent of total billed charges,86% of total billed charges,195.83,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,237.45,97,,,percent of total billed charges,97% of total billed charges,220.31,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,237.45,97,,,percent of total billed charges,97% of total billed charges,227.65,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,237.45,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40,5279.31,
46600-Diagnostic anoscopy spx,3430923,CDM,361,RC,46600,HCPCS,Outpatient,,,194.27,97.14,,174.84,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,155.42,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.84,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,188.44,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,178.73,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,174.84,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,135.99,70,,,percent of total billed charges,70% of total billed charges,174.84,90,,,percent of total billed charges,90% of total billed charges,184.56,95,,,percent of total billed charges,95% of total billed charges,184.56,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,167.07,86,,,percent of total billed charges,86% of total billed charges,155.42,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,188.44,97,,,percent of total billed charges,97% of total billed charges,174.84,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.44,97,,,percent of total billed charges,97% of total billed charges,180.67,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,188.44,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,566.05,
46606- Anoscopy/diag/w biopsy/single/mult,3431263,CDM,510,RC,46606,HCPCS,Outpatient,,,510.11,255.06,,459.1,90,,,percent of total billed charges,90% of total Billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,408.09,80,,,Percent of total Billed charges,80% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,459.1,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,494.81,97,,,Percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,469.3,92,,,Percent of total billed charges,92% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,2614.42,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4167.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,5279.31,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,459.1,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,357.08,70,,,percent of total billed charges,70% of total billed charges,459.1,90,,,percent of total billed charges,90% of total billed charges,484.6,95,,,percent of total billed charges,95% of total billed charges,484.6,95,,,percent of total billed charges,95% of total billed charges,983.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1967.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,438.69,86,,,percent of total billed charges,86% of total billed charges,408.09,80,,,percent of total billed charges,80% of total billed charges,1038.23,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,494.81,97,,,percent of total billed charges,97% of total billed charges,459.1,90,,,percent of total billed charges,90% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,494.81,97,,,percent of total billed charges,97% of total billed charges,474.4,93,,,percent of total billed charges,93% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,494.81,97,,,percent of total billed charges,97% of total billed charges,983.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,983.56,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,836.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,5279.31,
46916 - Cryosurgery Anal Les,4327324,CDM,510,RC,46916,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,128.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.03,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,117.03,980.65,
49411-Fiducial Placement -Pelvic,3916937,CDM,510,RC,49411,HCPCS,Outpatient,,,6230.02,3115.01,,5607.02,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4984.02,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,5607.02,90,,,Percent of total Billed charges,90% of total billed charges,173.93,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,6043.12,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.62,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,5607.02,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,4361.01,70,,,percent of total billed charges,70% of total billed charges,5607.02,90,,,percent of total billed charges,90% of total billed charges,5918.52,95,,,percent of total billed charges,95% of total billed charges,5918.52,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,5357.82,86,,,percent of total billed charges,86% of total billed charges,4984.02,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,6043.12,97,,,percent of total billed charges,97% of total billed charges,5607.02,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,6043.12,97,,,percent of total billed charges,97% of total billed charges,5793.92,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,6043.12,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,158.12,6535.92,
"50432 - PF Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/o",3641210,CDM,510,RC,50432,HCPCS,Outpatient,,,1745.03,872.52,,1570.53,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1396.02,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1570.53,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1692.68,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.43,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1570.53,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1221.52,70,,,percent of total billed charges,70% of total billed charges,1570.53,90,,,percent of total billed charges,90% of total billed charges,1657.78,95,,,percent of total billed charges,95% of total billed charges,1657.78,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1500.73,86,,,percent of total billed charges,86% of total billed charges,1396.02,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1692.68,97,,,percent of total billed charges,97% of total billed charges,1570.53,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1692.68,97,,,percent of total billed charges,97% of total billed charges,1622.88,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1692.68,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1221.52,9042.77,
50694 - PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH,4037566,CDM,983,RC,50694,HCPCS,Outpatient,,,2110.63,1055.32,,1899.57,90,,,percent of total billed charges,90% of total Billed charges,1310.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,410.12,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,461.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,461.28,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,411.29,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,244.83,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,516.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,485.32,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,305.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,400.46,155,,,Fee Schedule,155% of CMS OPPS Rate,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,2031.83,155,,,Fee Schedule,155% of CMS OPPS Rate,2031.83,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1226.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,258.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,244.83,2031.83,
51700- Bladder irrigate/lavage/instill,3435948,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,1043.57,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.57,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.73,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.76,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.66,70,,,percent of total billed charges,70% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.19,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.73,97,,,percent of total billed charges,97% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.73,97,,,percent of total billed charges,97% of total billed charges,1078.35,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.73,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1124.73,
AMB alprostidil Admin Charge:Admin alprostadil Charge 51700,3444221,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,1043.57,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.57,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.73,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.76,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.66,70,,,percent of total billed charges,70% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.19,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.73,97,,,percent of total billed charges,97% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.73,97,,,percent of total billed charges,97% of total billed charges,1078.35,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.73,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1124.73,
AMB Bladder Irrigation Charge:Bladder Irrigation- 51700,3444232,CDM,510,RC,51700,HCPCS,Outpatient,,,1159.52,579.76,,1043.57,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.57,90,,,Percent of total Billed charges,90% of total billed charges,31.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.73,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.76,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.66,70,,,percent of total billed charges,70% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,1101.54,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.19,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.73,97,,,percent of total billed charges,97% of total billed charges,1043.57,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.73,97,,,percent of total billed charges,97% of total billed charges,1078.35,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.73,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.7,1124.73,
51701- Insert/non-indwelling bladder cath,3435949,CDM,510,RC,51701,HCPCS,Outpatient,,,626.6,313.30,,563.94,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,501.28,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.94,90,,,Percent of total Billed charges,90% of total billed charges,28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,607.8,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,576.47,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,438.62,70,,,percent of total billed charges,70% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,538.88,86,,,percent of total billed charges,86% of total billed charges,501.28,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,607.8,97,,,percent of total billed charges,97% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.8,97,,,percent of total billed charges,97% of total billed charges,582.74,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.8,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.45,607.8,
51702- Insert temp indwell blad cath/simp,3435950,CDM,510,RC,51702,HCPCS,Outpatient,,,626.6,313.30,,563.94,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,501.28,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.94,90,,,Percent of total Billed charges,90% of total billed charges,30.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,607.8,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,576.47,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,438.62,70,,,percent of total billed charges,70% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,538.88,86,,,percent of total billed charges,86% of total billed charges,501.28,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,607.8,97,,,percent of total billed charges,97% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.8,97,,,percent of total billed charges,97% of total billed charges,582.74,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.8,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.51,607.8,
51703- Insert temp indwell blad cath/comp,3435951,CDM,510,RC,51703,HCPCS,Outpatient,,,784.78,392.39,,706.3,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,627.82,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.3,90,,,Percent of total Billed charges,90% of total billed charges,82.07,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,761.24,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,722,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,706.3,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,549.35,70,,,percent of total billed charges,70% of total billed charges,706.3,90,,,percent of total billed charges,90% of total billed charges,745.54,95,,,percent of total billed charges,95% of total billed charges,745.54,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.91,86,,,percent of total billed charges,86% of total billed charges,627.82,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,761.24,97,,,percent of total billed charges,97% of total billed charges,706.3,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.24,97,,,percent of total billed charges,97% of total billed charges,729.85,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.61,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.24,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,74.61,761.24,
51705- Change Cystostomy (Bladder) Tube,4363185,CDM,510,RC,51705,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,1124.74,
51720- Bladder instill/anticancer agent,3435955,CDM,510,RC,51720,HCPCS,Outpatient,,,3374.57,1687.29,,3037.11,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.66,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.11,90,,,Percent of total Billed charges,90% of total billed charges,73.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.33,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.6,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.11,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.2,70,,,percent of total billed charges,70% of total billed charges,3037.11,90,,,percent of total billed charges,90% of total billed charges,3205.84,95,,,percent of total billed charges,95% of total billed charges,3205.84,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.13,86,,,percent of total billed charges,86% of total billed charges,2699.66,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.33,97,,,percent of total billed charges,97% of total billed charges,3037.11,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.33,97,,,percent of total billed charges,97% of total billed charges,3138.35,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.33,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.94,3273.33,
AMB Bladder Instill/Anticarcin:Bladder Instill/Anticarcin-51720,3444225,CDM,510,RC,51720,HCPCS,Outpatient,,,3374.57,1687.29,,3037.11,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.66,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.11,90,,,Percent of total Billed charges,90% of total billed charges,73.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.33,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.6,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.11,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.2,70,,,percent of total billed charges,70% of total billed charges,3037.11,90,,,percent of total billed charges,90% of total billed charges,3205.84,95,,,percent of total billed charges,95% of total billed charges,3205.84,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.13,86,,,percent of total billed charges,86% of total billed charges,2699.66,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.33,97,,,percent of total billed charges,97% of total billed charges,3037.11,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.33,97,,,percent of total billed charges,97% of total billed charges,3138.35,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.33,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.94,3273.33,
Clinic Cystometrogram Simple,3550630,CDM,510,RC,51725,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1124.74,
Clinic Cystometrogram Complex,3550631,CDM,510,RC,51726,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,46.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42.5,1124.74,
Clinic Compl Cystometrogram Void Press Stu - 51728,4305354,CDM,510,RC,51728,HCPCS,Outpatient,,,3013.05,1506.53,,2711.75,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2410.44,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2711.75,90,,,Percent of total Billed charges,90% of total billed charges,154.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2922.66,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2772.01,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2711.75,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2109.14,70,,,percent of total billed charges,70% of total billed charges,2711.75,90,,,percent of total billed charges,90% of total billed charges,2862.4,95,,,percent of total billed charges,95% of total billed charges,2862.4,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2591.22,86,,,percent of total billed charges,86% of total billed charges,2410.44,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2922.66,97,,,percent of total billed charges,97% of total billed charges,2711.75,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2922.66,97,,,percent of total billed charges,97% of total billed charges,2802.14,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2922.66,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,140.4,3048.61,
51729- Comp cystometrogram/void/uret pres,3435958,CDM,510,RC,51729,HCPCS,Outpatient,,,3374.62,1687.31,,3037.16,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.7,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.16,90,,,Percent of total Billed charges,90% of total billed charges,159.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.38,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.65,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.23,70,,,percent of total billed charges,70% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.17,86,,,percent of total billed charges,86% of total billed charges,2699.7,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.38,97,,,percent of total billed charges,97% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.38,97,,,percent of total billed charges,97% of total billed charges,3138.4,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.57,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.38,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,144.57,3273.38,
51736 Urine flow measurement,4267409,CDM,510,RC,51736,HCPCS,Outpatient,,,626.61,313.31,,563.95,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,501.29,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.95,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,607.81,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,576.48,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,563.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,438.63,70,,,percent of total billed charges,70% of total billed charges,563.95,90,,,percent of total billed charges,90% of total billed charges,595.28,95,,,percent of total billed charges,95% of total billed charges,595.28,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,538.88,86,,,percent of total billed charges,86% of total billed charges,501.29,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,607.81,97,,,percent of total billed charges,97% of total billed charges,563.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.81,97,,,percent of total billed charges,97% of total billed charges,582.75,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.81,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,607.81,
Clinic Complex Uroflometry - 51741,4305355,CDM,510,RC,51741,HCPCS,Outpatient,,,700.71,350.36,,630.64,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,560.57,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.64,90,,,Percent of total Billed charges,90% of total billed charges,26.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679.69,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,630.64,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,490.5,70,,,percent of total billed charges,70% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,602.61,86,,,percent of total billed charges,86% of total billed charges,560.57,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,679.69,97,,,percent of total billed charges,97% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,679.69,97,,,percent of total billed charges,97% of total billed charges,651.66,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,24,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679.69,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,24,708.98,
Clinic EMG stds Anal/Urtl Sphnctr Other/Thn Ndl -51784,4305356,CDM,510,RC,51784,HCPCS,Outpatient,,,700.71,350.36,,630.64,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,560.57,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.64,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,679.69,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,630.64,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,490.5,70,,,percent of total billed charges,70% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,602.61,86,,,percent of total billed charges,86% of total billed charges,560.57,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,679.69,97,,,percent of total billed charges,97% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,679.69,97,,,percent of total billed charges,97% of total billed charges,651.66,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,679.69,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,708.98,
51798- PVR urine/bladder capacity/US,3435963,CDM,510,RC,51798,HCPCS,Outpatient,,,310.18,155.09,,279.16,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,248.14,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.16,90,,,Percent of total Billed charges,90% of total billed charges,15.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,300.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,285.37,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,279.16,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,217.13,70,,,percent of total billed charges,70% of total billed charges,279.16,90,,,percent of total billed charges,90% of total billed charges,294.67,95,,,percent of total billed charges,95% of total billed charges,294.67,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,266.75,86,,,percent of total billed charges,86% of total billed charges,248.14,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,300.87,97,,,percent of total billed charges,97% of total billed charges,279.16,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.87,97,,,percent of total billed charges,97% of total billed charges,288.47,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.07,300.87,
PVR POC,3444218,CDM,761,RC,51798,HCPCS,Outpatient,,,310.18,155.09,,279.16,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,248.14,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.16,90,,,Percent of total Billed charges,90% of total billed charges,15.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,300.87,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,285.37,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,279.16,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,217.13,70,,,percent of total billed charges,70% of total billed charges,279.16,90,,,percent of total billed charges,90% of total billed charges,294.67,95,,,percent of total billed charges,95% of total billed charges,294.67,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,266.75,86,,,percent of total billed charges,86% of total billed charges,248.14,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,300.87,97,,,percent of total billed charges,97% of total billed charges,279.16,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,300.87,97,,,percent of total billed charges,97% of total billed charges,288.47,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,300.87,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.07,300.87,
Clinic Cystoscopy,3550628,CDM,510,RC,52000,HCPCS,Outpatient,,,3374.62,1687.31,,3037.16,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.7,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.16,90,,,Percent of total Billed charges,90% of total billed charges,82.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.38,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.65,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.23,70,,,percent of total billed charges,70% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.17,86,,,percent of total billed charges,86% of total billed charges,2699.7,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.38,97,,,percent of total billed charges,97% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.38,97,,,percent of total billed charges,97% of total billed charges,3138.4,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,75,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.38,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,75,3273.38,
52005- Cystourethroscop/cath/exc rad serv,3435968,CDM,510,RC,52005,HCPCS,Outpatient,,,399.25,199.63,,359.33,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,319.4,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.33,90,,,Percent of total Billed charges,90% of total billed charges,127.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,387.27,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,367.31,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,359.33,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,279.48,70,,,percent of total billed charges,70% of total billed charges,359.33,90,,,percent of total billed charges,90% of total billed charges,379.29,95,,,percent of total billed charges,95% of total billed charges,379.29,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,343.36,86,,,percent of total billed charges,86% of total billed charges,319.4,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,387.27,97,,,percent of total billed charges,97% of total billed charges,359.33,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.27,97,,,percent of total billed charges,97% of total billed charges,371.3,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,116,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.27,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,116,9042.77,
Clinic Cysto Calib Dilat Urtl Strix/Stenosis 52281,4301628,CDM,510,RC,52281,HCPCS,Outpatient,,,8937.23,4468.62,,8043.51,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7149.78,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,8043.51,90,,,Percent of total Billed charges,90% of total billed charges,118.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8669.11,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8222.25,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8043.51,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,6256.06,70,,,percent of total billed charges,70% of total billed charges,8043.51,90,,,percent of total billed charges,90% of total billed charges,8490.37,95,,,percent of total billed charges,95% of total billed charges,8490.37,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7686.02,86,,,percent of total billed charges,86% of total billed charges,7149.78,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8669.11,97,,,percent of total billed charges,97% of total billed charges,8043.51,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,8669.11,97,,,percent of total billed charges,97% of total billed charges,8311.62,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8669.11,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,107.5,9042.77,
52287- Cystoscopy chemodenervation,3435976,CDM,510,RC,52287,HCPCS,Outpatient,,,10009.69,5004.85,,9008.72,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.75,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.72,90,,,Percent of total Billed charges,90% of total billed charges,143.81,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.4,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.91,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.72,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.78,70,,,percent of total billed charges,70% of total billed charges,9008.72,90,,,percent of total billed charges,90% of total billed charges,9509.21,95,,,percent of total billed charges,95% of total billed charges,9509.21,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.33,86,,,percent of total billed charges,86% of total billed charges,8007.75,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.4,97,,,percent of total billed charges,97% of total billed charges,9008.72,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.4,97,,,percent of total billed charges,97% of total billed charges,9309.01,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,130.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.4,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,130.74,9709.4,
Clinic Cystoscopy w/stent removal,3550633,CDM,510,RC,52310,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,141.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,129,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,129,9709.41,
53200 Biopsy of urethra,3621304,CDM,510,RC,53200,HCPCS,Outpatient,,,40.26,20.13,,36.23,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,32.21,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.23,90,,,Percent of total Billed charges,90% of total billed charges,70.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,39.05,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,37.04,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,36.23,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,28.18,70,,,percent of total billed charges,70% of total billed charges,36.23,90,,,percent of total billed charges,90% of total billed charges,38.25,95,,,percent of total billed charges,95% of total billed charges,38.25,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,34.62,86,,,percent of total billed charges,86% of total billed charges,32.21,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,39.05,97,,,percent of total billed charges,97% of total billed charges,36.23,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.05,97,,,percent of total billed charges,97% of total billed charges,37.44,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,39.05,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28.18,9042.77,
53600-Dilate urethra stricture,3435998,CDM,510,RC,53600,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1124.74,
53601 -Dilation Urethral Stricture Passage of Sound/Urethral,4271221,CDM,510,RC,53601,HCPCS,Outpatient,,,626.61,313.31,,563.95,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,501.29,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.95,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,607.81,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,576.48,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,563.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,438.63,70,,,percent of total billed charges,70% of total billed charges,563.95,90,,,percent of total billed charges,90% of total billed charges,595.28,95,,,percent of total billed charges,95% of total billed charges,595.28,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,538.88,86,,,percent of total billed charges,86% of total billed charges,501.29,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,607.81,97,,,percent of total billed charges,97% of total billed charges,563.95,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.81,97,,,percent of total billed charges,97% of total billed charges,582.75,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.81,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,607.81,
53605- Dilate urethral stricture/anesth,3435999,CDM,510,RC,53605,HCPCS,Outpatient,,,17296.19,8648.10,,15566.57,90,,,percent of total billed charges,90% of total Billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,13836.95,80,,,Percent of total Billed charges,80% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,15566.57,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,16777.3,97,,,Percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,15912.49,92,,,Percent of total billed charges,92% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,7738,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12335.97,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15625.36,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,15566.57,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,12107.33,70,,,percent of total billed charges,70% of total billed charges,15566.57,90,,,percent of total billed charges,90% of total billed charges,16431.38,95,,,percent of total billed charges,95% of total billed charges,16431.38,95,,,percent of total billed charges,95% of total billed charges,2911.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5822.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14874.72,86,,,percent of total billed charges,86% of total billed charges,13836.95,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,16777.3,97,,,percent of total billed charges,97% of total billed charges,15566.57,90,,,percent of total billed charges,90% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,16777.3,97,,,percent of total billed charges,97% of total billed charges,16085.46,93,,,percent of total billed charges,93% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,16777.3,97,,,percent of total billed charges,97% of total billed charges,2911.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2911.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2474.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,16777.3,
53620- Dilation/urethral strict/male/ini,3436000,CDM,510,RC,53620,HCPCS,Outpatient,,,3374.62,1687.31,,3037.16,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.7,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.16,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.38,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.65,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.23,70,,,percent of total billed charges,70% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.17,86,,,percent of total billed charges,86% of total billed charges,2699.7,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.38,97,,,percent of total billed charges,97% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.38,97,,,percent of total billed charges,97% of total billed charges,3138.4,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.38,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,3273.38,
53621- Dilation/urethral strict/male/subs,3436001,CDM,510,RC,53621,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,1124.74,
53660- Dilation/female urethra/initial,3436002,CDM,510,RC,53660,HCPCS,Outpatient,,,784.8,392.40,,706.32,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,627.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,706.32,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,761.26,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,722.02,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,706.32,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,549.36,70,,,percent of total billed charges,70% of total billed charges,706.32,90,,,percent of total billed charges,90% of total billed charges,745.56,95,,,percent of total billed charges,95% of total billed charges,745.56,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.93,86,,,percent of total billed charges,86% of total billed charges,627.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,761.26,97,,,percent of total billed charges,97% of total billed charges,706.32,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,761.26,97,,,percent of total billed charges,97% of total billed charges,729.86,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,761.26,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,761.26,
53661- Dilation/female urethra/subsequent,3436003,CDM,510,RC,53661,HCPCS,Outpatient,,,626.6,313.30,,563.94,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,501.28,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,563.94,90,,,Percent of total Billed charges,90% of total billed charges,22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,607.8,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,576.47,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,438.62,70,,,percent of total billed charges,70% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,595.27,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,538.88,86,,,percent of total billed charges,86% of total billed charges,501.28,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,607.8,97,,,percent of total billed charges,97% of total billed charges,563.94,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,607.8,97,,,percent of total billed charges,97% of total billed charges,582.74,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,607.8,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,20,607.8,
54055- Destruct penis les/smp/electrodesi,3431643,CDM,510,RC,54055,HCPCS,Outpatient,,,9313.47,4656.74,,8382.12,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7450.78,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8382.12,90,,,Percent of total Billed charges,90% of total billed charges,42.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9034.07,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8568.39,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8382.12,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6519.43,70,,,percent of total billed charges,70% of total billed charges,8382.12,90,,,percent of total billed charges,90% of total billed charges,8847.8,95,,,percent of total billed charges,95% of total billed charges,8847.8,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8009.58,86,,,percent of total billed charges,86% of total billed charges,7450.78,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9034.07,97,,,percent of total billed charges,97% of total billed charges,8382.12,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9034.07,97,,,percent of total billed charges,97% of total billed charges,8661.53,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9034.07,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.5,9034.07,
54056- Cryosurgery/penis lesion(s),3431644,CDM,510,RC,54056,HCPCS,Outpatient,,,974.51,487.26,,877.06,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,779.61,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,877.06,90,,,Percent of total Billed charges,90% of total billed charges,30.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,945.27,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,896.55,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,877.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,682.16,70,,,percent of total billed charges,70% of total billed charges,877.06,90,,,percent of total billed charges,90% of total billed charges,925.78,95,,,percent of total billed charges,95% of total billed charges,925.78,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,838.08,86,,,percent of total billed charges,86% of total billed charges,779.61,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,945.27,97,,,percent of total billed charges,97% of total billed charges,877.06,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,945.27,97,,,percent of total billed charges,97% of total billed charges,906.29,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,945.27,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,28,945.27,
54060- Destruct penis lesion/smp/excision,3431645,CDM,510,RC,54060,HCPCS,Outpatient,,,9313.47,4656.74,,8382.12,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7450.78,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8382.12,90,,,Percent of total Billed charges,90% of total billed charges,70.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9034.07,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8568.39,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8382.12,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6519.43,70,,,percent of total billed charges,70% of total billed charges,8382.12,90,,,percent of total billed charges,90% of total billed charges,8847.8,95,,,percent of total billed charges,95% of total billed charges,8847.8,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8009.58,86,,,percent of total billed charges,86% of total billed charges,7450.78,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9034.07,97,,,percent of total billed charges,97% of total billed charges,8382.12,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,9034.07,97,,,percent of total billed charges,97% of total billed charges,8661.53,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9034.07,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,64.5,9034.07,
54065 - Dstr lesion penis extensive,4241824,CDM,510,RC,54065,HCPCS,Outpatient,,,95.15,47.58,,85.64,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,76.12,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.64,90,,,Percent of total Billed charges,90% of total billed charges,149.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,92.3,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,87.54,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,85.64,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,66.61,70,,,percent of total billed charges,70% of total billed charges,85.64,90,,,percent of total billed charges,90% of total billed charges,90.39,95,,,percent of total billed charges,95% of total billed charges,90.39,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,81.83,86,,,percent of total billed charges,86% of total billed charges,76.12,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,92.3,97,,,percent of total billed charges,97% of total billed charges,85.64,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,92.3,97,,,percent of total billed charges,97% of total billed charges,88.49,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.3,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.61,8413.78,
54100- Biopsy of penis,3431646,CDM,510,RC,54100,HCPCS,Outpatient,,,8187.18,4093.59,,7368.46,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6549.74,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7368.46,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7941.56,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7532.21,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5731.03,70,,,percent of total billed charges,70% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,7777.82,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7040.97,86,,,percent of total billed charges,86% of total billed charges,6549.74,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7941.56,97,,,percent of total billed charges,97% of total billed charges,7368.46,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7941.56,97,,,percent of total billed charges,97% of total billed charges,7614.08,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7941.56,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,7941.56,
54150- Circumcision/clamp/other device,3431648,CDM,510,RC,54150,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,86.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,79,9709.41,
54160- Circumcise/surg/28 days or <,3431649,CDM,510,RC,54160,HCPCS,Outpatient,,,3374.62,1687.31,,3037.16,90,,,percent of total billed charges,90% of total Billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2699.7,80,,,Percent of total Billed charges,80% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3037.16,90,,,Percent of total Billed charges,90% of total billed charges,140.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3273.38,97,,,Percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,3104.65,92,,,Percent of total billed charges,92% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1509.72,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2406.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3048.61,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2362.23,70,,,percent of total billed charges,70% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,3205.89,95,,,percent of total billed charges,95% of total billed charges,567.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1135.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2902.17,86,,,percent of total billed charges,86% of total billed charges,2699.7,80,,,percent of total billed charges,80% of total billed charges,575.37,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3273.38,97,,,percent of total billed charges,97% of total billed charges,3037.16,90,,,percent of total billed charges,90% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,3273.38,97,,,percent of total billed charges,97% of total billed charges,3138.4,93,,,percent of total billed charges,93% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3273.38,97,,,percent of total billed charges,97% of total billed charges,567.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,567.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,482.76,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128,3273.38,
54161- Circumcise/surg/> 28 days of age,3431650,CDM,510,RC,54161,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,140.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,128,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128,9709.41,
54200- Peyronie disease/injection proc,3431654,CDM,510,RC,54200,HCPCS,Outpatient,,,70.28,35.14,,63.25,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.22,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.17,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,64.66,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.25,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,49.2,70,,,percent of total billed charges,70% of total billed charges,63.25,90,,,percent of total billed charges,90% of total billed charges,66.77,95,,,percent of total billed charges,95% of total billed charges,66.77,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.44,86,,,percent of total billed charges,86% of total billed charges,56.22,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.17,97,,,percent of total billed charges,97% of total billed charges,63.25,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.17,97,,,percent of total billed charges,97% of total billed charges,65.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,68.17,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.2,1047.51,
AMB Injection Procedure -> Initial Admin: 54200,3561577,CDM,510,RC,54200,HCPCS,Outpatient,,,70.3,35.15,,63.27,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.24,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.19,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,64.68,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.27,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,49.21,70,,,percent of total billed charges,70% of total billed charges,63.27,90,,,percent of total billed charges,90% of total billed charges,66.79,95,,,percent of total billed charges,95% of total billed charges,66.79,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.46,86,,,percent of total billed charges,86% of total billed charges,56.24,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.19,97,,,percent of total billed charges,97% of total billed charges,63.27,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.19,97,,,percent of total billed charges,97% of total billed charges,65.38,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,68.19,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.21,1047.51,
AMB Injection Procedure -> Subsequent Admin: 54200-58,3561578,CDM,510,RC,54200,HCPCS,Outpatient,,,70.3,35.15,,63.27,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,56.24,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,68.19,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,64.68,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,63.27,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,49.21,70,,,percent of total billed charges,70% of total billed charges,63.27,90,,,percent of total billed charges,90% of total billed charges,66.79,95,,,percent of total billed charges,95% of total billed charges,66.79,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,60.46,86,,,percent of total billed charges,86% of total billed charges,56.24,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,68.19,97,,,percent of total billed charges,97% of total billed charges,63.27,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.19,97,,,percent of total billed charges,97% of total billed charges,65.38,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,68.19,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49.21,1047.51,
54235- Corpora cavernosa injection,3431656,CDM,510,RC,54235,HCPCS,Outpatient,,,37.12,18.56,,33.41,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,29.7,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.41,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.01,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,34.15,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,33.41,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,25.98,70,,,percent of total billed charges,70% of total billed charges,33.41,90,,,percent of total billed charges,90% of total billed charges,35.26,95,,,percent of total billed charges,95% of total billed charges,35.26,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,31.92,86,,,percent of total billed charges,86% of total billed charges,29.7,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36.01,97,,,percent of total billed charges,97% of total billed charges,33.41,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.01,97,,,percent of total billed charges,97% of total billed charges,34.52,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.01,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.98,1047.51,
54450 - PF Foreskin manipulation including lysis of preputial adhesions and stretching,3699545,CDM,510,RC,54450,HCPCS,Outpatient,,,1035.3,517.65,,931.77,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,828.24,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,931.77,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1004.24,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,952.48,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,931.77,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,724.71,70,,,percent of total billed charges,70% of total billed charges,931.77,90,,,percent of total billed charges,90% of total billed charges,983.54,95,,,percent of total billed charges,95% of total billed charges,983.54,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,890.36,86,,,percent of total billed charges,86% of total billed charges,828.24,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1004.24,97,,,percent of total billed charges,97% of total billed charges,931.77,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1004.24,97,,,percent of total billed charges,97% of total billed charges,962.83,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1004.24,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,1047.51,
Clinic Puncture Asp of Hydrocele,3550632,CDM,510,RC,55000,HCPCS,Outpatient,,,3502.12,1751.06,,3151.91,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2801.7,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3151.91,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3397.06,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,3221.95,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3151.91,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2451.48,70,,,percent of total billed charges,70% of total billed charges,3151.91,90,,,percent of total billed charges,90% of total billed charges,3327.01,95,,,percent of total billed charges,95% of total billed charges,3327.01,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,3011.82,86,,,percent of total billed charges,86% of total billed charges,2801.7,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3397.06,97,,,percent of total billed charges,97% of total billed charges,3151.91,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,3397.06,97,,,percent of total billed charges,97% of total billed charges,3256.97,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3397.06,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,3397.06,
55100- Drainage of scrotal wall abscess,3430108,CDM,360,RC,55100,HCPCS,Outpatient,,,8092.19,4046.10,,7282.97,90,,,percent of total billed charges,90% of total Billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,6473.75,80,,,Percent of total Billed charges,80% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7282.97,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,7849.42,97,,,Percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,7444.81,92,,,Percent of total billed charges,92% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,3620.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5771.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7310.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,7282.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,5664.53,70,,,percent of total billed charges,70% of total billed charges,7282.97,90,,,percent of total billed charges,90% of total billed charges,7687.58,95,,,percent of total billed charges,95% of total billed charges,7687.58,95,,,percent of total billed charges,95% of total billed charges,1361.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2723.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6959.28,86,,,percent of total billed charges,86% of total billed charges,6473.75,80,,,percent of total billed charges,80% of total billed charges,1419.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7849.42,97,,,percent of total billed charges,97% of total billed charges,7282.97,90,,,percent of total billed charges,90% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,7849.42,97,,,percent of total billed charges,97% of total billed charges,7525.74,93,,,percent of total billed charges,93% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,7849.42,97,,,percent of total billed charges,97% of total billed charges,1361.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,1361.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1157.67,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,7849.42,
Clinic Vasectomy,3550629,CDM,510,RC,55250,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,163.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,148.5,9709.41,
55700- Bx/prostate/needle/punch/sng/mul,3431675,CDM,510,RC,55700,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,98.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.5,9709.41,
URMC US Prostate w Biopsy w Nav PR:URMC US Exam,3575338,CDM,402,RC,55700,HCPCS,Outpatient,,,10009.7,5004.85,,9008.73,90,,,percent of total billed charges,90% of total Billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,8007.76,80,,,Percent of total Billed charges,80% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9008.73,90,,,Percent of total Billed charges,90% of total billed charges,98.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,9709.41,97,,,Percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,9208.92,92,,,Percent of total billed charges,92% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,4478.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,7139.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,9042.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,7006.79,70,,,percent of total billed charges,70% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,9509.22,95,,,percent of total billed charges,95% of total billed charges,1684.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3369.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,8608.34,86,,,percent of total billed charges,86% of total billed charges,8007.76,80,,,percent of total billed charges,80% of total billed charges,1831.56,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,9709.41,97,,,percent of total billed charges,97% of total billed charges,9008.73,90,,,percent of total billed charges,90% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,9709.41,97,,,percent of total billed charges,97% of total billed charges,9309.02,93,,,percent of total billed charges,93% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,89.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,9709.41,97,,,percent of total billed charges,97% of total billed charges,1684.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,1684.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1431.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.5,9709.41,
55876- Place interstitdevice/rad tx guide/prostate/sng/mult,3431680,CDM,510,RC,55876,HCPCS,Outpatient,,,7234.8,3617.40,,6511.32,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5787.84,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,6511.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7017.76,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6656.02,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6511.32,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5064.36,70,,,percent of total billed charges,70% of total billed charges,6511.32,90,,,percent of total billed charges,90% of total billed charges,6873.06,95,,,percent of total billed charges,95% of total billed charges,6873.06,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6221.93,86,,,percent of total billed charges,86% of total billed charges,5787.84,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7017.76,97,,,percent of total billed charges,97% of total billed charges,6511.32,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,7017.76,97,,,percent of total billed charges,97% of total billed charges,6728.36,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7017.76,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1035.01,7017.76,
55876-PROSTATE FIDUCIAL,3565264,CDM,360,RC,55876,HCPCS,Outpatient,,,2474.12,1237.06,,2226.71,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1979.3,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2226.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2399.9,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2276.19,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2226.71,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.88,70,,,percent of total billed charges,70% of total billed charges,2226.71,90,,,percent of total billed charges,90% of total billed charges,2350.41,95,,,percent of total billed charges,95% of total billed charges,2350.41,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2127.74,86,,,percent of total billed charges,86% of total billed charges,1979.3,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2399.9,97,,,percent of total billed charges,97% of total billed charges,2226.71,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2399.9,97,,,percent of total billed charges,97% of total billed charges,2300.93,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2399.9,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1035.01,6535.92,
URMC US w Fiducial Marker Placement PR:URMC US Exam,3575344,CDM,402,RC,55876,HCPCS,Outpatient,,,7234.8,3617.40,,6511.32,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5787.84,80,,,Percent of total Billed charges,80% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,6511.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7017.76,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,6656.02,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,6511.32,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,5064.36,70,,,percent of total billed charges,70% of total billed charges,6511.32,90,,,percent of total billed charges,90% of total billed charges,6873.06,95,,,percent of total billed charges,95% of total billed charges,6873.06,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,6221.93,86,,,percent of total billed charges,86% of total billed charges,5787.84,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7017.76,97,,,percent of total billed charges,97% of total billed charges,6511.32,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,7017.76,97,,,percent of total billed charges,97% of total billed charges,6728.36,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,7017.76,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1035.01,7017.76,
"55899 - PF Unlisted procedure, male genital system",3641214,CDM,510,RC,55899,HCPCS,Outpatient,,,2659.33,1329.67,,2393.4,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,2127.46,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2393.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2579.55,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,2446.58,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2393.4,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1861.53,70,,,percent of total billed charges,70% of total billed charges,2393.4,90,,,percent of total billed charges,90% of total billed charges,2526.36,95,,,percent of total billed charges,95% of total billed charges,2526.36,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2287.02,86,,,percent of total billed charges,86% of total billed charges,2127.46,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2579.55,97,,,percent of total billed charges,97% of total billed charges,2393.4,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,2579.55,97,,,percent of total billed charges,97% of total billed charges,2473.18,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,2579.55,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,2579.55,
55899- Unlisted proc/male genital system,3431681,CDM,510,RC,55899,HCPCS,Outpatient,,,1159.53,579.77,,1043.58,90,,,percent of total billed charges,90% of total Billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,927.62,80,,,Percent of total Billed charges,80% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1043.58,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1124.74,97,,,Percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,1066.77,92,,,Percent of total billed charges,92% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,518.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,826.99,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1047.51,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,811.67,70,,,percent of total billed charges,70% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,1101.55,95,,,percent of total billed charges,95% of total billed charges,195.15,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,390.31,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,997.2,86,,,percent of total billed charges,86% of total billed charges,927.62,80,,,percent of total billed charges,80% of total billed charges,242.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1124.74,97,,,percent of total billed charges,97% of total billed charges,1043.58,90,,,percent of total billed charges,90% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,1124.74,97,,,percent of total billed charges,97% of total billed charges,1078.36,93,,,percent of total billed charges,93% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1124.74,97,,,percent of total billed charges,97% of total billed charges,195.15,100,,,Fee Schedule,100% of CMS OPPS Rate ,195.15,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,165.87,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.87,1124.74,
56405- Vulva/perineal abscess/ I & D,3431352,CDM,360,RC,56405,HCPCS,Outpatient,,,52.93,26.47,,47.64,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,42.34,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.64,90,,,Percent of total Billed charges,90% of total billed charges,103.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,51.34,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,48.7,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,47.64,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,37.05,70,,,percent of total billed charges,70% of total billed charges,47.64,90,,,percent of total billed charges,90% of total billed charges,50.28,95,,,percent of total billed charges,95% of total billed charges,50.28,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,45.52,86,,,percent of total billed charges,86% of total billed charges,42.34,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,51.34,97,,,percent of total billed charges,97% of total billed charges,47.64,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.34,97,,,percent of total billed charges,97% of total billed charges,49.22,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,51.34,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.05,1423.33,
56420- Bartholin's gland abscess/I & D,3431353,CDM,510,RC,56420,HCPCS,Outpatient,,,961.27,480.64,,865.14,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,769.02,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,865.14,90,,,Percent of total Billed charges,90% of total billed charges,55.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,932.43,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,884.37,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,865.14,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,672.89,70,,,percent of total billed charges,70% of total billed charges,865.14,90,,,percent of total billed charges,90% of total billed charges,913.21,95,,,percent of total billed charges,95% of total billed charges,913.21,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,826.69,86,,,percent of total billed charges,86% of total billed charges,769.02,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,932.43,97,,,percent of total billed charges,97% of total billed charges,865.14,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,932.43,97,,,percent of total billed charges,97% of total billed charges,893.98,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,932.43,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.5,932.43,
"56501-MA DESTROY, VULVA LESIONS",3430122,CDM,510,RC,56501,HCPCS,Outpatient,,,9208.91,4604.46,,8288.02,90,,,percent of total billed charges,90% of total Billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,7367.13,80,,,Percent of total Billed charges,80% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8288.02,90,,,Percent of total Billed charges,90% of total billed charges,69.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,8932.64,97,,,Percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,8472.2,92,,,Percent of total billed charges,92% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,4166.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6642.54,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8413.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,6446.24,70,,,percent of total billed charges,70% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,8748.46,95,,,percent of total billed charges,95% of total billed charges,1567.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3135.05,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,7919.66,86,,,percent of total billed charges,86% of total billed charges,7367.13,80,,,percent of total billed charges,80% of total billed charges,1677.71,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,8932.64,97,,,percent of total billed charges,97% of total billed charges,8288.02,90,,,percent of total billed charges,90% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,8932.64,97,,,percent of total billed charges,97% of total billed charges,8564.29,93,,,percent of total billed charges,93% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,8932.64,97,,,percent of total billed charges,97% of total billed charges,1567.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,1567.53,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1332.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,63.5,8932.64,
56605- BX vulva or perineum/1 lesion,3431357,CDM,360,RC,56605,HCPCS,Outpatient,,,90.79,45.40,,81.71,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,72.63,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.71,90,,,Percent of total Billed charges,90% of total billed charges,61.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.07,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,83.53,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,81.71,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,63.55,70,,,percent of total billed charges,70% of total billed charges,81.71,90,,,percent of total billed charges,90% of total billed charges,86.25,95,,,percent of total billed charges,95% of total billed charges,86.25,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.08,86,,,percent of total billed charges,86% of total billed charges,72.63,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.07,97,,,percent of total billed charges,97% of total billed charges,81.71,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.07,97,,,percent of total billed charges,97% of total billed charges,84.43,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,55.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.07,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55.51,3429.49,
56606- Bx vulva or perineum/ea add lesion,3431358,CDM,360,RC,56606,HCPCS,Outpatient,,,22.09,11.05,,19.88,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,17.67,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,19.88,90,,,Percent of total Billed charges,90% of total billed charges,30.14,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,21.43,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,20.32,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,14.11,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,17.37,78.65,,,percent of total billed charges,78.65% of total billed charges,19.73,89.33,,,percent of total billed charges,89.33% of total billed charges,19.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15.46,70,,,percent of total billed charges,70% of total billed charges,19.88,90,,,percent of total billed charges,90% of total billed charges,20.99,95,,,percent of total billed charges,95% of total billed charges,20.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19,86,,,percent of total billed charges,86% of total billed charges,17.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,21.43,97,,,percent of total billed charges,97% of total billed charges,19.88,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,21.43,97,,,percent of total billed charges,97% of total billed charges,20.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.43,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.11,30.14,
57061-MA DESTROY VAG LESIONS,3430142,CDM,510,RC,57061,HCPCS,Outpatient,,,15787.48,7893.74,,14208.73,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,12629.98,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,14208.73,90,,,Percent of total Billed charges,90% of total billed charges,77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15313.86,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,14524.48,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14208.73,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11051.24,70,,,percent of total billed charges,70% of total billed charges,14208.73,90,,,percent of total billed charges,90% of total billed charges,14998.11,95,,,percent of total billed charges,95% of total billed charges,14998.11,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13577.23,86,,,percent of total billed charges,86% of total billed charges,12629.98,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15313.86,97,,,percent of total billed charges,97% of total billed charges,14208.73,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,15313.86,97,,,percent of total billed charges,97% of total billed charges,14682.36,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,70,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15313.86,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70,15313.86,
57100 - Bx vaginal mucosa; simple,3431363,CDM,360,RC,57100,HCPCS,Outpatient,,,91.62,45.81,,82.46,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,73.3,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.46,90,,,Percent of total Billed charges,90% of total billed charges,65.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,88.87,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,84.29,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,82.46,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,64.13,70,,,percent of total billed charges,70% of total billed charges,82.46,90,,,percent of total billed charges,90% of total billed charges,87.04,95,,,percent of total billed charges,95% of total billed charges,87.04,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,78.79,86,,,percent of total billed charges,86% of total billed charges,73.3,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,88.87,97,,,percent of total billed charges,97% of total billed charges,82.46,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,88.87,97,,,percent of total billed charges,97% of total billed charges,85.21,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88.87,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.99,3429.49,
57135-MA REMOVE VAGINA LESION,3430152,CDM,510,RC,57135,HCPCS,Outpatient,,,147.64,73.82,,132.88,90,,,percent of total billed charges,90% of total Billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,118.11,80,,,Percent of total Billed charges,80% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.88,90,,,Percent of total Billed charges,90% of total billed charges,157.3,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,143.21,97,,,Percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,135.83,92,,,Percent of total billed charges,92% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,6826.18,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,10882.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,13784.12,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,132.88,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,103.35,70,,,percent of total billed charges,70% of total billed charges,132.88,90,,,percent of total billed charges,90% of total billed charges,140.26,95,,,percent of total billed charges,95% of total billed charges,140.26,95,,,percent of total billed charges,95% of total billed charges,2568.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5136.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,126.97,86,,,percent of total billed charges,86% of total billed charges,118.11,80,,,percent of total billed charges,80% of total billed charges,2582.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,143.21,97,,,percent of total billed charges,97% of total billed charges,132.88,90,,,percent of total billed charges,90% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.21,97,,,percent of total billed charges,97% of total billed charges,137.31,93,,,percent of total billed charges,93% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,143,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,143.21,97,,,percent of total billed charges,97% of total billed charges,2568.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2568.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2182.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,103.35,13784.12,
57156 - Insertion of a vaginal radiation afterloading appara,3938956,CDM,510,RC,57156,HCPCS,Outpatient,,,183.97,91.99,,165.57,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,147.18,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,178.45,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,169.25,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,165.57,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,128.78,70,,,percent of total billed charges,70% of total billed charges,165.57,90,,,percent of total billed charges,90% of total billed charges,174.77,95,,,percent of total billed charges,95% of total billed charges,174.77,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,158.21,86,,,percent of total billed charges,86% of total billed charges,147.18,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,178.45,97,,,percent of total billed charges,97% of total billed charges,165.57,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,178.45,97,,,percent of total billed charges,97% of total billed charges,171.09,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,178.45,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,128.78,1423.33,
57156-Ins Vag Brachytx Device,4169512,CDM,360,RC,57156,HCPCS,Outpatient,,,164.26,82.13,,147.83,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,131.41,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.83,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.33,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,151.12,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,147.83,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,114.98,70,,,percent of total billed charges,70% of total billed charges,147.83,90,,,percent of total billed charges,90% of total billed charges,156.05,95,,,percent of total billed charges,95% of total billed charges,156.05,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,141.26,86,,,percent of total billed charges,86% of total billed charges,131.41,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,159.33,97,,,percent of total billed charges,97% of total billed charges,147.83,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.33,97,,,percent of total billed charges,97% of total billed charges,152.76,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,159.33,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.98,1423.33,
57454- Colposcopy/cervix/biopsy/curettage,3431388,CDM,510,RC,57454,HCPCS,Outpatient,,,1575.53,787.77,,1417.98,90,,,percent of total billed charges,90% of total Billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1260.42,80,,,Percent of total Billed charges,80% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1417.98,90,,,Percent of total Billed charges,90% of total billed charges,116.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1528.26,97,,,Percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1449.49,92,,,Percent of total billed charges,92% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.33,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1417.98,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,1102.87,70,,,percent of total billed charges,70% of total billed charges,1417.98,90,,,percent of total billed charges,90% of total billed charges,1496.75,95,,,percent of total billed charges,95% of total billed charges,1496.75,95,,,percent of total billed charges,95% of total billed charges,265.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1354.96,86,,,percent of total billed charges,86% of total billed charges,1260.42,80,,,percent of total billed charges,80% of total billed charges,279.88,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1528.26,97,,,percent of total billed charges,97% of total billed charges,1417.98,90,,,percent of total billed charges,90% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,1528.26,97,,,percent of total billed charges,97% of total billed charges,1465.24,93,,,percent of total billed charges,93% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1528.26,97,,,percent of total billed charges,97% of total billed charges,265.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.16,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,105.94,1528.26,
57500- Biopsy/cervix/single/multiple,3431393,CDM,514,RC,57500,HCPCS,Outpatient,,,3389.46,1694.73,,3050.51,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2711.57,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,3050.51,90,,,Percent of total Billed charges,90% of total billed charges,72.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3287.78,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,3118.3,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,3050.51,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,2372.62,70,,,percent of total billed charges,70% of total billed charges,3050.51,90,,,percent of total billed charges,90% of total billed charges,3219.99,95,,,percent of total billed charges,95% of total billed charges,3219.99,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2914.94,86,,,percent of total billed charges,86% of total billed charges,2711.57,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3287.78,97,,,percent of total billed charges,97% of total billed charges,3050.51,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,3287.78,97,,,percent of total billed charges,97% of total billed charges,3152.2,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3287.78,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,66.12,3429.49,
57505- Endocervical curettage,3431394,CDM,360,RC,57505,HCPCS,Outpatient,,,113.71,56.86,,102.34,90,,,percent of total billed charges,90% of total Billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,90.97,80,,,Percent of total Billed charges,80% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,102.34,90,,,Percent of total Billed charges,90% of total billed charges,24.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,110.3,97,,,Percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,104.61,92,,,Percent of total billed charges,92% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,1698.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2707.53,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3429.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,102.34,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,79.6,70,,,percent of total billed charges,70% of total billed charges,102.34,90,,,percent of total billed charges,90% of total billed charges,108.02,95,,,percent of total billed charges,95% of total billed charges,108.02,95,,,percent of total billed charges,95% of total billed charges,638.92,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1277.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,97.79,86,,,percent of total billed charges,86% of total billed charges,90.97,80,,,percent of total billed charges,80% of total billed charges,660.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,110.3,97,,,percent of total billed charges,97% of total billed charges,102.34,90,,,percent of total billed charges,90% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.3,97,,,percent of total billed charges,97% of total billed charges,105.75,93,,,percent of total billed charges,93% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.3,97,,,percent of total billed charges,97% of total billed charges,638.92,100,,,Fee Schedule,100% of CMS OPPS Rate ,638.92,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,543.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22,3429.49,
58100- EMB w/o cervical dilation,3431398,CDM,360,RC,58100,HCPCS,Outpatient,,,93.96,46.98,,84.56,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,75.17,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.56,90,,,Percent of total Billed charges,90% of total billed charges,56.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,91.14,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,86.44,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.56,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,65.77,70,,,percent of total billed charges,70% of total billed charges,84.56,90,,,percent of total billed charges,90% of total billed charges,89.26,95,,,percent of total billed charges,95% of total billed charges,89.26,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.81,86,,,percent of total billed charges,86% of total billed charges,75.17,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,91.14,97,,,percent of total billed charges,97% of total billed charges,84.56,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.14,97,,,percent of total billed charges,97% of total billed charges,87.38,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.14,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51,868.4,
58110- EMB w/colposcopy,3431399,CDM,510,RC,58110,HCPCS,Outpatient,,,275.6,137.80,,248.04,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,220.48,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,248.04,90,,,Percent of total Billed charges,90% of total billed charges,35.26,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,267.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,253.55,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,176,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,216.77,78.65,,,percent of total billed charges,78.65% of total billed charges,246.2,89.33,,,percent of total billed charges,89.33% of total billed charges,248.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,192.92,70,,,percent of total billed charges,70% of total billed charges,248.04,90,,,percent of total billed charges,90% of total billed charges,261.82,95,,,percent of total billed charges,95% of total billed charges,261.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,237.02,86,,,percent of total billed charges,86% of total billed charges,220.48,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,267.33,97,,,percent of total billed charges,97% of total billed charges,248.04,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,267.33,97,,,percent of total billed charges,97% of total billed charges,256.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.05,267.33,
58300- Insertion/intrauterine device,3431410,CDM,360,RC,58300,HCPCS,Outpatient,,,95.88,47.94,,86.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,76.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.29,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,61.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,75.41,78.65,,,percent of total billed charges,78.65% of total billed charges,85.65,89.33,,,percent of total billed charges,89.33% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.12,70,,,percent of total billed charges,70% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,91.09,95,,,percent of total billed charges,95% of total billed charges,91.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.46,86,,,percent of total billed charges,86% of total billed charges,76.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93,97,,,percent of total billed charges,97% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93,97,,,percent of total billed charges,97% of total billed charges,89.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,93,
AMB IUD Admin Charge:Insert Intrauterine Device 58300,3444234,CDM,510,RC,58300,HCPCS,Outpatient,,,95.88,47.94,,86.29,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,76.7,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.29,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,61.23,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,75.41,78.65,,,percent of total billed charges,78.65% of total billed charges,85.65,89.33,,,percent of total billed charges,89.33% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.12,70,,,percent of total billed charges,70% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,91.09,95,,,percent of total billed charges,95% of total billed charges,91.09,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.46,86,,,percent of total billed charges,86% of total billed charges,76.7,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93,97,,,percent of total billed charges,97% of total billed charges,86.29,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93,97,,,percent of total billed charges,97% of total billed charges,89.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.25,93,
58301- Remove intrauterine device,3431411,CDM,360,RC,58301,HCPCS,Outpatient,,,1312.71,656.36,,1181.44,90,,,percent of total billed charges,90% of total Billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1050.17,80,,,Percent of total Billed charges,80% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1181.44,90,,,Percent of total Billed charges,90% of total billed charges,18.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1273.33,97,,,Percent of total billed charges,97% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1207.69,92,,,Percent of total billed charges,92% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,704.86,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,265.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1123.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1423.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1181.44,90,,,percent of total billed charges,90% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,918.9,70,,,percent of total billed charges,70% of total billed charges,1181.44,90,,,percent of total billed charges,90% of total billed charges,1247.07,95,,,percent of total billed charges,95% of total billed charges,1247.07,95,,,percent of total billed charges,95% of total billed charges,265.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,530.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1128.93,86,,,percent of total billed charges,86% of total billed charges,1050.17,80,,,percent of total billed charges,80% of total billed charges,279.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1273.33,97,,,percent of total billed charges,97% of total billed charges,1181.44,90,,,percent of total billed charges,90% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,1273.33,97,,,percent of total billed charges,97% of total billed charges,1220.82,93,,,percent of total billed charges,93% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1273.33,97,,,percent of total billed charges,97% of total billed charges,265.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,225.39,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.25,1423.34,
Clinic NST,3428544,CDM,920,RC,59025,HCPCS,Outpatient,,,890.47,445.24,,801.42,90,,,percent of total billed charges,90% of total Billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,712.38,80,,,Percent of total Billed charges,80% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,801.42,90,,,Percent of total Billed charges,90% of total billed charges,5.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,863.76,97,,,Percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,819.23,92,,,Percent of total billed charges,92% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,430.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.59,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,868.4,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,801.42,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,623.33,70,,,percent of total billed charges,70% of total billed charges,801.42,90,,,percent of total billed charges,90% of total billed charges,845.95,95,,,percent of total billed charges,95% of total billed charges,845.95,95,,,percent of total billed charges,95% of total billed charges,161.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,765.8,86,,,percent of total billed charges,86% of total billed charges,712.38,80,,,percent of total billed charges,80% of total billed charges,171.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,863.76,97,,,percent of total billed charges,97% of total billed charges,801.42,90,,,percent of total billed charges,90% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,863.76,97,,,percent of total billed charges,97% of total billed charges,828.14,93,,,percent of total billed charges,93% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.72,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,863.76,97,,,percent of total billed charges,97% of total billed charges,161.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,161.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,137.52,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4.72,868.4,
"59300 - Episiotomy or vaginal repair, by other than attending",4037736,CDM,983,RC,59300,HCPCS,Outpatient,,,207.66,103.83,,186.89,90,,,percent of total billed charges,90% of total Billed charges,357.52,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,132.94,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195.73,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,220.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,220.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,229.8,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,143.53,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,299.72,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,207.66,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,200.3,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,232.28,155,,,Fee Schedule,155% of CMS OPPS Rate,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.16,155,,,Fee Schedule,155% of CMS OPPS Rate,554.16,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,187.23,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,149.86,100,,,Fee Schedule,100% of CMS OPPS Rate ,389.64,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,389.64,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,132.94,554.16,
60300- Thyroid cyst/aspiration and/or inj,3431285,CDM,361,RC,60300,HCPCS,Outpatient,,,3070.13,1535.07,,2763.12,90,,,percent of total billed charges,90% of total Billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2456.1,80,,,Percent of total Billed charges,80% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2763.12,90,,,Percent of total Billed charges,90% of total billed charges,40.49,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2978.03,97,,,Percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2824.52,92,,,Percent of total billed charges,92% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,1566.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2497.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3163.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2763.12,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,2149.09,70,,,percent of total billed charges,70% of total billed charges,2763.12,90,,,percent of total billed charges,90% of total billed charges,2916.62,95,,,percent of total billed charges,95% of total billed charges,2916.62,95,,,percent of total billed charges,95% of total billed charges,589.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1178.85,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2640.31,86,,,percent of total billed charges,86% of total billed charges,2456.1,80,,,percent of total billed charges,80% of total billed charges,630.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2978.03,97,,,percent of total billed charges,97% of total billed charges,2763.12,90,,,percent of total billed charges,90% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,2978.03,97,,,percent of total billed charges,97% of total billed charges,2855.22,93,,,percent of total billed charges,93% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2978.03,97,,,percent of total billed charges,97% of total billed charges,589.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.42,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,501.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.81,3163.8,
Clinic Lumbar Puncture,3435540,CDM,510,RC,62270,HCPCS,Outpatient,,,2928.85,1464.43,,2635.97,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2343.08,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2635.97,90,,,Percent of total Billed charges,90% of total billed charges,46.2,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2840.98,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2694.54,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2635.97,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,2050.2,70,,,percent of total billed charges,70% of total billed charges,2635.97,90,,,percent of total billed charges,90% of total billed charges,2782.41,95,,,percent of total billed charges,95% of total billed charges,2782.41,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2518.81,86,,,percent of total billed charges,86% of total billed charges,2343.08,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2840.98,97,,,percent of total billed charges,97% of total billed charges,2635.97,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,2840.98,97,,,percent of total billed charges,97% of total billed charges,2723.83,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,42,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2840.98,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,42,3141.23,
64425- Inj/anest/ilioing/hypogastric nerv,3435387,CDM,510,RC,64425,HCPCS,Outpatient,,,135.82,67.91,,122.24,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,108.66,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,122.24,90,,,Percent of total Billed charges,90% of total billed charges,38.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,131.75,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,124.95,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,122.24,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,95.07,70,,,percent of total billed charges,70% of total billed charges,122.24,90,,,percent of total billed charges,90% of total billed charges,129.03,95,,,percent of total billed charges,95% of total billed charges,129.03,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,116.81,86,,,percent of total billed charges,86% of total billed charges,108.66,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,131.75,97,,,percent of total billed charges,97% of total billed charges,122.24,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,131.75,97,,,percent of total billed charges,97% of total billed charges,126.31,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.75,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,35,3141.23,
64450- Inj/anesth/other perph nerv/branch,3435391,CDM,360,RC,64450,HCPCS,Outpatient,,,80.55,40.28,,72.5,90,,,percent of total billed charges,90% of total Billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,64.44,80,,,Percent of total Billed charges,80% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.5,90,,,Percent of total Billed charges,90% of total billed charges,23.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,78.13,97,,,Percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,74.11,92,,,Percent of total billed charges,92% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,1555.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2479.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3141.23,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,72.5,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,56.39,70,,,percent of total billed charges,70% of total billed charges,72.5,90,,,percent of total billed charges,90% of total billed charges,76.52,95,,,percent of total billed charges,95% of total billed charges,76.52,95,,,percent of total billed charges,95% of total billed charges,585.22,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1170.45,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,69.27,86,,,percent of total billed charges,86% of total billed charges,64.44,80,,,percent of total billed charges,80% of total billed charges,646.21,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,78.13,97,,,percent of total billed charges,97% of total billed charges,72.5,90,,,percent of total billed charges,90% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.13,97,,,percent of total billed charges,97% of total billed charges,74.91,93,,,percent of total billed charges,93% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,21,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,78.13,97,,,percent of total billed charges,97% of total billed charges,585.22,100,,,Fee Schedule,100% of CMS OPPS Rate ,585.22,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,497.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21,3141.23,
Clinic PNE,3550634,CDM,510,RC,64561,HCPCS,Outpatient,,,32010.38,16005.19,,28809.34,90,,,percent of total billed charges,90% of total Billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,25608.3,80,,,Percent of total Billed charges,80% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,28809.34,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31050.07,97,,,Percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,29449.55,92,,,Percent of total billed charges,92% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,15943.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25417.11,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32194.6,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,28809.34,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,22407.27,70,,,percent of total billed charges,70% of total billed charges,28809.34,90,,,percent of total billed charges,90% of total billed charges,30409.86,95,,,percent of total billed charges,95% of total billed charges,30409.86,95,,,percent of total billed charges,95% of total billed charges,5998.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11996.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,27528.93,86,,,percent of total billed charges,86% of total billed charges,25608.3,80,,,percent of total billed charges,80% of total billed charges,6396.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,31050.07,97,,,percent of total billed charges,97% of total billed charges,28809.34,90,,,percent of total billed charges,90% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31050.07,97,,,percent of total billed charges,97% of total billed charges,29769.65,93,,,percent of total billed charges,93% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,31050.07,97,,,percent of total billed charges,97% of total billed charges,5998.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,5998.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5098.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5098.3,32194.6,
64595- Rev/rmv prph sac/gstr npgr,3621302,CDM,510,RC,64595,HCPCS,Outpatient,,,255.06,127.53,,229.55,90,,,percent of total billed charges,90% of total Billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,204.05,80,,,Percent of total Billed charges,80% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,247.41,97,,,Percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,234.66,92,,,Percent of total billed charges,92% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,7840.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12499.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,15832.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,229.55,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,178.54,70,,,percent of total billed charges,70% of total billed charges,229.55,90,,,percent of total billed charges,90% of total billed charges,242.31,95,,,percent of total billed charges,95% of total billed charges,242.31,95,,,percent of total billed charges,95% of total billed charges,2949.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5899.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,219.35,86,,,percent of total billed charges,86% of total billed charges,204.05,80,,,percent of total billed charges,80% of total billed charges,3255.15,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,247.41,97,,,percent of total billed charges,97% of total billed charges,229.55,90,,,percent of total billed charges,90% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.41,97,,,percent of total billed charges,97% of total billed charges,237.21,93,,,percent of total billed charges,93% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,247.41,97,,,percent of total billed charges,97% of total billed charges,2949.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,2949.73,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2507.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,178.54,15832.85,
64612- Chemodenerv/facial nerv musc/uni,3435409,CDM,510,RC,64612,HCPCS,Outpatient,,,1495.66,747.83,,1346.09,90,,,percent of total billed charges,90% of total Billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1196.53,80,,,Percent of total Billed charges,80% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1346.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1450.79,97,,,Percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1376.01,92,,,Percent of total billed charges,92% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,656.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1046.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1325.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1346.09,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,1046.96,70,,,percent of total billed charges,70% of total billed charges,1346.09,90,,,percent of total billed charges,90% of total billed charges,1420.88,95,,,percent of total billed charges,95% of total billed charges,1420.88,95,,,percent of total billed charges,95% of total billed charges,246.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,493.89,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1286.27,86,,,percent of total billed charges,86% of total billed charges,1196.53,80,,,percent of total billed charges,80% of total billed charges,270.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1450.79,97,,,percent of total billed charges,97% of total billed charges,1346.09,90,,,percent of total billed charges,90% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,1450.79,97,,,percent of total billed charges,97% of total billed charges,1390.96,93,,,percent of total billed charges,93% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1450.79,97,,,percent of total billed charges,97% of total billed charges,246.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,209.89,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,209.89,1450.79,
65220- Removal/FB/corneal/slit lamp,3431305,CDM,510,RC,65220,HCPCS,Outpatient,,,2012.04,1006.02,,1810.84,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1609.63,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1810.84,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1951.68,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1851.08,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1810.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1408.43,70,,,percent of total billed charges,70% of total billed charges,1810.84,90,,,percent of total billed charges,90% of total billed charges,1911.44,95,,,percent of total billed charges,95% of total billed charges,1911.44,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1730.35,86,,,percent of total billed charges,86% of total billed charges,1609.63,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1951.68,97,,,percent of total billed charges,97% of total billed charges,1810.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.68,97,,,percent of total billed charges,97% of total billed charges,1871.2,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1951.68,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,1951.68,
65222- Rmv FB/extern eye/cornea/slit lamp,3431306,CDM,510,RC,65222,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,28.6,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26,625.71,
67700- Drainage of eyelid abscess,3431315,CDM,510,RC,67700,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
67800- Excision of chalazion/single,3431316,CDM,510,RC,67800,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
"67801 Excision of chalazion; multiple, same lid",3621303,CDM,510,RC,67801,HCPCS,Outpatient,,,5112.59,2556.30,,4601.33,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4090.07,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4601.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4959.21,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4703.58,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3578.81,70,,,percent of total billed charges,70% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4396.83,86,,,percent of total billed charges,86% of total billed charges,4090.07,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4959.21,97,,,percent of total billed charges,97% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4959.21,97,,,percent of total billed charges,97% of total billed charges,4754.71,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4959.21,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,4959.21,
67805- EXCIS CHALAZION MULT BOTH,3431317,CDM,510,RC,67805,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
67810- Incisional biopsy/eyelid,3586925,CDM,983,RC,67810,HCPCS,Outpatient,,,281.89,140.95,,253.7,90,,,percent of total billed charges,90% of total Billed charges,237.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.43,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,121.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,121.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,104.25,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,61.01,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,131.36,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,123,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,77.23,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,101.8,155,,,Fee Schedule,155% of CMS OPPS Rate,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,368.22,155,,,Fee Schedule,155% of CMS OPPS Rate,368.22,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,238.84,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.28,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,422.28,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,61.01,422.28,
67820- Revise eyelashes,3431319,CDM,510,RC,67820,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,625.71,
67840-EYE RMV EYELID LESION -NOT CHAL,3430499,CDM,510,RC,67840,HCPCS,Outpatient,,,5112.59,2556.30,,4601.33,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4090.07,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4601.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4959.21,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4703.58,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3578.81,70,,,percent of total billed charges,70% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4396.83,86,,,percent of total billed charges,86% of total billed charges,4090.07,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4959.21,97,,,percent of total billed charges,97% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4959.21,97,,,percent of total billed charges,97% of total billed charges,4754.71,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4959.21,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,4959.21,
67840-OCC Exc eyelid lesion/excpt chalazion,3536978,CDM,983,RC,67840,HCPCS,Outpatient,,,302.45,151.23,,272.21,90,,,percent of total billed charges,90% of total Billed charges,409.11,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.95,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.95,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,226.47,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,124.6,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,295.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,267.23,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,161.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,228.8,155,,,Fee Schedule,155% of CMS OPPS Rate,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,634.12,155,,,Fee Schedule,155% of CMS OPPS Rate,634.12,155,,,Fee Schedule,155% of CMS CUSTOMIZED Fee Schedule,,,,,Other,Not Separately reimbursable,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,566.75,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,147.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,535.84,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,535.84,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,124.6,634.12,
67850- Destruction/lid lesion/up to 1 cm,3431321,CDM,510,RC,67850,HCPCS,Outpatient,,,5112.59,2556.30,,4601.33,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4090.07,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4601.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4959.21,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4703.58,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3578.81,70,,,percent of total billed charges,70% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4396.83,86,,,percent of total billed charges,86% of total billed charges,4090.07,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4959.21,97,,,percent of total billed charges,97% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4959.21,97,,,percent of total billed charges,97% of total billed charges,4754.71,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4959.21,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,4959.21,
67875- Temp eyelid closure/suture,3431322,CDM,510,RC,67875,HCPCS,Outpatient,,,5112.59,2556.30,,4601.33,90,,,percent of total billed charges,90% of total Billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4090.07,80,,,Percent of total Billed charges,80% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4601.33,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4959.21,97,,,Percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,4703.58,92,,,Percent of total billed charges,92% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,2106.78,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3358.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4254.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,3578.81,70,,,percent of total billed charges,70% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,4856.96,95,,,percent of total billed charges,95% of total billed charges,792.58,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1585.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4396.83,86,,,percent of total billed charges,86% of total billed charges,4090.07,80,,,percent of total billed charges,80% of total billed charges,834.3,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,4959.21,97,,,percent of total billed charges,97% of total billed charges,4601.33,90,,,percent of total billed charges,90% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,4959.21,97,,,percent of total billed charges,97% of total billed charges,4754.71,93,,,percent of total billed charges,93% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,4959.21,97,,,percent of total billed charges,97% of total billed charges,792.58,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.58,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,673.69,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,673.69,4959.21,
67880- Revision of eyelid,3431323,CDM,510,RC,67880,HCPCS,Outpatient,,,11800.34,5900.17,,10620.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.27,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.33,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.31,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.24,70,,,percent of total billed charges,70% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.29,86,,,percent of total billed charges,86% of total billed charges,9440.27,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.33,97,,,percent of total billed charges,97% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.33,97,,,percent of total billed charges,97% of total billed charges,10974.32,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.33,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.33,
67903 -OCC Blepharoptosis/levator resct/int,3548670,CDM,510,RC,67903,HCPCS,Outpatient,,,304.79,152.40,,274.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,243.83,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,274.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,295.65,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,280.41,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,274.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,213.35,70,,,percent of total billed charges,70% of total billed charges,274.31,90,,,percent of total billed charges,90% of total billed charges,289.55,95,,,percent of total billed charges,95% of total billed charges,289.55,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,262.12,86,,,percent of total billed charges,86% of total billed charges,243.83,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,295.65,97,,,percent of total billed charges,97% of total billed charges,274.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.65,97,,,percent of total billed charges,97% of total billed charges,283.45,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,295.65,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,213.35,10307.08,
67909- Revise eyelid defect,3431327,CDM,510,RC,67909,HCPCS,Outpatient,,,11800.34,5900.17,,10620.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.27,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.33,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.31,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.24,70,,,percent of total billed charges,70% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.29,86,,,percent of total billed charges,86% of total billed charges,9440.27,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.33,97,,,percent of total billed charges,97% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.33,97,,,percent of total billed charges,97% of total billed charges,10974.32,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.33,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.33,
67935- Eyelid/recent wound sut/full thick,3431332,CDM,510,RC,67935,HCPCS,Outpatient,,,11800.34,5900.17,,10620.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.27,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.33,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.31,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.24,70,,,percent of total billed charges,70% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.29,86,,,percent of total billed charges,86% of total billed charges,9440.27,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.33,97,,,percent of total billed charges,97% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.33,97,,,percent of total billed charges,97% of total billed charges,10974.32,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.33,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.33,
67938- Removal of embedded FB/eyelid,3431333,CDM,510,RC,67938,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
67961- Exc/rpr eyelid/to 1/4 lid margin,3431335,CDM,510,RC,67961,HCPCS,Outpatient,,,11800.34,5900.17,,10620.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.27,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.33,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.31,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.24,70,,,percent of total billed charges,70% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.29,86,,,percent of total billed charges,86% of total billed charges,9440.27,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.33,97,,,percent of total billed charges,97% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.33,97,,,percent of total billed charges,97% of total billed charges,10974.32,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.33,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.33,
68761- Close lacrimal punctum/plug/each,3431340,CDM,510,RC,68761,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
68801- Dilation of lacrimal punctum,3431341,CDM,510,RC,68801,HCPCS,Outpatient,,,2012.04,1006.02,,1810.84,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1609.63,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1810.84,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1951.68,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1851.08,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1810.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1408.43,70,,,percent of total billed charges,70% of total billed charges,1810.84,90,,,percent of total billed charges,90% of total billed charges,1911.44,95,,,percent of total billed charges,95% of total billed charges,1911.44,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1730.35,86,,,percent of total billed charges,86% of total billed charges,1609.63,80,,,percent of total billed charges,80% of total billed charges,375.9,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1951.68,97,,,percent of total billed charges,97% of total billed charges,1810.84,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1951.68,97,,,percent of total billed charges,97% of total billed charges,1871.2,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1951.68,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,291.49,1951.68,
"68811 - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia",3699550,CDM,510,RC,68811,HCPCS,Outpatient,,,11800.34,5900.17,,10620.31,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.27,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.33,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.31,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.24,70,,,percent of total billed charges,70% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,11210.32,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.29,86,,,percent of total billed charges,86% of total billed charges,9440.27,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.33,97,,,percent of total billed charges,97% of total billed charges,10620.31,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.33,97,,,percent of total billed charges,97% of total billed charges,10974.32,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.33,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.33,
68815- Probe/nasolacrimal/tube/stent,3431342,CDM,510,RC,68815,HCPCS,Outpatient,,,11800.4,5900.20,,10620.36,90,,,percent of total billed charges,90% of total Billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9440.32,80,,,Percent of total Billed charges,80% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,10620.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,11446.39,97,,,Percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,10856.37,92,,,Percent of total billed charges,92% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,5104.28,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8137.27,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10307.08,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,10620.36,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,8260.28,70,,,percent of total billed charges,70% of total billed charges,10620.36,90,,,percent of total billed charges,90% of total billed charges,11210.38,95,,,percent of total billed charges,95% of total billed charges,11210.38,95,,,percent of total billed charges,95% of total billed charges,1920.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3840.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,10148.34,86,,,percent of total billed charges,86% of total billed charges,9440.32,80,,,percent of total billed charges,80% of total billed charges,2000.75,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,11446.39,97,,,percent of total billed charges,97% of total billed charges,10620.36,90,,,percent of total billed charges,90% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,11446.39,97,,,percent of total billed charges,97% of total billed charges,10974.37,93,,,percent of total billed charges,93% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,11446.39,97,,,percent of total billed charges,97% of total billed charges,1920.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,1920.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1632.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1632.21,11446.39,
68840- Probe lacrimal canaliculi,3431343,CDM,510,RC,68840,HCPCS,Outpatient,,,1471.07,735.54,,1323.96,90,,,percent of total billed charges,90% of total Billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1176.86,80,,,Percent of total Billed charges,80% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1323.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1426.94,97,,,Percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1353.38,92,,,Percent of total billed charges,92% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,639.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1018.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1290.49,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,1029.75,70,,,percent of total billed charges,70% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,1397.52,95,,,percent of total billed charges,95% of total billed charges,240.41,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,480.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1265.12,86,,,percent of total billed charges,86% of total billed charges,1176.86,80,,,percent of total billed charges,80% of total billed charges,279.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1426.94,97,,,percent of total billed charges,97% of total billed charges,1323.96,90,,,percent of total billed charges,90% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.94,97,,,percent of total billed charges,97% of total billed charges,1368.1,93,,,percent of total billed charges,93% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1426.94,97,,,percent of total billed charges,97% of total billed charges,240.41,100,,,Fee Schedule,100% of CMS OPPS Rate ,240.41,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,204.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,204.35,1426.94,
69100- Biopsy external ear,3430622,CDM,510,RC,69100,HCPCS,Outpatient,,,1233.47,616.74,,1110.12,90,,,percent of total billed charges,90% of total Billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,986.78,80,,,Percent of total Billed charges,80% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1110.12,90,,,Percent of total Billed charges,90% of total billed charges,45.86,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1196.47,97,,,Percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,1134.79,92,,,Percent of total billed charges,92% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,501.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,799.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1013.19,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1110.12,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,863.43,70,,,percent of total billed charges,70% of total billed charges,1110.12,90,,,percent of total billed charges,90% of total billed charges,1171.8,95,,,percent of total billed charges,95% of total billed charges,1171.8,95,,,percent of total billed charges,95% of total billed charges,188.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,377.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1060.78,86,,,percent of total billed charges,86% of total billed charges,986.78,80,,,percent of total billed charges,80% of total billed charges,210.53,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1196.47,97,,,percent of total billed charges,97% of total billed charges,1110.12,90,,,percent of total billed charges,90% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,1196.47,97,,,percent of total billed charges,97% of total billed charges,1147.13,93,,,percent of total billed charges,93% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1196.47,97,,,percent of total billed charges,97% of total billed charges,188.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,160.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.69,1196.47,
WW Chest single view AP or PA,3373170,CDM,972,RC,71045,HCPCS,Outpatient,,,48.89,24.45,,44,90,,,percent of total billed charges,90% of total Billed charges,30.55,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.48,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,21.41,155,,,Fee Schedule,155% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,49.44,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,49.44,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,35.22,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,17.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,23.85,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.41,140,,,Fee Schedule,140% of CMS OPPS Rate,42.77,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,15.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,21.22,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,15.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.29,49.44,
WW Chest PA and Lat:WW DR Exam,3373168,CDM,972,RC,71046,HCPCS,Outpatient,,,54.81,27.41,,49.33,90,,,percent of total billed charges,90% of total Billed charges,41.13,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.74,155,,,Fee Schedule,155% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.17,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,63.17,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,44.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.61,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.74,140,,,Fee Schedule,140% of CMS OPPS Rate,57.58,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.43,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.53,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.53,63.17,
WW Hand Rt AP Lat & Oblique,3373218,CDM,972,RC,73130,HCPCS,Outpatient,,,66.64,33.32,,59.98,90,,,percent of total billed charges,90% of total Billed charges,50.25,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,155,,,Fee Schedule,155% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.83,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.29,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,67.29,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,47.21,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,24.55,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,50.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.71,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.28,140,,,Fee Schedule,140% of CMS OPPS Rate,70.35,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.08,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,25.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,61.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,24.55,70.35,
WW Knee Rt Series,3373252,CDM,972,RC,73564,HCPCS,Outpatient,,,84.01,42.01,,75.61,90,,,percent of total billed charges,90% of total Billed charges,62.91,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,155,,,Fee Schedule,155% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.09,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,84.46,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,84.46,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,59.19,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,31.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,62.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.85,140,,,Fee Schedule,140% of CMS OPPS Rate,88.07,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,48,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,31.32,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.58,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,82.58,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,31.32,88.07,
CT Abdomen Pelvis ENH no oral,3351172,CDM,350,RC,74177,HCPCS,Outpatient,,,1816.78,908.39,,1635.1,90,,,percent of total billed charges,90% of total Billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,478.98,250,,,Fee Schedule,250% of Fee Schedule Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1635.1,90,,,Percent of total Billed charges,90% of total billed charges,212,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1762.28,97,,,Percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1671.44,92,,,Percent of total billed charges,92% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,889.48,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1418.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1796.13,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1635.1,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,1271.75,70,,,percent of total billed charges,70% of total billed charges,1635.1,90,,,percent of total billed charges,90% of total billed charges,1725.94,95,,,percent of total billed charges,95% of total billed charges,1725.94,95,,,percent of total billed charges,95% of total billed charges,334.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,669.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1562.43,86,,,percent of total billed charges,86% of total billed charges,1453.42,80,,,percent of total billed charges,80% of total billed charges,394.78,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1762.28,97,,,percent of total billed charges,97% of total billed charges,1635.1,90,,,percent of total billed charges,90% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,1762.28,97,,,percent of total billed charges,97% of total billed charges,1689.61,93,,,percent of total billed charges,93% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,192.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1762.28,97,,,percent of total billed charges,97% of total billed charges,334.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,334.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,284.43,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,192.73,1796.13,
"74740 - PB Tech - Hysterosalpingography, radiological supervision and interpretation",3640902,CDM,510,RC,74740,HCPCS,Outpatient,,,189.82,94.91,,170.84,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,133.7,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.84,90,,,Percent of total Billed charges,90% of total billed charges,29.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.13,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,174.63,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.84,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,132.87,70,,,percent of total billed charges,70% of total billed charges,170.84,90,,,percent of total billed charges,90% of total billed charges,180.33,95,,,percent of total billed charges,95% of total billed charges,180.33,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.25,86,,,percent of total billed charges,86% of total billed charges,151.86,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.13,97,,,percent of total billed charges,97% of total billed charges,170.84,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.13,97,,,percent of total billed charges,97% of total billed charges,176.53,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.13,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.5,1138.43,
75565- Cardiac MRI for velocity flow mapping,3569427,CDM,510,RC,75565,HCPCS,Outpatient,,,87.65,43.83,,78.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,86.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,85.02,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,80.64,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,55.98,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,68.94,78.65,,,percent of total billed charges,78.65% of total billed charges,78.3,89.33,,,percent of total billed charges,89.33% of total billed charges,78.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.36,70,,,percent of total billed charges,70% of total billed charges,78.89,90,,,percent of total billed charges,90% of total billed charges,83.27,95,,,percent of total billed charges,95% of total billed charges,83.27,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75.38,86,,,percent of total billed charges,86% of total billed charges,70.12,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,85.02,97,,,percent of total billed charges,97% of total billed charges,78.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,85.02,97,,,percent of total billed charges,97% of total billed charges,81.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85.02,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.98,86.88,
"75605- Aortography/thor, serialogrph,radio sup& intp",3569425,CDM,510,RC,75605,HCPCS,Outpatient,,,161.71,80.86,,145.54,90,,,percent of total billed charges,90% of total Billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,165.15,250,,,Fee Schedule,250% of Fee Schedule Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.54,90,,,Percent of total Billed charges,90% of total billed charges,30.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,156.86,97,,,Percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,148.77,92,,,Percent of total billed charges,92% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,12408.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,19782.08,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,25056.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,145.54,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,113.2,70,,,percent of total billed charges,70% of total billed charges,145.54,90,,,percent of total billed charges,90% of total billed charges,153.62,95,,,percent of total billed charges,95% of total billed charges,153.62,95,,,percent of total billed charges,95% of total billed charges,4668.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,9336.47,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,139.07,86,,,percent of total billed charges,86% of total billed charges,129.37,80,,,percent of total billed charges,80% of total billed charges,4751.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,156.86,97,,,percent of total billed charges,97% of total billed charges,145.54,90,,,percent of total billed charges,90% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.86,97,,,percent of total billed charges,97% of total billed charges,150.39,93,,,percent of total billed charges,93% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,156.86,97,,,percent of total billed charges,97% of total billed charges,4668.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4668.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3968,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.5,25056.98,
"75630 - PF - Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialo",3640904,CDM,510,RC,75630,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.98,15613.27,
Peripheral Angio Aortagram w Runoff,3427191,CDM,320,RC,75630,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,164.4,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,170.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,154.98,15613.27,
"75710 - Angiography, extremity, unilateral, radiological supervision and interpretation",3640905,CDM,510,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15613.27,
Peripheral Angio Lower Extremity LT,3427218,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15613.27,
Peripheral Angio Lower Extremity RT,3427219,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15613.27,
Peripheral Angio Tibal Peroneal,3427225,CDM,320,RC,75710,HCPCS,Outpatient,,,16096.15,8048.08,,14486.54,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,14486.54,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,15613.27,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,14808.46,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,11267.31,70,,,percent of total billed charges,70% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,15291.34,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,13842.69,86,,,percent of total billed charges,86% of total billed charges,12876.92,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15613.27,97,,,percent of total billed charges,97% of total billed charges,14486.54,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,15613.27,97,,,percent of total billed charges,97% of total billed charges,14969.42,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,15613.27,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,15613.27,
"75822 - Venography, extremity, bilateral, radiological supervision and interpretation",3761052,CDM,320,RC,75822,HCPCS,Outpatient,,,155.86,77.93,,140.27,90,,,percent of total billed charges,90% of total Billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,250,,,Fee Schedule,250% of Fee Schedule Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,140.27,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,151.18,97,,,Percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,143.39,92,,,Percent of total billed charges,92% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,3592.06,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5726.48,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,7253.45,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,140.27,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,109.1,70,,,percent of total billed charges,70% of total billed charges,140.27,90,,,percent of total billed charges,90% of total billed charges,148.07,95,,,percent of total billed charges,95% of total billed charges,148.07,95,,,percent of total billed charges,95% of total billed charges,1351.35,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2702.7,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,134.04,86,,,percent of total billed charges,86% of total billed charges,124.69,80,,,percent of total billed charges,80% of total billed charges,1686.38,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,151.18,97,,,percent of total billed charges,97% of total billed charges,140.27,90,,,percent of total billed charges,90% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.18,97,,,percent of total billed charges,97% of total billed charges,144.95,93,,,percent of total billed charges,93% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,151.18,97,,,percent of total billed charges,97% of total billed charges,1351.35,100,,,Fee Schedule,100% of CMS OPPS Rate ,1351.35,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1148.64,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,7253.45,
75825 - Venography caval inferior w/ serial,4241822,CDM,510,RC,75825,HCPCS,Outpatient,,,93.86,46.93,,84.47,90,,,percent of total billed charges,90% of total Billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,157.68,250,,,Fee Schedule,250% of Fee Schedule Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.47,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,91.04,97,,,Percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,86.35,92,,,Percent of total billed charges,92% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,7192.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11465.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14522.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,84.47,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,65.7,70,,,percent of total billed charges,70% of total billed charges,84.47,90,,,percent of total billed charges,90% of total billed charges,89.17,95,,,percent of total billed charges,95% of total billed charges,89.17,95,,,percent of total billed charges,95% of total billed charges,2705.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5411.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,80.72,86,,,percent of total billed charges,86% of total billed charges,75.09,80,,,percent of total billed charges,80% of total billed charges,2865.16,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,91.04,97,,,percent of total billed charges,97% of total billed charges,84.47,90,,,percent of total billed charges,90% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.04,97,,,percent of total billed charges,97% of total billed charges,87.29,93,,,percent of total billed charges,93% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,91.04,97,,,percent of total billed charges,97% of total billed charges,2705.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2705.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2299.82,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.5,14522.85,
75894 XR Transcatheter Embolization Any Meth RS&I,3436057,CDM,761,RC,75894,HCPCS,Outpatient,,,5431,2715.50,,4887.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2102.5,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,4887.9,90,,,Percent of total Billed charges,90% of total billed charges,103.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5268.07,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4996.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,3468.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,4271.6,78.65,,,percent of total billed charges,78.65% of total billed charges,4851.6,89.33,,,percent of total billed charges,89.33% of total billed charges,4887.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3801.7,70,,,percent of total billed charges,70% of total billed charges,4887.9,90,,,percent of total billed charges,90% of total billed charges,5159.45,95,,,percent of total billed charges,95% of total billed charges,5159.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4670.66,86,,,percent of total billed charges,86% of total billed charges,4344.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5268.07,97,,,percent of total billed charges,97% of total billed charges,4887.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5268.07,97,,,percent of total billed charges,97% of total billed charges,5050.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.04,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5268.07,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94.04,5268.07,
75957-ENDOVASCULAR TAA REPAIR INTERP,3430924,CDM,510,RC,75957,HCPCS,Outpatient,,,777.51,388.76,,699.76,90,,,percent of total billed charges,90% of total Billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,622.01,80,,,Percent of total Billed charges,80% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,699.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,754.18,97,,,Percent of total billed charges,97% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,715.31,92,,,Percent of total billed charges,92% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,699.76,90,,,percent of total billed charges,90% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.26,70,,,percent of total billed charges,70% of total billed charges,699.76,90,,,percent of total billed charges,90% of total billed charges,738.63,95,,,percent of total billed charges,95% of total billed charges,738.63,95,,,percent of total billed charges,95% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,668.66,86,,,percent of total billed charges,86% of total billed charges,622.01,80,,,percent of total billed charges,80% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,754.18,97,,,percent of total billed charges,97% of total billed charges,699.76,90,,,percent of total billed charges,90% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,754.18,97,,,percent of total billed charges,97% of total billed charges,723.08,93,,,percent of total billed charges,93% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,,,,,Other,Not Separately reimbursable,754.18,97,,,percent of total billed charges,97% of total billed charges,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,777.51,100,,,Fee Schedule,Pays at line item charges due to Status Indicator C on the CMS APC fee schedule,544.26,777.51,
SCMP US Guided Fine Needle Asp. Thyroid,3370908,CDM,972,RC,76536,HCPCS,Outpatient,,,534.4,267.20,,480.96,90,,,percent of total billed charges,90% of total Billed charges,150.28,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.35,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,103.82,155,,,Fee Schedule,155% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,208.96,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,235.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,235.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,156.89,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,93.42,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,127.04,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.82,140,,,Fee Schedule,140% of CMS OPPS Rate,210.39,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.35,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,105,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,74.16,100,,,Fee Schedule,100% of CMS OPPS Rate ,228.08,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,228.08,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,74.16,480.96,
SCMP US Thyroid,3370915,CDM,402,RC,76536,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,554.06,
SCSN US Exam,4345735,CDM,402,RC,76536,HCPCS,Outpatient,,,534.4,267.20,,480.96,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.96,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,518.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,491.65,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,374.08,70,,,percent of total billed charges,70% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.58,86,,,percent of total billed charges,86% of total billed charges,427.52,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,518.37,97,,,percent of total billed charges,97% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.37,97,,,percent of total billed charges,97% of total billed charges,496.99,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,518.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
SCSN US Exam,4345741,CDM,402,RC,76536,HCPCS,Outpatient,,,534.4,267.20,,480.96,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,480.96,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,518.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,491.65,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,374.08,70,,,percent of total billed charges,70% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,507.68,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,459.58,86,,,percent of total billed charges,86% of total billed charges,427.52,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,518.37,97,,,percent of total billed charges,97% of total billed charges,480.96,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,518.37,97,,,percent of total billed charges,97% of total billed charges,496.99,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,518.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,521.05,
US Neck Including Thyroid,596513,CDM,402,RC,76536,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,56.08,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.98,554.06,
76641- US  breast complete,3430614,CDM,402,RC,76641,HCPCS,Outpatient,,,163.76,81.88,,147.38,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,147.38,90,,,Percent of total Billed charges,90% of total billed charges,58.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,158.85,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,150.66,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,147.38,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,114.63,70,,,percent of total billed charges,70% of total billed charges,147.38,90,,,percent of total billed charges,90% of total billed charges,155.57,95,,,percent of total billed charges,95% of total billed charges,155.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,140.83,86,,,percent of total billed charges,86% of total billed charges,131.01,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,158.85,97,,,percent of total billed charges,97% of total billed charges,147.38,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.85,97,,,percent of total billed charges,97% of total billed charges,152.3,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,158.85,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.43,521.05,
Read,3370897,CDM,402,RC,76641,HCPCS,Outpatient,,,537.19,268.60,,483.47,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,148.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,483.47,90,,,Percent of total Billed charges,90% of total billed charges,58.77,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,521.07,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,494.21,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,483.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,376.03,70,,,percent of total billed charges,70% of total billed charges,483.47,90,,,percent of total billed charges,90% of total billed charges,510.33,95,,,percent of total billed charges,95% of total billed charges,510.33,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,461.98,86,,,percent of total billed charges,86% of total billed charges,429.75,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,521.07,97,,,percent of total billed charges,97% of total billed charges,483.47,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,521.07,97,,,percent of total billed charges,97% of total billed charges,499.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.43,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,521.07,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,53.43,521.07,
SCMP US Breast L,3370898,CDM,972,RC,76641,HCPCS,Outpatient,,,537.19,268.60,,483.47,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,483.47,
SCMP US Breast R,3370900,CDM,972,RC,76641,HCPCS,Outpatient,,,537.19,268.60,,483.47,90,,,percent of total billed charges,90% of total Billed charges,122.04,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,155,,,Fee Schedule,155% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,192.99,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,217.06,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,217.06,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,146.61,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,92.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,120.92,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,102.4,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.64,140,,,Fee Schedule,140% of CMS OPPS Rate,170.86,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,113.98,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,60.46,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.46,483.47,
76642- US  breast limited,3430615,CDM,402,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limite Bilat Interp,3575276,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
SCSN US Breast Limited Bilat,3569759,CDM,401,RC,76642,HCPCS,Outpatient,,,250.14,125.07,,225.13,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.13,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,242.64,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225.13,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,175.1,70,,,percent of total billed charges,70% of total billed charges,225.13,90,,,percent of total billed charges,90% of total billed charges,237.63,95,,,percent of total billed charges,95% of total billed charges,237.63,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215.12,86,,,percent of total billed charges,86% of total billed charges,200.11,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,242.64,97,,,percent of total billed charges,97% of total billed charges,225.13,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.64,97,,,percent of total billed charges,97% of total billed charges,232.63,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.64,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited LT,3569761,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited RT,3569763,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast Limited RT Interp,3575280,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w Axilla Bilat,3569765,CDM,401,RC,76642,HCPCS,Outpatient,,,250.14,125.07,,225.13,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,225.13,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,242.64,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,230.13,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,225.13,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,175.1,70,,,percent of total billed charges,70% of total billed charges,225.13,90,,,percent of total billed charges,90% of total billed charges,237.63,95,,,percent of total billed charges,95% of total billed charges,237.63,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,215.12,86,,,percent of total billed charges,86% of total billed charges,200.11,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,242.64,97,,,percent of total billed charges,97% of total billed charges,225.13,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.64,97,,,percent of total billed charges,97% of total billed charges,232.63,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,242.64,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w axilla BILAT PR,3575282,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
SCSN US Breast w Axilla LT,3575284,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w Axilla LT,3575286,CDM,510,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w Axilla LT,3569767,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Breast w Axilla RT,3569769,CDM,401,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,112.56,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,121.32,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,115.06,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,87.55,70,,,percent of total billed charges,70% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,118.82,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,107.56,86,,,percent of total billed charges,86% of total billed charges,100.06,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,121.32,97,,,percent of total billed charges,97% of total billed charges,112.56,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.32,97,,,percent of total billed charges,97% of total billed charges,116.32,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,121.32,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
SCSN US Exam,3575278,CDM,972,RC,76642,HCPCS,Outpatient,,,125.07,62.54,,112.56,90,,,percent of total billed charges,90% of total Billed charges,93.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,155,,,Fee Schedule,155% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,157.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.53,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.53,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,120.71,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.07,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,92.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,77.75,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.06,140,,,Fee Schedule,140% of CMS OPPS Rate,130.9,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,94.12,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,46.47,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.47,177.53,
US Breast Left Limited,3318564,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,359.17,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.17,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,387.11,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,367.15,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,279.36,70,,,percent of total billed charges,70% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,343.21,86,,,percent of total billed charges,86% of total billed charges,319.26,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,387.11,97,,,percent of total billed charges,97% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.11,97,,,percent of total billed charges,97% of total billed charges,371.14,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.11,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
US Breast Right Limited,3318566,CDM,402,RC,76642,HCPCS,Outpatient,,,399.08,199.54,,359.17,90,,,percent of total billed charges,90% of total Billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,112.73,250,,,Fee Schedule,250% of Fee Schedule Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,359.17,90,,,Percent of total Billed charges,90% of total billed charges,45.03,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,387.11,97,,,Percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,367.15,92,,,Percent of total billed charges,92% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,209.75,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,334.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,423.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,279.36,70,,,percent of total billed charges,70% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,379.13,95,,,percent of total billed charges,95% of total billed charges,78.9,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.81,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,343.21,86,,,percent of total billed charges,86% of total billed charges,319.26,80,,,percent of total billed charges,80% of total billed charges,82.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,387.11,97,,,percent of total billed charges,97% of total billed charges,359.17,90,,,percent of total billed charges,90% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,387.11,97,,,percent of total billed charges,97% of total billed charges,371.14,93,,,percent of total billed charges,93% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,387.11,97,,,percent of total billed charges,97% of total billed charges,78.9,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.9,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,67.07,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.94,423.55,
76700- US abdommen complete,3430616,CDM,402,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,170.13,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.13,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,183.36,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,173.91,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132.32,70,,,percent of total billed charges,70% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,162.57,86,,,percent of total billed charges,86% of total billed charges,151.22,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.36,97,,,percent of total billed charges,97% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.36,97,,,percent of total billed charges,97% of total billed charges,175.8,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.36,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
SCSN US Abdomen Complete PR:SCSN US Exam,3575254,CDM,510,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,170.13,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.13,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,183.36,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,173.91,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132.32,70,,,percent of total billed charges,70% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,162.57,86,,,percent of total billed charges,86% of total billed charges,151.22,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.36,97,,,percent of total billed charges,97% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.36,97,,,percent of total billed charges,97% of total billed charges,175.8,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.36,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
SCSN US Abdomen Complete:SCSN US Exam,3555174,CDM,402,RC,76700,HCPCS,Outpatient,,,189.03,94.52,,170.13,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,170.13,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,183.36,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,173.91,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,132.32,70,,,percent of total billed charges,70% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,179.58,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,162.57,86,,,percent of total billed charges,86% of total billed charges,151.22,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,183.36,97,,,percent of total billed charges,97% of total billed charges,170.13,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,183.36,97,,,percent of total billed charges,97% of total billed charges,175.8,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,183.36,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,521.04,
US Abdomen Complete,596620,CDM,402,RC,76700,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,171.15,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,63.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,57.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.5,554.06,
76705 - (TC) Echo Exam of Abdomen -Limited,3897025,CDM,960,RC,76705,HCPCS,Outpatient,,,142.44,71.22,,128.2,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,200.55,
"76705 Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, qua",3715135,CDM,510,RC,76705,HCPCS,Outpatient,,,142.44,71.22,,128.2,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.2,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,138.17,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,131.04,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,128.2,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,99.71,70,,,percent of total billed charges,70% of total billed charges,128.2,90,,,percent of total billed charges,90% of total billed charges,135.32,95,,,percent of total billed charges,95% of total billed charges,135.32,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.5,86,,,percent of total billed charges,86% of total billed charges,113.95,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,138.17,97,,,percent of total billed charges,97% of total billed charges,128.2,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.17,97,,,percent of total billed charges,97% of total billed charges,132.47,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.17,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
SCMP US Abdomen,3370896,CDM,972,RC,76705,HCPCS,Outpatient,,,534.4,267.20,,480.96,90,,,percent of total billed charges,90% of total Billed charges,106.44,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,74.03,155,,,Fee Schedule,155% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,184.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,184.71,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.71,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,105.76,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,89.56,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.03,140,,,Fee Schedule,140% of CMS OPPS Rate,149.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,102.51,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,52.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,200.55,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,200.55,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,52.88,480.96,
SCSN US Exam,3575310,CDM,402,RC,76705,HCPCS,Outpatient,,,142.43,71.22,,128.19,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.19,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,138.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,131.04,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,128.19,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,99.7,70,,,percent of total billed charges,70% of total billed charges,128.19,90,,,percent of total billed charges,90% of total billed charges,135.31,95,,,percent of total billed charges,95% of total billed charges,135.31,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.49,86,,,percent of total billed charges,86% of total billed charges,113.94,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,138.16,97,,,percent of total billed charges,97% of total billed charges,128.19,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.16,97,,,percent of total billed charges,97% of total billed charges,132.46,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
SCSN US RUQ/GB Ultrasound,3370960,CDM,402,RC,76705,HCPCS,Outpatient,,,142.43,71.22,,128.19,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,128.19,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,138.16,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,131.04,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,128.19,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,99.7,70,,,percent of total billed charges,70% of total billed charges,128.19,90,,,percent of total billed charges,90% of total billed charges,135.31,95,,,percent of total billed charges,95% of total billed charges,135.31,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,122.49,86,,,percent of total billed charges,86% of total billed charges,113.94,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,138.16,97,,,percent of total billed charges,97% of total billed charges,128.19,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,138.16,97,,,percent of total billed charges,97% of total billed charges,132.46,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,138.16,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,521.04,
URMC US Abdomen,3358605,CDM,402,RC,76705,HCPCS,Outpatient,,,1633.23,816.62,,1469.91,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,129.95,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1469.91,90,,,Percent of total Billed charges,90% of total billed charges,41.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1584.23,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1502.57,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1469.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.26,70,,,percent of total billed charges,70% of total billed charges,1469.91,90,,,percent of total billed charges,90% of total billed charges,1551.57,95,,,percent of total billed charges,95% of total billed charges,1551.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1404.58,86,,,percent of total billed charges,86% of total billed charges,1306.58,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1584.23,97,,,percent of total billed charges,97% of total billed charges,1469.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1584.23,97,,,percent of total billed charges,97% of total billed charges,1518.9,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1584.23,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.5,1584.23,
76770- US abdomen back wall complete,3430617,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCMP US Aorta/ Retro,3563000,CDM,972,RC,76770,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,131.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,81.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,91.17,155,,,Fee Schedule,155% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,203.84,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,229.27,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,229.27,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,154.56,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,98.79,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,110.61,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.17,140,,,Fee Schedule,140% of CMS OPPS Rate,184.03,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,81.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,111,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,65.12,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.74,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.74,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,65.12,514.08,
SCMP US Exam,3575228,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Aorta/ Retro Complete,3575258,CDM,320,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Aorta/ Retro Complete,3370930,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Renal BILAT,3569771,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
SCSN US Renal Bilat Interp,3575304,CDM,402,RC,76770,HCPCS,Outpatient,,,176.39,88.20,,158.75,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,159.93,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,158.75,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.1,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,162.28,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,123.47,70,,,percent of total billed charges,70% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,167.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,151.7,86,,,percent of total billed charges,86% of total billed charges,141.11,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.1,97,,,percent of total billed charges,97% of total billed charges,158.75,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.1,97,,,percent of total billed charges,97% of total billed charges,164.04,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.1,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,521.04,
76775- Us exam abdo back wall lim,3430507,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
CL Renal Artery Ultrasound LT,3427573,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
CL Renal Artery Ultrasound RT,3427574,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Aorta Stent,3575256,CDM,972,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,54.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,76.12,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,38.95,155,,,Fee Schedule,155% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.08,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,119.31,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,119.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,82.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,57.58,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.64,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,43.36,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.95,140,,,Fee Schedule,140% of CMS OPPS Rate,76.93,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,110.19,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,27.82,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.21,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,201.21,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,27.82,519.08,
SCSN US Aorta Stent,3370926,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Exam,3575302,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Renal Artery,3370956,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Renal LT,3569773,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Renal LT Interp,3575306,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Renal LT Interp,3575308,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
SCSN US Renal RT,3569775,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
URMC US Kidney,3370978,CDM,402,RC,76775,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.55,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,559.45,
76801 Ob us < 14 wks single fetus,3428328,CDM,983,RC,76801,HCPCS,Outpatient,,,158.96,79.48,,143.06,90,,,percent of total billed charges,90% of total Billed charges,125.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,84.09,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,87.5,155,,,Fee Schedule,155% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,210.63,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,236.9,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,236.9,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.99,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,101.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,125,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,104.97,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,87.5,140,,,Fee Schedule,140% of CMS OPPS Rate,176.2,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,84.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,133,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,62.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,239.22,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,239.22,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,62.5,239.22,
76802 Ob us < 14 wks addl fetus,3428329,CDM,983,RC,76802,HCPCS,Outpatient,,,47.67,23.84,,42.9,90,,,percent of total billed charges,90% of total Billed charges,37.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,54.96,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.11,155,,,Fee Schedule,155% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.67,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.23,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,122.23,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,89.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,59.63,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.31,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.11,140,,,Fee Schedule,140% of CMS OPPS Rate,52.71,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,77.44,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.8,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,127.8,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.65,127.8,
76805 Ob us >/= 14 wks sngl fetus,3428330,CDM,983,RC,76805,HCPCS,Outpatient,,,197.69,98.85,,177.92,90,,,percent of total billed charges,90% of total Billed charges,156.88,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,109.31,155,,,Fee Schedule,155% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,241.16,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,271.24,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,271.24,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,192.18,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,114.13,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,130.64,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.31,140,,,Fee Schedule,140% of CMS OPPS Rate,219.63,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.93,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,78.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,279.2,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,279.2,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,77.5,279.2,
76810 Ob us >/= 14 wks addl fetus,3428331,CDM,983,RC,76810,HCPCS,Outpatient,,,93.41,46.71,,84.07,90,,,percent of total billed charges,90% of total Billed charges,73.79,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,51.18,155,,,Fee Schedule,155% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,158.13,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,177.85,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,177.85,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,129.02,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,76.82,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,73.12,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,61.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.18,140,,,Fee Schedule,140% of CMS OPPS Rate,103.31,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,244.04,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,36.56,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.82,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,184.82,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,36.56,244.04,
"76811 OB US, DETAILED SINGL FETUS",3430508,CDM,960,RC,76811,HCPCS,Outpatient,,,198.65,99.33,,178.79,90,,,percent of total billed charges,90% of total Billed charges,150.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,184.11,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,106.44,155,,,Fee Schedule,155% of CMS OPPS Rate,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,305.87,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,76.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,344.02,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,344.02,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,248.82,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,248.82,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,170.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.06,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,120.09,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.44,140,,,Fee Schedule,140% of CMS OPPS Rate,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,106.44,140,,,Fee Schedule,140% of CMS OPPS Rate,211.02,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,292,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,76.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,352.61,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,352.61,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,76.03,352.61,
76815 Ob us limited fetus(s),3428332,CDM,983,RC,76815,HCPCS,Outpatient,,,113.52,56.76,,102.17,90,,,percent of total billed charges,90% of total Billed charges,89.67,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,62.2,155,,,Fee Schedule,155% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144.69,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,162.74,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,162.74,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,115.83,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,70.37,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,88.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,74.67,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.2,140,,,Fee Schedule,140% of CMS OPPS Rate,125.54,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,116,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,44.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.75,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,169.75,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.43,169.75,
76818- Fetal biophys profile/non-stress,3431737,CDM,402,RC,76818,HCPCS,Outpatient,,,153.02,76.51,,137.72,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,143.08,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,137.72,90,,,Percent of total Billed charges,90% of total billed charges,63.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,148.43,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,140.78,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,137.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,107.11,70,,,percent of total billed charges,70% of total billed charges,137.72,90,,,percent of total billed charges,90% of total billed charges,145.37,95,,,percent of total billed charges,95% of total billed charges,145.37,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,131.6,86,,,percent of total billed charges,86% of total billed charges,122.42,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,148.43,97,,,percent of total billed charges,97% of total billed charges,137.72,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,148.43,97,,,percent of total billed charges,97% of total billed charges,142.31,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,148.43,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.09,521.04,
76819- Fetal biophy profile w/o non-stres,3431738,CDM,402,RC,76819,HCPCS,Outpatient,,,110.88,55.44,,99.79,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.79,90,,,Percent of total Billed charges,90% of total billed charges,53.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,107.55,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,102.01,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,99.79,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,77.62,70,,,percent of total billed charges,70% of total billed charges,99.79,90,,,percent of total billed charges,90% of total billed charges,105.34,95,,,percent of total billed charges,95% of total billed charges,105.34,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,95.36,86,,,percent of total billed charges,86% of total billed charges,88.7,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,107.55,97,,,percent of total billed charges,97% of total billed charges,99.79,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,107.55,97,,,percent of total billed charges,97% of total billed charges,103.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,107.55,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,48.68,521.04,
76820 Umbilical artery echo,3428335,CDM,983,RC,76820,HCPCS,Outpatient,,,47.97,23.99,,43.17,90,,,percent of total billed charges,90% of total Billed charges,37.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,45.73,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,26.29,155,,,Fee Schedule,155% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.59,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,90.64,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,90.64,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,65.75,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,49.76,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,37.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,31.55,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.29,140,,,Fee Schedule,140% of CMS OPPS Rate,53.06,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.73,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,88,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,18.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.34,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,77.34,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,18.78,90.64,
76821 Middle cerebral artery echo,3430509,CDM,960,RC,76821,HCPCS,Outpatient,,,131.4,65.70,,118.26,90,,,percent of total billed charges,90% of total Billed charges,98.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,77.1,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,68.32,155,,,Fee Schedule,155% of CMS OPPS Rate,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155.68,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,48.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,175.1,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,175.1,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,124.35,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,124.35,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,77.68,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,80.84,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68.32,140,,,Fee Schedule,140% of CMS OPPS Rate,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.32,140,,,Fee Schedule,140% of CMS OPPS Rate,137.48,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,99,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,48.8,100,,,Fee Schedule,100% of CMS OPPS Rate ,180.89,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,180.89,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,48.8,180.89,
76825 Echo exam of fetal heart,3430510,CDM,960,RC,76825,HCPCS,Outpatient,,,441.85,220.93,,397.67,90,,,percent of total billed charges,90% of total Billed charges,327.86,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,32,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,226.39,155,,,Fee Schedule,155% of CMS OPPS Rate,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,470.71,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,161.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,529.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,529.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,372.09,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,372.09,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,276.68,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,226.39,140,,,Fee Schedule,140% of CMS OPPS Rate,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,226.39,140,,,Fee Schedule,140% of CMS OPPS Rate,459,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,197,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,161.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,416.83,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,416.83,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,32,529.42,
76826 Echo exam of fetal heart,3430511,CDM,960,RC,76826,HCPCS,Outpatient,,,284.1,142.05,,255.69,90,,,percent of total billed charges,90% of total Billed charges,210.56,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.8,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,145.22,155,,,Fee Schedule,155% of CMS OPPS Rate,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.62,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,103.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,314.5,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.5,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,219.96,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,219.96,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,131.43,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,207.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,176.05,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,145.22,140,,,Fee Schedule,140% of CMS OPPS Rate,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.22,140,,,Fee Schedule,140% of CMS OPPS Rate,294.78,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,68.79,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,103.73,100,,,Fee Schedule,100% of CMS OPPS Rate ,247.09,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,247.09,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,44.8,314.5,
76827 Echo exam of fetal heart,3430512,CDM,960,RC,76827,HCPCS,Outpatient,,,102.97,51.49,,92.67,90,,,percent of total billed charges,90% of total Billed charges,75.85,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,64.44,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,52,155,,,Fee Schedule,155% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.38,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,142.14,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,142.14,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,101.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,101.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,62.98,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,74.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,64.92,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52,140,,,Fee Schedule,140% of CMS OPPS Rate,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,52,140,,,Fee Schedule,140% of CMS OPPS Rate,106.19,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,92.37,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,37.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,116.01,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,116.01,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,37.14,142.14,
76828 Echo exam of fetal heart,3430513,CDM,960,RC,76828,HCPCS,Outpatient,,,54.81,27.41,,49.33,90,,,percent of total billed charges,90% of total Billed charges,40.84,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,47.74,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,28.34,155,,,Fee Schedule,155% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,100.94,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,100.94,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,73.17,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,73.17,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,46.09,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,40.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,35.14,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.34,140,,,Fee Schedule,140% of CMS OPPS Rate,57.18,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.74,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,70.56,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,20.24,100,,,Fee Schedule,100% of CMS OPPS Rate ,85.86,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,85.86,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,20.24,100.94,
"76830- US Transvaginal, non-ob",3430618,CDM,402,RC,76830,HCPCS,Outpatient,,,207.98,103.99,,187.18,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,183.88,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.18,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,201.74,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,191.34,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,187.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,145.59,70,,,percent of total billed charges,70% of total billed charges,187.18,90,,,percent of total billed charges,90% of total billed charges,197.58,95,,,percent of total billed charges,95% of total billed charges,197.58,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,178.86,86,,,percent of total billed charges,86% of total billed charges,166.38,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,201.74,97,,,percent of total billed charges,97% of total billed charges,187.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.74,97,,,percent of total billed charges,97% of total billed charges,193.42,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,201.74,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,521.04,
"76831 - PB Tech - Saline infusion sonohysterography (SIS), including color flow Doppler, when perfor",3640910,CDM,510,RC,76831,HCPCS,Outpatient,,,1458.24,729.12,,1312.42,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,173.4,250,,,Fee Schedule,250% of Fee Schedule Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1312.42,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1414.49,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1341.58,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1312.42,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1020.77,70,,,percent of total billed charges,70% of total billed charges,1312.42,90,,,percent of total billed charges,90% of total billed charges,1385.33,95,,,percent of total billed charges,95% of total billed charges,1385.33,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1254.09,86,,,percent of total billed charges,86% of total billed charges,1166.59,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1414.49,97,,,percent of total billed charges,97% of total billed charges,1312.42,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1414.49,97,,,percent of total billed charges,97% of total billed charges,1356.16,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1414.49,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,173.4,1414.49,
76856- US pelvic complete,3430619,CDM,402,RC,76856,HCPCS,Outpatient,,,174.83,87.42,,157.35,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,158.43,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,157.35,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,169.59,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,160.84,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,157.35,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,122.38,70,,,percent of total billed charges,70% of total billed charges,157.35,90,,,percent of total billed charges,90% of total billed charges,166.09,95,,,percent of total billed charges,95% of total billed charges,166.09,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,150.35,86,,,percent of total billed charges,86% of total billed charges,139.86,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,169.59,97,,,percent of total billed charges,97% of total billed charges,157.35,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,169.59,97,,,percent of total billed charges,97% of total billed charges,162.59,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,169.59,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,521.04,
76857 Us exam pelvic limited,3428336,CDM,402,RC,76857,HCPCS,Outpatient,,,54.67,27.34,,49.2,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,50.58,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.2,90,,,Percent of total Billed charges,90% of total billed charges,20.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,53.03,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,50.3,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,49.2,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,38.27,70,,,percent of total billed charges,70% of total billed charges,49.2,90,,,percent of total billed charges,90% of total billed charges,51.94,95,,,percent of total billed charges,95% of total billed charges,51.94,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,47.02,86,,,percent of total billed charges,86% of total billed charges,43.74,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,53.03,97,,,percent of total billed charges,97% of total billed charges,49.2,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,53.03,97,,,percent of total billed charges,97% of total billed charges,50.84,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,53.03,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19,521.04,
"URMC US NON OB Pelvic, Limited PR:URMC US Exam",3575336,CDM,402,RC,76857,HCPCS,Outpatient,,,1633.23,816.62,,1469.91,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,50.58,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1469.91,90,,,Percent of total Billed charges,90% of total billed charges,20.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1584.23,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1502.57,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1469.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,1143.26,70,,,percent of total billed charges,70% of total billed charges,1469.91,90,,,percent of total billed charges,90% of total billed charges,1551.57,95,,,percent of total billed charges,95% of total billed charges,1551.57,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1404.58,86,,,percent of total billed charges,86% of total billed charges,1306.58,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1584.23,97,,,percent of total billed charges,97% of total billed charges,1469.91,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,1584.23,97,,,percent of total billed charges,97% of total billed charges,1518.9,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,19,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1584.23,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19,1584.23,
76870- Us exam scrotum,3430514,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,154.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,559.45,
URMC US Kidney,3584947,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,154.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,559.45,
URMC US Scrotum,3370986,CDM,402,RC,76870,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,154.68,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,559.45,
"76872 Ultrasound, transrectal",3430515,CDM,402,RC,76872,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.35,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,59.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.15,559.45,
URMC US Prostate w/o Biopsy PR,3575342,CDM,402,RC,76872,HCPCS,Outpatient,,,576.75,288.38,,519.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,200.35,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.08,90,,,Percent of total Billed charges,90% of total billed charges,59.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,559.45,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,530.61,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,403.73,70,,,percent of total billed charges,70% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,547.91,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,496.01,86,,,percent of total billed charges,86% of total billed charges,461.4,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,559.45,97,,,percent of total billed charges,97% of total billed charges,519.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,559.45,97,,,percent of total billed charges,97% of total billed charges,536.38,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,54.15,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,559.45,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,54.15,559.45,
SCSN US Exam,3575300,CDM,510,RC,76881,HCPCS,Outpatient,,,67.45,33.73,,60.71,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,120.98,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,60.71,90,,,Percent of total Billed charges,90% of total billed charges,72.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,65.43,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,62.05,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,60.71,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,47.22,70,,,percent of total billed charges,70% of total billed charges,60.71,90,,,percent of total billed charges,90% of total billed charges,64.08,95,,,percent of total billed charges,95% of total billed charges,64.08,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,58.01,86,,,percent of total billed charges,86% of total billed charges,53.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,65.43,97,,,percent of total billed charges,97% of total billed charges,60.71,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.43,97,,,percent of total billed charges,97% of total billed charges,62.73,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,66.18,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,65.43,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,47.22,521.04,
76882 US Extrem limited/nonvasc anatomic struct,3428337,CDM,983,RC,76882,HCPCS,Outpatient,,,74.03,37.02,,66.63,90,,,percent of total billed charges,90% of total Billed charges,37.8,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,155,,,Fee Schedule,155% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.89,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,115.72,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,115.72,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,79.13,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,28.29,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,47.46,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.61,140,,,Fee Schedule,140% of CMS OPPS Rate,52.92,140,,,Fee Schedule,140% OF CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.67,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,8.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.33,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,58.33,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,8.29,115.72,
76937-MA US GUIDE VASCULAR ACCESS,3430516,CDM,402,RC,76937,HCPCS,Outpatient,,,60.8,30.40,,54.72,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,41.2,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,54.72,90,,,Percent of total Billed charges,90% of total billed charges,13.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,58.98,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,55.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,38.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,47.82,78.65,,,percent of total billed charges,78.65% of total billed charges,54.31,89.33,,,percent of total billed charges,89.33% of total billed charges,54.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,42.56,70,,,percent of total billed charges,70% of total billed charges,54.72,90,,,percent of total billed charges,90% of total billed charges,57.76,95,,,percent of total billed charges,95% of total billed charges,57.76,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.29,86,,,percent of total billed charges,86% of total billed charges,48.64,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,58.98,97,,,percent of total billed charges,97% of total billed charges,54.72,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,58.98,97,,,percent of total billed charges,97% of total billed charges,56.54,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,58.98,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.62,58.98,
"76942 - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization de",3676896,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
"76942 (TC) - Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676898,CDM,402,RC,76942,HCPCS,Outpatient,,,65.07,32.54,,58.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,58.56,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,63.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,59.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,41.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,51.18,78.65,,,percent of total billed charges,78.65% of total billed charges,58.13,89.33,,,percent of total billed charges,89.33% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.55,70,,,percent of total billed charges,70% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.96,86,,,percent of total billed charges,86% of total billed charges,52.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.12,97,,,percent of total billed charges,97% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.12,97,,,percent of total billed charges,97% of total billed charges,60.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.56,63.12,
"76942- Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localizati",3676897,CDM,402,RC,76942,HCPCS,Outpatient,,,65.07,32.54,,58.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,58.56,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,63.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,59.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,41.56,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,51.18,78.65,,,percent of total billed charges,78.65% of total billed charges,58.13,89.33,,,percent of total billed charges,89.33% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,45.55,70,,,percent of total billed charges,70% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55.96,86,,,percent of total billed charges,86% of total billed charges,52.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,63.12,97,,,percent of total billed charges,97% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.12,97,,,percent of total billed charges,97% of total billed charges,60.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41.56,63.12,
SCSN US Breast Cyst Aspiration,3370938,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,4345731,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,4345733,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3370948,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3575274,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3575292,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3575294,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3575314,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3749006,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
SCSN US Exam,3749008,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
URMC US Prostate w/ Biopsy:URMC US Exam,3575340,CDM,402,RC,76942,HCPCS,Outpatient,,,610.56,305.28,,549.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,549.5,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.24,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,561.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,389.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,480.22,78.65,,,percent of total billed charges,78.65% of total billed charges,545.42,89.33,,,percent of total billed charges,89.33% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.39,70,,,percent of total billed charges,70% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,580.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.08,86,,,percent of total billed charges,86% of total billed charges,488.45,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,549.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.24,97,,,percent of total billed charges,97% of total billed charges,567.82,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.24,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,592.24,
US Guidance Aspiration Bx or Injection,596562,CDM,402,RC,76942,HCPCS,Outpatient,,,984.74,492.37,,886.27,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,52.8,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,886.27,90,,,Percent of total Billed charges,90% of total billed charges,47.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,955.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,905.96,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,628.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,774.52,78.65,,,percent of total billed charges,78.65% of total billed charges,879.68,89.33,,,percent of total billed charges,89.33% of total billed charges,886.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,689.32,70,,,percent of total billed charges,70% of total billed charges,886.27,90,,,percent of total billed charges,90% of total billed charges,935.5,95,,,percent of total billed charges,95% of total billed charges,935.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,846.88,86,,,percent of total billed charges,86% of total billed charges,787.79,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,955.2,97,,,percent of total billed charges,97% of total billed charges,886.27,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,955.2,97,,,percent of total billed charges,97% of total billed charges,915.81,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,955.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.2,955.2,
76946- Echo guide for amniocentesis,3430620,CDM,510,RC,76946,HCPCS,Outpatient,,,33.47,16.74,,30.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.1,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,30.12,90,,,Percent of total Billed charges,90% of total billed charges,20.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,32.47,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,30.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,21.37,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,26.32,78.65,,,percent of total billed charges,78.65% of total billed charges,29.9,89.33,,,percent of total billed charges,89.33% of total billed charges,30.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.43,70,,,percent of total billed charges,70% of total billed charges,30.12,90,,,percent of total billed charges,90% of total billed charges,31.8,95,,,percent of total billed charges,95% of total billed charges,31.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.78,86,,,percent of total billed charges,86% of total billed charges,26.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.47,97,,,percent of total billed charges,97% of total billed charges,30.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.47,97,,,percent of total billed charges,97% of total billed charges,31.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,32.47,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.6,32.47,
"77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only o",3620980,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,180.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.8,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,194.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,184.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158,78.65,,,percent of total billed charges,78.65% of total billed charges,179.46,89.33,,,percent of total billed charges,89.33% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,140.62,70,,,percent of total billed charges,70% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.77,86,,,percent of total billed charges,86% of total billed charges,160.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,186.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,194.86,
SCSN US Assist with Venefit PR:SCSN US Exam,3575272,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,180.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.8,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,194.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,184.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158,78.65,,,percent of total billed charges,78.65% of total billed charges,179.46,89.33,,,percent of total billed charges,89.33% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,140.62,70,,,percent of total billed charges,70% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.77,86,,,percent of total billed charges,86% of total billed charges,160.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,186.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,194.86,
SCSN US Assist with Venefit:SCSN US Exam,3370936,CDM,510,RC,77001,HCPCS,Outpatient,,,200.89,100.45,,180.8,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,151.68,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,180.8,90,,,Percent of total Billed charges,90% of total billed charges,50.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,194.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,184.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,128.29,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,158,78.65,,,percent of total billed charges,78.65% of total billed charges,179.46,89.33,,,percent of total billed charges,89.33% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,140.62,70,,,percent of total billed charges,70% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,190.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.77,86,,,percent of total billed charges,86% of total billed charges,160.71,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,180.8,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,194.86,97,,,percent of total billed charges,97% of total billed charges,186.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,194.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.26,194.86,
77061 (TC) - Diagnostic digital breast tomosynthesis; unilateral,4037468,CDM,401,RC,77061,HCPCS,Outpatient,,,135.84,67.92,,122.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,195.88,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,122.26,90,,,Percent of total Billed charges,90% of total billed charges,24.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,131.76,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,124.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,86.75,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,106.84,78.65,,,percent of total billed charges,78.65% of total billed charges,121.35,89.33,,,percent of total billed charges,89.33% of total billed charges,122.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,95.09,70,,,percent of total billed charges,70% of total billed charges,122.26,90,,,percent of total billed charges,90% of total billed charges,129.05,95,,,percent of total billed charges,95% of total billed charges,129.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116.82,86,,,percent of total billed charges,86% of total billed charges,108.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,131.76,97,,,percent of total billed charges,97% of total billed charges,122.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,131.76,97,,,percent of total billed charges,97% of total billed charges,126.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,131.76,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.51,195.88,
MA Mammogram Rt Unilat Diagnostic,603851,CDM,401,RC,77065,HCPCS,Outpatient,,,655.33,327.67,,589.8,90,,,percent of total billed charges,90% of total Billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,195.88,250,,,Fee Schedule,250% of Fee Schedule Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,589.8,90,,,Percent of total Billed charges,90% of total billed charges,78.11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,635.67,97,,,Percent of total billed charges,97% of total billed charges,76.44,100,,,Fee Schedule,100% of CMS OPPS Rate,602.9,92,,,Percent of total billed charges,92% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,310.29,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,378.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,350.74,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,589.8,90,,,percent of total billed charges,90% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,458.73,70,,,percent of total billed charges,70% of total billed charges,589.8,90,,,percent of total billed charges,90% of total billed charges,622.56,95,,,percent of total billed charges,95% of total billed charges,622.56,95,,,percent of total billed charges,95% of total billed charges,76.49,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.98,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,563.58,86,,,percent of total billed charges,86% of total billed charges,524.26,80,,,percent of total billed charges,80% of total billed charges,90.1,111,,,Fee Schedule,111% of CMS OPPS Rate,635.67,97,,,percent of total billed charges,97% of total billed charges,589.8,90,,,percent of total billed charges,90% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,635.67,97,,,percent of total billed charges,97% of total billed charges,609.46,93,,,percent of total billed charges,93% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,71.01,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,635.67,97,,,percent of total billed charges,97% of total billed charges,76.49,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.49,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,65.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,65.02,635.67,
"77080- Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skelet",3623708,CDM,510,RC,77080,HCPCS,Outpatient,,,65.07,32.54,,58.56,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,64.05,250,,,Fee Schedule,250% of Fee Schedule Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.56,90,,,Percent of total Billed charges,90% of total billed charges,57.13,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,63.12,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,59.86,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,58.56,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,45.55,70,,,percent of total billed charges,70% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,61.82,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,55.96,86,,,percent of total billed charges,86% of total billed charges,52.06,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,63.12,97,,,percent of total billed charges,97% of total billed charges,58.56,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,63.12,97,,,percent of total billed charges,97% of total billed charges,60.52,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,51.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,63.12,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.55,521.04,
77261-Radiation Therapy Planning Simple,4169504,CDM,333,RC,77261,HCPCS,Outpatient,,,164.33,82.17,,147.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,131.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,147.9,90,,,Percent of total Billed charges,90% of total billed charges,72.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,159.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,151.18,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,104.94,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,129.25,78.65,,,percent of total billed charges,78.65% of total billed charges,146.8,89.33,,,percent of total billed charges,89.33% of total billed charges,147.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.03,70,,,percent of total billed charges,70% of total billed charges,147.9,90,,,percent of total billed charges,90% of total billed charges,156.11,95,,,percent of total billed charges,95% of total billed charges,156.11,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.32,86,,,percent of total billed charges,86% of total billed charges,131.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,159.4,97,,,percent of total billed charges,97% of total billed charges,147.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.4,97,,,percent of total billed charges,97% of total billed charges,152.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,159.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.02,159.4,
77280-SET RADIATION THERAPY FIELD SIMPLE,3435794,CDM,333,RC,77280,HCPCS,Outpatient,,,541.19,270.60,,487.07,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,513.43,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,487.07,90,,,Percent of total Billed charges,90% of total billed charges,40.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,524.95,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,497.89,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,487.07,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,378.83,70,,,percent of total billed charges,70% of total billed charges,487.07,90,,,percent of total billed charges,90% of total billed charges,514.13,95,,,percent of total billed charges,95% of total billed charges,514.13,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,465.42,86,,,percent of total billed charges,86% of total billed charges,432.95,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,524.95,97,,,percent of total billed charges,97% of total billed charges,487.07,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,524.95,97,,,percent of total billed charges,97% of total billed charges,503.31,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,524.95,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,36.5,650.24,
77285-SET RAD THERAPY FIELD INTERMEDIATE,3537566,CDM,333,RC,77285,HCPCS,Outpatient,,,1216.88,608.44,,1095.19,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,860,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1095.19,90,,,Percent of total Billed charges,90% of total billed charges,56.1,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1180.37,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1119.53,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1095.19,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,851.82,70,,,percent of total billed charges,70% of total billed charges,1095.19,90,,,percent of total billed charges,90% of total billed charges,1156.04,95,,,percent of total billed charges,95% of total billed charges,1156.04,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1046.52,86,,,percent of total billed charges,86% of total billed charges,973.5,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1180.37,97,,,percent of total billed charges,97% of total billed charges,1095.19,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1180.37,97,,,percent of total billed charges,97% of total billed charges,1131.7,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1180.37,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,51,1748.8,
77290-SET RADIATION THERAPY FIELD COMPLEX,3400445,CDM,333,RC,77290,HCPCS,Outpatient,,,881.03,440.52,,792.93,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,916,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,792.93,90,,,Percent of total Billed charges,90% of total billed charges,79.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,854.6,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,810.55,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,792.93,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,616.72,70,,,percent of total billed charges,70% of total billed charges,792.93,90,,,percent of total billed charges,90% of total billed charges,836.98,95,,,percent of total billed charges,95% of total billed charges,836.98,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,757.69,86,,,percent of total billed charges,86% of total billed charges,704.82,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,854.6,97,,,percent of total billed charges,97% of total billed charges,792.93,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,854.6,97,,,percent of total billed charges,97% of total billed charges,819.36,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,72.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,854.6,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,72.5,1748.8,
77293-RESPIRATOR MOTION MGMT SIMUL,3400446,CDM,333,RC,77293,HCPCS,Outpatient,,,734.79,367.40,,661.31,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,762.78,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,661.31,90,,,Percent of total Billed charges,90% of total billed charges,266.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,712.75,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,676.01,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,469.25,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,577.93,78.65,,,percent of total billed charges,78.65% of total billed charges,656.4,89.33,,,percent of total billed charges,89.33% of total billed charges,661.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,514.35,70,,,percent of total billed charges,70% of total billed charges,661.31,90,,,percent of total billed charges,90% of total billed charges,698.05,95,,,percent of total billed charges,95% of total billed charges,698.05,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.92,86,,,percent of total billed charges,86% of total billed charges,587.83,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,712.75,97,,,percent of total billed charges,97% of total billed charges,661.31,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,712.75,97,,,percent of total billed charges,97% of total billed charges,683.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,712.75,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,242.07,762.78,
77299-RADIATION THERAPY PLANNING,3400447,CDM,333,RC,77299,HCPCS,Outpatient,,,459.45,229.73,,413.51,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,367.56,80,,,Percent of total Billed charges,80% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,445.67,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,422.69,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,321.62,70,,,percent of total billed charges,70% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,395.13,86,,,percent of total billed charges,86% of total billed charges,367.56,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,445.67,97,,,percent of total billed charges,97% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.67,97,,,percent of total billed charges,97% of total billed charges,427.29,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,445.67,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,102.96,650.24,
77300-RADIATION THERAPY DOSE PLAN,3400448,CDM,333,RC,77300,HCPCS,Outpatient,,,76.11,38.06,,68.5,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,73.03,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.5,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,73.83,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,70.02,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,68.5,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,53.28,70,,,percent of total billed charges,70% of total billed charges,68.5,90,,,percent of total billed charges,90% of total billed charges,72.3,95,,,percent of total billed charges,95% of total billed charges,72.3,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,65.45,86,,,percent of total billed charges,86% of total billed charges,60.89,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,73.83,97,,,percent of total billed charges,97% of total billed charges,68.5,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,73.83,97,,,percent of total billed charges,97% of total billed charges,70.78,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,73.83,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,650.24,
77301-RADIOTHERAPY DOSE PLAN IMRT,3400449,CDM,333,RC,77301,HCPCS,Outpatient,,,3296.85,1648.43,,2967.17,90,,,percent of total billed charges,90% of total Billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3272.93,250,,,Fee Schedule,250% of Fee Schedule Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,2967.17,90,,,Percent of total Billed charges,90% of total billed charges,778.61,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3197.94,97,,,Percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3033.1,92,,,Percent of total billed charges,92% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,3236.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5160,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,6535.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2967.17,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,2307.8,70,,,percent of total billed charges,70% of total billed charges,2967.17,90,,,percent of total billed charges,90% of total billed charges,3132.01,95,,,percent of total billed charges,95% of total billed charges,3132.01,95,,,percent of total billed charges,95% of total billed charges,1217.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2435.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2835.29,86,,,percent of total billed charges,86% of total billed charges,2637.48,80,,,percent of total billed charges,80% of total billed charges,1287.52,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3197.94,97,,,percent of total billed charges,97% of total billed charges,2967.17,90,,,percent of total billed charges,90% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,3197.94,97,,,percent of total billed charges,97% of total billed charges,3066.07,93,,,percent of total billed charges,93% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,707.83,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3197.94,97,,,percent of total billed charges,97% of total billed charges,1217.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,1217.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1035.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,707.83,6535.92,
77307-TELETHX ISODOSE PLAN CPLX,3400450,CDM,333,RC,77307,HCPCS,Outpatient,,,1764.15,882.08,,1587.74,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,296.28,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1587.74,90,,,Percent of total Billed charges,90% of total billed charges,109.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1711.23,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1623.02,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1587.74,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,1234.91,70,,,percent of total billed charges,70% of total billed charges,1587.74,90,,,percent of total billed charges,90% of total billed charges,1675.94,95,,,percent of total billed charges,95% of total billed charges,1675.94,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1517.17,86,,,percent of total billed charges,86% of total billed charges,1411.32,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1711.23,97,,,percent of total billed charges,97% of total billed charges,1587.74,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,1711.23,97,,,percent of total billed charges,97% of total billed charges,1640.66,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,99.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1711.23,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,99.96,1748.8,
77317-(TC)-BRACHYTX ISODOSE INTERMED,3537569,CDM,333,RC,77317,HCPCS,Outpatient,,,437.15,218.58,,393.44,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,367.8,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,393.44,90,,,Percent of total Billed charges,90% of total billed charges,121.96,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,424.04,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,402.18,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,393.44,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,306.01,70,,,percent of total billed charges,70% of total billed charges,393.44,90,,,percent of total billed charges,90% of total billed charges,415.29,95,,,percent of total billed charges,95% of total billed charges,415.29,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,375.95,86,,,percent of total billed charges,86% of total billed charges,349.72,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,424.04,97,,,percent of total billed charges,97% of total billed charges,393.44,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,424.04,97,,,percent of total billed charges,97% of total billed charges,406.55,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,110.87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,424.04,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,110.87,1748.8,
77318-(TC)-BRACHYTX ISODOSE COMPLEX,3537570,CDM,333,RC,77318,HCPCS,Outpatient,,,590.27,295.14,,531.24,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,498.73,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,531.24,90,,,Percent of total Billed charges,90% of total billed charges,165.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,572.56,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,543.05,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,531.24,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,413.19,70,,,percent of total billed charges,70% of total billed charges,531.24,90,,,percent of total billed charges,90% of total billed charges,560.76,95,,,percent of total billed charges,95% of total billed charges,560.76,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,507.63,86,,,percent of total billed charges,86% of total billed charges,472.22,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,572.56,97,,,percent of total billed charges,97% of total billed charges,531.24,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,572.56,97,,,percent of total billed charges,97% of total billed charges,548.95,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,150.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,572.56,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,150.49,1748.8,
77321-SPECIAL TELETX PORT PLAN,3400451,CDM,333,RC,77321,HCPCS,Outpatient,,,101.38,50.69,,91.24,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,94.23,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,91.24,90,,,Percent of total Billed charges,90% of total billed charges,34.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,98.34,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,93.27,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,91.24,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,70.97,70,,,percent of total billed charges,70% of total billed charges,91.24,90,,,percent of total billed charges,90% of total billed charges,96.31,95,,,percent of total billed charges,95% of total billed charges,96.31,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,87.19,86,,,percent of total billed charges,86% of total billed charges,81.1,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,98.34,97,,,percent of total billed charges,97% of total billed charges,91.24,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.34,97,,,percent of total billed charges,97% of total billed charges,94.28,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,98.34,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.5,1748.8,
77331-SPECIAL RADIATION DOSIMETRY,3400452,CDM,333,RC,77331,HCPCS,Outpatient,,,43.75,21.88,,39.38,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,41.25,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,39.38,90,,,Percent of total Billed charges,90% of total billed charges,19.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,42.44,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,40.25,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,39.38,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,30.63,70,,,percent of total billed charges,70% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,41.56,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,37.63,86,,,percent of total billed charges,86% of total billed charges,35,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,42.44,97,,,percent of total billed charges,97% of total billed charges,39.38,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,42.44,97,,,percent of total billed charges,97% of total billed charges,40.69,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.46,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,42.44,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.46,650.24,
77332-RADIATION TREATMENT AID(S) SIMPLE,3400453,CDM,333,RC,77332,HCPCS,Outpatient,,,34.27,17.14,,30.84,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,61.68,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,90,,,Percent of total Billed charges,90% of total billed charges,35.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33.24,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,31.53,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,30.84,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,23.99,70,,,percent of total billed charges,70% of total billed charges,30.84,90,,,percent of total billed charges,90% of total billed charges,32.56,95,,,percent of total billed charges,95% of total billed charges,32.56,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,29.47,86,,,percent of total billed charges,86% of total billed charges,27.42,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33.24,97,,,percent of total billed charges,97% of total billed charges,30.84,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,33.24,97,,,percent of total billed charges,97% of total billed charges,31.87,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33.24,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.99,650.24,
77333-RADIATION TREAT AID(S) INTERMEDIATE,3400454,CDM,333,RC,77333,HCPCS,Outpatient,,,459.45,229.73,,413.51,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,150.23,250,,,Fee Schedule,250% of Fee Schedule Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.51,90,,,Percent of total Billed charges,90% of total billed charges,18.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,445.67,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,422.69,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,321.62,70,,,percent of total billed charges,70% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,395.13,86,,,percent of total billed charges,86% of total billed charges,367.56,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,445.67,97,,,percent of total billed charges,97% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.67,97,,,percent of total billed charges,97% of total billed charges,427.29,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.97,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,445.67,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.97,650.24,
77334-RADIATION TREATMENT AID(S) COMPLEX,3400455,CDM,333,RC,77334,HCPCS,Outpatient,,,148.77,74.39,,133.89,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,145.68,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.89,90,,,Percent of total Billed charges,90% of total billed charges,60.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,144.31,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,136.87,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.89,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,104.14,70,,,percent of total billed charges,70% of total billed charges,133.89,90,,,percent of total billed charges,90% of total billed charges,141.33,95,,,percent of total billed charges,95% of total billed charges,141.33,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.94,86,,,percent of total billed charges,86% of total billed charges,119.02,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,144.31,97,,,percent of total billed charges,97% of total billed charges,133.89,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,144.31,97,,,percent of total billed charges,97% of total billed charges,138.36,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,144.31,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,55,1748.8,
77336-RADIATION PHYSICS CONSULT,3400456,CDM,333,RC,77336,HCPCS,Outpatient,,,194.37,97.19,,174.93,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,155.5,80,,,Percent of total Billed charges,80% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.93,90,,,Percent of total Billed charges,90% of total billed charges,53.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,188.54,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,178.82,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,174.93,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,136.06,70,,,percent of total billed charges,70% of total billed charges,174.93,90,,,percent of total billed charges,90% of total billed charges,184.65,95,,,percent of total billed charges,95% of total billed charges,184.65,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,167.16,86,,,percent of total billed charges,86% of total billed charges,155.5,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,188.54,97,,,percent of total billed charges,97% of total billed charges,174.93,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,188.54,97,,,percent of total billed charges,97% of total billed charges,180.76,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,188.54,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,49,650.24,
77338-DESIGN MIC DEVICE FOR IMRT,3400457,CDM,333,RC,77338,HCPCS,Outpatient,,,546.86,273.43,,492.17,90,,,percent of total billed charges,90% of total Billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,589.53,250,,,Fee Schedule,250% of Fee Schedule Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,492.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,530.45,97,,,Percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,503.11,92,,,Percent of total billed charges,92% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,866.04,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1380.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1748.8,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,492.17,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,382.8,70,,,percent of total billed charges,70% of total billed charges,492.17,90,,,percent of total billed charges,90% of total billed charges,519.52,95,,,percent of total billed charges,95% of total billed charges,519.52,95,,,percent of total billed charges,95% of total billed charges,325.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,651.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,470.3,86,,,percent of total billed charges,86% of total billed charges,437.49,80,,,percent of total billed charges,80% of total billed charges,346.5,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,530.45,97,,,percent of total billed charges,97% of total billed charges,492.17,90,,,percent of total billed charges,90% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,530.45,97,,,percent of total billed charges,97% of total billed charges,508.58,93,,,percent of total billed charges,93% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,530.45,97,,,percent of total billed charges,97% of total billed charges,325.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,325.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,276.93,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,276.93,1748.8,
77370-SPECIAL MEDICAL RAD PHYSICS CONSULT,3400458,CDM,333,RC,77370,HCPCS,Outpatient,,,459.45,229.73,,413.51,90,,,percent of total billed charges,90% of total Billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,367.56,80,,,Percent of total Billed charges,80% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,413.51,90,,,Percent of total Billed charges,90% of total billed charges,106.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,445.67,97,,,Percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,422.69,92,,,Percent of total billed charges,92% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,322.01,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,513.34,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,650.24,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,321.62,70,,,percent of total billed charges,70% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,436.48,95,,,percent of total billed charges,95% of total billed charges,121.14,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,242.28,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,395.13,86,,,percent of total billed charges,86% of total billed charges,367.56,80,,,percent of total billed charges,80% of total billed charges,130.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,445.67,97,,,percent of total billed charges,97% of total billed charges,413.51,90,,,percent of total billed charges,90% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,445.67,97,,,percent of total billed charges,97% of total billed charges,427.29,93,,,percent of total billed charges,93% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,445.67,97,,,percent of total billed charges,97% of total billed charges,121.14,100,,,Fee Schedule,100% of CMS OPPS Rate ,121.14,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,102.96,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,96.5,650.24,
"77371-RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT""",4169517,CDM,333,RC,77371,HCPCS,Outpatient,,,34259.03,17129.52,,30833.13,90,,,percent of total billed charges,90% of total Billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,2698.95,250,,,Fee Schedule,250% of Fee Schedule Rate,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,30833.13,90,,,Percent of total Billed charges,90% of total billed charges,915.42,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,33231.26,97,,,Percent of total billed charges,97% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,31518.31,92,,,Percent of total billed charges,92% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,18567.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6985.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29599.72,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,37492.5,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,30833.13,90,,,percent of total billed charges,90% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,23981.32,70,,,percent of total billed charges,70% of total billed charges,30833.13,90,,,percent of total billed charges,90% of total billed charges,32546.08,95,,,percent of total billed charges,95% of total billed charges,32546.08,95,,,percent of total billed charges,95% of total billed charges,6985.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13970.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,29462.77,86,,,percent of total billed charges,86% of total billed charges,27407.22,80,,,percent of total billed charges,80% of total billed charges,8211.46,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,33231.26,97,,,percent of total billed charges,97% of total billed charges,30833.13,90,,,percent of total billed charges,90% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,33231.26,97,,,percent of total billed charges,97% of total billed charges,31860.9,93,,,percent of total billed charges,93% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,832.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,33231.26,97,,,percent of total billed charges,97% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,6985.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5937.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,832.2,37492.5,
77372-SRS Linear Based,4169506,CDM,333,RC,77372,HCPCS,Outpatient,,,2055.9,1027.95,,1850.31,90,,,percent of total billed charges,90% of total Billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,2294.45,250,,,Fee Schedule,250% of Fee Schedule Rate,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1850.31,90,,,Percent of total Billed charges,90% of total billed charges,694.74,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1994.22,97,,,Percent of total billed charges,97% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,1891.43,92,,,Percent of total billed charges,92% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,18567.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6985.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29599.72,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,37492.5,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1850.31,90,,,percent of total billed charges,90% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,1439.13,70,,,percent of total billed charges,70% of total billed charges,1850.31,90,,,percent of total billed charges,90% of total billed charges,1953.11,95,,,percent of total billed charges,95% of total billed charges,1953.11,95,,,percent of total billed charges,95% of total billed charges,6985.03,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13970.07,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1768.07,86,,,percent of total billed charges,86% of total billed charges,1644.72,80,,,percent of total billed charges,80% of total billed charges,8211.46,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1994.22,97,,,percent of total billed charges,97% of total billed charges,1850.31,90,,,percent of total billed charges,90% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,1994.22,97,,,percent of total billed charges,97% of total billed charges,1911.99,93,,,percent of total billed charges,93% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,631.58,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1994.22,97,,,percent of total billed charges,97% of total billed charges,6985.03,100,,,Fee Schedule,100% of CMS OPPS Rate ,6985.03,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5937.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,631.58,37492.5,
77373-SBRT DELIVERY,3565235,CDM,333,RC,77373,HCPCS,Outpatient,,,2379.35,1189.68,,2141.42,90,,,percent of total billed charges,90% of total Billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2778.03,250,,,Fee Schedule,250% of Fee Schedule Rate,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2141.42,90,,,Percent of total Billed charges,90% of total billed charges,1100,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2307.97,97,,,Percent of total billed charges,97% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate,2189,92,,,Percent of total billed charges,92% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate,4267.08,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,1605.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,6802.61,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,8616.53,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2141.42,90,,,percent of total billed charges,90% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1665.55,70,,,percent of total billed charges,70% of total billed charges,2141.42,90,,,percent of total billed charges,90% of total billed charges,2260.38,95,,,percent of total billed charges,95% of total billed charges,2260.38,95,,,percent of total billed charges,95% of total billed charges,1605.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3210.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2046.24,86,,,percent of total billed charges,86% of total billed charges,1903.48,80,,,percent of total billed charges,80% of total billed charges,1828.34,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2307.97,97,,,percent of total billed charges,97% of total billed charges,2141.42,90,,,percent of total billed charges,90% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,2307.97,97,,,percent of total billed charges,97% of total billed charges,2212.8,93,,,percent of total billed charges,93% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1000,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2307.97,97,,,percent of total billed charges,97% of total billed charges,1605.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,1605.3,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1364.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1000,8616.53,
77385-NTSTY MODUL RAD TX DIVR SMPL,3400459,CDM,333,RC,77385,HCPCS,Outpatient,,,2164.69,1082.35,,1948.22,90,,,percent of total billed charges,90% of total Billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.75,80,,,Percent of total Billed charges,80% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1948.22,90,,,Percent of total Billed charges,90% of total billed charges,295.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2099.75,97,,,Percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1991.51,92,,,Percent of total billed charges,92% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2203.33,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2790.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1948.22,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1515.28,70,,,percent of total billed charges,70% of total billed charges,1948.22,90,,,percent of total billed charges,90% of total billed charges,2056.46,95,,,percent of total billed charges,95% of total billed charges,2056.46,95,,,percent of total billed charges,95% of total billed charges,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1861.63,86,,,percent of total billed charges,86% of total billed charges,1731.75,80,,,percent of total billed charges,80% of total billed charges,557.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2099.75,97,,,percent of total billed charges,97% of total billed charges,1948.22,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,2099.75,97,,,percent of total billed charges,97% of total billed charges,2013.16,93,,,percent of total billed charges,93% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,268.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2099.75,97,,,percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,441.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,268.8,2790.85,
77386-NTSTY MODUL RAD TX DIVR CPLX,3400460,CDM,333,RC,77386,HCPCS,Outpatient,,,2164.69,1082.35,,1948.22,90,,,percent of total billed charges,90% of total Billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1731.75,80,,,Percent of total Billed charges,80% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1948.22,90,,,Percent of total Billed charges,90% of total billed charges,312.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2099.75,97,,,Percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1991.51,92,,,Percent of total billed charges,92% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2203.33,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2790.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1948.22,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1515.28,70,,,percent of total billed charges,70% of total billed charges,1948.22,90,,,percent of total billed charges,90% of total billed charges,2056.46,95,,,percent of total billed charges,95% of total billed charges,2056.46,95,,,percent of total billed charges,95% of total billed charges,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1861.63,86,,,percent of total billed charges,86% of total billed charges,1731.75,80,,,percent of total billed charges,80% of total billed charges,557.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2099.75,97,,,percent of total billed charges,97% of total billed charges,1948.22,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,2099.75,97,,,percent of total billed charges,97% of total billed charges,2013.16,93,,,percent of total billed charges,93% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,284.49,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2099.75,97,,,percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,441.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,284.49,2790.85,
77387 TC Guidance for localization of target volume for de,3623294,CDM,510,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.9,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,59.83,90,,,Percent of total Billed charges,90% of total billed charges,70.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,42.46,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,52.29,78.65,,,percent of total billed charges,78.65% of total billed charges,59.39,89.33,,,percent of total billed charges,89.33% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,46.54,70,,,percent of total billed charges,70% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,63.16,95,,,percent of total billed charges,95% of total billed charges,63.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.17,86,,,percent of total billed charges,86% of total billed charges,53.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.49,97,,,percent of total billed charges,97% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,64.49,97,,,percent of total billed charges,97% of total billed charges,61.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.46,113.9,
77387-GUIDANCE FOR RADJ TX DLVR,3400461,CDM,333,RC,77387,HCPCS,Outpatient,,,66.48,33.24,,59.83,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,113.9,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,59.83,90,,,Percent of total Billed charges,90% of total billed charges,70.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,64.49,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.16,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,42.46,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,52.29,78.65,,,percent of total billed charges,78.65% of total billed charges,59.39,89.33,,,percent of total billed charges,89.33% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,46.54,70,,,percent of total billed charges,70% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,63.16,95,,,percent of total billed charges,95% of total billed charges,63.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.17,86,,,percent of total billed charges,86% of total billed charges,53.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.49,97,,,percent of total billed charges,97% of total billed charges,59.83,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,64.49,97,,,percent of total billed charges,97% of total billed charges,61.83,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.81,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,64.49,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.46,113.9,
77412-RADIATION TREAT DELIVERY COMPLEX,3400462,CDM,333,RC,77412,HCPCS,Outpatient,,,894.86,447.43,,805.37,90,,,percent of total billed charges,90% of total Billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate,715.89,80,,,Percent of total Billed charges,80% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,805.37,90,,,Percent of total Billed charges,90% of total billed charges,48.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,868.01,97,,,Percent of total billed charges,97% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate,823.27,92,,,Percent of total billed charges,92% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate,634.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,238.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1011.96,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1281.81,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,805.37,90,,,percent of total billed charges,90% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate,626.4,70,,,percent of total billed charges,70% of total billed charges,805.37,90,,,percent of total billed charges,90% of total billed charges,850.12,95,,,percent of total billed charges,95% of total billed charges,850.12,95,,,percent of total billed charges,95% of total billed charges,238.81,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,477.61,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,769.58,86,,,percent of total billed charges,86% of total billed charges,715.89,80,,,percent of total billed charges,80% of total billed charges,244.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,868.01,97,,,percent of total billed charges,97% of total billed charges,805.37,90,,,percent of total billed charges,90% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,868.01,97,,,percent of total billed charges,97% of total billed charges,832.22,93,,,percent of total billed charges,93% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,868.01,97,,,percent of total billed charges,97% of total billed charges,238.81,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.81,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,202.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44,1281.81,
77417-RADIOLOGY PORT IMAGES(S),3400463,CDM,333,RC,77417,HCPCS,Outpatient,,,29.51,14.76,,26.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,24.6,250,,,Fee Schedule,250% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,26.56,90,,,Percent of total Billed charges,90% of total billed charges,14.21,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,28.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,27.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,18.85,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,23.21,78.65,,,percent of total billed charges,78.65% of total billed charges,26.36,89.33,,,percent of total billed charges,89.33% of total billed charges,26.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,20.66,70,,,percent of total billed charges,70% of total billed charges,26.56,90,,,percent of total billed charges,90% of total billed charges,28.03,95,,,percent of total billed charges,95% of total billed charges,28.03,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.38,86,,,percent of total billed charges,86% of total billed charges,23.61,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,28.62,97,,,percent of total billed charges,97% of total billed charges,26.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,28.62,97,,,percent of total billed charges,97% of total billed charges,27.44,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.92,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,28.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.92,28.62,
Hospital Outpatient Clinic Visit,3400485,CDM,510,RC,77427,HCPCS,Outpatient,,,225.57,112.79,,203.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,180.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,203.01,90,,,Percent of total Billed charges,90% of total billed charges,151.38,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,218.8,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,207.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,144.05,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,177.42,78.65,,,percent of total billed charges,78.65% of total billed charges,201.51,89.33,,,percent of total billed charges,89.33% of total billed charges,203.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,157.9,70,,,percent of total billed charges,70% of total billed charges,203.01,90,,,percent of total billed charges,90% of total billed charges,214.29,95,,,percent of total billed charges,95% of total billed charges,214.29,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,193.99,86,,,percent of total billed charges,86% of total billed charges,180.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,218.8,97,,,percent of total billed charges,97% of total billed charges,203.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,218.8,97,,,percent of total billed charges,97% of total billed charges,209.78,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,218.8,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137.62,218.8,
77432-Sterotactic Radiation Treatment,4169511,CDM,333,RC,77432,HCPCS,Outpatient,,,985.49,492.75,,886.94,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,788.39,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,886.94,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,955.93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,906.65,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,629.36,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,775.11,78.65,,,percent of total billed charges,78.65% of total billed charges,880.35,89.33,,,percent of total billed charges,89.33% of total billed charges,886.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,689.84,70,,,percent of total billed charges,70% of total billed charges,886.94,90,,,percent of total billed charges,90% of total billed charges,936.22,95,,,percent of total billed charges,95% of total billed charges,936.22,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,847.52,86,,,percent of total billed charges,86% of total billed charges,788.39,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,955.93,97,,,percent of total billed charges,97% of total billed charges,886.94,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,955.93,97,,,percent of total billed charges,97% of total billed charges,916.51,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,955.93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,629.36,955.93,
77470-SPECIAL RADIATION TREATMENT,3565236,CDM,333,RC,77470,HCPCS,Outpatient,,,1932.76,966.38,,1739.48,90,,,percent of total billed charges,90% of total Billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,54.88,250,,,Fee Schedule,250% of Fee Schedule Rate,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1739.48,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1874.78,97,,,Percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1778.14,92,,,Percent of total billed charges,92% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1382.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2203.33,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2790.85,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1739.48,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,1352.93,70,,,percent of total billed charges,70% of total billed charges,1739.48,90,,,percent of total billed charges,90% of total billed charges,1836.12,95,,,percent of total billed charges,95% of total billed charges,1836.12,95,,,percent of total billed charges,95% of total billed charges,519.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1039.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1662.17,86,,,percent of total billed charges,86% of total billed charges,1546.21,80,,,percent of total billed charges,80% of total billed charges,557.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1874.78,97,,,percent of total billed charges,97% of total billed charges,1739.48,90,,,percent of total billed charges,90% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,1874.78,97,,,percent of total billed charges,97% of total billed charges,1797.47,93,,,percent of total billed charges,93% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1874.78,97,,,percent of total billed charges,97% of total billed charges,519.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,519.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,441.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,2790.85,
77770 - (TC) Remote afterloading high dose rate radionuclide,3938962,CDM,333,RC,77770,HCPCS,Outpatient,,,567.71,283.86,,510.94,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.94,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,550.68,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,522.29,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,510.94,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,397.4,70,,,percent of total billed charges,70% of total billed charges,510.94,90,,,percent of total billed charges,90% of total billed charges,539.32,95,,,percent of total billed charges,95% of total billed charges,539.32,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,488.23,86,,,percent of total billed charges,86% of total billed charges,454.17,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,550.68,97,,,percent of total billed charges,97% of total billed charges,510.94,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.68,97,,,percent of total billed charges,97% of total billed charges,527.97,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,550.68,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77770 - Remote afterloading high dose rate radionuclide brac,3938960,CDM,342,RC,77770,HCPCS,Outpatient,,,567.71,283.86,,510.94,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,510.94,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,550.68,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,522.29,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,510.94,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,397.4,70,,,percent of total billed charges,70% of total billed charges,510.94,90,,,percent of total billed charges,90% of total billed charges,539.32,95,,,percent of total billed charges,95% of total billed charges,539.32,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,488.23,86,,,percent of total billed charges,86% of total billed charges,454.17,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,550.68,97,,,percent of total billed charges,97% of total billed charges,510.94,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,550.68,97,,,percent of total billed charges,97% of total billed charges,527.97,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,550.68,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77770-HDR RDNCL NTRSTL/ICAV BRCHTX,3537576,CDM,333,RC,77770,HCPCS,Outpatient,,,506.89,253.45,,456.2,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,490.38,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.2,90,,,Percent of total Billed charges,90% of total billed charges,181.84,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,491.68,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,466.34,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,456.2,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,354.82,70,,,percent of total billed charges,70% of total billed charges,456.2,90,,,percent of total billed charges,90% of total billed charges,481.55,95,,,percent of total billed charges,95% of total billed charges,481.55,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,435.93,86,,,percent of total billed charges,86% of total billed charges,405.51,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,491.68,97,,,percent of total billed charges,97% of total billed charges,456.2,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,491.68,97,,,percent of total billed charges,97% of total billed charges,471.41,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,165.31,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,491.68,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,165.31,3518.47,
77771 - (TC) Remote afterloading high dose rate radionuclide,3938959,CDM,333,RC,77771,HCPCS,Outpatient,,,925.88,462.94,,833.29,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,833.29,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,898.1,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,851.81,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,833.29,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,648.12,70,,,percent of total billed charges,70% of total billed charges,833.29,90,,,percent of total billed charges,90% of total billed charges,879.59,95,,,percent of total billed charges,95% of total billed charges,879.59,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,796.26,86,,,percent of total billed charges,86% of total billed charges,740.7,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,898.1,97,,,percent of total billed charges,97% of total billed charges,833.29,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.1,97,,,percent of total billed charges,97% of total billed charges,861.07,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,898.1,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
77771 - Remote afterloading high dose rate radionuclide brac,3938957,CDM,333,RC,77771,HCPCS,Outpatient,,,925.88,462.94,,833.29,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,833.29,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,898.1,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,851.81,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,833.29,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,648.12,70,,,percent of total billed charges,70% of total billed charges,833.29,90,,,percent of total billed charges,90% of total billed charges,879.59,95,,,percent of total billed charges,95% of total billed charges,879.59,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,796.26,86,,,percent of total billed charges,86% of total billed charges,740.7,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,898.1,97,,,percent of total billed charges,97% of total billed charges,833.29,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,898.1,97,,,percent of total billed charges,97% of total billed charges,861.07,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,898.1,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
77771-HDR RDNCL NTRSTL/ICAV BRCHTX 2-12,3537577,CDM,333,RC,77771,HCPCS,Outpatient,,,826.67,413.34,,744,90,,,percent of total billed charges,90% of total Billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,865.35,250,,,Fee Schedule,250% of Fee Schedule Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,744,90,,,Percent of total Billed charges,90% of total billed charges,331.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,801.87,97,,,Percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,760.54,92,,,Percent of total billed charges,92% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,1742.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2777.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3518.47,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,744,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,578.67,70,,,percent of total billed charges,70% of total billed charges,744,90,,,percent of total billed charges,90% of total billed charges,785.34,95,,,percent of total billed charges,95% of total billed charges,785.34,95,,,percent of total billed charges,95% of total billed charges,655.5,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1311.01,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,710.94,86,,,percent of total billed charges,86% of total billed charges,661.34,80,,,percent of total billed charges,80% of total billed charges,765.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,801.87,97,,,percent of total billed charges,97% of total billed charges,744,90,,,percent of total billed charges,90% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,801.87,97,,,percent of total billed charges,97% of total billed charges,768.8,93,,,percent of total billed charges,93% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,301.07,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,801.87,97,,,percent of total billed charges,97% of total billed charges,655.5,100,,,Fee Schedule,100% of CMS OPPS Rate ,655.5,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,557.17,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,301.07,3518.47,
Urinalysis Dipstick POC,3630956,CDM,300,RC,81003,HCPCS,Outpatient,,,13.36,6.68,,12.02,90,,,percent of total billed charges,90% of total Billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,3.38,150,,,Fee Schedule,150% of Fee Schedule Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.02,90,,,Percent of total Billed charges,90% of total billed charges,3.41,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.96,97,,,Percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,12.29,92,,,Percent of total billed charges,92% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.12,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.12,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,10.31,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,9.35,70,,,percent of total billed charges,70% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,12.69,95,,,percent of total billed charges,95% of total billed charges,2.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,4.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.49,86,,,percent of total billed charges,86% of total billed charges,10.69,80,,,percent of total billed charges,80% of total billed charges,2.49,111,,,Fee Schedule,111% of CMS OPPS Rate,12.96,97,,,percent of total billed charges,97% of total billed charges,12.02,90,,,percent of total billed charges,90% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.96,97,,,percent of total billed charges,97% of total billed charges,12.42,93,,,percent of total billed charges,93% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.96,97,,,percent of total billed charges,97% of total billed charges,2.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,1.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.91,12.96,
"HCG, Urine POC",3444192,CDM,300,RC,81025,HCPCS,Outpatient,,,51.11,25.56,,46,90,,,percent of total billed charges,90% of total Billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,40.89,80,,,Percent of total Billed charges,80% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,46,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,49.58,97,,,Percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,47.02,92,,,Percent of total billed charges,92% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,34.92,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.48,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,35.78,70,,,percent of total billed charges,70% of total billed charges,46,90,,,percent of total billed charges,90% of total billed charges,48.55,95,,,percent of total billed charges,95% of total billed charges,48.55,95,,,percent of total billed charges,95% of total billed charges,8.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.22,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,43.95,86,,,percent of total billed charges,86% of total billed charges,40.89,80,,,percent of total billed charges,80% of total billed charges,9.55,111,,,Fee Schedule,111% of CMS OPPS Rate,49.58,97,,,percent of total billed charges,97% of total billed charges,46,90,,,percent of total billed charges,90% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.58,97,,,percent of total billed charges,97% of total billed charges,47.53,93,,,percent of total billed charges,93% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.58,97,,,percent of total billed charges,97% of total billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.32,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,4,49.58,
Stool for Occult Blood POC,3444208,CDM,300,RC,82272,HCPCS,Outpatient,,,107.14,53.57,,96.43,90,,,percent of total billed charges,90% of total Billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,85.71,80,,,Percent of total Billed charges,80% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,96.43,90,,,Percent of total Billed charges,90% of total billed charges,3.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,103.93,97,,,Percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,98.57,92,,,Percent of total billed charges,92% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,17.15,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.39,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,96.43,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,75,70,,,percent of total billed charges,70% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,101.78,95,,,percent of total billed charges,95% of total billed charges,4.23,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.46,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,92.14,86,,,percent of total billed charges,86% of total billed charges,85.71,80,,,percent of total billed charges,80% of total billed charges,4.69,111,,,Fee Schedule,111% of CMS OPPS Rate,103.93,97,,,percent of total billed charges,97% of total billed charges,96.43,90,,,percent of total billed charges,90% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,103.93,97,,,percent of total billed charges,97% of total billed charges,99.64,93,,,percent of total billed charges,93% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,3.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,103.93,97,,,percent of total billed charges,97% of total billed charges,4.23,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.23,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.6,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.6,103.93,
85610- Prothrombin time,3430526,CDM,300,RC,85610,HCPCS,Outpatient,,,25.44,12.72,,22.9,90,,,percent of total billed charges,90% of total Billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,5.9,150,,,Fee Schedule,150% of Fee Schedule Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.9,90,,,Percent of total Billed charges,90% of total billed charges,4.4,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,24.68,97,,,Percent of total billed charges,97% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,23.4,92,,,Percent of total billed charges,92% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,17.4,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,4.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,21.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,19.67,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,22.9,90,,,percent of total billed charges,90% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,17.81,70,,,percent of total billed charges,70% of total billed charges,22.9,90,,,percent of total billed charges,90% of total billed charges,24.17,95,,,percent of total billed charges,95% of total billed charges,24.17,95,,,percent of total billed charges,95% of total billed charges,4.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,8.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,21.88,86,,,percent of total billed charges,86% of total billed charges,20.35,80,,,percent of total billed charges,80% of total billed charges,4.76,111,,,Fee Schedule,111% of CMS OPPS Rate,24.68,97,,,percent of total billed charges,97% of total billed charges,22.9,90,,,percent of total billed charges,90% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.68,97,,,percent of total billed charges,97% of total billed charges,23.66,93,,,percent of total billed charges,93% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,24.68,97,,,percent of total billed charges,97% of total billed charges,4.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.29,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,3.65,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,3.65,24.68,
BladderChek POC,3444187,CDM,300,RC,86386,HCPCS,Outpatient,,,51.72,25.86,,46.55,90,,,percent of total billed charges,90% of total Billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,41.38,80,,,Percent of total Billed charges,80% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.55,90,,,Percent of total Billed charges,90% of total billed charges,19.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,50.17,97,,,Percent of total billed charges,97% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,47.58,92,,,Percent of total billed charges,92% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,88.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,21.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,107.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,99.87,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.55,90,,,percent of total billed charges,90% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,36.2,70,,,percent of total billed charges,70% of total billed charges,46.55,90,,,percent of total billed charges,90% of total billed charges,49.13,95,,,percent of total billed charges,95% of total billed charges,49.13,95,,,percent of total billed charges,95% of total billed charges,21.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,43.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.48,86,,,percent of total billed charges,86% of total billed charges,41.38,80,,,percent of total billed charges,80% of total billed charges,24.17,111,,,Fee Schedule,111% of CMS OPPS Rate,50.17,97,,,percent of total billed charges,97% of total billed charges,46.55,90,,,percent of total billed charges,90% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.17,97,,,percent of total billed charges,97% of total billed charges,48.1,93,,,percent of total billed charges,93% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.09,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,50.17,97,,,percent of total billed charges,97% of total billed charges,21.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,18.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.09,107.64,
Culture Wound_NonSurgical,593562,CDM,300,RC,87070,HCPCS,Outpatient,,,51.17,25.59,,46.05,90,,,percent of total billed charges,90% of total Billed charges,8.61,100,,,Fee Schedule,100% of CMS OPPS Rate,12.96,150,,,Fee Schedule,150% of Fee Schedule Rate,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.05,90,,,Percent of total Billed charges,90% of total billed charges,7.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,49.63,97,,,Percent of total billed charges,97% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,47.08,92,,,Percent of total billed charges,92% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,34.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,42.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,39.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,46.05,90,,,percent of total billed charges,90% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,35.82,70,,,percent of total billed charges,70% of total billed charges,46.05,90,,,percent of total billed charges,90% of total billed charges,48.61,95,,,percent of total billed charges,95% of total billed charges,48.61,95,,,percent of total billed charges,95% of total billed charges,8.62,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,17.24,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,44.01,86,,,percent of total billed charges,86% of total billed charges,40.94,80,,,percent of total billed charges,80% of total billed charges,9.56,111,,,Fee Schedule,111% of CMS OPPS Rate,49.63,97,,,percent of total billed charges,97% of total billed charges,46.05,90,,,percent of total billed charges,90% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,49.63,97,,,percent of total billed charges,97% of total billed charges,47.59,93,,,percent of total billed charges,93% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,49.63,97,,,percent of total billed charges,97% of total billed charges,8.62,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.62,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,7.33,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.9,49.63,
Culture Urine,593561,CDM,300,RC,87086,HCPCS,Outpatient,,,47.9,23.95,,43.11,90,,,percent of total billed charges,90% of total Billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,12.15,150,,,Fee Schedule,150% of Fee Schedule Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.11,90,,,Percent of total Billed charges,90% of total billed charges,8.8,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,46.46,97,,,Percent of total billed charges,97% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,44.07,92,,,Percent of total billed charges,92% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,32.73,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,8.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,43.11,90,,,percent of total billed charges,90% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,33.53,70,,,percent of total billed charges,70% of total billed charges,43.11,90,,,percent of total billed charges,90% of total billed charges,45.51,95,,,percent of total billed charges,95% of total billed charges,45.51,95,,,percent of total billed charges,95% of total billed charges,8.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,16.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,41.19,86,,,percent of total billed charges,86% of total billed charges,38.32,80,,,percent of total billed charges,80% of total billed charges,8.95,111,,,Fee Schedule,111% of CMS OPPS Rate,46.46,97,,,percent of total billed charges,97% of total billed charges,43.11,90,,,percent of total billed charges,90% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.46,97,,,percent of total billed charges,97% of total billed charges,44.55,93,,,percent of total billed charges,93% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,46.46,97,,,percent of total billed charges,97% of total billed charges,8.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,6.86,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,6.86,46.46,
88305- Tissue exam by pathologist; Level IV,3430541,CDM,310,RC,88305,HCPCS,Outpatient,,,103.69,51.85,,93.32,90,,,percent of total billed charges,90% of total Billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,84.11,150,,,Fee Schedule,150% of Fee Schedule Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,93.32,90,,,Percent of total Billed charges,90% of total billed charges,9.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,100.58,97,,,Percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,95.39,92,,,Percent of total billed charges,92% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,121.05,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,192.98,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,244.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,93.32,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,72.58,70,,,percent of total billed charges,70% of total billed charges,93.32,90,,,percent of total billed charges,90% of total billed charges,98.51,95,,,percent of total billed charges,95% of total billed charges,98.51,95,,,percent of total billed charges,95% of total billed charges,45.54,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,91.08,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,89.17,86,,,percent of total billed charges,86% of total billed charges,82.95,80,,,percent of total billed charges,80% of total billed charges,51.14,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,100.58,97,,,percent of total billed charges,97% of total billed charges,93.32,90,,,percent of total billed charges,90% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,100.58,97,,,percent of total billed charges,97% of total billed charges,96.43,93,,,percent of total billed charges,93% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,100.58,97,,,percent of total billed charges,97% of total billed charges,45.54,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.54,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.7,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9,244.43,
90620 - Meningococcal (Bexsero),3918914,CDM,636,RC,90620,HCPCS,Outpatient,,,543.15,271.58,,488.84,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,434.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,488.84,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,526.86,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,499.7,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,346.87,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,427.2,78.65,,,percent of total billed charges,78.65% of total billed charges,485.2,89.33,,,percent of total billed charges,89.33% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,380.21,70,,,percent of total billed charges,70% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,515.99,95,,,percent of total billed charges,95% of total billed charges,515.99,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,467.11,86,,,percent of total billed charges,86% of total billed charges,434.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,526.86,97,,,percent of total billed charges,97% of total billed charges,488.84,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,526.86,97,,,percent of total billed charges,97% of total billed charges,505.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,526.86,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,526.86,
"90670 - Pneumococcal conjugate vaccine, 13 valent (PCV13), f",3918923,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,549.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,488.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,549.93,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,562.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.72,70,,,percent of total billed charges,70% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.49,86,,,percent of total billed charges,86% of total billed charges,488.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,568.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,592.7,
90670 - Prevnar 13,3918924,CDM,636,RC,90670,HCPCS,Outpatient,,,611.03,305.52,,549.93,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,488.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,549.93,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,592.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,562.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,427.72,70,,,percent of total billed charges,70% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,580.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,525.49,86,,,percent of total billed charges,86% of total billed charges,488.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,549.93,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,592.7,97,,,percent of total billed charges,97% of total billed charges,568.26,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,592.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,592.7,
Flu Adult Recombinant (egg-free),4183112,CDM,636,RC,90682,HCPCS,Outpatient,,,153.89,76.95,,138.5,90,,,percent of total billed charges,90% of total Billed charges,73.4,100,,,Fee Schedule,100% of CMS OPPS Rate,123.11,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,138.5,90,,,Percent of total Billed charges,90% of total billed charges,11,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,149.27,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,141.58,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,297.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,362.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,336.57,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,138.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,107.72,70,,,percent of total billed charges,70% of total billed charges,138.5,90,,,percent of total billed charges,90% of total billed charges,146.2,95,,,percent of total billed charges,95% of total billed charges,146.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132.35,86,,,percent of total billed charges,86% of total billed charges,123.11,80,,,percent of total billed charges,80% of total billed charges,67.69,111,,,Fee Schedule,111% of CMS OPPS Rate,149.27,97,,,percent of total billed charges,97% of total billed charges,138.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,149.27,97,,,percent of total billed charges,97% of total billed charges,143.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,149.27,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10,362.77,
"91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode pla",3696909,CDM,510,RC,91035,HCPCS,Outpatient,,,2329.3,1164.65,,2096.37,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1863.44,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2096.37,90,,,Percent of total Billed charges,90% of total billed charges,314.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2259.42,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2142.96,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2096.37,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1630.51,70,,,percent of total billed charges,70% of total billed charges,2096.37,90,,,percent of total billed charges,90% of total billed charges,2212.84,95,,,percent of total billed charges,95% of total billed charges,2212.84,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2003.2,86,,,percent of total billed charges,86% of total billed charges,1863.44,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2259.42,97,,,percent of total billed charges,97% of total billed charges,2096.37,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2259.42,97,,,percent of total billed charges,97% of total billed charges,2166.25,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,285.85,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2259.42,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.85,2356.78,
92060- Sensorimotor exam/mult measure/I&R,3435585,CDM,510,RC,92060,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,12.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,299.61,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,299.61,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.59,299.61,
92526- Tx swallow dysfunc/oral func/feed,3435639,CDM,430,RC,92526,HCPCS,Outpatient,,,338,169.00,,304.2,90,,,percent of total billed charges,90% of total Billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,270.4,80,,,Percent of total Billed charges,80% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,304.2,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,327.86,97,,,Percent of total billed charges,97% of total billed charges,80.45,100,,,Fee Schedule,100% of CMS OPPS Rate,310.96,92,,,Percent of total billed charges,92% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,327.09,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,80.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,398.5,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.72,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,304.2,90,,,percent of total billed charges,90% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,236.6,70,,,percent of total billed charges,70% of total billed charges,304.2,90,,,percent of total billed charges,90% of total billed charges,321.1,95,,,percent of total billed charges,95% of total billed charges,321.1,95,,,percent of total billed charges,95% of total billed charges,80.63,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,161.26,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,290.68,86,,,percent of total billed charges,86% of total billed charges,270.4,80,,,percent of total billed charges,80% of total billed charges,93.6,111,,,Fee Schedule,111% of CMS OPPS Rate,327.86,97,,,percent of total billed charges,97% of total billed charges,304.2,90,,,percent of total billed charges,90% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.86,97,,,percent of total billed charges,97% of total billed charges,314.34,93,,,percent of total billed charges,93% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,327.86,97,,,percent of total billed charges,97% of total billed charges,80.63,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.63,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,68.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,68.54,398.5,
92610- Eval/oral/pharyngeal swallow func,3435658,CDM,440,RC,92610,HCPCS,Outpatient,,,264.61,132.31,,238.15,90,,,percent of total billed charges,90% of total Billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,211.69,80,,,Percent of total Billed charges,80% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,238.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,256.67,97,,,Percent of total billed charges,97% of total billed charges,67.14,100,,,Fee Schedule,100% of CMS OPPS Rate,243.44,92,,,Percent of total billed charges,92% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,273.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,67.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,332.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,308.74,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,238.15,90,,,percent of total billed charges,90% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,185.23,70,,,percent of total billed charges,70% of total billed charges,238.15,90,,,percent of total billed charges,90% of total billed charges,251.38,95,,,percent of total billed charges,95% of total billed charges,251.38,95,,,percent of total billed charges,95% of total billed charges,67.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,227.56,86,,,percent of total billed charges,86% of total billed charges,211.69,80,,,percent of total billed charges,80% of total billed charges,79.44,111,,,Fee Schedule,111% of CMS OPPS Rate,256.67,97,,,percent of total billed charges,97% of total billed charges,238.15,90,,,percent of total billed charges,90% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,256.67,97,,,percent of total billed charges,97% of total billed charges,246.09,93,,,percent of total billed charges,93% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,256.67,97,,,percent of total billed charges,97% of total billed charges,67.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,67.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,57.23,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,57.23,332.77,
Cardioversion,604545,CDM,480,RC,92960,HCPCS,Outpatient,,,3286.53,1643.27,,2957.88,90,,,percent of total billed charges,90% of total Billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2629.22,80,,,Percent of total Billed charges,80% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,2957.88,90,,,Percent of total Billed charges,90% of total billed charges,95.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,3187.93,97,,,Percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,3023.61,92,,,Percent of total billed charges,92% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,1419.91,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2263.64,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2867.25,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2957.88,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,2300.57,70,,,percent of total billed charges,70% of total billed charges,2957.88,90,,,percent of total billed charges,90% of total billed charges,3122.2,95,,,percent of total billed charges,95% of total billed charges,3122.2,95,,,percent of total billed charges,95% of total billed charges,534.17,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1068.35,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2826.42,86,,,percent of total billed charges,86% of total billed charges,2629.22,80,,,percent of total billed charges,80% of total billed charges,554.63,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,3187.93,97,,,percent of total billed charges,97% of total billed charges,2957.88,90,,,percent of total billed charges,90% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,3187.93,97,,,percent of total billed charges,97% of total billed charges,3056.47,93,,,percent of total billed charges,93% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,87,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,3187.93,97,,,percent of total billed charges,97% of total billed charges,534.17,100,,,Fee Schedule,100% of CMS OPPS Rate ,534.17,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,454.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,87,3187.93,
Stress Test,,,480,RC,93017,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,1537.47,
93242 - Ext ECG >48HR <7D Recording,3896947,CDM,510,RC,93242,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,81.98,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,165.55,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,30.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,30.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,196.43,
93246 - EXT ECG>7D<15D RECORDING,3997218,CDM,510,RC,93246,HCPCS,Outpatient,,,202.51,101.26,,182.26,90,,,percent of total billed charges,90% of total Billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,162.01,80,,,Percent of total Billed charges,80% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,Percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,186.31,92,,,Percent of total billed charges,92% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,138.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,280.22,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,141.76,70,,,percent of total billed charges,70% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,192.38,95,,,percent of total billed charges,95% of total billed charges,52.2,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,104.41,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.16,86,,,percent of total billed charges,86% of total billed charges,162.01,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,182.26,90,,,percent of total billed charges,90% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.43,97,,,percent of total billed charges,97% of total billed charges,188.33,93,,,percent of total billed charges,93% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.43,97,,,percent of total billed charges,97% of total billed charges,52.2,100,,,Fee Schedule,100% of CMS OPPS Rate ,52.2,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,44.37,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.37,280.22,
93264-CardioMEMS recalibration,3432003,CDM,960,RC,93264,HCPCS,Outpatient,,,33.95,16.98,,30.56,90,,,percent of total billed charges,90% of total Billed charges,67.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.23,155,,,Fee Schedule,155% of CMS OPPS Rate,33.95,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.79,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,33.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,44.75,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,44.75,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,72.81,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,30.85,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,33.95,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,39.34,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,49.23,145,,,Fee Schedule,145% of CMS OPPS Rate,33.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.46,145,,,Fee Schedule,145% of CMS OPPS Rate,49.23,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,33.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,55.4,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,33.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,98.46,
CardioMEMS recalibration,3427124,CDM,480,RC,93264,HCPCS,Outpatient,,,33.95,16.98,,30.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,27.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,31.23,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.77,70,,,percent of total billed charges,70% of total billed charges,30.56,90,,,percent of total billed charges,90% of total billed charges,32.25,95,,,percent of total billed charges,95% of total billed charges,32.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.2,86,,,percent of total billed charges,86% of total billed charges,27.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.93,97,,,percent of total billed charges,97% of total billed charges,30.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,32.93,97,,,percent of total billed charges,97% of total billed charges,31.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,32.93,
Event Monitoring,604570,CDM,731,RC,93270,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,16.17,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.7,184.72,
93279- PPM eval/test/program/sgn lead,3430968,CDM,480,RC,93279,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,11.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,10.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,10.54,184.72,
93280- PPM eval/test/program/dual lead,3430969,CDM,480,RC,93280,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,184.72,
93281- PPM eval/test/program/multi lead,3430970,CDM,480,RC,93281,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,15.52,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.11,184.72,
93282- ICD eval/test/program/single lead,3430971,CDM,480,RC,93282,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,13.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.64,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.64,184.72,
93283- ICD eval/test/program/dual lead,3430972,CDM,480,RC,93283,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,15.98,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,14.53,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.53,184.72,
93284- ICD eval/test/program/mult lead,3430973,CDM,480,RC,93284,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,18.29,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,16.63,184.72,
93285- ILR eval/test/program,3430974,CDM,480,RC,93285,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,10.67,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.7,184.72,
93288 - Interrogation Eval in Person 1/Dual/Mlt Lead Pm,3430977,CDM,480,RC,93288,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,10.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,9.91,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.91,184.72,
93289- ICD interr/in person/sng/dual/mult,3430978,CDM,480,RC,93289,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,184.72,
ICD Generator Testing,3427177,CDM,480,RC,93289,HCPCS,Outpatient,,,190.43,95.22,,171.39,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,152.34,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.39,90,,,Percent of total Billed charges,90% of total billed charges,13.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,184.72,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,175.2,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.7,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,133.3,70,,,percent of total billed charges,70% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,180.91,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,163.77,86,,,percent of total billed charges,86% of total billed charges,152.34,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,184.72,97,,,percent of total billed charges,97% of total billed charges,171.39,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,184.72,97,,,percent of total billed charges,97% of total billed charges,177.1,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.22,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,184.72,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.22,184.72,
93291- Internal loop rec/interr/in person,3430980,CDM,480,RC,93291,HCPCS,Outpatient,,,150.36,75.18,,135.32,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,120.29,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,135.32,90,,,Percent of total Billed charges,90% of total billed charges,13.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,145.85,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,138.33,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.26,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,135.32,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,105.25,70,,,percent of total billed charges,70% of total billed charges,135.32,90,,,percent of total billed charges,90% of total billed charges,142.84,95,,,percent of total billed charges,95% of total billed charges,142.84,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,129.31,86,,,percent of total billed charges,86% of total billed charges,120.29,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,145.85,97,,,percent of total billed charges,97% of total billed charges,135.32,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,145.85,97,,,percent of total billed charges,97% of total billed charges,139.83,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.98,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,145.85,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.98,145.85,
93306- TTE/2D/M-mode/spec dop/color flow,3430992,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2702.26,
CL Adult Echocardiogram,3334933,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2702.26,
Echocardiogram,604555,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2702.26,
MCNH Echo Transthoracic Complete,3805223,CDM,483,RC,93306,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,107.95,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,98.14,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,98.14,2702.26,
93308- TTE/2D/M-mode/follow-up/limited  (GLOBAL),3430994,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1200.27,
CL Limited Echocardiogram,3334936,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1200.27,
Dobutamine Valve Study,4179565,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1200.27,
Limited Study-Echo,645295,CDM,483,RC,93308,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,23.65,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.5,1200.27,
93325 Doppler echo color flow,4061247,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,460.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,409.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,460.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,470.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,358.34,70,,,percent of total billed charges,70% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.25,86,,,percent of total billed charges,86% of total billed charges,409.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,476.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.34,496.56,
93325- Doppler echo color flow,3431006,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,460.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,409.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,460.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,470.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,358.34,70,,,percent of total billed charges,70% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.25,86,,,percent of total billed charges,86% of total billed charges,409.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,476.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.34,496.56,
Color Flow Mapping,604586,CDM,483,RC,93325,HCPCS,Outpatient,,,511.92,255.96,,460.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,409.54,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,460.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,470.97,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,358.34,70,,,percent of total billed charges,70% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,486.32,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,440.25,86,,,percent of total billed charges,86% of total billed charges,409.54,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,460.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,476.09,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,496.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,358.34,496.56,
93350 (26)- Stress Echo w/ I&R (PRO FEE),3431007,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2702.26,
93350- Stress echo/2D/M-mode/I&R,3431008,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2702.26,
CL Exercise Stress Echocardiogram,3334934,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2702.26,
CVS Charge Stress Echo,1157011,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2702.26,
Stress Echocardiogram,604568,CDM,483,RC,93350,HCPCS,Outpatient,,,2785.84,1392.92,,2507.26,90,,,percent of total billed charges,90% of total Billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2228.67,80,,,Percent of total Billed charges,80% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2507.26,90,,,Percent of total Billed charges,90% of total billed charges,51.15,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2702.26,97,,,Percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,2562.97,92,,,Percent of total billed charges,92% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1214.67,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1936.45,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2452.82,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,1950.09,70,,,percent of total billed charges,70% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,2646.55,95,,,percent of total billed charges,95% of total billed charges,456.97,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,913.94,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2395.82,86,,,percent of total billed charges,86% of total billed charges,2228.67,80,,,percent of total billed charges,80% of total billed charges,497.89,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2702.26,97,,,percent of total billed charges,97% of total billed charges,2507.26,90,,,percent of total billed charges,90% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,2702.26,97,,,percent of total billed charges,97% of total billed charges,2590.83,93,,,percent of total billed charges,93% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,46.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2702.26,97,,,percent of total billed charges,97% of total billed charges,456.97,100,,,Fee Schedule,100% of CMS OPPS Rate ,456.97,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,388.42,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,46.5,2702.26,
Myocardial Strain Imaging,3824895,CDM,483,RC,93356,HCPCS,Outpatient,,,191.47,95.74,,172.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,153.18,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,172.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,185.73,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,176.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.03,70,,,percent of total billed charges,70% of total billed charges,172.32,90,,,percent of total billed charges,90% of total billed charges,181.9,95,,,percent of total billed charges,95% of total billed charges,181.9,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,164.66,86,,,percent of total billed charges,86% of total billed charges,153.18,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,185.73,97,,,percent of total billed charges,97% of total billed charges,172.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,185.73,97,,,percent of total billed charges,97% of total billed charges,178.07,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.73,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.03,185.73,
Coronary Angiography,604572,CDM,480,RC,93454,HCPCS,Outpatient,,,16455.07,8227.54,,14809.56,90,,,percent of total billed charges,90% of total Billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,13164.06,80,,,Percent of total Billed charges,80% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,14809.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,15961.42,97,,,Percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,15138.66,92,,,Percent of total billed charges,92% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,7142.5,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11386.62,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,14422.86,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,14809.56,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,11518.55,70,,,percent of total billed charges,70% of total billed charges,14809.56,90,,,percent of total billed charges,90% of total billed charges,15632.32,95,,,percent of total billed charges,95% of total billed charges,15632.32,95,,,percent of total billed charges,95% of total billed charges,2687.05,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,5374.1,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,14151.36,86,,,percent of total billed charges,86% of total billed charges,13164.06,80,,,percent of total billed charges,80% of total billed charges,2946.49,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,15961.42,97,,,percent of total billed charges,97% of total billed charges,14809.56,90,,,percent of total billed charges,90% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,15961.42,97,,,percent of total billed charges,97% of total billed charges,15303.22,93,,,percent of total billed charges,93% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15961.42,97,,,percent of total billed charges,97% of total billed charges,2687.05,100,,,Fee Schedule,100% of CMS OPPS Rate ,2687.05,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,2283.98,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,2283.98,15961.42,
AV Nodal Ablation,3427172,CDM,480,RC,93650,HCPCS,Outpatient,,,37712.79,18856.40,,33941.51,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30170.23,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,33941.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36581.41,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34695.77,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,33941.51,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,26398.95,70,,,percent of total billed charges,70% of total billed charges,33941.51,90,,,percent of total billed charges,90% of total billed charges,35827.15,95,,,percent of total billed charges,95% of total billed charges,35827.15,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32433,86,,,percent of total billed charges,86% of total billed charges,30170.23,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36581.41,97,,,percent of total billed charges,97% of total billed charges,33941.51,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,36581.41,97,,,percent of total billed charges,97% of total billed charges,35072.89,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36581.41,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5197.81,36581.41,
AV Node Ablation,651265,CDM,480,RC,93650,HCPCS,Outpatient,,,37712.79,18856.40,,33941.51,90,,,percent of total billed charges,90% of total Billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,30170.23,80,,,Percent of total Billed charges,80% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,33941.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36581.41,97,,,Percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,34695.77,92,,,Percent of total billed charges,92% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16254.62,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,25913.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,32823,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,33941.51,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,26398.95,70,,,percent of total billed charges,70% of total billed charges,33941.51,90,,,percent of total billed charges,90% of total billed charges,35827.15,95,,,percent of total billed charges,95% of total billed charges,35827.15,95,,,percent of total billed charges,95% of total billed charges,6115.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12230.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32433,86,,,percent of total billed charges,86% of total billed charges,30170.23,80,,,percent of total billed charges,80% of total billed charges,6085.08,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36581.41,97,,,percent of total billed charges,97% of total billed charges,33941.51,90,,,percent of total billed charges,90% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,36581.41,97,,,percent of total billed charges,97% of total billed charges,35072.89,93,,,percent of total billed charges,93% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36581.41,97,,,percent of total billed charges,97% of total billed charges,6115.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,6115.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5197.81,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5197.81,36581.41,
93880 - Duplex scan of extracranial arteries; complete bilat,3898967,CDM,510,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
CL Carotid Duplex Complete BILAT,3427518,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
CL Carotid Duplex Complete LT,3427513,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
CL Carotid Duplex Complete RT,3427515,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
US Carotids Bilat,596598,CDM,921,RC,93880,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1200.27,
93882- Dup scan/extracran art/unilat/ltd,3435543,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Carotid Duplex Limited BILAT,3427517,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Carotid Duplex Limited LT,3427514,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Carotid Duplex Limited RT,3427516,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Limited Carotid Post Procedure BILAT,3427524,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Limited Carotid Post Procedure LT,3427522,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
CL Limited Carotid Post Procedure RT,3427523,CDM,921,RC,93882,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,82.5,538.52,
93922 Non-Invas Physiologic STD Extremity Art 2 Level,3436059,CDM,761,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,625.71,
SCSN US Exam,3575290,CDM,510,RC,93922,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,40.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.11,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.11,625.71,
93923 - Non-Invasive Physiologic Study Extremity 3 Lvls,3897046,CDM,510,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
93923- Upr/lxtr art stdy 3+ lvls,3430796,CDM,920,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Extrem Art Physiologic BILAT,3427525,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Extrem Art Physiologic LT,3427526,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Extrem Art Physiologic RT,3427527,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Periph Art Duplex wo Exer BILAT,3427532,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Periph Art Duplex wo Exer LT,3427528,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL Lower Periph Art Duplex wo Exer RT,3427530,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL US Lower Extrem Art Comp w ABI BILAT,3427501,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL US Lower Extrem Art Complete LT,3427503,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
CL US Lower Extrem Art Complete RT,3427505,CDM,921,RC,93923,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,77.06,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,70.05,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,70.05,765.14,
93924 - Lwr xtr vasc stdy bilat,3435544,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Ext Art Physio w Exer BILAT,3569307,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer BILAT,3427533,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer LT,3427529,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
CL Lower Periph Art Duplex w Exer RT,3427531,CDM,921,RC,93924,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,84.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,765.14,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,76.59,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,765.14,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,76.59,1365.32,
93925 - PF Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral stu,3641209,CDM,510,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,348.62,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,309.89,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.62,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,375.74,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,356.37,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271.15,70,,,percent of total billed charges,70% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,333.13,86,,,percent of total billed charges,86% of total billed charges,309.89,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,375.74,97,,,percent of total billed charges,97% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.74,97,,,percent of total billed charges,97% of total billed charges,360.24,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.74,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93925 26 Duplex scan of lower extremity arteries or arteri,3622799,CDM,510,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,348.62,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,309.89,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.62,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,375.74,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,356.37,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271.15,70,,,percent of total billed charges,70% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,333.13,86,,,percent of total billed charges,86% of total billed charges,309.89,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,375.74,97,,,percent of total billed charges,97% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.74,97,,,percent of total billed charges,97% of total billed charges,360.24,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.74,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93925- Dup scan/LE art/graft/bilat/comp,3435545,CDM,921,RC,93925,HCPCS,Outpatient,,,387.36,193.68,,348.62,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,309.89,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,348.62,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,375.74,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,356.37,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,271.15,70,,,percent of total billed charges,70% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,367.99,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,333.13,86,,,percent of total billed charges,86% of total billed charges,309.89,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,375.74,97,,,percent of total billed charges,97% of total billed charges,348.62,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,375.74,97,,,percent of total billed charges,97% of total billed charges,360.24,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,375.74,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93926 - Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited,3620984,CDM,510,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
93926- Dup scan/LE art/graft/unilat/ltd,3435546,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL Femoral Groin Artery BILAT,3427521,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL Femoral Groin Artery LT,3427519,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL Femoral Groin Artery RT,3427520,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
US Lower Ext Arterial Lt Limited,3374600,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
US Lower Ext Arterial Rt Complete,3374602,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
US Lower Ext Arterial Rt Limited,3374604,CDM,921,RC,93926,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
93930- Dup scan/UE art/graft/bilat/comp,3435547,CDM,921,RC,93930,HCPCS,Outpatient,,,276.2,138.10,,248.58,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,220.96,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,248.58,90,,,Percent of total Billed charges,90% of total billed charges,131.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,267.91,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,254.1,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,248.58,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,193.34,70,,,percent of total billed charges,70% of total billed charges,248.58,90,,,percent of total billed charges,90% of total billed charges,262.39,95,,,percent of total billed charges,95% of total billed charges,262.39,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,237.53,86,,,percent of total billed charges,86% of total billed charges,220.96,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,267.91,97,,,percent of total billed charges,97% of total billed charges,248.58,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,267.91,97,,,percent of total billed charges,97% of total billed charges,256.87,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,119.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,267.91,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,119.34,1138.43,
93931- Dup scan/UE/art/graft/unilat/ltd,3435548,CDM,921,RC,93931,HCPCS,Outpatient,,,177.3,88.65,,159.57,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,141.84,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,159.57,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,171.98,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,163.12,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,159.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,124.11,70,,,percent of total billed charges,70% of total billed charges,159.57,90,,,percent of total billed charges,90% of total billed charges,168.44,95,,,percent of total billed charges,95% of total billed charges,168.44,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,152.48,86,,,percent of total billed charges,86% of total billed charges,141.84,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,171.98,97,,,percent of total billed charges,97% of total billed charges,159.57,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,171.98,97,,,percent of total billed charges,97% of total billed charges,164.89,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,171.98,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,521.04,
93970- Dup scan/extremity vein/bilat/comp,3435549,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970 Dup-Scan XTR Veins Complete Bilateral Study,3436060,CDM,761,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL Periph Venous US Lower BILAT,3432087,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL Periph Venous US Upper BILAT,3432088,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL Upper Periph Arterial Duplex BILAT,3432089,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL US Vein Map Mark Lower Extrem BILAT,3432090,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL US Vein Map Mark Upper Extrem BILAT,3432091,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL US Venous Insuff Lower Extrem BILAT,3432092,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93970-CL US Venous Insuff Upper Extrem BILAT,3432093,CDM,481,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL Periph Venous US Lower BILAT,3427536,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL Periph Venous US Upper BILAT,3427537,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL Upper Periph Arterial Duplex BILAT,3427571,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL US Vein Map Mark Lower Extrem BILAT,3427463,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL US Vein Map Mark Upper Extrem BILAT,3427498,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL US Venous Insuff Lower Extrem BILAT,3427507,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
CL US Venous Insuff Upper Extrem BILAT,3427510,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
SCSN US Exam,4345743,CDM,402,RC,93970,HCPCS,Outpatient,,,1041.7,520.85,,937.53,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,833.36,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,937.53,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1010.45,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,958.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,937.53,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,729.19,70,,,percent of total billed charges,70% of total billed charges,937.53,90,,,percent of total billed charges,90% of total billed charges,989.62,95,,,percent of total billed charges,95% of total billed charges,989.62,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,895.86,86,,,percent of total billed charges,86% of total billed charges,833.36,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1010.45,97,,,percent of total billed charges,97% of total billed charges,937.53,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.45,97,,,percent of total billed charges,97% of total billed charges,968.78,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1010.45,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
SCSN US Exam,4345745,CDM,402,RC,93970,HCPCS,Outpatient,,,1041.7,520.85,,937.53,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,833.36,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,937.53,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1010.45,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,958.36,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,937.53,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,729.19,70,,,percent of total billed charges,70% of total billed charges,937.53,90,,,percent of total billed charges,90% of total billed charges,989.62,95,,,percent of total billed charges,95% of total billed charges,989.62,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,895.86,86,,,percent of total billed charges,86% of total billed charges,833.36,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1010.45,97,,,percent of total billed charges,97% of total billed charges,937.53,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1010.45,97,,,percent of total billed charges,97% of total billed charges,968.78,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1010.45,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
SCSN US Venous Lower Bilat Interp,3575318,CDM,510,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,251.88,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,223.9,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.88,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,271.47,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,257.48,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,195.91,70,,,percent of total billed charges,70% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,240.69,86,,,percent of total billed charges,86% of total billed charges,223.9,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,271.47,97,,,percent of total billed charges,97% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.47,97,,,percent of total billed charges,97% of total billed charges,260.28,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.47,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
SCSN US Venous Upper BILAT,3569783,CDM,402,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,251.88,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,223.9,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.88,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,271.47,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,257.48,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,195.91,70,,,percent of total billed charges,70% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,240.69,86,,,percent of total billed charges,86% of total billed charges,223.9,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,271.47,97,,,percent of total billed charges,97% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.47,97,,,percent of total billed charges,97% of total billed charges,260.28,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.47,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
SCSN Venous Insuff Bilat,3569789,CDM,920,RC,93970,HCPCS,Outpatient,,,279.87,139.94,,251.88,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,223.9,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,251.88,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,271.47,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,257.48,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,195.91,70,,,percent of total billed charges,70% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,265.88,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,240.69,86,,,percent of total billed charges,86% of total billed charges,223.9,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,271.47,97,,,percent of total billed charges,97% of total billed charges,251.88,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,271.47,97,,,percent of total billed charges,97% of total billed charges,260.28,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,271.47,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1138.43,
US Extremity Complete Bilat Upper for DVT,3347591,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
US Extremity Vein Complete Bilat for DVT,1257040,CDM,921,RC,93970,HCPCS,Outpatient,,,1237.39,618.70,,1113.65,90,,,percent of total billed charges,90% of total Billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,989.91,80,,,Percent of total Billed charges,80% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1113.65,90,,,Percent of total Billed charges,90% of total billed charges,125.62,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1200.27,97,,,Percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,1138.4,92,,,Percent of total billed charges,92% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,563.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,898.77,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1138.43,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,866.17,70,,,percent of total billed charges,70% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,1175.52,95,,,percent of total billed charges,95% of total billed charges,212.09,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,424.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1064.16,86,,,percent of total billed charges,86% of total billed charges,989.91,80,,,percent of total billed charges,80% of total billed charges,240.93,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1200.27,97,,,percent of total billed charges,97% of total billed charges,1113.65,90,,,percent of total billed charges,90% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.27,97,,,percent of total billed charges,97% of total billed charges,1150.77,93,,,percent of total billed charges,93% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,114.2,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1200.27,97,,,percent of total billed charges,97% of total billed charges,212.09,100,,,Fee Schedule,100% of CMS OPPS Rate ,212.09,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,180.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,114.2,1200.27,
93971 - PB Tech Duplex scan of extremity veins including responses to compression and other maneuver,3641197,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93971- Dup scan/extremity vein/unilat/ltd,3435550,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93971 -Duplex scan of extremity veins including responses to compression and other maneuvers; unilat,3641196,CDM,510,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93971 Dup-Scan XTR Veins Unilateral/Limited Study,3436061,CDM,761,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
CL Periph Venous US Lower LT,3427534,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL Upper Periph Arterial Duplex RT,3427570,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL US Venous Insuff Lower Extrem LT,3427508,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
CL US Venous Insuff Lower Extrem RT,3427509,CDM,921,RC,93971,HCPCS,Outpatient,,,555.18,277.59,,499.66,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,444.14,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,499.66,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,538.52,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,510.77,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,388.63,70,,,percent of total billed charges,70% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,527.42,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,477.45,86,,,percent of total billed charges,86% of total billed charges,444.14,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,538.52,97,,,percent of total billed charges,97% of total billed charges,499.66,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,538.52,97,,,percent of total billed charges,97% of total billed charges,516.32,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,538.52,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,538.52,
US Extremity Vein Unilat Lt for DVT,1257042,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Lt Lower for DVT,3347593,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Lt Upper for DVT,3347595,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Rt,596566,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Rt for DVT,1257044,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Rt Lower for DVT,3347597,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Extremity Vein Unilat Rt Upper for DVT,3347599,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Vein Map/Marking Lower Extremity Lt,3352010,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Vein Map/Marking Lower Extremity Rt,3352014,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Vein Map/Marking Upper Extrem Bilat,3352016,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Vein Map/Marking Upper Extrem Lt,3352018,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Vein Map/Marking Upper Extrem Rt,3352020,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Venous Insufficiency Lower Extrem Lt,3352022,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
US Venous Insufficiency Lower Extrem Rt,3352024,CDM,921,RC,93971,HCPCS,Outpatient,,,571.2,285.60,,514.08,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,456.96,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,514.08,90,,,Percent of total Billed charges,90% of total billed charges,86.46,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,554.06,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,525.5,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.02,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.04,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,399.84,70,,,percent of total billed charges,70% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,542.64,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.15,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,491.23,86,,,percent of total billed charges,86% of total billed charges,456.96,80,,,percent of total billed charges,80% of total billed charges,115.86,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,554.06,97,,,percent of total billed charges,97% of total billed charges,514.08,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,554.06,97,,,percent of total billed charges,97% of total billed charges,531.22,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,78.6,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,554.06,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.5,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,78.6,554.06,
93990- Dup scan/hemodialysis access,3435559,CDM,921,RC,93990,HCPCS,Outpatient,,,231.31,115.66,,208.18,90,,,percent of total billed charges,90% of total Billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,185.05,80,,,Percent of total Billed charges,80% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.18,90,,,Percent of total Billed charges,90% of total billed charges,88.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,224.37,97,,,Percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,212.81,92,,,Percent of total billed charges,92% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,258.03,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,411.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,521.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,208.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,161.92,70,,,percent of total billed charges,70% of total billed charges,208.18,90,,,percent of total billed charges,90% of total billed charges,219.74,95,,,percent of total billed charges,95% of total billed charges,219.74,95,,,percent of total billed charges,95% of total billed charges,97.07,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,194.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,198.93,86,,,percent of total billed charges,86% of total billed charges,185.05,80,,,percent of total billed charges,80% of total billed charges,115.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,224.37,97,,,percent of total billed charges,97% of total billed charges,208.18,90,,,percent of total billed charges,90% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,224.37,97,,,percent of total billed charges,97% of total billed charges,215.12,93,,,percent of total billed charges,93% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.51,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,224.37,97,,,percent of total billed charges,97% of total billed charges,97.07,100,,,Fee Schedule,100% of CMS OPPS Rate ,97.07,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,82.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.51,521.05,
94060- Spirometry/pre/post bronchodilator,3435316,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1537.47,
Clinic Spirometry w/ Diffusion Capacity,3435733,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1537.47,
Clinic Spirometry with and without,3435734,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1537.47,
PFT,617666,CDM,460,RC,94060,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,12.54,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.4,1537.47,
6 Minute Walk,658839,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,625.71,
Clinic 6 min walk,3435728,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,625.71,
Clinic 6 min walk with Oxygen titration,3435729,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,625.71,
Six Minute Walk Test,634111,CDM,460,RC,94618,HCPCS,Outpatient,,,645.06,322.53,,580.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,516.05,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,580.55,90,,,Percent of total Billed charges,90% of total billed charges,9.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,625.71,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,593.46,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,451.54,70,,,percent of total billed charges,70% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,612.81,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,554.75,86,,,percent of total billed charges,86% of total billed charges,516.05,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,625.71,97,,,percent of total billed charges,97% of total billed charges,580.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,625.71,97,,,percent of total billed charges,97% of total billed charges,599.91,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,8.66,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,625.71,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.66,625.71,
Nebulizer,617710,CDM,410,RC,94640,HCPCS,Outpatient,,,927.37,463.69,,834.63,90,,,percent of total billed charges,90% of total Billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,741.9,80,,,Percent of total Billed charges,80% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,834.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,899.55,97,,,Percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,853.18,92,,,Percent of total billed charges,92% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,462.33,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,737.05,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,933.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,834.63,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,649.16,70,,,percent of total billed charges,70% of total billed charges,834.63,90,,,percent of total billed charges,90% of total billed charges,881,95,,,percent of total billed charges,95% of total billed charges,881,95,,,percent of total billed charges,95% of total billed charges,173.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,347.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,797.54,86,,,percent of total billed charges,86% of total billed charges,741.9,80,,,percent of total billed charges,80% of total billed charges,190.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,899.55,97,,,percent of total billed charges,97% of total billed charges,834.63,90,,,percent of total billed charges,90% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,899.55,97,,,percent of total billed charges,97% of total billed charges,862.45,93,,,percent of total billed charges,93% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,899.55,97,,,percent of total billed charges,97% of total billed charges,173.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,173.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,147.84,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,147.84,933.58,
94726 - (TC) Plethysmography Lung Volumes w/wo airway resist,3896962,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1537.47,
94726 - Plethysmography Lung Volumes w/wo airway resist,3896968,CDM,510,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1537.47,
94726- Plethysmography/lung volume,3435709,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1537.47,
Clinic Lung Volumes,3435732,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1537.47,
Lung Vol & Capacity,617686,CDM,460,RC,94726,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1268.02,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1426.52,90,,,Percent of total Billed charges,90% of total billed charges,33.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1537.47,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1458.22,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1109.51,70,,,percent of total billed charges,70% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,1505.77,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1363.12,86,,,percent of total billed charges,86% of total billed charges,1268.02,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1537.47,97,,,percent of total billed charges,97% of total billed charges,1426.52,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1537.47,97,,,percent of total billed charges,97% of total billed charges,1474.07,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.44,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1537.47,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30.44,1537.47,
94729- Diffusing capacity/CO2/add on,3435712,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,207.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.03,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.02,70,,,percent of total billed charges,70% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.83,86,,,percent of total billed charges,86% of total billed charges,184.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,213.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,223.13,
Carbon Monoxide Diffusing Capacity,625084,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,207.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.03,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.02,70,,,percent of total billed charges,70% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.83,86,,,percent of total billed charges,86% of total billed charges,184.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,213.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,223.13,
Clinic Diffusion Capacity,3435730,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,207.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.03,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.02,70,,,percent of total billed charges,70% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.83,86,,,percent of total billed charges,86% of total billed charges,184.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,213.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,223.13,
DLCO,617682,CDM,460,RC,94729,HCPCS,Outpatient,,,230.03,115.02,,207.03,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,184.02,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,207.03,90,,,Percent of total Billed charges,90% of total billed charges,36.43,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,223.13,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,211.63,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,161.02,70,,,percent of total billed charges,70% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,218.53,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,197.83,86,,,percent of total billed charges,86% of total billed charges,184.02,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,207.03,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.13,97,,,percent of total billed charges,97% of total billed charges,213.93,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,223.13,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.12,223.13,
95800- Stdy Unatnd w/Hrt Rt/O2 Sat/Resp/Slp Time,4347083,CDM,510,RC,95800,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,765.14,
95801- Slp Stdy Unatnd w/Min Hrt Rt/O2 Sat/Resp Analys,4347084,CDM,510,RC,95801,HCPCS,Outpatient,,,308.88,154.44,,277.99,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,247.1,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,277.99,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,299.61,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,284.17,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,277.99,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,216.22,70,,,percent of total billed charges,70% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,293.44,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,265.64,86,,,percent of total billed charges,86% of total billed charges,247.1,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,299.61,97,,,percent of total billed charges,97% of total billed charges,277.99,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,299.61,97,,,percent of total billed charges,97% of total billed charges,287.26,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,299.61,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,89.63,566.05,
Sleep Study - In Lab MSLT 95805,3575514,CDM,920,RC,95805,HCPCS,Outpatient,,,2706.6,1353.30,,2435.94,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2165.28,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2435.94,90,,,Percent of total Billed charges,90% of total billed charges,221.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2625.4,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2490.07,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2435.94,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1894.62,70,,,percent of total billed charges,70% of total billed charges,2435.94,90,,,percent of total billed charges,90% of total billed charges,2571.27,95,,,percent of total billed charges,95% of total billed charges,2571.27,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2327.68,86,,,percent of total billed charges,86% of total billed charges,2165.28,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2625.4,97,,,percent of total billed charges,97% of total billed charges,2435.94,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2625.4,97,,,percent of total billed charges,97% of total billed charges,2517.14,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,201.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2625.4,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,201.32,2625.4,
Sleep Study - Home Study 95806,3575513,CDM,920,RC,95806,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,765.14,
95807 - Sleep Study - Attended,4347085,CDM,510,RC,95807,HCPCS,Outpatient,,,2415.26,1207.63,,2173.73,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1932.21,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2173.73,90,,,Percent of total Billed charges,90% of total billed charges,310.19,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2342.8,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2222.04,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2173.73,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1690.68,70,,,percent of total billed charges,70% of total billed charges,2173.73,90,,,percent of total billed charges,90% of total billed charges,2294.5,95,,,percent of total billed charges,95% of total billed charges,2294.5,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2077.12,86,,,percent of total billed charges,86% of total billed charges,1932.21,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2342.8,97,,,percent of total billed charges,97% of total billed charges,2173.73,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2342.8,97,,,percent of total billed charges,97% of total billed charges,2246.19,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,281.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2342.8,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,281.99,2356.78,
95808- Polysomnography/any age/tech,3430545,CDM,510,RC,95808,HCPCS,Outpatient,,,5279.75,2639.88,,4751.78,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4223.8,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4751.78,90,,,Percent of total Billed charges,90% of total billed charges,301.16,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5121.36,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4857.37,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.83,70,,,percent of total billed charges,70% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4540.59,86,,,percent of total billed charges,86% of total billed charges,4223.8,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5121.36,97,,,percent of total billed charges,97% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5121.36,97,,,percent of total billed charges,97% of total billed charges,4910.17,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,273.78,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5121.36,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,273.78,5121.36,
Sleep Study - In Lab PSG 95810,3575515,CDM,740,RC,95810,HCPCS,Outpatient,,,5279.75,2639.88,,4751.78,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4223.8,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4751.78,90,,,Percent of total Billed charges,90% of total billed charges,297.35,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5121.36,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4857.37,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.83,70,,,percent of total billed charges,70% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4540.59,86,,,percent of total billed charges,86% of total billed charges,4223.8,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5121.36,97,,,percent of total billed charges,97% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5121.36,97,,,percent of total billed charges,97% of total billed charges,4910.17,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,270.32,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5121.36,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,270.32,5121.36,
Sleep Study - In Lab Titration 95811,3575516,CDM,740,RC,95811,HCPCS,Outpatient,,,5279.75,2639.88,,4751.78,90,,,percent of total billed charges,90% of total Billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4223.8,80,,,Percent of total Billed charges,80% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,4751.78,90,,,Percent of total Billed charges,90% of total billed charges,569.44,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,5121.36,97,,,Percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,4857.37,92,,,Percent of total billed charges,92% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,2255.83,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,3596.26,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,4555.21,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,3695.83,70,,,percent of total billed charges,70% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,5015.76,95,,,percent of total billed charges,95% of total billed charges,848.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1697.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,4540.59,86,,,percent of total billed charges,86% of total billed charges,4223.8,80,,,percent of total billed charges,80% of total billed charges,939.73,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,5121.36,97,,,percent of total billed charges,97% of total billed charges,4751.78,90,,,percent of total billed charges,90% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,5121.36,97,,,percent of total billed charges,97% of total billed charges,4910.17,93,,,percent of total billed charges,93% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,517.67,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,5121.36,97,,,percent of total billed charges,97% of total billed charges,848.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,848.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,721.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,517.67,5121.36,
Clinic EEG,3435538,CDM,740,RC,95812,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,42.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.93,1365.32,
"EEG, ROUTINE 41-60 MINS",3435541,CDM,740,RC,95812,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,42.82,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,38.93,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.93,1365.32,
95813- EEG Routine 61 - 199 Minutes,3435464,CDM,740,RC,95813,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,48.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.45,1365.32,
CL EEG Routine 61- 199 Minutes 95813,4339185,CDM,740,RC,95813,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,48.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.45,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,44.45,1365.32,
95816- EEG w/recording/awake/drowsy,3435465,CDM,740,RC,95816,HCPCS,Outpatient,,,1334.35,667.18,,1200.92,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1067.48,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1200.92,90,,,Percent of total Billed charges,90% of total billed charges,14.85,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1294.32,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1227.6,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1200.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,934.05,70,,,percent of total billed charges,70% of total billed charges,1200.92,90,,,percent of total billed charges,90% of total billed charges,1267.63,95,,,percent of total billed charges,95% of total billed charges,1267.63,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1147.54,86,,,percent of total billed charges,86% of total billed charges,1067.48,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1294.32,97,,,percent of total billed charges,97% of total billed charges,1200.92,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1294.32,97,,,percent of total billed charges,97% of total billed charges,1240.95,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1294.32,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.5,1365.32,
95822 - (TC) Electroencephalogram (EEG); recording in coma or sleep only,3899092,CDM,983,RC,95822,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,632.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,455.91,155,,,Fee Schedule,155% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.91,145,,,Fee Schedule,145% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.82,145,,,Fee Schedule,145% of CMS OPPS Rate,455.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,1426.52,
95822 - Electroencephalogram (EEG); recording in coma or sleep only,3800934,CDM,983,RC,95822,HCPCS,Outpatient,,,1585.02,792.51,,1426.52,90,,,percent of total billed charges,90% of total Billed charges,632.29,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,22.5,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,455.91,155,,,Fee Schedule,155% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,478.32,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,537.98,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,537.98,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,524.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,300.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,628.84,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,395.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,455.91,145,,,Fee Schedule,145% of CMS OPPS Rate,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,916.82,145,,,Fee Schedule,145% of CMS OPPS Rate,455.91,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,293.5,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,314.42,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.15,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,594.15,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,22.5,1426.52,
95860 - Needle electromyography; 1 extremity with or without related paraspinal areas,3715346,CDM,510,RC,95860,HCPCS,Outpatient,,,18.88,9.44,,16.99,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,15.1,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.99,90,,,Percent of total Billed charges,90% of total billed charges,19.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,18.31,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,17.37,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16.99,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,13.22,70,,,percent of total billed charges,70% of total billed charges,16.99,90,,,percent of total billed charges,90% of total billed charges,17.94,95,,,percent of total billed charges,95% of total billed charges,17.94,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,16.24,86,,,percent of total billed charges,86% of total billed charges,15.1,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,18.31,97,,,percent of total billed charges,97% of total billed charges,16.99,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.31,97,,,percent of total billed charges,97% of total billed charges,17.56,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,18.31,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.22,566.05,
95861 - Needle electromyography; 2 extremities with or without related paraspinal areas,3715353,CDM,510,RC,95861,HCPCS,Outpatient,,,12.83,6.42,,11.55,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,10.26,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.55,90,,,Percent of total Billed charges,90% of total billed charges,24.75,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,12.45,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,11.8,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,11.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,8.98,70,,,percent of total billed charges,70% of total billed charges,11.55,90,,,percent of total billed charges,90% of total billed charges,12.19,95,,,percent of total billed charges,95% of total billed charges,12.19,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,11.03,86,,,percent of total billed charges,86% of total billed charges,10.26,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,12.45,97,,,percent of total billed charges,97% of total billed charges,11.55,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.45,97,,,percent of total billed charges,97% of total billed charges,11.93,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.5,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,12.45,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,8.98,566.05,
95863 - Needle electromyography; 3 extremities with or without related paraspinal areas,3715354,CDM,510,RC,95863,HCPCS,Outpatient,,,20.74,10.37,,18.67,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,16.59,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.67,90,,,Percent of total Billed charges,90% of total billed charges,27.5,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,20.12,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,19.08,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,18.67,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,14.52,70,,,percent of total billed charges,70% of total billed charges,18.67,90,,,percent of total billed charges,90% of total billed charges,19.7,95,,,percent of total billed charges,95% of total billed charges,19.7,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,17.84,86,,,percent of total billed charges,86% of total billed charges,16.59,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,20.12,97,,,percent of total billed charges,97% of total billed charges,18.67,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.12,97,,,percent of total billed charges,97% of total billed charges,19.29,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,20.12,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,14.52,708.98,
95864 - Needle electromyography; 4 extremities with or without related paraspinal areas,3715360,CDM,510,RC,95864,HCPCS,Outpatient,,,46.19,23.10,,41.57,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,36.95,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.57,90,,,Percent of total Billed charges,90% of total billed charges,31.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,44.8,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,42.49,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,41.57,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,32.33,70,,,percent of total billed charges,70% of total billed charges,41.57,90,,,percent of total billed charges,90% of total billed charges,43.88,95,,,percent of total billed charges,95% of total billed charges,43.88,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,39.72,86,,,percent of total billed charges,86% of total billed charges,36.95,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,44.8,97,,,percent of total billed charges,97% of total billed charges,41.57,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.8,97,,,percent of total billed charges,97% of total billed charges,42.96,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,44.8,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29,708.98,
95869- Needle electromyograp/thor/paraspi,3435479,CDM,510,RC,95869,HCPCS,Outpatient,,,661.05,330.53,,594.95,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,528.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.95,90,,,Percent of total Billed charges,90% of total billed charges,8.57,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,641.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,608.17,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,462.74,70,,,percent of total billed charges,70% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,568.5,86,,,percent of total billed charges,86% of total billed charges,528.84,80,,,percent of total billed charges,80% of total billed charges,143.03,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,641.22,97,,,percent of total billed charges,97% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.22,97,,,percent of total billed charges,97% of total billed charges,614.78,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,7.79,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,7.79,708.98,
95870- Needle electromyography/lmt/1 ext,3435480,CDM,510,RC,95870,HCPCS,Outpatient,,,527.8,263.90,,475.02,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,422.24,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.02,90,,,Percent of total Billed charges,90% of total billed charges,18.99,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,511.97,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,485.58,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,475.02,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,369.46,70,,,percent of total billed charges,70% of total billed charges,475.02,90,,,percent of total billed charges,90% of total billed charges,501.41,95,,,percent of total billed charges,95% of total billed charges,501.41,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,453.91,86,,,percent of total billed charges,86% of total billed charges,422.24,80,,,percent of total billed charges,80% of total billed charges,56.87,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,511.97,97,,,percent of total billed charges,97% of total billed charges,475.02,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,511.97,97,,,percent of total billed charges,97% of total billed charges,490.85,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.26,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,511.97,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.26,566.05,
95873- Electric stim/w chemodenervation,3435482,CDM,510,RC,95873,HCPCS,Outpatient,,,955,477.50,,859.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,764,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,859.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,926.35,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,878.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,609.88,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,751.13,78.65,,,percent of total billed charges,78.65% of total billed charges,853.12,89.33,,,percent of total billed charges,89.33% of total billed charges,859.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,668.5,70,,,percent of total billed charges,70% of total billed charges,859.5,90,,,percent of total billed charges,90% of total billed charges,907.25,95,,,percent of total billed charges,95% of total billed charges,907.25,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,821.3,86,,,percent of total billed charges,86% of total billed charges,764,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,926.35,97,,,percent of total billed charges,97% of total billed charges,859.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,926.35,97,,,percent of total billed charges,97% of total billed charges,888.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,926.35,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,609.88,926.35,
95874- Needle EMG/chemodenervation,3435483,CDM,510,RC,95874,HCPCS,Outpatient,,,850,425.00,,765,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,680,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,765,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,782,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,542.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,668.54,78.65,,,percent of total billed charges,78.65% of total billed charges,759.32,89.33,,,percent of total billed charges,89.33% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,595,70,,,percent of total billed charges,70% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,807.5,95,,,percent of total billed charges,95% of total billed charges,807.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731,86,,,percent of total billed charges,86% of total billed charges,680,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,790.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.83,824.5,
Clinic EMG,3435539,CDM,510,RC,95874,HCPCS,Outpatient,,,850,425.00,,765,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,680,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,765,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,782,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,542.83,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,668.54,78.65,,,percent of total billed charges,78.65% of total billed charges,759.32,89.33,,,percent of total billed charges,89.33% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,595,70,,,percent of total billed charges,70% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,807.5,95,,,percent of total billed charges,95% of total billed charges,807.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,731,86,,,percent of total billed charges,86% of total billed charges,680,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,765,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,790.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,824.5,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,542.83,824.5,
95885- Needle electromyography/ea ext/lmt,3435485,CDM,510,RC,95885,HCPCS,Outpatient,,,1470,735.00,,1323,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1176,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1323,90,,,Percent of total Billed charges,90% of total billed charges,30.68,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1425.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1352.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,938.77,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1156.19,78.65,,,percent of total billed charges,78.65% of total billed charges,1313.17,89.33,,,percent of total billed charges,89.33% of total billed charges,1323,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1029,70,,,percent of total billed charges,70% of total billed charges,1323,90,,,percent of total billed charges,90% of total billed charges,1396.5,95,,,percent of total billed charges,95% of total billed charges,1396.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1264.2,86,,,percent of total billed charges,86% of total billed charges,1176,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1425.9,97,,,percent of total billed charges,97% of total billed charges,1323,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1425.9,97,,,percent of total billed charges,97% of total billed charges,1367.1,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1425.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27.89,1425.9,
95886- Needle electromyography/ea ext/com,3435486,CDM,510,RC,95886,HCPCS,Outpatient,,,1674.75,837.38,,1507.28,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1339.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1507.28,90,,,Percent of total Billed charges,90% of total billed charges,32.33,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1624.51,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1540.77,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,1069.53,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1317.23,78.65,,,percent of total billed charges,78.65% of total billed charges,1496.08,89.33,,,percent of total billed charges,89.33% of total billed charges,1507.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1172.33,70,,,percent of total billed charges,70% of total billed charges,1507.28,90,,,percent of total billed charges,90% of total billed charges,1591.01,95,,,percent of total billed charges,95% of total billed charges,1591.01,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1440.29,86,,,percent of total billed charges,86% of total billed charges,1339.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1624.51,97,,,percent of total billed charges,97% of total billed charges,1507.28,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1624.51,97,,,percent of total billed charges,97% of total billed charges,1557.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1624.51,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.39,1624.51,
95887- Needle electromyography/non-ext,3435487,CDM,510,RC,95887,HCPCS,Outpatient,,,1310,655.00,,1179,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1048,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1179,90,,,Percent of total Billed charges,90% of total billed charges,32.88,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1270.7,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1205.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,836.59,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,1030.34,78.65,,,percent of total billed charges,78.65% of total billed charges,1170.24,89.33,,,percent of total billed charges,89.33% of total billed charges,1179,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,917,70,,,percent of total billed charges,70% of total billed charges,1179,90,,,percent of total billed charges,90% of total billed charges,1244.5,95,,,percent of total billed charges,95% of total billed charges,1244.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1126.6,86,,,percent of total billed charges,86% of total billed charges,1048,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1270.7,97,,,percent of total billed charges,97% of total billed charges,1179,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1270.7,97,,,percent of total billed charges,97% of total billed charges,1218.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1270.7,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.89,1270.7,
95905- Motor/sensory nerve conduction/I&R,3435490,CDM,510,RC,95905,HCPCS,Outpatient,,,1716.25,858.13,,1544.63,90,,,percent of total billed charges,90% of total Billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1373,80,,,Percent of total Billed charges,80% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1544.63,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1664.76,97,,,Percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1578.95,92,,,Percent of total billed charges,92% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,911.55,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1453.2,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1840.7,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1544.63,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,1201.38,70,,,percent of total billed charges,70% of total billed charges,1544.63,90,,,percent of total billed charges,90% of total billed charges,1630.44,95,,,percent of total billed charges,95% of total billed charges,1630.44,95,,,percent of total billed charges,95% of total billed charges,342.93,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,685.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1475.98,86,,,percent of total billed charges,86% of total billed charges,1373,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1664.76,97,,,percent of total billed charges,97% of total billed charges,1544.63,90,,,percent of total billed charges,90% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,1664.76,97,,,percent of total billed charges,97% of total billed charges,1596.11,93,,,percent of total billed charges,93% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1664.76,97,,,percent of total billed charges,97% of total billed charges,342.93,100,,,Fee Schedule,100% of CMS OPPS Rate ,342.93,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,291.49,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.72,1840.7,
95907- Nerve conduction study/1-2 study,3435491,CDM,510,RC,95907,HCPCS,Outpatient,,,661.05,330.53,,594.95,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,528.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.95,90,,,Percent of total Billed charges,90% of total billed charges,34.63,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,641.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,608.17,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,462.74,70,,,percent of total billed charges,70% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,568.5,86,,,percent of total billed charges,86% of total billed charges,528.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,641.22,97,,,percent of total billed charges,97% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.22,97,,,percent of total billed charges,97% of total billed charges,614.78,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.48,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.48,708.98,
95908- Nerve conduction study/3-4 study,3435492,CDM,510,RC,95908,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,41.73,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,37.94,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,37.94,1365.32,
95909- Nerve conduction study/5-6 study,3435493,CDM,510,RC,95909,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,50.34,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,45.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.76,1365.32,
95910- Nerve conduction study/7-8 study,3435494,CDM,510,RC,95910,HCPCS,Outpatient,,,1273,636.50,,1145.7,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1018.4,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1145.7,90,,,Percent of total Billed charges,90% of total billed charges,64.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1234.81,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1171.16,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,891.1,70,,,percent of total billed charges,70% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,1209.35,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1094.78,86,,,percent of total billed charges,86% of total billed charges,1018.4,80,,,percent of total billed charges,80% of total billed charges,261.67,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1234.81,97,,,percent of total billed charges,97% of total billed charges,1145.7,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1234.81,97,,,percent of total billed charges,97% of total billed charges,1183.89,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.99,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1234.81,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.99,1365.32,
95911- Nerve conduction study/9-10 study,3435495,CDM,510,RC,95911,HCPCS,Outpatient,,,2197.45,1098.73,,1977.71,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.96,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.71,90,,,Percent of total Billed charges,90% of total billed charges,75.39,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2131.53,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2021.65,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.22,70,,,percent of total billed charges,70% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1889.81,86,,,percent of total billed charges,86% of total billed charges,1757.96,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2131.53,97,,,percent of total billed charges,97% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2131.53,97,,,percent of total billed charges,97% of total billed charges,2043.63,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2131.53,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,68.54,2356.78,
95912- Nerve conduction study/11-12 study,3435496,CDM,510,RC,95912,HCPCS,Outpatient,,,2197.45,1098.73,,1977.71,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.96,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.71,90,,,Percent of total Billed charges,90% of total billed charges,85.31,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2131.53,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2021.65,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.22,70,,,percent of total billed charges,70% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1889.81,86,,,percent of total billed charges,86% of total billed charges,1757.96,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2131.53,97,,,percent of total billed charges,97% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2131.53,97,,,percent of total billed charges,97% of total billed charges,2043.63,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,77.55,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2131.53,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,77.55,2356.78,
95913- Nerve conduction studies/13 >,3435497,CDM,510,RC,95913,HCPCS,Outpatient,,,2197.45,1098.73,,1977.71,90,,,percent of total billed charges,90% of total Billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1757.96,80,,,Percent of total Billed charges,80% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,1977.71,90,,,Percent of total Billed charges,90% of total billed charges,95.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2131.53,97,,,Percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,2021.65,92,,,Percent of total billed charges,92% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1167.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1860.63,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,2356.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,1538.22,70,,,percent of total billed charges,70% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,2087.58,95,,,percent of total billed charges,95% of total billed charges,439.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,878.16,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1889.81,86,,,percent of total billed charges,86% of total billed charges,1757.96,80,,,percent of total billed charges,80% of total billed charges,502.05,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2131.53,97,,,percent of total billed charges,97% of total billed charges,1977.71,90,,,percent of total billed charges,90% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,2131.53,97,,,percent of total billed charges,97% of total billed charges,2043.63,93,,,percent of total billed charges,93% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,86.86,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2131.53,97,,,percent of total billed charges,97% of total billed charges,439.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,439.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,373.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,86.86,2356.78,
95937- Neuromuscular junc test/ea nerve,3435504,CDM,510,RC,95937,HCPCS,Outpatient,,,661.05,330.53,,594.95,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,528.84,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,594.95,90,,,Percent of total Billed charges,90% of total billed charges,13.45,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,641.22,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,608.17,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,462.74,70,,,percent of total billed charges,70% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,628,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,568.5,86,,,percent of total billed charges,86% of total billed charges,528.84,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,641.22,97,,,percent of total billed charges,97% of total billed charges,594.95,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,641.22,97,,,percent of total billed charges,97% of total billed charges,614.78,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,641.22,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.23,708.98,
95970- VNS evaluation,3435519,CDM,510,RC,95970,HCPCS,Outpatient,,,527.8,263.90,,475.02,90,,,percent of total billed charges,90% of total Billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,422.24,80,,,Percent of total Billed charges,80% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,475.02,90,,,Percent of total Billed charges,90% of total billed charges,21.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,511.97,97,,,Percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,485.58,92,,,Percent of total billed charges,92% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,280.32,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,446.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,566.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,475.02,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,369.46,70,,,percent of total billed charges,70% of total billed charges,475.02,90,,,percent of total billed charges,90% of total billed charges,501.41,95,,,percent of total billed charges,95% of total billed charges,501.41,95,,,percent of total billed charges,95% of total billed charges,105.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,210.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,453.91,86,,,percent of total billed charges,86% of total billed charges,422.24,80,,,percent of total billed charges,80% of total billed charges,112.72,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,511.97,97,,,percent of total billed charges,97% of total billed charges,475.02,90,,,percent of total billed charges,90% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,511.97,97,,,percent of total billed charges,97% of total billed charges,490.85,93,,,percent of total billed charges,93% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.34,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,511.97,97,,,percent of total billed charges,97% of total billed charges,105.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.45,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,89.63,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.34,566.05,
95972- Elec Anlys Implt Npgt Cplx Sp/Pn Prgrmg,4327334,CDM,510,RC,95972,HCPCS,Outpatient,,,411.5,205.75,,370.35,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,329.2,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,370.35,90,,,Percent of total Billed charges,90% of total billed charges,71.24,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,399.16,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,378.58,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,370.35,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,288.05,70,,,percent of total billed charges,70% of total billed charges,370.35,90,,,percent of total billed charges,90% of total billed charges,390.93,95,,,percent of total billed charges,95% of total billed charges,390.93,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,353.89,86,,,percent of total billed charges,86% of total billed charges,329.2,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,399.16,97,,,percent of total billed charges,97% of total billed charges,370.35,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,399.16,97,,,percent of total billed charges,97% of total billed charges,382.7,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,64.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,399.16,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,64.76,486.58,
"95976 - (PF) Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, conta",3635243,CDM,510,RC,95976,HCPCS,Outpatient,,,1.57,0.79,,1.41,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1.26,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1.41,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1.52,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1.44,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1.41,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,1.1,70,,,percent of total billed charges,70% of total billed charges,1.41,90,,,percent of total billed charges,90% of total billed charges,1.49,95,,,percent of total billed charges,95% of total billed charges,1.49,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1.35,86,,,percent of total billed charges,86% of total billed charges,1.26,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1.52,97,,,percent of total billed charges,97% of total billed charges,1.41,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,1.52,97,,,percent of total billed charges,97% of total billed charges,1.46,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1.52,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.1,170.62,
"95976- Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gro",3692914,CDM,510,RC,95976,HCPCS,Outpatient,,,159.1,79.55,,143.19,90,,,percent of total billed charges,90% of total Billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,127.28,80,,,Percent of total Billed charges,80% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.19,90,,,Percent of total Billed charges,90% of total billed charges,35.53,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,154.33,97,,,Percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,146.37,92,,,Percent of total billed charges,92% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,84.49,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,134.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,170.62,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,143.19,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,111.37,70,,,percent of total billed charges,70% of total billed charges,143.19,90,,,percent of total billed charges,90% of total billed charges,151.15,95,,,percent of total billed charges,95% of total billed charges,151.15,95,,,percent of total billed charges,95% of total billed charges,31.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.57,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,136.83,86,,,percent of total billed charges,86% of total billed charges,127.28,80,,,percent of total billed charges,80% of total billed charges,37.47,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,154.33,97,,,percent of total billed charges,97% of total billed charges,143.19,90,,,percent of total billed charges,90% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.33,97,,,percent of total billed charges,97% of total billed charges,147.96,93,,,percent of total billed charges,93% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,32.3,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,154.33,97,,,percent of total billed charges,97% of total billed charges,31.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.02,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.02,170.62,
"95977 - Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3715361,CDM,510,RC,95977,HCPCS,Outpatient,,,2.36,1.18,,2.12,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1.89,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.12,90,,,Percent of total Billed charges,90% of total billed charges,47.37,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,2.29,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,2.17,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,2.12,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,1.65,70,,,percent of total billed charges,70% of total billed charges,2.12,90,,,percent of total billed charges,90% of total billed charges,2.24,95,,,percent of total billed charges,95% of total billed charges,2.24,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,2.03,86,,,percent of total billed charges,86% of total billed charges,1.89,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,2.29,97,,,percent of total billed charges,97% of total billed charges,2.12,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,2.29,97,,,percent of total billed charges,97% of total billed charges,2.19,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,2.29,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,1.65,486.58,
"95977-  Electronic analysis of implanted neurostimulator pulse generator/transmitter (eg, contact gr",3692915,CDM,510,RC,95977,HCPCS,Outpatient,,,453.7,226.85,,408.33,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,362.96,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.33,90,,,Percent of total Billed charges,90% of total billed charges,47.37,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,440.09,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,417.4,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,408.33,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,317.59,70,,,percent of total billed charges,70% of total billed charges,408.33,90,,,percent of total billed charges,90% of total billed charges,431.02,95,,,percent of total billed charges,95% of total billed charges,431.02,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,390.18,86,,,percent of total billed charges,86% of total billed charges,362.96,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,440.09,97,,,percent of total billed charges,97% of total billed charges,408.33,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.09,97,,,percent of total billed charges,97% of total billed charges,421.94,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.06,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.09,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.06,486.58,
95983 - Elec Anlys Implnt Brn Npgt Prgrmg 1st 15 Min,4315922,CDM,920,RC,95983,HCPCS,Outpatient,,,453.7,226.85,,408.33,90,,,percent of total billed charges,90% of total Billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,362.96,80,,,Percent of total Billed charges,80% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.33,90,,,Percent of total Billed charges,90% of total billed charges,44.9,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,440.09,97,,,Percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,417.4,92,,,Percent of total billed charges,92% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,240.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,384.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,486.58,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,408.33,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,317.59,70,,,percent of total billed charges,70% of total billed charges,408.33,90,,,percent of total billed charges,90% of total billed charges,431.02,95,,,percent of total billed charges,95% of total billed charges,431.02,95,,,percent of total billed charges,95% of total billed charges,90.65,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,181.3,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,390.18,86,,,percent of total billed charges,86% of total billed charges,362.96,80,,,percent of total billed charges,80% of total billed charges,117.26,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,440.09,97,,,percent of total billed charges,97% of total billed charges,408.33,90,,,percent of total billed charges,90% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,440.09,97,,,percent of total billed charges,97% of total billed charges,421.94,93,,,percent of total billed charges,93% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.82,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,440.09,97,,,percent of total billed charges,97% of total billed charges,90.65,100,,,Fee Schedule,100% of CMS OPPS Rate ,90.65,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,77.04,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.82,486.58,
95984 - Elec Anlys Implnt Brn Npgt Prgrmg Ea Addl 15 Min,4315923,CDM,920,RC,95984,HCPCS,Outpatient,,,595.55,297.78,,536,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,476.44,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,536,90,,,Percent of total Billed charges,90% of total billed charges,39.27,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,577.68,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,547.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,380.33,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,468.41,78.65,,,percent of total billed charges,78.65% of total billed charges,532.01,89.33,,,percent of total billed charges,89.33% of total billed charges,536,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,416.89,70,,,percent of total billed charges,70% of total billed charges,536,90,,,percent of total billed charges,90% of total billed charges,565.77,95,,,percent of total billed charges,95% of total billed charges,565.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,512.17,86,,,percent of total billed charges,86% of total billed charges,476.44,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,577.68,97,,,percent of total billed charges,97% of total billed charges,536,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,577.68,97,,,percent of total billed charges,97% of total billed charges,553.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,577.68,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.7,577.68,
95992 - Epley Maneuver,3575063,CDM,510,RC,95992,HCPCS,Outpatient,,,783.95,391.98,,705.56,90,,,percent of total billed charges,90% of total Billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,627.16,80,,,Percent of total Billed charges,80% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,705.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,760.43,97,,,Percent of total billed charges,97% of total billed charges,35.1,100,,,Fee Schedule,100% of CMS OPPS Rate,721.23,92,,,Percent of total billed charges,92% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,143.16,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,174.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,161.82,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,705.56,90,,,percent of total billed charges,90% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,548.77,70,,,percent of total billed charges,70% of total billed charges,705.56,90,,,percent of total billed charges,90% of total billed charges,744.75,95,,,percent of total billed charges,95% of total billed charges,744.75,95,,,percent of total billed charges,95% of total billed charges,35.29,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,70.58,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,674.2,86,,,percent of total billed charges,86% of total billed charges,627.16,80,,,percent of total billed charges,80% of total billed charges,42.15,111,,,Fee Schedule,111% of CMS OPPS Rate,760.43,97,,,percent of total billed charges,97% of total billed charges,705.56,90,,,percent of total billed charges,90% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,760.43,97,,,percent of total billed charges,97% of total billed charges,729.07,93,,,percent of total billed charges,93% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,760.43,97,,,percent of total billed charges,97% of total billed charges,35.29,100,,,Fee Schedule,100% of CMS OPPS Rate ,35.29,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,30,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,30,760.43,
96156 - Health Coach Assessment,3635244,CDM,510,RC,96156,HCPCS,Outpatient,,,450.13,225.07,,405.12,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,360.1,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,405.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,436.63,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,414.12,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,405.12,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,315.09,70,,,percent of total billed charges,70% of total billed charges,405.12,90,,,percent of total billed charges,90% of total billed charges,427.62,95,,,percent of total billed charges,95% of total billed charges,427.62,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,387.11,86,,,percent of total billed charges,86% of total billed charges,360.1,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,436.63,97,,,percent of total billed charges,97% of total billed charges,405.12,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,436.63,97,,,percent of total billed charges,97% of total billed charges,418.62,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,436.63,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,436.63,
96158 - Health Coach Initial 30 Mins,3635247,CDM,510,RC,96158,HCPCS,Outpatient,,,805.12,402.56,,724.61,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,644.1,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,724.61,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,780.97,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,740.71,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,724.61,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,563.58,70,,,percent of total billed charges,70% of total billed charges,724.61,90,,,percent of total billed charges,90% of total billed charges,764.86,95,,,percent of total billed charges,95% of total billed charges,764.86,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,692.4,86,,,percent of total billed charges,86% of total billed charges,644.1,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,780.97,97,,,percent of total billed charges,97% of total billed charges,724.61,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,780.97,97,,,percent of total billed charges,97% of total billed charges,748.76,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,780.97,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.55,780.97,
96372- Subq/IM Injection,3428362,CDM,761,RC,96372,HCPCS,Outpatient,,,364.11,182.06,,327.7,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,291.29,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.7,90,,,Percent of total Billed charges,90% of total billed charges,13.97,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.19,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,334.98,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,254.88,70,,,percent of total billed charges,70% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.13,86,,,percent of total billed charges,86% of total billed charges,291.29,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.19,97,,,percent of total billed charges,97% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.19,97,,,percent of total billed charges,97% of total billed charges,338.62,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,12.7,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.19,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.7,353.19,
"96374- IV Injection, single/initial",3428364,CDM,940,RC,96374,HCPCS,Outpatient,,,1082.37,541.19,,974.13,90,,,percent of total billed charges,90% of total Billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,865.9,80,,,Percent of total Billed charges,80% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,974.13,90,,,Percent of total Billed charges,90% of total billed charges,34.12,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,1049.9,97,,,Percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,995.78,92,,,Percent of total billed charges,92% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,498.7,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,795.04,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1007.05,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,974.13,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,757.66,70,,,percent of total billed charges,70% of total billed charges,974.13,90,,,percent of total billed charges,90% of total billed charges,1028.25,95,,,percent of total billed charges,95% of total billed charges,1028.25,95,,,percent of total billed charges,95% of total billed charges,187.61,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,375.23,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,930.84,86,,,percent of total billed charges,86% of total billed charges,865.9,80,,,percent of total billed charges,80% of total billed charges,189.96,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1049.9,97,,,percent of total billed charges,97% of total billed charges,974.13,90,,,percent of total billed charges,90% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,1049.9,97,,,percent of total billed charges,97% of total billed charges,1006.6,93,,,percent of total billed charges,93% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.02,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,1049.9,97,,,percent of total billed charges,97% of total billed charges,187.61,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.61,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,159.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.02,1049.9,
96401- Chemo admin/SQ/IM/anti-neo,3431073,CDM,331,RC,96401,HCPCS,Outpatient,,,364.11,182.06,,327.7,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,291.29,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.7,90,,,Percent of total Billed charges,90% of total billed charges,55.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.19,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,334.98,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,254.88,70,,,percent of total billed charges,70% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.13,86,,,percent of total billed charges,86% of total billed charges,291.29,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.19,97,,,percent of total billed charges,97% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.19,97,,,percent of total billed charges,97% of total billed charges,338.62,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.19,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.23,353.19,
Admin leuprolide Charge:INJ Admin Charge 96401,3444231,CDM,331,RC,96401,HCPCS,Outpatient,,,364.11,182.06,,327.7,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,291.29,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,327.7,90,,,Percent of total Billed charges,90% of total billed charges,55.25,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,353.19,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,334.98,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,254.88,70,,,percent of total billed charges,70% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,345.9,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,313.13,86,,,percent of total billed charges,86% of total billed charges,291.29,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,353.19,97,,,percent of total billed charges,97% of total billed charges,327.7,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,353.19,97,,,percent of total billed charges,97% of total billed charges,338.62,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,50.23,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,353.19,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,50.23,353.19,
"96402 - Chemotherapy administration, subcutaneous or intramu",3918947,CDM,331,RC,96402,HCPCS,Outpatient,,,327.84,163.92,,295.06,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,262.27,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.06,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,318,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,301.61,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,295.06,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,229.49,70,,,percent of total billed charges,70% of total billed charges,295.06,90,,,percent of total billed charges,90% of total billed charges,311.45,95,,,percent of total billed charges,95% of total billed charges,311.45,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,281.94,86,,,percent of total billed charges,86% of total billed charges,262.27,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,318,97,,,percent of total billed charges,97% of total billed charges,295.06,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,318,97,,,percent of total billed charges,97% of total billed charges,304.89,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,318,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,328.92,
INJ Nonhormonal A/Neo 96402,4297300,CDM,331,RC,96402,HCPCS,Outpatient,,,327.84,163.92,,295.06,90,,,percent of total billed charges,90% of total Billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,262.27,80,,,Percent of total Billed charges,80% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,295.06,90,,,Percent of total Billed charges,90% of total billed charges,34.94,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,318,97,,,Percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,301.61,92,,,Percent of total billed charges,92% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,162.89,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,259.68,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,328.92,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,295.06,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,229.49,70,,,percent of total billed charges,70% of total billed charges,295.06,90,,,percent of total billed charges,90% of total billed charges,311.45,95,,,percent of total billed charges,95% of total billed charges,311.45,95,,,percent of total billed charges,95% of total billed charges,61.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,122.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,281.94,86,,,percent of total billed charges,86% of total billed charges,262.27,80,,,percent of total billed charges,80% of total billed charges,62.51,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,318,97,,,percent of total billed charges,97% of total billed charges,295.06,90,,,percent of total billed charges,90% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,318,97,,,percent of total billed charges,97% of total billed charges,304.89,93,,,percent of total billed charges,93% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.76,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,318,97,,,percent of total billed charges,97% of total billed charges,61.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,61.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,52.08,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.76,328.92,
96920 Excimer lsr psriasis<250sqcm,3431074,CDM,940,RC,96920,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,64.55,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.68,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,58.68,980.65,
96921- Excimer lsr psriasis 250-500,3431095,CDM,940,RC,96921,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,65.01,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,59.1,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,59.1,980.65,
97010-HOT/COLD PACKS,3430549,CDM,421,RC,97010,HCPCS,Outpatient,,,38.12,19.06,,34.31,90,,,percent of total billed charges,90% of total Billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,30.5,80,,,Percent of total Billed charges,80% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.31,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.98,97,,,Percent of total billed charges,97% of total billed charges,5.91,100,,,Fee Schedule,100% of CMS OPPS Rate,35.07,92,,,Percent of total billed charges,92% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,24.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,29.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,27.28,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,34.31,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.68,70,,,percent of total billed charges,70% of total billed charges,34.31,90,,,percent of total billed charges,90% of total billed charges,36.21,95,,,percent of total billed charges,95% of total billed charges,36.21,95,,,percent of total billed charges,95% of total billed charges,5.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,11.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.78,86,,,percent of total billed charges,86% of total billed charges,30.5,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,36.98,97,,,percent of total billed charges,97% of total billed charges,34.31,90,,,percent of total billed charges,90% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.98,97,,,percent of total billed charges,97% of total billed charges,35.45,93,,,percent of total billed charges,93% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.98,97,,,percent of total billed charges,97% of total billed charges,5.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.06,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.06,36.98,
97014 Appl Modality 1/> Areas Elec Stimj Unattended,3351852,CDM,761,RC,97014,HCPCS,Outpatient,,,205,102.50,,184.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,164,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,184.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,188.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,130.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,161.24,78.65,,,percent of total billed charges,78.65% of total billed charges,183.13,89.33,,,percent of total billed charges,89.33% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,194.75,95,,,percent of total billed charges,95% of total billed charges,194.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.3,86,,,percent of total billed charges,86% of total billed charges,164,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,190.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.92,198.85,
97014-PT E-STIM UNATTENDED(WOUND),3430550,CDM,421,RC,97014,HCPCS,Outpatient,,,205,102.50,,184.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,164,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,184.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,188.6,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,130.92,63.86,,,percent of total billed charges,63.86% of total billed charges,,,,,Other,Not Separately reimbursable,161.24,78.65,,,percent of total billed charges,78.65% of total billed charges,183.13,89.33,,,percent of total billed charges,89.33% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,143.5,70,,,percent of total billed charges,70% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,194.75,95,,,percent of total billed charges,95% of total billed charges,194.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,176.3,86,,,percent of total billed charges,86% of total billed charges,164,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,184.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,190.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,198.85,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,130.92,198.85,
97016 Appl Modality 1/> Areas Vasopneumatic Devices,3436064,CDM,761,RC,97016,HCPCS,Outpatient,,,211,105.50,,189.9,90,,,percent of total billed charges,90% of total Billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,168.8,80,,,Percent of total Billed charges,80% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,189.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,204.67,97,,,Percent of total billed charges,97% of total billed charges,11.14,100,,,Fee Schedule,100% of CMS OPPS Rate,194.12,92,,,Percent of total billed charges,92% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,45.39,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.3,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,51.31,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,189.9,90,,,percent of total billed charges,90% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,147.7,70,,,percent of total billed charges,70% of total billed charges,189.9,90,,,percent of total billed charges,90% of total billed charges,200.45,95,,,percent of total billed charges,95% of total billed charges,200.45,95,,,percent of total billed charges,95% of total billed charges,11.19,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,22.38,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,181.46,86,,,percent of total billed charges,86% of total billed charges,168.8,80,,,percent of total billed charges,80% of total billed charges,13.2,111,,,Fee Schedule,111% of CMS OPPS Rate,204.67,97,,,percent of total billed charges,97% of total billed charges,189.9,90,,,percent of total billed charges,90% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,204.67,97,,,percent of total billed charges,97% of total billed charges,196.23,93,,,percent of total billed charges,93% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,204.67,97,,,percent of total billed charges,97% of total billed charges,11.19,100,,,Fee Schedule,100% of CMS OPPS Rate ,11.19,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,9.51,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,9.51,204.67,
97026 Application Modality 1/> Areas Infrared,3351933,CDM,761,RC,97026,HCPCS,Outpatient,,,31.23,15.62,,28.11,90,,,percent of total billed charges,90% of total Billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,24.98,80,,,Percent of total Billed charges,80% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.29,97,,,Percent of total billed charges,97% of total billed charges,6.2,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,92,,,Percent of total billed charges,92% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,28.11,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.86,70,,,percent of total billed charges,70% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.86,86,,,percent of total billed charges,86% of total billed charges,24.98,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,30.29,97,,,percent of total billed charges,97% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.29,97,,,percent of total billed charges,97% of total billed charges,29.04,93,,,percent of total billed charges,93% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.29,97,,,percent of total billed charges,97% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.31,30.89,
97026-INFRARED,3430551,CDM,420,RC,97026,HCPCS,Outpatient,,,31.23,15.62,,28.11,90,,,percent of total billed charges,90% of total Billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,24.98,80,,,Percent of total Billed charges,80% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.11,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.29,97,,,Percent of total billed charges,97% of total billed charges,6.2,100,,,Fee Schedule,100% of CMS OPPS Rate,28.73,92,,,Percent of total billed charges,92% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,25.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,30.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,28.66,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,28.11,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,21.86,70,,,percent of total billed charges,70% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,29.67,95,,,percent of total billed charges,95% of total billed charges,6.25,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.86,86,,,percent of total billed charges,86% of total billed charges,24.98,80,,,percent of total billed charges,80% of total billed charges,6.67,111,,,Fee Schedule,111% of CMS OPPS Rate,30.29,97,,,percent of total billed charges,97% of total billed charges,28.11,90,,,percent of total billed charges,90% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.29,97,,,percent of total billed charges,97% of total billed charges,29.04,93,,,percent of total billed charges,93% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.29,97,,,percent of total billed charges,97% of total billed charges,6.25,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.25,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.31,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.31,30.89,
97035 Appl Modality 1/> Areas Ultrasound Ea 15 Min,3351853,CDM,761,RC,97035,HCPCS,Outpatient,,,215,107.50,,193.5,90,,,percent of total billed charges,90% of total Billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,172,80,,,Percent of total Billed charges,80% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.55,97,,,Percent of total billed charges,97% of total billed charges,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,197.8,92,,,Percent of total billed charges,92% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,62.64,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,193.5,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,150.5,70,,,percent of total billed charges,70% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.9,86,,,percent of total billed charges,86% of total billed charges,172,80,,,percent of total billed charges,80% of total billed charges,15.43,111,,,Fee Schedule,111% of CMS OPPS Rate,208.55,97,,,percent of total billed charges,97% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.55,97,,,percent of total billed charges,97% of total billed charges,199.95,93,,,percent of total billed charges,93% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,208.55,97,,,percent of total billed charges,97% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.61,208.55,
97035-PT ULTRASOUND(WOUND),3430552,CDM,420,RC,97035,HCPCS,Outpatient,,,215,107.50,,193.5,90,,,percent of total billed charges,90% of total Billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,172,80,,,Percent of total Billed charges,80% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,193.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,208.55,97,,,Percent of total billed charges,97% of total billed charges,13.61,100,,,Fee Schedule,100% of CMS OPPS Rate,197.8,92,,,Percent of total billed charges,92% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,55.41,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,67.51,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,62.64,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,193.5,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,150.5,70,,,percent of total billed charges,70% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,204.25,95,,,percent of total billed charges,95% of total billed charges,13.66,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,27.32,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,184.9,86,,,percent of total billed charges,86% of total billed charges,172,80,,,percent of total billed charges,80% of total billed charges,15.43,111,,,Fee Schedule,111% of CMS OPPS Rate,208.55,97,,,percent of total billed charges,97% of total billed charges,193.5,90,,,percent of total billed charges,90% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,208.55,97,,,percent of total billed charges,97% of total billed charges,199.95,93,,,percent of total billed charges,93% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,208.55,97,,,percent of total billed charges,97% of total billed charges,13.66,100,,,Fee Schedule,100% of CMS OPPS Rate ,13.66,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,11.61,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,11.61,208.55,
97039 Unlist Modality Spec Type&Time Constant Attend,3351932,CDM,761,RC,97039,HCPCS,Outpatient,,,164.88,82.44,,148.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,131.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,148.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,151.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.42,70,,,percent of total billed charges,70% of total billed charges,148.39,90,,,percent of total billed charges,90% of total billed charges,156.64,95,,,percent of total billed charges,95% of total billed charges,156.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.8,86,,,percent of total billed charges,86% of total billed charges,131.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,148.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,153.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.42,159.93,
97039-LASER/OTHER,3430553,CDM,420,RC,97039,HCPCS,Outpatient,,,164.88,82.44,,148.39,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,131.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,148.39,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,151.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.42,70,,,percent of total billed charges,70% of total billed charges,148.39,90,,,percent of total billed charges,90% of total billed charges,156.64,95,,,percent of total billed charges,95% of total billed charges,156.64,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.8,86,,,percent of total billed charges,86% of total billed charges,131.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,148.39,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,153.34,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,159.93,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.42,159.93,
97110 Therapeutic Px 1/> Areas Each 15 Min Exercises,3436066,CDM,761,RC,97110,HCPCS,Outpatient,,,274,137.00,,246.6,90,,,percent of total billed charges,90% of total Billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,219.2,80,,,Percent of total Billed charges,80% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,246.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,265.78,97,,,Percent of total billed charges,97% of total billed charges,27.87,100,,,Fee Schedule,100% of CMS OPPS Rate,252.08,92,,,Percent of total billed charges,92% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,113.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,127.98,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,246.6,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,191.8,70,,,percent of total billed charges,70% of total billed charges,246.6,90,,,percent of total billed charges,90% of total billed charges,260.3,95,,,percent of total billed charges,95% of total billed charges,260.3,95,,,percent of total billed charges,95% of total billed charges,27.91,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,55.82,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,235.64,86,,,percent of total billed charges,86% of total billed charges,219.2,80,,,percent of total billed charges,80% of total billed charges,32.76,111,,,Fee Schedule,111% of CMS OPPS Rate,265.78,97,,,percent of total billed charges,97% of total billed charges,246.6,90,,,percent of total billed charges,90% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,265.78,97,,,percent of total billed charges,97% of total billed charges,254.82,93,,,percent of total billed charges,93% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,265.78,97,,,percent of total billed charges,97% of total billed charges,27.91,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.91,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,23.72,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,23.72,265.78,
97112 Therapeutic Px 1/> Areas Each 15 Min Neuromusc ReEd,3984924,CDM,761,RC,97112,HCPCS,Outpatient,,,203,101.50,,182.7,90,,,percent of total billed charges,90% of total Billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,162.4,80,,,Percent of total Billed charges,80% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,182.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,196.91,97,,,Percent of total billed charges,97% of total billed charges,31.89,100,,,Fee Schedule,100% of CMS OPPS Rate,186.76,92,,,Percent of total billed charges,92% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,129.57,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,146.46,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,182.7,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,142.1,70,,,percent of total billed charges,70% of total billed charges,182.7,90,,,percent of total billed charges,90% of total billed charges,192.85,95,,,percent of total billed charges,95% of total billed charges,192.85,95,,,percent of total billed charges,95% of total billed charges,31.94,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.88,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,174.58,86,,,percent of total billed charges,86% of total billed charges,162.4,80,,,percent of total billed charges,80% of total billed charges,37.51,111,,,Fee Schedule,111% of CMS OPPS Rate,196.91,97,,,percent of total billed charges,97% of total billed charges,182.7,90,,,percent of total billed charges,90% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,196.91,97,,,percent of total billed charges,97% of total billed charges,188.79,93,,,percent of total billed charges,93% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,196.91,97,,,percent of total billed charges,97% of total billed charges,31.94,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.94,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,27.15,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27.15,196.91,
97140 Manual Therapy TQS 1/> Regions Each 15 Minutes - OT,3436071,CDM,761,RC,97140,HCPCS,Outpatient,,,230,115.00,,207,90,,,percent of total billed charges,90% of total Billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,184,80,,,Percent of total Billed charges,80% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,207,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,223.1,97,,,Percent of total billed charges,97% of total billed charges,25.73,100,,,Fee Schedule,100% of CMS OPPS Rate,211.6,92,,,Percent of total billed charges,92% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,104.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,127.41,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,118.21,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,207,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,161,70,,,percent of total billed charges,70% of total billed charges,207,90,,,percent of total billed charges,90% of total billed charges,218.5,95,,,percent of total billed charges,95% of total billed charges,218.5,95,,,percent of total billed charges,95% of total billed charges,25.78,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,51.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,197.8,86,,,percent of total billed charges,86% of total billed charges,184,80,,,percent of total billed charges,80% of total billed charges,30.24,111,,,Fee Schedule,111% of CMS OPPS Rate,223.1,97,,,percent of total billed charges,97% of total billed charges,207,90,,,percent of total billed charges,90% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,223.1,97,,,percent of total billed charges,97% of total billed charges,213.9,93,,,percent of total billed charges,93% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,223.1,97,,,percent of total billed charges,97% of total billed charges,25.78,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.78,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,21.91,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,21.91,223.1,
97165 OT Eval Low Complex 30 Minutes,3436073,CDM,761,RC,97165,HCPCS,Outpatient,,,421.5,210.75,,379.35,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,337.2,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,379.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,408.86,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,387.78,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,379.35,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,295.05,70,,,percent of total billed charges,70% of total billed charges,379.35,90,,,percent of total billed charges,90% of total billed charges,400.43,95,,,percent of total billed charges,95% of total billed charges,400.43,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,362.49,86,,,percent of total billed charges,86% of total billed charges,337.2,80,,,percent of total billed charges,80% of total billed charges,96.23,111,,,Fee Schedule,111% of CMS OPPS Rate,408.86,97,,,percent of total billed charges,97% of total billed charges,379.35,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.86,97,,,percent of total billed charges,97% of total billed charges,392,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,408.86,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
97166 OT Eval Mod Complex 45 Minutes,3436074,CDM,761,RC,97166,HCPCS,Outpatient,,,446,223.00,,401.4,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,356.8,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,401.4,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,432.62,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,410.32,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,401.4,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,312.2,70,,,percent of total billed charges,70% of total billed charges,401.4,90,,,percent of total billed charges,90% of total billed charges,423.7,95,,,percent of total billed charges,95% of total billed charges,423.7,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,383.56,86,,,percent of total billed charges,86% of total billed charges,356.8,80,,,percent of total billed charges,80% of total billed charges,95.88,111,,,Fee Schedule,111% of CMS OPPS Rate,432.62,97,,,percent of total billed charges,97% of total billed charges,401.4,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,432.62,97,,,percent of total billed charges,97% of total billed charges,414.78,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,432.62,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
97167 OT Eval High Complex 60 Minutes,3436075,CDM,761,RC,97167,HCPCS,Outpatient,,,469.5,234.75,,422.55,90,,,percent of total billed charges,90% of total Billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,375.6,80,,,Percent of total Billed charges,80% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,422.55,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,455.42,97,,,Percent of total billed charges,97% of total billed charges,95.09,100,,,Fee Schedule,100% of CMS OPPS Rate,431.94,92,,,Percent of total billed charges,92% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,386.52,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,470.9,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,436.9,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,422.55,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,328.65,70,,,percent of total billed charges,70% of total billed charges,422.55,90,,,percent of total billed charges,90% of total billed charges,446.03,95,,,percent of total billed charges,95% of total billed charges,446.03,95,,,percent of total billed charges,95% of total billed charges,95.28,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,190.56,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,403.77,86,,,percent of total billed charges,86% of total billed charges,375.6,80,,,percent of total billed charges,80% of total billed charges,95.88,111,,,Fee Schedule,111% of CMS OPPS Rate,455.42,97,,,percent of total billed charges,97% of total billed charges,422.55,90,,,percent of total billed charges,90% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,455.42,97,,,percent of total billed charges,97% of total billed charges,436.64,93,,,percent of total billed charges,93% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,455.42,97,,,percent of total billed charges,97% of total billed charges,95.28,100,,,Fee Schedule,100% of CMS OPPS Rate ,95.28,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,80.99,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,80.99,470.9,
97168 OT Re-Eval Est Plan Care 30 Minutes,3436076,CDM,761,RC,97168,HCPCS,Outpatient,,,307,153.50,,276.3,90,,,percent of total billed charges,90% of total Billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,245.6,80,,,Percent of total Billed charges,80% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,276.3,90,,,Percent of total Billed charges,90% of total billed charges,44.76,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,297.79,97,,,Percent of total billed charges,97% of total billed charges,65.24,100,,,Fee Schedule,100% of CMS OPPS Rate,282.44,92,,,Percent of total billed charges,92% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,265.43,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,323.38,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,300.02,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,276.3,90,,,percent of total billed charges,90% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,214.9,70,,,percent of total billed charges,70% of total billed charges,276.3,90,,,percent of total billed charges,90% of total billed charges,291.65,95,,,percent of total billed charges,95% of total billed charges,291.65,95,,,percent of total billed charges,95% of total billed charges,65.43,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,130.86,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,264.02,86,,,percent of total billed charges,86% of total billed charges,245.6,80,,,percent of total billed charges,80% of total billed charges,65.87,111,,,Fee Schedule,111% of CMS OPPS Rate,297.79,97,,,percent of total billed charges,97% of total billed charges,276.3,90,,,percent of total billed charges,90% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,297.79,97,,,percent of total billed charges,97% of total billed charges,285.51,93,,,percent of total billed charges,93% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,40.69,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,297.79,97,,,percent of total billed charges,97% of total billed charges,65.43,100,,,Fee Schedule,100% of CMS OPPS Rate ,65.43,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,55.62,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,40.69,323.38,
97530 Therapeut Activity Direct  Contact Each 15 Min,3436077,CDM,761,RC,97530,HCPCS,Outpatient,,,171.5,85.75,,154.35,90,,,percent of total billed charges,90% of total Billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,137.2,80,,,Percent of total Billed charges,80% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,154.35,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.36,97,,,Percent of total billed charges,97% of total billed charges,34.52,100,,,Fee Schedule,100% of CMS OPPS Rate,157.78,92,,,Percent of total billed charges,92% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,140.24,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,170.86,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,158.52,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,154.35,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,120.05,70,,,percent of total billed charges,70% of total billed charges,154.35,90,,,percent of total billed charges,90% of total billed charges,162.93,95,,,percent of total billed charges,95% of total billed charges,162.93,95,,,percent of total billed charges,95% of total billed charges,34.57,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,69.14,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,147.49,86,,,percent of total billed charges,86% of total billed charges,137.2,80,,,percent of total billed charges,80% of total billed charges,41.28,111,,,Fee Schedule,111% of CMS OPPS Rate,166.36,97,,,percent of total billed charges,97% of total billed charges,154.35,90,,,percent of total billed charges,90% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.36,97,,,percent of total billed charges,97% of total billed charges,159.5,93,,,percent of total billed charges,93% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,166.36,97,,,percent of total billed charges,97% of total billed charges,34.57,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.57,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,29.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,29.38,170.86,
97535 Self Care Mngment Training,3436078,CDM,761,RC,97535,HCPCS,Outpatient,,,174,87.00,,156.6,90,,,percent of total billed charges,90% of total Billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,139.2,80,,,Percent of total Billed charges,80% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,156.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,168.78,97,,,Percent of total billed charges,97% of total billed charges,30.78,100,,,Fee Schedule,100% of CMS OPPS Rate,160.08,92,,,Percent of total billed charges,92% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,125.07,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,152.37,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,141.37,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,156.6,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,121.8,70,,,percent of total billed charges,70% of total billed charges,156.6,90,,,percent of total billed charges,90% of total billed charges,165.3,95,,,percent of total billed charges,95% of total billed charges,165.3,95,,,percent of total billed charges,95% of total billed charges,30.83,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,61.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,149.64,86,,,percent of total billed charges,86% of total billed charges,139.2,80,,,percent of total billed charges,80% of total billed charges,36.19,111,,,Fee Schedule,111% of CMS OPPS Rate,168.78,97,,,percent of total billed charges,97% of total billed charges,156.6,90,,,percent of total billed charges,90% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,168.78,97,,,percent of total billed charges,97% of total billed charges,161.82,93,,,percent of total billed charges,93% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,168.78,97,,,percent of total billed charges,97% of total billed charges,30.83,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.83,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.21,168.78,
97537 Community or Work Reint Training Ea 15 Min,4305641,CDM,761,RC,97537,HCPCS,Outpatient,,,131,65.50,,117.9,90,,,percent of total billed charges,90% of total Billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,104.8,80,,,Percent of total Billed charges,80% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,117.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,127.07,97,,,Percent of total billed charges,97% of total billed charges,30.05,100,,,Fee Schedule,100% of CMS OPPS Rate,120.52,92,,,Percent of total billed charges,92% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,122.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,148.76,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,138.02,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,117.9,90,,,percent of total billed charges,90% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,91.7,70,,,percent of total billed charges,70% of total billed charges,117.9,90,,,percent of total billed charges,90% of total billed charges,124.45,95,,,percent of total billed charges,95% of total billed charges,124.45,95,,,percent of total billed charges,95% of total billed charges,30.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,60.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,112.66,86,,,percent of total billed charges,86% of total billed charges,104.8,80,,,percent of total billed charges,80% of total billed charges,34.99,111,,,Fee Schedule,111% of CMS OPPS Rate,127.07,97,,,percent of total billed charges,97% of total billed charges,117.9,90,,,percent of total billed charges,90% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,127.07,97,,,percent of total billed charges,97% of total billed charges,121.83,93,,,percent of total billed charges,93% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,127.07,97,,,percent of total billed charges,97% of total billed charges,30.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.1,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,25.59,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,25.59,148.76,
97597- Debrid/select/1st 20 sq cm or less,3430558,CDM,420,RC,97597,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,980.65,
97597 Debridement Open Wound 20 Sq Cm/<,3436079,CDM,761,RC,97597,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,34.69,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.01,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.34,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.4,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,31.54,980.65,
"97598 - Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement wi",3715362,CDM,510,RC,97598,HCPCS,Outpatient,,,354.5,177.25,,319.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,283.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,319.05,90,,,Percent of total Billed charges,90% of total billed charges,12.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,343.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,326.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.15,70,,,percent of total billed charges,70% of total billed charges,319.05,90,,,percent of total billed charges,90% of total billed charges,336.78,95,,,percent of total billed charges,95% of total billed charges,336.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.87,86,,,percent of total billed charges,86% of total billed charges,283.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,343.87,97,,,percent of total billed charges,97% of total billed charges,319.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,343.87,97,,,percent of total billed charges,97% of total billed charges,329.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,343.87,
97598 Debridement Open Wound Each Addtl 20 Sq Cm,3436082,CDM,761,RC,97598,HCPCS,Outpatient,,,354.5,177.25,,319.05,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,283.6,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,319.05,90,,,Percent of total Billed charges,90% of total billed charges,12.72,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,343.87,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,326.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,319.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,248.15,70,,,percent of total billed charges,70% of total billed charges,319.05,90,,,percent of total billed charges,90% of total billed charges,336.78,95,,,percent of total billed charges,95% of total billed charges,336.78,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,304.87,86,,,percent of total billed charges,86% of total billed charges,283.6,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,343.87,97,,,percent of total billed charges,97% of total billed charges,319.05,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,343.87,97,,,percent of total billed charges,97% of total billed charges,329.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,343.87,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,343.87,
"97602 -Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e",3641199,CDM,510,RC,97602,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,980.65,
97602 Rmvl Devital Tiss N-Slctv Dbrdmt W/O Anes 1 Sess,3436083,CDM,761,RC,97602,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,29.7,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,27,980.65,
97605 Negative Pressure Wound Therapy DME <=50 Sq Cm,3436085,CDM,761,RC,97605,HCPCS,Outpatient,,,1010.98,505.49,,909.88,90,,,percent of total billed charges,90% of total Billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,808.78,80,,,Percent of total Billed charges,80% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,909.88,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,980.65,97,,,Percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,930.1,92,,,Percent of total billed charges,92% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,435.96,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,695.02,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,880.35,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,707.69,70,,,percent of total billed charges,70% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,960.43,95,,,percent of total billed charges,95% of total billed charges,164.01,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,328.02,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,869.44,86,,,percent of total billed charges,86% of total billed charges,808.78,80,,,percent of total billed charges,80% of total billed charges,180.64,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,980.65,97,,,percent of total billed charges,97% of total billed charges,909.88,90,,,percent of total billed charges,90% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,980.65,97,,,percent of total billed charges,97% of total billed charges,940.21,93,,,percent of total billed charges,93% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,980.65,97,,,percent of total billed charges,97% of total billed charges,164.01,100,,,Fee Schedule,100% of CMS OPPS Rate ,164.01,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,139.41,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,139.41,980.65,
97606- Neg press wound therapy/>50 sq cm,3430560,CDM,510,RC,97606,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,1953.17,
97606 Negative Pressure Wound Therapy DME >50 Sq Cm,3436088,CDM,761,RC,97606,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.88,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.33,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288.01,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288.01,1953.17,
97607 Negative Pressure Wound Therapy Non DME <=50 Sq Cm,3351838,CDM,761,RC,97607,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288,1953.17,
97608 Negative Pressure Wound Therapy Non DME >50 Sq Cm,3351843,CDM,761,RC,97608,HCPCS,Outpatient,,,2013.58,1006.79,,1812.22,90,,,percent of total billed charges,90% of total Billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1610.86,80,,,Percent of total Billed charges,80% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1812.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1953.17,97,,,Percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1852.49,92,,,Percent of total billed charges,92% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,900.68,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1435.87,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1818.76,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,1409.51,70,,,percent of total billed charges,70% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,1912.9,95,,,percent of total billed charges,95% of total billed charges,338.84,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,677.68,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1731.68,86,,,percent of total billed charges,86% of total billed charges,1610.86,80,,,percent of total billed charges,80% of total billed charges,330.32,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1953.17,97,,,percent of total billed charges,97% of total billed charges,1812.22,90,,,percent of total billed charges,90% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,1953.17,97,,,percent of total billed charges,97% of total billed charges,1872.63,93,,,percent of total billed charges,93% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1953.17,97,,,percent of total billed charges,97% of total billed charges,338.84,100,,,Fee Schedule,100% of CMS OPPS Rate ,338.84,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,288,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,288,1953.17,
97750 Physical Perf Test/Meas w/ Reprt Ea 15 Min,4305640,CDM,761,RC,97750,HCPCS,Outpatient,,,237,118.50,,213.3,90,,,percent of total billed charges,90% of total Billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,189.6,80,,,Percent of total Billed charges,80% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,213.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,229.89,97,,,Percent of total billed charges,97% of total billed charges,31.65,100,,,Fee Schedule,100% of CMS OPPS Rate,218.04,92,,,Percent of total billed charges,92% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,128.6,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,156.67,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,145.36,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,213.3,90,,,percent of total billed charges,90% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,165.9,70,,,percent of total billed charges,70% of total billed charges,213.3,90,,,percent of total billed charges,90% of total billed charges,225.15,95,,,percent of total billed charges,95% of total billed charges,225.15,95,,,percent of total billed charges,95% of total billed charges,31.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,63.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,203.82,86,,,percent of total billed charges,86% of total billed charges,189.6,80,,,percent of total billed charges,80% of total billed charges,36.87,111,,,Fee Schedule,111% of CMS OPPS Rate,229.89,97,,,percent of total billed charges,97% of total billed charges,213.3,90,,,percent of total billed charges,90% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,229.89,97,,,percent of total billed charges,97% of total billed charges,220.41,93,,,percent of total billed charges,93% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,229.89,97,,,percent of total billed charges,97% of total billed charges,31.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,31.7,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,26.95,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,26.95,229.89,
97760 Orthotics Mgmt & Traing Initial Enctr Ea 15 Mins,3436091,CDM,761,RC,97760,HCPCS,Outpatient,,,213,106.50,,191.7,90,,,percent of total billed charges,90% of total Billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,170.4,80,,,Percent of total Billed charges,80% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,191.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,206.61,97,,,Percent of total billed charges,97% of total billed charges,44.71,100,,,Fee Schedule,100% of CMS OPPS Rate,195.96,92,,,Percent of total billed charges,92% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,181.58,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,221.22,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,205.24,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,191.7,90,,,percent of total billed charges,90% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,149.1,70,,,percent of total billed charges,70% of total billed charges,191.7,90,,,percent of total billed charges,90% of total billed charges,202.35,95,,,percent of total billed charges,95% of total billed charges,202.35,95,,,percent of total billed charges,95% of total billed charges,44.76,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,89.52,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,183.18,86,,,percent of total billed charges,86% of total billed charges,170.4,80,,,percent of total billed charges,80% of total billed charges,51.24,111,,,Fee Schedule,111% of CMS OPPS Rate,206.61,97,,,percent of total billed charges,97% of total billed charges,191.7,90,,,percent of total billed charges,90% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,206.61,97,,,percent of total billed charges,97% of total billed charges,198.09,93,,,percent of total billed charges,93% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,206.61,97,,,percent of total billed charges,97% of total billed charges,44.76,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.76,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,38.05,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,38.05,221.22,
97763 Orthotics/Prosth Mgmt & Traing Sbsq Enctr 15 Min,3436092,CDM,761,RC,97763,HCPCS,Outpatient,,,193.5,96.75,,174.15,90,,,percent of total billed charges,90% of total Billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,154.8,80,,,Percent of total Billed charges,80% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,174.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,187.7,97,,,Percent of total billed charges,97% of total billed charges,48.7,100,,,Fee Schedule,100% of CMS OPPS Rate,178.02,92,,,Percent of total billed charges,92% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,197.76,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,240.94,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,223.54,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,174.15,90,,,percent of total billed charges,90% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,135.45,70,,,percent of total billed charges,70% of total billed charges,174.15,90,,,percent of total billed charges,90% of total billed charges,183.83,95,,,percent of total billed charges,95% of total billed charges,183.83,95,,,percent of total billed charges,95% of total billed charges,48.75,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,97.5,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,166.41,86,,,percent of total billed charges,86% of total billed charges,154.8,80,,,percent of total billed charges,80% of total billed charges,54.56,111,,,Fee Schedule,111% of CMS OPPS Rate,187.7,97,,,percent of total billed charges,97% of total billed charges,174.15,90,,,percent of total billed charges,90% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,187.7,97,,,percent of total billed charges,97% of total billed charges,179.96,93,,,percent of total billed charges,93% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,187.7,97,,,percent of total billed charges,97% of total billed charges,48.75,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.75,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,41.44,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,41.44,240.94,
98925 Osteopathic Manipulations 1-2 body regions,3438184,CDM,510,RC,98925,HCPCS,Outpatient,,,17.89,8.95,,16.1,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,14.31,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,16.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.35,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,16.46,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,16.1,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,12.52,70,,,percent of total billed charges,70% of total billed charges,16.1,90,,,percent of total billed charges,90% of total billed charges,17,95,,,percent of total billed charges,95% of total billed charges,17,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,15.39,86,,,percent of total billed charges,86% of total billed charges,14.31,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,17.35,97,,,percent of total billed charges,97% of total billed charges,16.1,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.35,97,,,percent of total billed charges,97% of total billed charges,16.64,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,17.35,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,12.52,121.78,
98925 Osteopathic manipulative treatment (OMT); 1-2 body regions involved,3620985,CDM,510,RC,98925,HCPCS,Outpatient,,,18.96,9.48,,17.06,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,15.17,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.06,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,18.39,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,17.44,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,17.06,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,13.27,70,,,percent of total billed charges,70% of total billed charges,17.06,90,,,percent of total billed charges,90% of total billed charges,18.01,95,,,percent of total billed charges,95% of total billed charges,18.01,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,16.31,86,,,percent of total billed charges,86% of total billed charges,15.17,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,18.39,97,,,percent of total billed charges,97% of total billed charges,17.06,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,18.39,97,,,percent of total billed charges,97% of total billed charges,17.63,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,18.39,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,13.27,121.78,
98926 Osteopathic Manipulations 3-4 body regions,3438185,CDM,761,RC,98926,HCPCS,Outpatient,,,27.51,13.76,,24.76,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.01,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.76,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.68,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,25.31,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,24.76,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.26,70,,,percent of total billed charges,70% of total billed charges,24.76,90,,,percent of total billed charges,90% of total billed charges,26.13,95,,,percent of total billed charges,95% of total billed charges,26.13,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.66,86,,,percent of total billed charges,86% of total billed charges,22.01,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,26.68,97,,,percent of total billed charges,97% of total billed charges,24.76,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.68,97,,,percent of total billed charges,97% of total billed charges,25.58,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.68,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.26,121.78,
98927 Osteopathic Manipulations 5-6 body regions,3438186,CDM,510,RC,98927,HCPCS,Outpatient,,,26.06,13.03,,23.45,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,20.85,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,23.45,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.28,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,23.98,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,23.45,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,18.24,70,,,percent of total billed charges,70% of total billed charges,23.45,90,,,percent of total billed charges,90% of total billed charges,24.76,95,,,percent of total billed charges,95% of total billed charges,24.76,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,22.41,86,,,percent of total billed charges,86% of total billed charges,20.85,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,25.28,97,,,percent of total billed charges,97% of total billed charges,23.45,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.28,97,,,percent of total billed charges,97% of total billed charges,24.24,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,25.28,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,18.24,121.78,
98927 Osteopathic manipulative treatment (OMT); 5-6 body regions involved,3621071,CDM,510,RC,98927,HCPCS,Outpatient,,,27.62,13.81,,24.86,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.1,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,24.86,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,26.79,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,25.41,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,24.86,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.33,70,,,percent of total billed charges,70% of total billed charges,24.86,90,,,percent of total billed charges,90% of total billed charges,26.24,95,,,percent of total billed charges,95% of total billed charges,26.24,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,23.75,86,,,percent of total billed charges,86% of total billed charges,22.1,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,26.79,97,,,percent of total billed charges,97% of total billed charges,24.86,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.79,97,,,percent of total billed charges,97% of total billed charges,25.69,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,26.79,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98928 Osteopathic Manipulations  7-8 body regions,3438187,CDM,510,RC,98928,HCPCS,Outpatient,,,28.3,14.15,,25.47,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.64,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,25.47,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,27.45,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,26.04,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,25.47,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,19.81,70,,,percent of total billed charges,70% of total billed charges,25.47,90,,,percent of total billed charges,90% of total billed charges,26.89,95,,,percent of total billed charges,95% of total billed charges,26.89,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,24.34,86,,,percent of total billed charges,86% of total billed charges,22.64,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,27.45,97,,,percent of total billed charges,97% of total billed charges,25.47,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,27.45,97,,,percent of total billed charges,97% of total billed charges,26.32,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,27.45,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98928 Osteopathic manipulative treatment (OMT); 7-8 body regions involved,3621072,CDM,510,RC,98928,HCPCS,Outpatient,,,30,15.00,,27,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,24,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,27,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,29.1,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,27.6,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,27,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21,70,,,percent of total billed charges,70% of total billed charges,27,90,,,percent of total billed charges,90% of total billed charges,28.5,95,,,percent of total billed charges,95% of total billed charges,28.5,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,25.8,86,,,percent of total billed charges,86% of total billed charges,24,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,29.1,97,,,percent of total billed charges,97% of total billed charges,27,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.1,97,,,percent of total billed charges,97% of total billed charges,27.9,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,29.1,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98929 Osteopathic Manipulations 9-10 body regions,3438188,CDM,510,RC,98929,HCPCS,Outpatient,,,31.28,15.64,,28.15,90,,,percent of total billed charges,90% of total Billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,25.02,80,,,Percent of total Billed charges,80% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,28.15,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,30.34,97,,,Percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,28.78,92,,,Percent of total billed charges,92% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,60.3,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.14,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.78,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,28.15,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,21.9,70,,,percent of total billed charges,70% of total billed charges,28.15,90,,,percent of total billed charges,90% of total billed charges,29.72,95,,,percent of total billed charges,95% of total billed charges,29.72,95,,,percent of total billed charges,95% of total billed charges,22.68,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.37,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,26.9,86,,,percent of total billed charges,86% of total billed charges,25.02,80,,,percent of total billed charges,80% of total billed charges,25.35,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,30.34,97,,,percent of total billed charges,97% of total billed charges,28.15,90,,,percent of total billed charges,90% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,30.34,97,,,percent of total billed charges,97% of total billed charges,29.09,93,,,percent of total billed charges,93% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,30.34,97,,,percent of total billed charges,97% of total billed charges,22.68,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.68,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.28,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.28,121.78,
98960 - Education Training for self-mgmt,4323185,CDM,761,RC,98960,HCPCS,Outpatient,,,165,82.50,,148.5,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,132,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,148.5,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,160.05,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,151.8,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,148.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.5,70,,,percent of total billed charges,70% of total billed charges,148.5,90,,,percent of total billed charges,90% of total billed charges,156.75,95,,,percent of total billed charges,95% of total billed charges,156.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141.9,86,,,percent of total billed charges,86% of total billed charges,132,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,160.05,97,,,percent of total billed charges,97% of total billed charges,148.5,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,160.05,97,,,percent of total billed charges,97% of total billed charges,153.45,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,160.05,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.5,160.05,
99152 - MOD SED SAME PHYS/QHP 5/>YRS,3997219,CDM,370,RC,99152,HCPCS,Outpatient,,,89.99,45.00,,80.99,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,71.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,80.99,90,,,Percent of total Billed charges,90% of total billed charges,10.89,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,87.29,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,82.79,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,62.99,70,,,percent of total billed charges,70% of total billed charges,80.99,90,,,percent of total billed charges,90% of total billed charges,85.49,95,,,percent of total billed charges,95% of total billed charges,85.49,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.39,86,,,percent of total billed charges,86% of total billed charges,71.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,87.29,97,,,percent of total billed charges,97% of total billed charges,80.99,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,87.29,97,,,percent of total billed charges,97% of total billed charges,83.69,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,87.29,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.9,87.29,
99183 Phys/QHP Attn&Supvj Hyprbaric Oxygen Tx/Session,3436093,CDM,761,RC,99183,HCPCS,Outpatient,,,216,108.00,,194.4,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,172.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,194.4,90,,,Percent of total Billed charges,90% of total billed charges,117.48,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,209.52,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,198.72,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,194.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,151.2,70,,,percent of total billed charges,70% of total billed charges,194.4,90,,,percent of total billed charges,90% of total billed charges,205.2,95,,,percent of total billed charges,95% of total billed charges,205.2,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,185.76,86,,,percent of total billed charges,86% of total billed charges,172.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,209.52,97,,,percent of total billed charges,97% of total billed charges,194.4,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,209.52,97,,,percent of total billed charges,97% of total billed charges,200.88,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,209.52,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106.8,209.52,
99202 Office Outpt visist new StrFrwd or 15 to 29 mins,3572774,CDM,510,RC,99202,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99202 Office/OP New SF MDM 15-29 Minutes,3438254,CDM,761,RC,99202,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99203 Office OP New Low MDM 30-44 Minutes,3436094,CDM,761,RC,99203,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99203 Office Outpt visit new Low or 30 to 44 mins,3572775,CDM,510,RC,99203,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99204 Office Outpt visit new Mod or 45 to 59 mins,3572776,CDM,510,RC,99204,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99204 Office/OP New Moderate MDM 45-59 Minutes,3984931,CDM,761,RC,99204,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99205 Office Outpt visist new High 60 to 74 mins,3572777,CDM,510,RC,99205,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99205 Office/OP New High MDM 60-74 Minutes,3436095,CDM,761,RC,99205,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99211 Office outpatient visit est  nursing visit only,3572778,CDM,510,RC,99211,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99211 Office/OP Established  May Not Rqr Phys/QHP,3441817,CDM,761,RC,99211,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99212 Office Outpt visit est Strtforward or 10 to 19 mins,3572779,CDM,510,RC,99212,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99212 Office/OP Established SF MDM 10-19 Min,3435838,CDM,761,RC,99212,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99213- Office/OP Est SF 20 Minutes,3572780,CDM,510,RC,99213,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99213 Office/OP Established  Low MDM 20-29 Min,3436097,CDM,761,RC,99213,HCPCS,Outpatient,,,266.67,133.34,,240,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,213.34,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,240,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,258.67,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,245.34,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,240,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,186.67,70,,,percent of total billed charges,70% of total billed charges,240,90,,,percent of total billed charges,90% of total billed charges,253.34,95,,,percent of total billed charges,95% of total billed charges,253.34,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,229.34,86,,,percent of total billed charges,86% of total billed charges,213.34,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,258.67,97,,,percent of total billed charges,97% of total billed charges,240,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,258.67,97,,,percent of total billed charges,97% of total billed charges,248,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,258.67,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186.67,258.67,
99214- Office/OP Est Mod 30 Minutes,3572781,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99214 Office/OP Established Mod MDM 30-39 Min,3436098,CDM,761,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99214-EST PATIENT LEVEL 4 (30-39 min),3537583,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99214-Office outpatient visit est Moderate or 30 39 minutes,4223209,CDM,510,RC,99214,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99215 Office Outpatient visit est High or 40 to 54 minutes,3572782,CDM,510,RC,99215,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99215 Office/OP Established High MDM 40-54 Min,3436099,CDM,761,RC,99215,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99244-Office Consult New/Est PT Mod MDM Level 4 (40 min),4355203,CDM,761,RC,99244,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99245-Office Consult New/Est PT High MDM Level 5 (55 min),4355205,CDM,761,RC,99245,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,190.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,219.21,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166.79,231.12,
99253- Initl IP/OBV Consult New/Est Pt Low MDM (45 min),3437947,CDM,510,RC,99253,HCPCS,Outpatient,,,358.4,179.20,,322.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,286.72,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,322.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,347.65,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,329.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,322.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,250.88,70,,,percent of total billed charges,70% of total billed charges,322.56,90,,,percent of total billed charges,90% of total billed charges,340.48,95,,,percent of total billed charges,95% of total billed charges,340.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.22,86,,,percent of total billed charges,86% of total billed charges,286.72,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,347.65,97,,,percent of total billed charges,97% of total billed charges,322.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,347.65,97,,,percent of total billed charges,97% of total billed charges,333.31,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,347.65,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,250.88,347.65,
99291- Critical care first hour,3437957,CDM,983,RC,99291,HCPCS,Outpatient,,,136.33,68.17,,122.7,90,,,percent of total billed charges,90% of total Billed charges,272.66,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,408.77,90,,,Percent of total Billed charges,90% of total billed charges,151.63,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,197.68,155,,,Fee Schedule,155% of CMS OPPS Rate,136.33,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,278.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,136.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,313.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,313.05,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,334.64,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,223.19,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,272.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,136.33,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,250.46,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,197.68,145,,,Fee Schedule,145% of CMS OPPS Rate,136.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,395.36,145,,,Fee Schedule,145% of CMS OPPS Rate,197.68,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,136.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,151.63,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,279.31,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,136.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,393,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,393,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,122.7,408.77,
99292- Critical care addl 30 min,3437958,CDM,983,RC,99292,HCPCS,Outpatient,,,28.3,14.15,,25.47,90,,,percent of total billed charges,90% of total Billed charges,56.6,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,74.4,100,,,Fee Schedule,100% of PA Medicaid Fee Schedule Rate for Physician,41.04,155,,,Fee Schedule,155% of CMS OPPS Rate,28.3,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.05,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,157.52,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,157.52,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,168.45,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,112.4,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,56.6,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,126.68,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,41.04,145,,,Fee Schedule,145% of CMS OPPS Rate,28.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,82.07,145,,,Fee Schedule,145% of CMS OPPS Rate,41.04,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,28.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.4,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,127,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,28.3,100,,,Fee Schedule,100% of CMS OPPS Rate ,177.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,177.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,25.47,177.5,
99406 Tobacco Counseling (as part of MWV),3428377,CDM,983,RC,99406,HCPCS,Outpatient,,,7.45,3.73,,6.71,90,,,percent of total billed charges,90% of total Billed charges,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,155,,,Fee Schedule,155% of CMS OPPS Rate,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,10.8,145,,,Fee Schedule,145% of CMS OPPS Rate,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.61,145,,,Fee Schedule,145% of CMS OPPS Rate,10.8,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.71,21.61,
99406- Tobacco Use Cessation Intermediate 3-10 Minutes,3438055,CDM,983,RC,99406,HCPCS,Outpatient,,,7.45,3.73,,6.71,90,,,percent of total billed charges,90% of total Billed charges,14.9,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.8,155,,,Fee Schedule,155% of CMS OPPS Rate,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.51,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,15.19,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,15.19,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,18.53,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,12.44,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.9,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,13.71,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,10.8,145,,,Fee Schedule,145% of CMS OPPS Rate,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,21.61,145,,,Fee Schedule,145% of CMS OPPS Rate,10.8,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,15.25,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.45,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.5,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,20.5,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.71,21.61,
99406-BEHAV CHNG SMOKING 3-10 MIN,3400474,CDM,510,RC,99406,HCPCS,Outpatient,,,148.4,74.20,,133.56,90,,,percent of total billed charges,90% of total Billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,118.72,80,,,Percent of total Billed charges,80% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,133.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,143.95,97,,,Percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,136.53,92,,,Percent of total billed charges,92% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,71.65,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,114.23,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,144.68,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,133.56,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,103.88,70,,,percent of total billed charges,70% of total billed charges,133.56,90,,,percent of total billed charges,90% of total billed charges,140.98,95,,,percent of total billed charges,95% of total billed charges,140.98,95,,,percent of total billed charges,95% of total billed charges,26.95,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,53.91,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,127.62,86,,,percent of total billed charges,86% of total billed charges,118.72,80,,,percent of total billed charges,80% of total billed charges,28.24,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,143.95,97,,,percent of total billed charges,97% of total billed charges,133.56,90,,,percent of total billed charges,90% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,143.95,97,,,percent of total billed charges,97% of total billed charges,138.01,93,,,percent of total billed charges,93% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,143.95,97,,,percent of total billed charges,97% of total billed charges,26.95,100,,,Fee Schedule,100% of CMS OPPS Rate ,26.95,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,22.9,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,22.9,144.68,
99407- Behav chng smoking > 10 min,3438056,CDM,983,RC,99407,HCPCS,Outpatient,,,6.7,3.35,,6.03,90,,,percent of total billed charges,90% of total Billed charges,13.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,155,,,Fee Schedule,155% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,9.72,145,,,Fee Schedule,145% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.43,145,,,Fee Schedule,145% of CMS OPPS Rate,9.72,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.03,40,
99407- Tobacco Use Cessation Intensive >10 Minutes,3438057,CDM,983,RC,99407,HCPCS,Outpatient,,,6.7,3.35,,6.03,90,,,percent of total billed charges,90% of total Billed charges,13.4,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.72,155,,,Fee Schedule,155% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,13.4,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,9.72,145,,,Fee Schedule,145% of CMS OPPS Rate,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.43,145,,,Fee Schedule,145% of CMS OPPS Rate,9.72,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,6.7,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.03,40,
99407-BEHAV CHNG SMOKING > 10 MIN,3537585,CDM,983,RC,99407,HCPCS,Outpatient,,,7.1,3.55,,6.39,90,,,percent of total billed charges,90% of total Billed charges,14.2,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.3,155,,,Fee Schedule,155% of CMS OPPS Rate,7.1,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28.55,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,7.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.11,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,32.11,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,39.26,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,26.39,100,,,Fee Schedule,100% of Maryland Medicaid Fee Schedule,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,14.2,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,29.59,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,10.3,145,,,Fee Schedule,145% of CMS OPPS Rate,7.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.59,145,,,Fee Schedule,145% of CMS OPPS Rate,10.3,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,7.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,28.95,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,7.1,100,,,Fee Schedule,100% of CMS OPPS Rate ,40,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,40,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,6.39,40,
99441 Phone E/M Phys/QHP 5-10 Min,3991169,CDM,761,RC,99441,HCPCS,Outpatient,,,140.2,70.10,,126.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,112.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,126.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,128.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.14,70,,,percent of total billed charges,70% of total billed charges,126.18,90,,,percent of total billed charges,90% of total billed charges,133.19,95,,,percent of total billed charges,95% of total billed charges,133.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.57,86,,,percent of total billed charges,86% of total billed charges,112.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,126.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,130.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.14,135.99,
99442 Phone E/M Phys/QHP 11-20 Min,3991175,CDM,761,RC,99442,HCPCS,Outpatient,,,140.2,70.10,,126.18,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,112.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,126.18,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,128.98,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,98.14,70,,,percent of total billed charges,70% of total billed charges,126.18,90,,,percent of total billed charges,90% of total billed charges,133.19,95,,,percent of total billed charges,95% of total billed charges,133.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120.57,86,,,percent of total billed charges,86% of total billed charges,112.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,126.18,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,130.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,135.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98.14,135.99,
99443 Phone E/M Phys/QHP 21-30 Min,3993118,CDM,761,RC,99443,HCPCS,Outpatient,,,324.95,162.48,,292.46,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,259.96,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,292.46,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,315.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,298.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,292.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,227.47,70,,,percent of total billed charges,70% of total billed charges,292.46,90,,,percent of total billed charges,90% of total billed charges,308.7,95,,,percent of total billed charges,95% of total billed charges,308.7,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,279.46,86,,,percent of total billed charges,86% of total billed charges,259.96,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,315.2,97,,,percent of total billed charges,97% of total billed charges,292.46,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,315.2,97,,,percent of total billed charges,97% of total billed charges,302.2,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,315.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227.47,315.2,
99495- Trans care mgmt 14 day disch,3438135,CDM,510,RC,99495,HCPCS,Outpatient,,,138.57,69.29,,124.71,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,110.86,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,124.71,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,134.41,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,127.48,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,124.71,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,97,70,,,percent of total billed charges,70% of total billed charges,124.71,90,,,percent of total billed charges,90% of total billed charges,131.64,95,,,percent of total billed charges,95% of total billed charges,131.64,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,119.17,86,,,percent of total billed charges,86% of total billed charges,110.86,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,134.41,97,,,percent of total billed charges,97% of total billed charges,124.71,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,134.41,97,,,percent of total billed charges,97% of total billed charges,128.87,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,134.41,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
99496- Trans care mgmt 7 day disch,3438136,CDM,510,RC,99496,HCPCS,Outpatient,,,184.72,92.36,,166.25,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,147.78,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,166.25,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,179.18,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,169.94,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,166.25,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,129.3,70,,,percent of total billed charges,70% of total billed charges,166.25,90,,,percent of total billed charges,90% of total billed charges,175.48,95,,,percent of total billed charges,95% of total billed charges,175.48,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,158.86,86,,,percent of total billed charges,86% of total billed charges,147.78,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,179.18,97,,,percent of total billed charges,97% of total billed charges,166.25,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,179.18,97,,,percent of total billed charges,97% of total billed charges,171.79,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,179.18,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
99497 Advanced Directives Counseling (as part of MWV),3428378,CDM,983,RC,99497,HCPCS,Outpatient,,,16.39,8.20,,14.75,90,,,percent of total billed charges,90% of total Billed charges,32.78,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.77,155,,,Fee Schedule,155% of CMS OPPS Rate,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60.82,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,16.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,68.41,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,68.41,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,116.97,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,116.97,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,4.92,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,32.78,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,83.73,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,23.77,145,,,Fee Schedule,145% of CMS OPPS Rate,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,47.53,145,,,Fee Schedule,145% of CMS OPPS Rate,23.77,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,92.3,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,16.39,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.92,116.97,
99498 - Advanced care plan addl 30 min,3678905,CDM,983,RC,99498,HCPCS,Outpatient,,,1.48,0.74,,1.33,90,,,percent of total billed charges,90% of total Billed charges,2.96,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.15,155,,,Fee Schedule,155% of CMS OPPS Rate,1.48,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.28,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,1.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,64.42,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,64.42,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,110.16,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,0.44,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.48,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,1.48,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,79.4,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,2.15,145,,,Fee Schedule,145% of CMS OPPS Rate,1.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,4.29,145,,,Fee Schedule,145% of CMS OPPS Rate,2.15,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,1.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,80.66,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,1.48,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.44,110.16,
0094A - ADM SARSCOV2 50MCG/0.5 MLBST,4113121,CDM,771,RC,0094A,HCPCS,Outpatient,,,96.62,48.31,,86.96,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,77.3,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,86.96,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,88.89,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86.96,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,67.63,70,,,percent of total billed charges,70% of total billed charges,86.96,90,,,percent of total billed charges,90% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,91.79,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.09,86,,,percent of total billed charges,86% of total billed charges,77.3,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93.72,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.63,93.72,
A4465- Circ Aid Reduction Kit,3726897,CDM,279,RC,A4465,HCPCS,Outpatient,,,1296.9,648.45,,1167.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1037.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1167.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1193.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.83,70,,,percent of total billed charges,70% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.33,86,,,percent of total billed charges,86% of total billed charges,1037.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1206.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.83,1257.99,
A4648-IMPLANTABLE TISSUE MARKER,3435845,CDM,278,RC,A4648,HCPCS,Outpatient,,,884.8,442.40,,796.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,707.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,796.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,814.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,619.36,70,,,percent of total billed charges,70% of total billed charges,796.32,90,,,percent of total billed charges,90% of total billed charges,840.56,95,,,percent of total billed charges,95% of total billed charges,840.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.93,86,,,percent of total billed charges,86% of total billed charges,707.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,796.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,822.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.36,858.26,
Fiducial Marker - Gold - Pelvic,3880988,CDM,278,RC,A4648,HCPCS,Outpatient,,,884.8,442.40,,796.32,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,707.84,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,796.32,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,814.02,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,796.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,619.36,70,,,percent of total billed charges,70% of total billed charges,796.32,90,,,percent of total billed charges,90% of total billed charges,840.56,95,,,percent of total billed charges,95% of total billed charges,840.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,760.93,86,,,percent of total billed charges,86% of total billed charges,707.84,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,796.32,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,822.86,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,858.26,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,619.36,858.26,
A6021-PRISMA 4.34 IN SQUARED,3436110,CDM,279,RC,A6021,HCPCS,Outpatient,,,90.63,45.32,,81.57,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,72.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,81.57,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,87.91,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,83.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,63.44,70,,,percent of total billed charges,70% of total billed charges,81.57,90,,,percent of total billed charges,90% of total billed charges,86.1,95,,,percent of total billed charges,95% of total billed charges,86.1,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.94,86,,,percent of total billed charges,86% of total billed charges,72.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,87.91,97,,,percent of total billed charges,97% of total billed charges,81.57,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,87.91,97,,,percent of total billed charges,97% of total billed charges,84.29,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87.91,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.44,87.91,
A6021-PROMOGRAN 4.23 IN SQUARED,3436111,CDM,279,RC,A6021,HCPCS,Outpatient,,,76.84,38.42,,69.16,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,61.47,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,69.16,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,74.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,70.69,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,53.79,70,,,percent of total billed charges,70% of total billed charges,69.16,90,,,percent of total billed charges,90% of total billed charges,73,95,,,percent of total billed charges,95% of total billed charges,73,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.08,86,,,percent of total billed charges,86% of total billed charges,61.47,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,74.53,97,,,percent of total billed charges,97% of total billed charges,69.16,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,74.53,97,,,percent of total billed charges,97% of total billed charges,71.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53.79,74.53,
A6196-ALGINATE AG TEGADERM < 16 SQ IN,3436112,CDM,279,RC,A6196,HCPCS,Outpatient,,,23.24,11.62,,20.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,18.59,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,20.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.27,70,,,percent of total billed charges,70% of total billed charges,20.92,90,,,percent of total billed charges,90% of total billed charges,22.08,95,,,percent of total billed charges,95% of total billed charges,22.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,86,,,percent of total billed charges,86% of total billed charges,18.59,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,20.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,21.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.27,22.54,
A6196-ALGISITE M CALCIUM ALG. 3/4X12IN,3436114,CDM,279,RC,A6196,HCPCS,Outpatient,,,34.16,17.08,,30.74,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,27.33,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,30.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.14,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,31.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,23.91,70,,,percent of total billed charges,70% of total billed charges,30.74,90,,,percent of total billed charges,90% of total billed charges,32.45,95,,,percent of total billed charges,95% of total billed charges,32.45,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29.38,86,,,percent of total billed charges,86% of total billed charges,27.33,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,33.14,97,,,percent of total billed charges,97% of total billed charges,30.74,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,33.14,97,,,percent of total billed charges,97% of total billed charges,31.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33.14,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23.91,33.14,
A6196-CALCIUM ALGINATE 4X4IN,3436115,CDM,279,RC,A6196,HCPCS,Outpatient,,,23.24,11.62,,20.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,18.59,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,20.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,21.38,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,16.27,70,,,percent of total billed charges,70% of total billed charges,20.92,90,,,percent of total billed charges,90% of total billed charges,22.08,95,,,percent of total billed charges,95% of total billed charges,22.08,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.99,86,,,percent of total billed charges,86% of total billed charges,18.59,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,20.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,21.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.54,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16.27,22.54,
A6196-DRAWTEX 4X4IN,3436116,CDM,279,RC,A6196,HCPCS,Outpatient,,,85.5,42.75,,76.95,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,68.4,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,76.95,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.94,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,78.66,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,59.85,70,,,percent of total billed charges,70% of total billed charges,76.95,90,,,percent of total billed charges,90% of total billed charges,81.23,95,,,percent of total billed charges,95% of total billed charges,81.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73.53,86,,,percent of total billed charges,86% of total billed charges,68.4,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.94,97,,,percent of total billed charges,97% of total billed charges,76.95,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,82.94,97,,,percent of total billed charges,97% of total billed charges,79.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.94,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.85,82.94,
A6197-AQUACEL  4X5IN,3436118,CDM,279,RC,A6197,HCPCS,Outpatient,,,35.98,17.99,,32.38,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,28.78,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,32.38,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,33.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,25.19,70,,,percent of total billed charges,70% of total billed charges,32.38,90,,,percent of total billed charges,90% of total billed charges,34.18,95,,,percent of total billed charges,95% of total billed charges,34.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.94,86,,,percent of total billed charges,86% of total billed charges,28.78,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,34.9,97,,,percent of total billed charges,97% of total billed charges,32.38,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.9,97,,,percent of total billed charges,97% of total billed charges,33.46,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.19,34.9,
A6197-SILVERCEL 4.25X4.25IN,3436120,CDM,279,RC,A6197,HCPCS,Outpatient,,,63.62,31.81,,57.26,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,50.9,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,57.26,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.71,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,58.53,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.53,70,,,percent of total billed charges,70% of total billed charges,57.26,90,,,percent of total billed charges,90% of total billed charges,60.44,95,,,percent of total billed charges,95% of total billed charges,60.44,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.71,86,,,percent of total billed charges,86% of total billed charges,50.9,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.71,97,,,percent of total billed charges,97% of total billed charges,57.26,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,61.71,97,,,percent of total billed charges,97% of total billed charges,59.17,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.71,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.53,61.71,
A6206-MEPITEL ONE 3X4IN,3436121,CDM,279,RC,A6206,HCPCS,Outpatient,,,44.41,22.21,,39.97,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,35.53,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,39.97,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,40.86,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,31.09,70,,,percent of total billed charges,70% of total billed charges,39.97,90,,,percent of total billed charges,90% of total billed charges,42.19,95,,,percent of total billed charges,95% of total billed charges,42.19,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38.19,86,,,percent of total billed charges,86% of total billed charges,35.53,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,43.08,97,,,percent of total billed charges,97% of total billed charges,39.97,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,43.08,97,,,percent of total billed charges,97% of total billed charges,41.3,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.09,43.08,
A6206-WOUND VEIL,3436122,CDM,279,RC,A6206,HCPCS,Outpatient,,,5.65,2.83,,5.09,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.09,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.48,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,5.2,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.96,70,,,percent of total billed charges,70% of total billed charges,5.09,90,,,percent of total billed charges,90% of total billed charges,5.37,95,,,percent of total billed charges,95% of total billed charges,5.37,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.86,86,,,percent of total billed charges,86% of total billed charges,4.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.48,97,,,percent of total billed charges,97% of total billed charges,5.09,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.48,97,,,percent of total billed charges,97% of total billed charges,5.25,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.48,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.96,5.48,
A6206-XEROFORM 1X8IN,3436123,CDM,279,RC,A6206,HCPCS,Outpatient,,,3.73,1.87,,3.36,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.98,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3.36,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.62,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,2.61,70,,,percent of total billed charges,70% of total billed charges,3.36,90,,,percent of total billed charges,90% of total billed charges,3.54,95,,,percent of total billed charges,95% of total billed charges,3.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.21,86,,,percent of total billed charges,86% of total billed charges,2.98,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3.62,97,,,percent of total billed charges,97% of total billed charges,3.36,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.62,97,,,percent of total billed charges,97% of total billed charges,3.47,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.62,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.61,3.62,
A6207-XEROFORM 5X9IN,3436124,CDM,279,RC,A6207,HCPCS,Outpatient,,,5.2,2.60,,4.68,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4.68,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,4.78,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3.64,70,,,percent of total billed charges,70% of total billed charges,4.68,90,,,percent of total billed charges,90% of total billed charges,4.94,95,,,percent of total billed charges,95% of total billed charges,4.94,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4.47,86,,,percent of total billed charges,86% of total billed charges,4.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,5.04,97,,,percent of total billed charges,97% of total billed charges,4.68,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.04,97,,,percent of total billed charges,97% of total billed charges,4.84,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.64,5.04,
A6209-ALLEVYN 4X4IN,3436125,CDM,279,RC,A6209,HCPCS,Outpatient,,,25.13,12.57,,22.62,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,20.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,22.62,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,23.12,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,17.59,70,,,percent of total billed charges,70% of total billed charges,22.62,90,,,percent of total billed charges,90% of total billed charges,23.87,95,,,percent of total billed charges,95% of total billed charges,23.87,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.61,86,,,percent of total billed charges,86% of total billed charges,20.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,24.38,97,,,percent of total billed charges,97% of total billed charges,22.62,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,24.38,97,,,percent of total billed charges,97% of total billed charges,23.37,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.59,24.38,
A6209-ALLEVYN HEEL 4 1/8X5 1/16IN,3436126,CDM,279,RC,A6209,HCPCS,Outpatient,,,74.58,37.29,,67.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,59.66,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,67.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.34,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,68.61,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,52.21,70,,,percent of total billed charges,70% of total billed charges,67.12,90,,,percent of total billed charges,90% of total billed charges,70.85,95,,,percent of total billed charges,95% of total billed charges,70.85,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.14,86,,,percent of total billed charges,86% of total billed charges,59.66,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.34,97,,,percent of total billed charges,97% of total billed charges,67.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,72.34,97,,,percent of total billed charges,97% of total billed charges,69.36,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.34,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52.21,72.34,
A6222-THERAHONEY SHEET 4X5IN,3436127,CDM,279,RC,A6222,HCPCS,Outpatient,,,68.59,34.30,,61.73,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,54.87,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,61.73,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.53,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,63.1,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,48.01,70,,,percent of total billed charges,70% of total billed charges,61.73,90,,,percent of total billed charges,90% of total billed charges,65.16,95,,,percent of total billed charges,95% of total billed charges,65.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58.99,86,,,percent of total billed charges,86% of total billed charges,54.87,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,66.53,97,,,percent of total billed charges,97% of total billed charges,61.73,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,66.53,97,,,percent of total billed charges,97% of total billed charges,63.79,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66.53,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.01,66.53,
A6234-DUODERM XTHIN 4X4IN,3436128,CDM,279,RC,A6234,HCPCS,Outpatient,,,111.37,55.69,,100.23,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,89.1,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,100.23,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,108.03,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,102.46,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,77.96,70,,,percent of total billed charges,70% of total billed charges,100.23,90,,,percent of total billed charges,90% of total billed charges,105.8,95,,,percent of total billed charges,95% of total billed charges,105.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,95.78,86,,,percent of total billed charges,86% of total billed charges,89.1,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,108.03,97,,,percent of total billed charges,97% of total billed charges,100.23,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,108.03,97,,,percent of total billed charges,97% of total billed charges,103.57,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108.03,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77.96,108.03,
A6252-EXUDRY 4X6IN,3436130,CDM,279,RC,A6252,HCPCS,Outpatient,,,14.69,7.35,,13.22,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,11.75,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.22,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.25,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,13.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,10.28,70,,,percent of total billed charges,70% of total billed charges,13.22,90,,,percent of total billed charges,90% of total billed charges,13.96,95,,,percent of total billed charges,95% of total billed charges,13.96,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.63,86,,,percent of total billed charges,86% of total billed charges,11.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,14.25,97,,,percent of total billed charges,97% of total billed charges,13.22,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.25,97,,,percent of total billed charges,97% of total billed charges,13.66,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.25,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.28,14.25,
A6252-EXUDRY 6X9IN,3436131,CDM,279,RC,A6252,HCPCS,Outpatient,,,20.57,10.29,,18.51,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,16.46,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,18.51,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.95,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,18.92,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,14.4,70,,,percent of total billed charges,70% of total billed charges,18.51,90,,,percent of total billed charges,90% of total billed charges,19.54,95,,,percent of total billed charges,95% of total billed charges,19.54,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17.69,86,,,percent of total billed charges,86% of total billed charges,16.46,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,19.95,97,,,percent of total billed charges,97% of total billed charges,18.51,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,19.95,97,,,percent of total billed charges,97% of total billed charges,19.13,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19.95,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.4,19.95,
A6253-ABD PAD,3436132,CDM,279,RC,A6253,HCPCS,Outpatient,,,1.24,0.62,,1.12,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,0.99,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1.12,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1.14,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,0.87,70,,,percent of total billed charges,70% of total billed charges,1.12,90,,,percent of total billed charges,90% of total billed charges,1.18,95,,,percent of total billed charges,95% of total billed charges,1.18,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.07,86,,,percent of total billed charges,86% of total billed charges,0.99,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1.2,97,,,percent of total billed charges,97% of total billed charges,1.12,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1.2,97,,,percent of total billed charges,97% of total billed charges,1.15,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,0.87,1.2,
A6448-ROSIDAL K 6CMX5M (5.47yds),3436134,CDM,279,RC,A6448,HCPCS,Outpatient,,,53.34,26.67,,48.01,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,42.67,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,48.01,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.74,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,49.07,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,37.34,70,,,percent of total billed charges,70% of total billed charges,48.01,90,,,percent of total billed charges,90% of total billed charges,50.67,95,,,percent of total billed charges,95% of total billed charges,50.67,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45.87,86,,,percent of total billed charges,86% of total billed charges,42.67,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,51.74,97,,,percent of total billed charges,97% of total billed charges,48.01,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,51.74,97,,,percent of total billed charges,97% of total billed charges,49.61,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51.74,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.34,51.74,
A6449-ROSIDAL K 10CMX5M (5.47yds),3436135,CDM,279,RC,A6449,HCPCS,Outpatient,,,81.02,40.51,,72.92,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,64.82,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,72.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,74.54,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,56.71,70,,,percent of total billed charges,70% of total billed charges,72.92,90,,,percent of total billed charges,90% of total billed charges,76.97,95,,,percent of total billed charges,95% of total billed charges,76.97,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69.68,86,,,percent of total billed charges,86% of total billed charges,64.82,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,78.59,97,,,percent of total billed charges,97% of total billed charges,72.92,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,78.59,97,,,percent of total billed charges,97% of total billed charges,75.35,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.71,78.59,
A6449-ROSIDAL K 12CMX5M (5.47yds),3991163,CDM,279,RC,A6449,HCPCS,Outpatient,,,92.1,46.05,,82.89,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,73.68,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,82.89,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,89.34,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,84.73,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,82.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,64.47,70,,,percent of total billed charges,70% of total billed charges,82.89,90,,,percent of total billed charges,90% of total billed charges,87.5,95,,,percent of total billed charges,95% of total billed charges,87.5,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79.21,86,,,percent of total billed charges,86% of total billed charges,73.68,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,89.34,97,,,percent of total billed charges,97% of total billed charges,82.89,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,89.34,97,,,percent of total billed charges,97% of total billed charges,85.65,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.34,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.47,89.34,
A6449-ROSIDAL K 8CMX5M (5.47yds),3436136,CDM,279,RC,A6449,HCPCS,Outpatient,,,66.56,33.28,,59.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,53.25,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,59.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,64.56,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,61.24,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,46.59,70,,,percent of total billed charges,70% of total billed charges,59.9,90,,,percent of total billed charges,90% of total billed charges,63.23,95,,,percent of total billed charges,95% of total billed charges,63.23,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57.24,86,,,percent of total billed charges,86% of total billed charges,53.25,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,64.56,97,,,percent of total billed charges,97% of total billed charges,59.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,64.56,97,,,percent of total billed charges,97% of total billed charges,61.9,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64.56,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46.59,64.56,
A6456-UNNA 3 IN X 10 YARDS,3436137,CDM,279,RC,A6456,HCPCS,Outpatient,,,49.38,24.69,,44.44,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,39.5,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,44.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.9,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,45.43,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,34.57,70,,,percent of total billed charges,70% of total billed charges,44.44,90,,,percent of total billed charges,90% of total billed charges,46.91,95,,,percent of total billed charges,95% of total billed charges,46.91,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42.47,86,,,percent of total billed charges,86% of total billed charges,39.5,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,47.9,97,,,percent of total billed charges,97% of total billed charges,44.44,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,47.9,97,,,percent of total billed charges,97% of total billed charges,45.92,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.9,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.57,47.9,
A6459 - Circ Aid Reduction Kit Knee,4023159,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,1167.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1037.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1167.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1193.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.83,70,,,percent of total billed charges,70% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.33,86,,,percent of total billed charges,86% of total billed charges,1037.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1206.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.83,1257.99,
A6459 - Circ Aid Reduction Kit Upper Leg,4023158,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,1167.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1037.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1167.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1193.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.83,70,,,percent of total billed charges,70% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.33,86,,,percent of total billed charges,86% of total billed charges,1037.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1206.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.83,1257.99,
A6549 - Circ Aid Reduction Kit Arm,4023156,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,1167.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1037.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1167.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1193.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.83,70,,,percent of total billed charges,70% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.33,86,,,percent of total billed charges,86% of total billed charges,1037.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1206.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.83,1257.99,
A6549 - Circ Aid Reduction Kit Lower Leg,4023157,CDM,272,RC,A6549,HCPCS,Outpatient,,,1296.9,648.45,,1167.21,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1037.52,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1167.21,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1193.15,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,907.83,70,,,percent of total billed charges,70% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,1232.06,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1115.33,86,,,percent of total billed charges,86% of total billed charges,1037.52,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1167.21,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,1206.12,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1257.99,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,907.83,1257.99,
"C1717-Brachytx, Non-Str, HDR IR-192",4169516,CDM,278,RC,C1717,HCPCS,Outpatient,,,765.45,382.73,,688.91,90,,,percent of total billed charges,90% of total Billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,612.36,80,,,Percent of total Billed charges,80% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,688.91,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,742.49,97,,,Percent of total billed charges,97% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,704.21,92,,,Percent of total billed charges,92% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,892.35,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,335.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1422.6,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1801.93,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,688.91,90,,,percent of total billed charges,90% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,535.82,70,,,percent of total billed charges,70% of total billed charges,688.91,90,,,percent of total billed charges,90% of total billed charges,727.18,95,,,percent of total billed charges,95% of total billed charges,727.18,95,,,percent of total billed charges,95% of total billed charges,335.71,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,671.42,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,658.29,86,,,percent of total billed charges,86% of total billed charges,612.36,80,,,percent of total billed charges,80% of total billed charges,357.44,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,742.49,97,,,percent of total billed charges,97% of total billed charges,688.91,90,,,percent of total billed charges,90% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,742.49,97,,,percent of total billed charges,97% of total billed charges,711.87,93,,,percent of total billed charges,93% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,742.49,97,,,percent of total billed charges,97% of total billed charges,335.71,100,,,Fee Schedule,100% of CMS OPPS Rate ,335.71,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,285.35,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,285.35,1801.93,
"C1897- lead, neurostimulator test kit, implanted",3690951,CDM,278,RC,C1897,HCPCS,Outpatient,,,1781,890.50,,1602.9,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,1424.8,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1602.9,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.57,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,1638.52,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1602.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1246.7,70,,,percent of total billed charges,70% of total billed charges,1602.9,90,,,percent of total billed charges,90% of total billed charges,1691.95,95,,,percent of total billed charges,95% of total billed charges,1691.95,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1531.66,86,,,percent of total billed charges,86% of total billed charges,1424.8,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1727.57,97,,,percent of total billed charges,97% of total billed charges,1602.9,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1727.57,97,,,percent of total billed charges,97% of total billed charges,1656.33,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1727.57,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1246.7,1727.57,
G0101- Cervical Or Vaginal Cancer Screening,3431440,CDM,510,RC,G0101,HCPCS,Outpatient,,,64.59,32.30,,58.13,90,,,percent of total billed charges,90% of total Billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,51.67,80,,,Percent of total Billed charges,80% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,58.13,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,62.65,97,,,Percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,59.42,92,,,Percent of total billed charges,92% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,183.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,291.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,369.77,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,58.13,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,45.21,70,,,percent of total billed charges,70% of total billed charges,58.13,90,,,percent of total billed charges,90% of total billed charges,61.36,95,,,percent of total billed charges,95% of total billed charges,61.36,95,,,percent of total billed charges,95% of total billed charges,68.88,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,137.77,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,55.55,86,,,percent of total billed charges,86% of total billed charges,51.67,80,,,percent of total billed charges,80% of total billed charges,81.19,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,62.65,97,,,percent of total billed charges,97% of total billed charges,58.13,90,,,percent of total billed charges,90% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,62.65,97,,,percent of total billed charges,97% of total billed charges,60.07,93,,,percent of total billed charges,93% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,62.65,97,,,percent of total billed charges,97% of total billed charges,68.88,100,,,Fee Schedule,100% of CMS OPPS Rate ,68.88,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,58.55,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,45.21,369.77,
G0270 - MNT subs tx for change dx,4037466,CDM,983,RC,G0270,HCPCS,Outpatient,,,10.27,5.14,,9.24,90,,,percent of total billed charges,90% of total Billed charges,20.54,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14.89,155,,,Fee Schedule,155% of CMS OPPS Rate,10.27,100,,,Fee Schedule,100% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34.97,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,10.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,39.33,100,,,Fee Schedule,100% of BCBS Physician Fee Schedule,39.33,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choice Care Fee Schedule,41.49,150,,,Fee Schedule,Pays based on 150% of Choicecare Fee Schedule,3.08,30,,,percent of total billed charges,30% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10.27,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,20.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,,,,,Other,Not Separately reimbursable,10.27,100,,,Fee Schedule,Pays based on 100% CMS RBRVS Fee Schedule,28.87,100,,,Fee Schedule,100% of HEALTH Plan PEIA Fee Schedule,,,,,Other,Not Separately reimbursable,14.89,145,,,Fee Schedule,145% of CMS OPPS Rate,10.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,29.78,145,,,Fee Schedule,145% of CMS OPPS Rate,14.89,145,,,Fee Schedule,145% of CMS CUSTOMIZED Fee Schedule Rate,,,,,Other,Not Separately reimbursable,10.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,23.02,100,,,Fee Schedule,100% of UPMC Physician Fee Schedule,10.27,100,,,Fee Schedule,100% of CMS OPPS Rate ,48.47,100,,,Fee Schedule,100% of Zelis Physician Fee Schedule,48.47,100,,,Fee Schedule,Pays based on 100% of Zelis Other Physician Fee Schedule,3.08,48.47,
"G0277 HBOT, Full Body Chamber, 30 Minutes",3436143,CDM,761,RC,G0277,HCPCS,Outpatient,,,700.71,350.36,,630.64,90,,,percent of total billed charges,90% of total Billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,560.57,80,,,Percent of total Billed charges,80% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,630.64,90,,,Percent of total Billed charges,90% of total billed charges,48.28,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679.69,97,,,Percent of total billed charges,97% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,644.65,92,,,Percent of total billed charges,92% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,301.95,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,113.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,481.36,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,609.72,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,630.64,90,,,percent of total billed charges,90% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,490.5,70,,,percent of total billed charges,70% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,665.67,95,,,percent of total billed charges,95% of total billed charges,113.59,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,227.19,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,602.61,86,,,percent of total billed charges,86% of total billed charges,560.57,80,,,percent of total billed charges,80% of total billed charges,118.95,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,679.69,97,,,percent of total billed charges,97% of total billed charges,630.64,90,,,percent of total billed charges,90% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,679.69,97,,,percent of total billed charges,97% of total billed charges,651.66,93,,,percent of total billed charges,93% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,43.89,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679.69,97,,,percent of total billed charges,97% of total billed charges,113.59,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.59,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,96.54,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,43.89,679.69,
MA TOMO Mammogram Diagnostic Rt,3332563,CDM,401,RC,G0279,HCPCS,Outpatient,,,117.01,58.51,,105.31,90,,,percent of total billed charges,90% of total Billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,93.61,80,,,Percent of total Billed charges,80% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,105.31,90,,,Percent of total Billed charges,90% of total billed charges,21.18,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,113.5,97,,,Percent of total billed charges,97% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,107.65,92,,,Percent of total billed charges,92% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,85.11,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,103.69,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,96.2,458.54,,,Fee Schedule,458.54% of CMS RBRVS Fee Schedule,105.31,90,,,percent of total billed charges,90% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,81.91,70,,,percent of total billed charges,70% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,111.16,95,,,percent of total billed charges,95% of total billed charges,20.98,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,41.96,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,100.63,86,,,percent of total billed charges,86% of total billed charges,93.61,80,,,percent of total billed charges,80% of total billed charges,24.03,111,,,Fee Schedule,111% of CMS OPPS Rate,113.5,97,,,percent of total billed charges,97% of total billed charges,105.31,90,,,percent of total billed charges,90% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,113.5,97,,,percent of total billed charges,97% of total billed charges,108.82,93,,,percent of total billed charges,93% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,19.25,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,113.5,97,,,percent of total billed charges,97% of total billed charges,20.98,100,,,Fee Schedule,100% of CMS OPPS Rate ,20.98,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,17.83,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,17.83,113.5,
G0399- Home Sleep Test 3,3430575,CDM,920,RC,G0399,HCPCS,Outpatient,,,788.8,394.40,,709.92,90,,,percent of total billed charges,90% of total Billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,631.04,80,,,Percent of total Billed charges,80% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,709.92,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,765.14,97,,,Percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,725.7,92,,,Percent of total billed charges,92% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,351.1,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,559.73,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,708.98,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,552.16,70,,,percent of total billed charges,70% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,749.36,95,,,percent of total billed charges,95% of total billed charges,132.08,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,264.17,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,678.37,86,,,percent of total billed charges,86% of total billed charges,631.04,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,765.14,97,,,percent of total billed charges,97% of total billed charges,709.92,90,,,percent of total billed charges,90% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,765.14,97,,,percent of total billed charges,97% of total billed charges,733.58,93,,,percent of total billed charges,93% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,765.14,97,,,percent of total billed charges,97% of total billed charges,132.08,100,,,Fee Schedule,100% of CMS OPPS Rate ,132.08,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,112.27,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,112.27,765.14,
G0400 - Home Sleep Test/Type 4 Portable-Unattended,4347086,CDM,510,RC,G0400,HCPCS,Outpatient,,,1414.42,707.21,,1272.98,90,,,percent of total billed charges,90% of total Billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1131.54,80,,,Percent of total Billed charges,80% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1272.98,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1371.99,97,,,Percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,1301.27,92,,,Percent of total billed charges,92% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,676.13,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1077.89,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,1365.32,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,1272.98,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,990.09,70,,,percent of total billed charges,70% of total billed charges,1272.98,90,,,percent of total billed charges,90% of total billed charges,1343.7,95,,,percent of total billed charges,95% of total billed charges,1343.7,95,,,percent of total billed charges,95% of total billed charges,254.36,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,508.73,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,1216.4,86,,,percent of total billed charges,86% of total billed charges,1131.54,80,,,percent of total billed charges,80% of total billed charges,143.02,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,1371.99,97,,,percent of total billed charges,97% of total billed charges,1272.98,90,,,percent of total billed charges,90% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,1371.99,97,,,percent of total billed charges,97% of total billed charges,1315.41,93,,,percent of total billed charges,93% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,1371.99,97,,,percent of total billed charges,97% of total billed charges,254.36,100,,,Fee Schedule,100% of CMS OPPS Rate ,254.36,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,216.21,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,143.02,1371.99,
G0463-EST PATIENT ( formerly LEVEL 3),3400467,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0463-EST PATIENT (formerly LEVEL 1),3400465,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0463-EST PATIENT (formerly LEVEL 2),3400466,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0463-EST PATIENT (formerly LEVEL 4),3400468,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0463-EST PATIENT (formerly LEVEL 5),3400469,CDM,510,RC,G0463,HCPCS,Outpatient,,,238.27,119.14,,214.44,90,,,percent of total billed charges,90% of total Billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,190.62,80,,,Percent of total Billed charges,80% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,214.44,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,231.12,97,,,Percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,219.21,92,,,Percent of total billed charges,92% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,291.77,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,465.16,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,589.2,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,166.79,70,,,percent of total billed charges,70% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,226.36,95,,,percent of total billed charges,95% of total billed charges,109.77,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,219.54,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,204.91,86,,,percent of total billed charges,86% of total billed charges,190.62,80,,,percent of total billed charges,80% of total billed charges,119.85,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,231.12,97,,,percent of total billed charges,97% of total billed charges,214.44,90,,,percent of total billed charges,90% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,231.12,97,,,percent of total billed charges,97% of total billed charges,221.59,93,,,percent of total billed charges,93% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,231.12,97,,,percent of total billed charges,97% of total billed charges,109.77,100,,,Fee Schedule,100% of CMS OPPS Rate ,109.77,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,93.3,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,93.3,589.2,
G0500 - MOD SEDAT ENDO SERVICE >5YRS,3999154,CDM,370,RC,G0500,HCPCS,Outpatient,,,119.22,59.61,,107.3,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,95.38,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,107.3,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,109.68,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,83.45,70,,,percent of total billed charges,70% of total billed charges,107.3,90,,,percent of total billed charges,90% of total billed charges,113.26,95,,,percent of total billed charges,95% of total billed charges,113.26,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102.53,86,,,percent of total billed charges,86% of total billed charges,95.38,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,115.64,97,,,percent of total billed charges,97% of total billed charges,107.3,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,115.64,97,,,percent of total billed charges,97% of total billed charges,110.87,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83.45,115.64,
G6012-RAD TREATMENT DELIVERY 6-10 MEV,3400470,CDM,333,RC,G6012,HCPCS,Outpatient,,,700.45,350.23,,630.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,560.36,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,630.41,90,,,Percent of total Billed charges,90% of total billed charges,186.22,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,644.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.32,70,,,percent of total billed charges,70% of total billed charges,630.41,90,,,percent of total billed charges,90% of total billed charges,665.43,95,,,percent of total billed charges,95% of total billed charges,665.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.39,86,,,percent of total billed charges,86% of total billed charges,560.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,679.44,97,,,percent of total billed charges,97% of total billed charges,630.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,679.44,97,,,percent of total billed charges,97% of total billed charges,651.42,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.29,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169.29,679.44,
G6013-RAD TREATMENT DELIVERY 11-19 MEV,3400471,CDM,333,RC,G6013,HCPCS,Outpatient,,,700.45,350.23,,630.41,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,560.36,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,630.41,90,,,Percent of total Billed charges,90% of total billed charges,209.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,679.44,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,644.41,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,630.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,490.32,70,,,percent of total billed charges,70% of total billed charges,630.41,90,,,percent of total billed charges,90% of total billed charges,665.43,95,,,percent of total billed charges,95% of total billed charges,665.43,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,602.39,86,,,percent of total billed charges,86% of total billed charges,560.36,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,679.44,97,,,percent of total billed charges,97% of total billed charges,630.41,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,679.44,97,,,percent of total billed charges,97% of total billed charges,651.42,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,679.44,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,679.44,
G6014-RAD TREATMENT DELIVERY >20 MEV,3400472,CDM,333,RC,G6014,HCPCS,Outpatient,,,701.64,350.82,,631.48,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,561.31,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,631.48,90,,,Percent of total Billed charges,90% of total billed charges,209.59,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,680.59,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,645.51,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,631.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,491.15,70,,,percent of total billed charges,70% of total billed charges,631.48,90,,,percent of total billed charges,90% of total billed charges,666.56,95,,,percent of total billed charges,95% of total billed charges,666.56,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,603.41,86,,,percent of total billed charges,86% of total billed charges,561.31,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,680.59,97,,,percent of total billed charges,97% of total billed charges,631.48,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,680.59,97,,,percent of total billed charges,97% of total billed charges,652.53,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,680.59,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,190.54,680.59,
AMB alprostadil Charge:2.5 mcg  alprostadil  Inj,3444238,CDM,636,RC,J0270,HCPCS,Outpatient,,,359.08,179.54,,323.17,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,12.2,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,323.17,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,330.35,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,323.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,251.36,70,,,percent of total billed charges,70% of total billed charges,323.17,90,,,percent of total billed charges,90% of total billed charges,341.13,95,,,percent of total billed charges,95% of total billed charges,341.13,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,308.81,86,,,percent of total billed charges,86% of total billed charges,287.26,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,348.31,97,,,percent of total billed charges,97% of total billed charges,323.17,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,348.31,97,,,percent of total billed charges,97% of total billed charges,333.94,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,348.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.2,348.31,
"J0585 - Injection, onabotulinumtoxinA, 1 unit",3430587,CDM,636,RC,J0585,HCPCS,Outpatient,,,38.04,19.02,,34.24,90,,,percent of total billed charges,90% of total Billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,9.56,150,,,Fee Schedule,150% of Fee Schedule Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,34.24,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,36.9,97,,,Percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,35,92,,,Percent of total billed charges,92% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,16.82,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,26.82,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,33.97,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,34.24,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,26.63,70,,,percent of total billed charges,70% of total billed charges,34.24,90,,,percent of total billed charges,90% of total billed charges,36.14,95,,,percent of total billed charges,95% of total billed charges,36.14,95,,,percent of total billed charges,95% of total billed charges,6.33,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,12.66,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,32.71,86,,,percent of total billed charges,86% of total billed charges,30.43,80,,,percent of total billed charges,80% of total billed charges,6.74,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,36.9,97,,,percent of total billed charges,97% of total billed charges,34.24,90,,,percent of total billed charges,90% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,36.9,97,,,percent of total billed charges,97% of total billed charges,35.38,93,,,percent of total billed charges,93% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,36.9,97,,,percent of total billed charges,97% of total billed charges,6.33,100,,,Fee Schedule,100% of CMS OPPS Rate ,6.33,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,5.38,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.38,36.9,
J1212-MUA DIMETHYL SULFOXIDE 50% 50 ML,3430595,CDM,636,RC,J1212,HCPCS,Outpatient,,,269.92,134.96,,242.93,90,,,percent of total billed charges,90% of total Billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,914.96,150,,,Fee Schedule,150% of Fee Schedule Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,242.93,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,261.82,97,,,Percent of total billed charges,97% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,248.33,92,,,Percent of total billed charges,92% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,1812.14,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,681.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,2888.93,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,3659.27,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,242.93,90,,,percent of total billed charges,90% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,188.94,70,,,percent of total billed charges,70% of total billed charges,242.93,90,,,percent of total billed charges,90% of total billed charges,256.42,95,,,percent of total billed charges,95% of total billed charges,256.42,95,,,percent of total billed charges,95% of total billed charges,681.74,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,1363.48,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,232.13,86,,,percent of total billed charges,86% of total billed charges,215.94,80,,,percent of total billed charges,80% of total billed charges,705.59,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,261.82,97,,,percent of total billed charges,97% of total billed charges,242.93,90,,,percent of total billed charges,90% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,261.82,97,,,percent of total billed charges,97% of total billed charges,251.03,93,,,percent of total billed charges,93% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,261.82,97,,,percent of total billed charges,97% of total billed charges,681.74,100,,,Fee Schedule,100% of CMS OPPS Rate ,681.74,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,579.47,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,188.94,3659.27,
J1580-MUA GARAMYCIN GENTAMICIN INJ,3430596,CDM,636,RC,J1580,HCPCS,Outpatient,,,13.44,6.72,,12.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,2.99,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,12.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,12.36,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,9.41,70,,,percent of total billed charges,70% of total billed charges,12.1,90,,,percent of total billed charges,90% of total billed charges,12.77,95,,,percent of total billed charges,95% of total billed charges,12.77,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11.56,86,,,percent of total billed charges,86% of total billed charges,10.75,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,12.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,12.5,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13.04,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2.99,13.04,
"J9030 - Bcg live intravesical instillation, 1 mg",4257722,CDM,636,RC,J9030,HCPCS,Outpatient,,,7.54,3.77,,6.79,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,4.4,150,,,Fee Schedule,150% of Fee Schedule Rate,,,,,Other,Not Separately reimbursable,6.79,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.31,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,6.94,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,5.28,70,,,percent of total billed charges,70% of total billed charges,6.79,90,,,percent of total billed charges,90% of total billed charges,7.16,95,,,percent of total billed charges,95% of total billed charges,7.16,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6.48,86,,,percent of total billed charges,86% of total billed charges,6.03,80,,,percent of total billed charges,80% of total billed charges,3.09,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,7.31,97,,,percent of total billed charges,97% of total billed charges,6.79,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,7.31,97,,,percent of total billed charges,97% of total billed charges,7.01,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7.31,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3.09,7.31,
"Q0091- Screening Pap Smear,Specimen Prep",3431441,CDM,510,RC,Q0091,HCPCS,Outpatient,,,46.38,23.19,,41.74,90,,,percent of total billed charges,90% of total Billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,37.1,80,,,Percent of total Billed charges,80% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,41.74,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,44.99,97,,,Percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,42.67,92,,,Percent of total billed charges,92% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,60.25,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,96.06,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,121.67,536.75,,,Fee Schedule,536.75% of CMS Fee Schedule,41.74,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,32.47,70,,,percent of total billed charges,70% of total billed charges,41.74,90,,,percent of total billed charges,90% of total billed charges,44.06,95,,,percent of total billed charges,95% of total billed charges,44.06,95,,,percent of total billed charges,95% of total billed charges,22.67,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,45.34,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,39.89,86,,,percent of total billed charges,86% of total billed charges,37.1,80,,,percent of total billed charges,80% of total billed charges,23.76,111,,,Fee Schedule,Pays based on 111% of CMS OPPS Rate,44.99,97,,,percent of total billed charges,97% of total billed charges,41.74,90,,,percent of total billed charges,90% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,44.99,97,,,percent of total billed charges,97% of total billed charges,43.13,93,,,percent of total billed charges,93% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,,,,,Other,Not Separately reimbursable,44.99,97,,,percent of total billed charges,97% of total billed charges,22.67,100,,,Fee Schedule,100% of CMS OPPS Rate ,22.67,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,19.26,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,19.26,121.67,
Q0111 Wet mounts w preparations,3428512,CDM,510,RC,Q0111,HCPCS,Outpatient,,,83.24,41.62,,74.92,90,,,percent of total billed charges,90% of total Billed charges,17.3,100,,,Fee Schedule,100% of CMS OPPS Rate,66.59,80,,,Percent of total Billed charges,80% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,74.92,90,,,Percent of total Billed charges,90% of total billed charges,6.56,110,,,Fee Schedule,110% of PA Medicaid Fee Schedule Rate for Hospital,80.74,97,,,Percent of total billed charges,97% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,76.58,92,,,Percent of total billed charges,92% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,70.22,265.81,,,Fee Schedule,265.81% of CMS OPPS Rate,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,85.55,423.75,,,Fee Schedule,423.75% of CMS OPPS Fee Schedule Rate,79.37,100,,,Fee Schedule,Pays based on 100% of BCBS Physician Fee Schedule,74.92,90,,,percent of total billed charges,90% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,58.27,70,,,percent of total billed charges,70% of total billed charges,74.92,90,,,percent of total billed charges,90% of total billed charges,79.08,95,,,percent of total billed charges,95% of total billed charges,79.08,95,,,percent of total billed charges,95% of total billed charges,17.31,100,,,Fee Schedule,Pays based on 100% of CMS OPPS Rate,34.62,200,,,Fee Schedule,Pays based on 200% of CMS OPPS Rate,71.59,86,,,percent of total billed charges,86% of total billed charges,66.59,80,,,percent of total billed charges,80% of total billed charges,16.78,111,,,Fee Schedule,111% of CMS OPPS Rate,80.74,97,,,percent of total billed charges,97% of total billed charges,74.92,90,,,percent of total billed charges,90% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,80.74,97,,,percent of total billed charges,97% of total billed charges,77.41,93,,,percent of total billed charges,93% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,5.96,100,,,Fee Schedule,Pays based on 100% of PA Medicaid Fee Schedule,80.74,97,,,percent of total billed charges,97% of total billed charges,17.31,100,,,Fee Schedule,100% of CMS OPPS Rate ,17.31,100,,,Fee Schedule,100% OF CMS OPPS Fee Schedule Rate,14.71,85,,,Fee Schedule,85% of CMS OPPS Fee Schedule Rate,5.96,85.55,
"Q4101 Apligraf (44), Per sq cm",3436158,CDM,278,RC,Q4101,HCPCS,Outpatient,,,208.64,104.32,,187.78,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,166.91,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,187.78,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,202.38,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,191.95,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,187.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,146.05,70,,,percent of total billed charges,70% of total billed charges,187.78,90,,,percent of total billed charges,90% of total billed charges,198.21,95,,,percent of total billed charges,95% of total billed charges,198.21,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,179.43,86,,,percent of total billed charges,86% of total billed charges,166.91,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,202.38,97,,,percent of total billed charges,97% of total billed charges,187.78,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,202.38,97,,,percent of total billed charges,97% of total billed charges,194.04,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202.38,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146.05,202.38,
"Q4121 Theraskin 7.6cm x 15.2cm (116), Per sq cm",3984944,CDM,278,RC,Q4121,HCPCS,Outpatient,,,156.33,78.17,,140.7,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,125.06,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,140.7,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,151.64,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,143.82,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,109.43,70,,,percent of total billed charges,70% of total billed charges,140.7,90,,,percent of total billed charges,90% of total billed charges,148.51,95,,,percent of total billed charges,95% of total billed charges,148.51,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134.44,86,,,percent of total billed charges,86% of total billed charges,125.06,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,151.64,97,,,percent of total billed charges,97% of total billed charges,140.7,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,151.64,97,,,percent of total billed charges,97% of total billed charges,145.39,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151.64,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109.43,151.64,
Q4124 Oasis Ultra Tri-Layer Wound Matrix 3 x 7 (21) Per sq c,3592974,CDM,278,RC,Q4124,HCPCS,Outpatient,,,523.95,261.98,,471.56,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,419.16,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,471.56,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,508.23,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,482.03,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,471.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,366.77,70,,,percent of total billed charges,70% of total billed charges,471.56,90,,,percent of total billed charges,90% of total billed charges,497.75,95,,,percent of total billed charges,95% of total billed charges,497.75,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,450.6,86,,,percent of total billed charges,86% of total billed charges,419.16,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,508.23,97,,,percent of total billed charges,97% of total billed charges,471.56,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,508.23,97,,,percent of total billed charges,97% of total billed charges,487.27,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,508.23,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,366.77,508.23,
"Q4124 Oasis Ultra Tri-Layer Wound Matrix 5 x 7 (35), Per sq",3592966,CDM,278,RC,Q4124,HCPCS,Outpatient,,,285.77,142.89,,257.19,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,228.62,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,257.19,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,277.2,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,262.91,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,257.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,200.04,70,,,percent of total billed charges,70% of total billed charges,257.19,90,,,percent of total billed charges,90% of total billed charges,271.48,95,,,percent of total billed charges,95% of total billed charges,271.48,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,245.76,86,,,percent of total billed charges,86% of total billed charges,228.62,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,277.2,97,,,percent of total billed charges,97% of total billed charges,257.19,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,277.2,97,,,percent of total billed charges,97% of total billed charges,265.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,277.2,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,200.04,277.2,
"Q4159 Affinity fresh amniotic 1.5x1.5cm (3), Per sq cm",4223262,CDM,278,RC,Q4159,HCPCS,Outpatient,,,4320,2160.00,,3888,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,3456,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,3888,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4190.4,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,3974.4,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3888,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,3024,70,,,percent of total billed charges,70% of total billed charges,3888,90,,,percent of total billed charges,90% of total billed charges,4104,95,,,percent of total billed charges,95% of total billed charges,4104,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3715.2,86,,,percent of total billed charges,86% of total billed charges,3456,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,4190.4,97,,,percent of total billed charges,97% of total billed charges,3888,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,4190.4,97,,,percent of total billed charges,97% of total billed charges,4017.6,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4190.4,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3024,4190.4,
Q4196 Puraply AM 3.02 x 3.02 (10) per sq cm,4363618,CDM,278,RC,Q4196,HCPCS,Outpatient,,,989,494.50,,890.1,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,791.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,890.1,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,959.33,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,909.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,890.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,692.3,70,,,percent of total billed charges,70% of total billed charges,890.1,90,,,percent of total billed charges,90% of total billed charges,939.55,95,,,percent of total billed charges,95% of total billed charges,939.55,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,850.54,86,,,percent of total billed charges,86% of total billed charges,791.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,959.33,97,,,percent of total billed charges,97% of total billed charges,890.1,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,959.33,97,,,percent of total billed charges,97% of total billed charges,919.77,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,959.33,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,692.3,959.33,
Q4197 Puraply XT 4.91x4.91 (25) per sq cm,4363619,CDM,278,RC,Q4197,HCPCS,Outpatient,,,1064,532.00,,957.6,90,,,percent of total billed charges,90% of total Billed charges,,,,,Other,Not Separately reimbursable,851.2,80,,,Percent of total Billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,957.6,90,,,Percent of total Billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1032.08,97,,,Percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,978.88,92,,,Percent of total billed charges,92% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,957.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,744.8,70,,,percent of total billed charges,70% of total billed charges,957.6,90,,,percent of total billed charges,90% of total billed charges,1010.8,95,,,percent of total billed charges,95% of total billed charges,1010.8,95,,,percent of total billed charges,95% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.04,86,,,percent of total billed charges,86% of total billed charges,851.2,80,,,percent of total billed charges,80% of total billed charges,,,,,Other,Not Separately reimbursable,1032.08,97,,,percent of total billed charges,97% of total billed charges,957.6,90,,,percent of total billed charges,90% of total billed charges,,,,,Other,Not Separately reimbursable,1032.08,97,,,percent of total billed charges,97% of total billed charges,989.52,93,,,percent of total billed charges,93% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1032.08,97,,,percent of total billed charges,97% of total billed charges,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,744.8,1032.08,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,505252.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,366006.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,462835.07,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,430066.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,342544.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,447081.37,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,171272.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,145581.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,145581.25,505252.58,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,228764.59,295,MS-DRG,,case rate,295% Medicare MS-DRG,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,285245.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,360708.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,335170.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,155094.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,202007.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,77547.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,65915.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,65915.22,360708.26,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,397700.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,262388.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,331804.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,308313.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,269627.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,351749.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,134813.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,114591.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,114591.69,397700.56,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,274476.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,177557.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,224531.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,208634.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,186085.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,242525.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,93042.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,79086.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,79086.42,274476.41,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,193509.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,195910.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,247739.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,230199.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,131192.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,170757.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,65596.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,55756.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,55756.99,247739.72,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,90893.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,89768.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,113516.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,105479.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,61622.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,79800.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,30811.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,26189.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,26189.72,113516.59,
LUNG TRANSPLANT,7,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,229179.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,207838.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,262822.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,244215.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,155376.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,202374.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,66034.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,66034.82,262822.84,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,98800.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,102637.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,129791.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,120602.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,66983.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,86809.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,33491.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,28467.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,28467.98,129791.12,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,90460.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,72809.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,92071.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,85552.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,61328.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,79416.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,30664.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,26064.77,85,MS-DRG,,case rate,85% Medicare MS-DRG,26064.77,92071.39,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,96838.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,74637.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,94382.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,87700.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,65653.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,85070.29,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32826.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,27902.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,27902.7,96838.79,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,75407.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,59826.53,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,75653.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,70297.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,51123.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,66074.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,25561.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,21727.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,21727.64,76326.16,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,50853.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,47390.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,59927.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,55684.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,34476.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,44309.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,17238.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,14652.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,14652.66,79682.37,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,214186.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,137704.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,174135.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,161806.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,145211.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,189085.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,72605.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,61714.85,85,MS-DRG,,case rate,85% Medicare MS-DRG,61714.85,214186.82,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,115837.18,295,MS-DRG,,case rate,295% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,65780.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,83183.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,77294.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,78533.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,101910.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,33376.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,33376.81,115837.18,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,115837.18,295,MS-DRG,,case rate,295% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,45750.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,57854.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,53758.35,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,78533.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,101910.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,39266.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,33376.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,33376.81,115837.18,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,686620.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,703390.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,889475.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,826501.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,465505.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,607842.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,232752.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,197839.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,197839.74,889475.41,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,149647.84,295,MS-DRG,,case rate,295% Medicare MS-DRG,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,101456.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,131879.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,50728.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,43118.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,43118.87,149647.84,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,158189.35,295,MS-DRG,,case rate,295% Medicare MS-DRG,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,155266.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,196342.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,182441.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,107247.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,139450.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,53623.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,45579.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,45579.98,196342.72,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,115174.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,136875.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,173086.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,160832.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,78084.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,101322.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,39042.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,33185.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,33185.88,173086.59,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,73877.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,92688.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,117209.93,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,108911.58,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,50086.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,57359.71,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,25043.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,21286.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,21286.81,117209.93,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,106377.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,85679.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,108345.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,100675.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,72120.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,93525.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,36060.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,30651.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,30651.28,139776.42,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,71385.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,58168.34,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,73557.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,68349.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,48396.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,62508.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,24198.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,20568.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,20568.68,196138.01,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,83059.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,60881.73,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,76988.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,71537.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,56311.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,72856.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,28155.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,23932.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,23932.41,83059.55,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,55830.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,43696.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,55257.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,51344.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,37851.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,48721.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,18925.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,16086.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,16086.75,55830.49,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,46147.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,35519.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,44915.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,41735.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,31286.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,40138.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,15643.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,13296.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,13296.86,46147.94,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,113028.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,78688.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,99505.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,92460.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,76629.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,99420.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,38314.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,32567.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,32567.52,113028.45,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,64673.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,41586.5,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,52588.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,48865.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,43846.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,56559.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,21923.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,18634.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,18634.75,64673.53,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,44027.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,25852.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32692.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30377.45,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,29849.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,38259.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,14924.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,12686,85,MS-DRG,,case rate,85% Medicare MS-DRG,12686,44027.89,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,77486.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,50254.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,63549.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,59050.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,52533.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,67916.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,26266.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,22326.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,22326.7,77486.79,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,40953.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,30035.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,37981.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35292.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,27764.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,35534.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,13882.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,11800.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,11800.03,40953.05,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,31071.35,295,MS-DRG,,case rate,295% Medicare MS-DRG,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,26606.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,33645.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31263.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,21065.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,26775.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10532.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,8952.76,85,MS-DRG,,case rate,85% Medicare MS-DRG,8952.76,33645.14,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,73481.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,72771.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,92023.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,85508.54,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,49817.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,64366.55,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24908.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,21172.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,21172.56,92023.74,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,43664.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,39344.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,49752.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,46230.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,29603.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,37937.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,14801.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,12581.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,12581.43,49752.86,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,34520.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,26606.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,33645.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31263.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,23403.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,29832.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,11701.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,9946.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,9946.54,34520.34,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,63694.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,51252.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,64812.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,60223.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,43182.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,55691.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,21591.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,18352.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,18352.65,64812.16,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,30643.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,28660.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,36242.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33676.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,20775.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,26395.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,10387.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,8829.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,8829.4,36242.39,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,22101.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,19766.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,24995.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23225.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,14984.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,18824.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,7492.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,6368.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,6368.29,24995.57,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,72533.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,50781.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,64216.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,59670,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,49175.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,63526.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,24587.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,20899.58,85,MS-DRG,,case rate,85% Medicare MS-DRG,20899.58,72533.83,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,42384.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,34934.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,44177.11,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,41049.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,28735.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,36802.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,14367.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,12212.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,12212.45,58071.64,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,33247.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,23214.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,29356.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27277.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,22540.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,28703.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,11270.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9579.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,9579.71,72583.44,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,37057.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,32749.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,41413.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38481.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,25123.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,32080.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,12561.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,10677.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,10677.53,54575.02,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19175.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19483.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,24638.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22893.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,13000.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,16231.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5525.21,85,MS-DRG,,case rate,85% Medicare MS-DRG,5525.21,68655.36,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,28290.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,16826.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,21278.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19771.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,19180.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,24310.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,9590.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,8151.51,85,MS-DRG,,case rate,85% Medicare MS-DRG,8151.51,88060.69,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,20839.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,14056.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,17775.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16517.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,14128.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,17706,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,7064.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,6004.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,6004.67,20839.74,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,45423.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,32165,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,40674.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37794.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,30795.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,39496.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,15397.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,13088.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,13088.23,45423.86,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,26237.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,19577.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,24757.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23004.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,17788.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,22490.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,8894.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,7559.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,7559.96,26237.51,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,33025.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,32711.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,41365.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38436.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,22390.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,28507.45,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11195.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9515.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,9515.88,41365.41,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,22961.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,15809.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,19991.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18576.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,15567.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,19586.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,7783.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,6616.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,6616.06,22961.62,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,17567.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,13755.39,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,17394.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16162.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,11910.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,14805.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,5955.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,5061.84,85,MS-DRG,,case rate,85% Medicare MS-DRG,5061.84,17567.55,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,53032.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,50254.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,63549.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,59050.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,35954.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,46241.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,17977.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,15280.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,15280.67,75561.04,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,35702.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,36894.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,46655.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43352.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,24204.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,30879.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,12102.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,10287.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,10287.09,77495.9,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,28538.12,295,MS-DRG,,case rate,295% Medicare MS-DRG,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,34482.69,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,43605.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40518.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,19347.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,24529.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,9673.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,8222.85,85,MS-DRG,,case rate,85% Medicare MS-DRG,8222.85,85488.51,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,38146.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,29526.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,37338.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34694.95,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,25861.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,33046.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,12930.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,10991.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,10991.28,122726.36,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,19782.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,18579.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,23494.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21831.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,13411.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,16768.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,6705.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,5700.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,5700.05,23494.41,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,13660.65,295,MS-DRG,,case rate,295% Medicare MS-DRG,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,15187.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,19205.37,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17845.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,9261.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,11342.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,4630.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,3936.12,85,MS-DRG,,case rate,85% Medicare MS-DRG,3936.12,19205.37,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,27237.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,27058.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,34217.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31794.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,18465.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,23376.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,9232.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,7847.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,7847.96,34217.01,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,17076.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,15319.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,19372.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18000.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,11577.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,14370.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5788.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,4920.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,4920.25,19372.16,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,15730.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13510.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,17084.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15875.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,10664.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,13177.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,4532.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,4532.5,17084.68,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,34172.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,24571.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,31071.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28871.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,23167.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,29523.74,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,11583.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,9846.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,9846.25,34172.27,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,20627.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,16638.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,21040.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19550.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,13984.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,17517.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,6992.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,5943.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,5943.53,80017.59,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,15438.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,12455.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,15750.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14635.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,10466.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,12918.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,5233.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,4448.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,4448.31,87171.75,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,29025.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,27755.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,35098.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32613.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19678.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,24961.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9839.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,8363.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,8363.36,120173.11,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,19964.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,14490.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,18323.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17026.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,13535.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,16930.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,6767.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,5752.6,85,MS-DRG,,case rate,85% Medicare MS-DRG,5752.6,186787.93,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,36485.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,15526.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,19634.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18244.18,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,24736.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,31574.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12368.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,10512.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,10512.89,36485.92,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,18034.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,11305.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,14296.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13284.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,12226.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,15219.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6113.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,5196.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,5196.45,18034.74,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,28986.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,29074.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,36766.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34163.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,19651.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,24927.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9825.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,8352.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,8352.09,36766.6,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,19791.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,18108.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,22898.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21277.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,13418.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,16777.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,6709.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5702.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,5702.73,22898.71,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,14652.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,13793.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,17442.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16207.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,9934.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,12221.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4967.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4221.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,4221.98,17442.1,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,41974.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,36404.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,46035.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42776.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,28457.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,36439.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,14228.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,12094.46,85,MS-DRG,,case rate,85% Medicare MS-DRG,12094.46,46035.7,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,17792.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,15036.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,19014.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17668.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,12062.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,15005.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,6031.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,5126.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,5126.72,40422.91,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,43270.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,36140.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,45702.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42466.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,29335.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,37588.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,14667.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,12467.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,12467.72,47969.07,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,26110.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,21801.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,27569,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25617.14,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,17702.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,22378.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,8851.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,7523.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,7523.5,62879.99,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,17982.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,14226.47,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,17990.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16716.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,12191.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,15173.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,6095.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,5181.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,5181.43,99870.95,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,43167.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,29866.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,37767.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35093.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,29266.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,37497.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,14633.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,12438.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,12438.23,43167.97,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,25379.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,17109.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,21635.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20104.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,17206.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,21729.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,8603.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,7312.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,7312.73,25379.47,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,17359.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,11569.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,14630.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13594.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,11768.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,14620.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,5884.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,5001.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,5001.78,17359.13,
CONCUSSION WITH MCC,88,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,29412.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,25777.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,32596.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30288.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,19940.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,25305.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,9970.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,8474.91,85,MS-DRG,,case rate,85% Medicare MS-DRG,8474.91,32596.7,
CONCUSSION WITH CC,89,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,22267.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,15036.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,19014.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17668.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,15096.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,18971.42,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,7548.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,6416.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,6416.02,22267.37,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,18263.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,12021.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,15202.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14125.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,12382.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,15422.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,6191.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,5262.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,5262.41,18263.66,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,34166.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,24043.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,30404.53,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28251.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,23163.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,29518.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,11581.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,9844.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,9844.65,51008.99,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,19963.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,17241.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,21802.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20259.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,13534.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,16928.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,6767.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,5752.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,5752.06,56676.31,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,15278.17,295,MS-DRG,,case rate,295% Medicare MS-DRG,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,13340.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,16870.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15675.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,10358.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,12776.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5179.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4402.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,4402.18,80058.61,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,68293.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,47974.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,60666.09,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,56370.99,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,46300.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,59768.46,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,23150.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,19677.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,19677.87,141263.25,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,45241.5,295,MS-DRG,,case rate,295% Medicare MS-DRG,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,39871.79,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,50420.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,46850.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,30672.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,39335.29,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,15336.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,13035.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,13035.69,50420.05,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,41435.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,36574.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,46250.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42975.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,28091.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,35961.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,14045.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,11938.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,11938.93,46250.15,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,68558.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,65121.41,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,82349.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,76519.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,46480.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,60002.74,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,23240.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,19754.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,19754.03,82349.57,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,40966.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,24345.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,30785.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28606.17,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,27773.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,35545.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,13886.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,11803.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,11803.78,40966.06,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,25437.17,295,MS-DRG,,case rate,295% Medicare MS-DRG,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,17241.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,21802.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20259.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,17245.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,21781.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,8622.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,7329.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,7329.35,25437.17,
SEIZURES WITH MCC,100,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,37764.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,24514.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,31000.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28805.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,25603.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,32707.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12801.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,10881.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,10881.33,37764.6,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,17794.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,10928.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,13820.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12841.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,12064.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,15006.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,6032.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,5127.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,5127.27,17794.64,
HEADACHES WITH MCC,102,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,23322.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,15809.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,19991.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18576.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,15812,200,MS-DRG,,case rate,200% Medicare MS-DRG,19906.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,7906,100,MS-DRG,,case rate,100% Medicare MS-DRG,6720.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,6720.1,23322.7,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,16543.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,11701.5,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,14797.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13749.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,11216.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,13898.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,5608.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,4766.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,4766.86,16543.81,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,47532.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,41115.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,51992.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,48311.66,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,32225.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,41366.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,16112.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,13695.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,13695.87,51992.7,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,23791.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,25061.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,31691.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29447.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,16130,200,MS-DRG,,case rate,200% Medicare MS-DRG,20322.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,8065,100,MS-DRG,,case rate,100% Medicare MS-DRG,6855.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,6855.25,31691.24,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,29982.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,26380.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,33359.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30997.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,20327.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,25809.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,10163.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,8639.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,8639.02,33359.2,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,34941.01,295,MS-DRG,,case rate,295% Medicare MS-DRG,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,34294.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,43366.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40296.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,23688.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,30205.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,11844.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,10067.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,10067.75,43366.96,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,23170.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,19427.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,24566.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22827.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,15708.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,19771.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,7854.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,6676.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,6676.13,24566.67,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,24711.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,15149.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,19157.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17801.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,16753.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,21137.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,8376.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,7120.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,7120.2,24711.27,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,14721.59,295,MS-DRG,,case rate,295% Medicare MS-DRG,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,8969.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,11342.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10539.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,9980.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,12283,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,4990.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,4241.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,4241.81,14721.59,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,15829.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,13453.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,17013.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15808.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,10731.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,13264.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,5365.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,4560.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,4560.93,17013.19,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,25468.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,25777.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,32596.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30288.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,17267,200,MS-DRG,,case rate,200% Medicare MS-DRG,21809.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,8633.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,7338.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,7338.48,32596.7,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,15708.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10495.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,13272.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12332.54,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10649.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,13157.41,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,5324.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,4526.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,4526.07,15708.13,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,50227.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,41247.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,52159.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,48466.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,34052.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,43755.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,17026.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,14472.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,14472.45,52159.49,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,20301.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,23026.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,29117.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27056.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,13763.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,15493.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6881.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,5849.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,5849.67,29117.82,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,28871.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,14980.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,18943.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17602.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,19573.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,24825.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,9786.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,8318.84,85,MS-DRG,,case rate,85% Medicare MS-DRG,8318.84,28871.27,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,16977.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,13680.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,17299.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16074.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11510.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,14282.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5755.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,4891.83,85,MS-DRG,,case rate,85% Medicare MS-DRG,4891.83,17299.13,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,22970.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,22498.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,28450.63,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26436.35,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,15573.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,19595.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,7786.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,6618.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,6618.75,28450.63,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,71186.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,75013.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,94859.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,88143.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,48261.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,62332.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,24130.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20511.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,20511.29,94859.27,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,39424.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,32051.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,40531.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37661.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,26728.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,34179.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,13364.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,11359.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,11359.71,40531.43,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,29621.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,28547.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,36099.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33543.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,20082.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,25489.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,10041.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,8534.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,8534.97,36099.42,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,62763.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,55850.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,70626.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,65625.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,42551.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,54866.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,21275.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,18084.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,18084.49,70626.19,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,33074.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,18598.04,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,23518.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21853.17,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,22423.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,28550.34,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,11211.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,9529.83,85,MS-DRG,,case rate,85% Medicare MS-DRG,9529.83,33074.13,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,23592.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,13453.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,17013.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15808.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,15994.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,20146.1,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,7997.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,6797.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,6797.87,23592.6,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,40156.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,36366.99,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,45988.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42732.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,27224.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,34827.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,13612.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,11570.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,11570.48,45988.04,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,23866.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,18221.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,23041.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21410.35,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,16180.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,20388.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8090.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,6876.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,6876.7,23866.21,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,17424.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,14452.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,18276.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16982.15,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,11813.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,14678.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5906.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5020.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,5020.55,18276.08,
DYSEQUILIBRIUM,149,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,14725.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,11211.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,14177.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13173.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,9983.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,12286.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4242.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,4242.89,14725.31,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,25331.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,24853.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,31429.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29203.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,17173.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,21687.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,8586.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,7298.79,85,MS-DRG,,case rate,85% Medicare MS-DRG,7298.79,31429.13,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,15209.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,10627.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,13438.99,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12487.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,10311.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,12715.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,5155.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,4382.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,4382.33,15209.26,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,22980.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,14678.7,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,18562.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17247.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,15579.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,19603.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,7789.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,6621.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,6621.43,22980.26,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,14541.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,7273.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9197.61,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,8546.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9858.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,12122.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,4929.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,4189.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,4189.81,14541.11,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,29494.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,24703.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,31238.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29026.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,19996.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,25377.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,9998.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8498.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,8498.5,31238.51,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,18483.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,10005.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,12652.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11756.87,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,12531.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,15617.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,6265.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,5325.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,5325.7,18483.31,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,13065.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,8385.14,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,10603.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9852.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,8857.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,10814.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,4428.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,3764.51,85,MS-DRG,,case rate,85% Medicare MS-DRG,3764.51,13065.08,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,32636.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,29187.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,36909.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34296.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,22126.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,28162.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,11063.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,9403.8,85,MS-DRG,,case rate,85% Medicare MS-DRG,9403.8,36909.57,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,18332.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,11079.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,14010.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13018.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,12428.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,15483.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,6214.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,5282.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,5282.27,18332.57,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,13431.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8083.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,10222.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9498.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,9106.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,11139.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,4553.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,3870.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,3870.16,13431.73,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,88598.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,65667.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,83040.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,77161.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,60066.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,77766.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,30033.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,25528.46,85,MS-DRG,,case rate,85% Medicare MS-DRG,25528.46,88598.77,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,48334.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,36913.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,46679.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43374.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,32769.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,42077.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,16384.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,13927.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,13927.02,48334.95,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,35789.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,28490.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,36027.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33477.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,24264.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,30957.45,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12132.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,10312.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,10312.29,36027.94,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,76392.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,49142.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,62143.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,57743.73,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,51791.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,66946.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,25895.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,22011.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,22011.35,76392.34,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,34736.25,295,MS-DRG,,case rate,295% Medicare MS-DRG,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,27793.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,35146.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32657.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,23550,200,MS-DRG,,case rate,200% Medicare MS-DRG,30023.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,11775,100,MS-DRG,,case rate,100% Medicare MS-DRG,10008.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,10008.75,35146.3,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,26097.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,20746.14,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,26234.63,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24377.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,17693.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,22366.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,8846.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,7519.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,7519.74,26234.63,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,58099.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,39389.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,50732.33,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,19694.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,16740.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,16740.5,58099.39,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,26978.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,20651.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,26115.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24266.54,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,18290.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,23147.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9145.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,7773.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,7773.41,26978.31,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,16045.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,12210.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,15440.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14347.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,10877.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,13456.03,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5438.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,4623.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,4623.14,16045.02,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,32439.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,24213.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,30618.98,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28451.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,21992.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,27987.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,10996.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9346.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,9346.95,32439.41,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,19229.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,18579.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,23494.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21831.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,13037.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,16278.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,6518.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,5540.76,85,MS-DRG,,case rate,85% Medicare MS-DRG,5540.76,23494.41,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,15071.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,13001.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,16441.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15277.29,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,10218,200,MS-DRG,,case rate,200% Medicare MS-DRG,12593.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,5109,100,MS-DRG,,case rate,100% Medicare MS-DRG,4342.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,4342.65,16441.32,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,33217.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,25419.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,32143.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29868.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,22520.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,28677.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11260.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9571.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,9571.13,33217.44,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,21359.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,17297.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,21874.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20325.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,14480.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,18166.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,7240.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,6154.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,6154.31,21874.1,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,15732.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,14999.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,18967.09,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17624.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10665.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,12522.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4533.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,4533.03,18967.09,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,30170.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,21462.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,27140.09,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25218.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,20454.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,25976.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,10227.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,8693.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,8693.19,30170.48,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,20443.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,15828.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,20015.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18598.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,13859.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,17354.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,6929.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,5890.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,5890.42,20443.23,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,14930.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,12210.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,15440.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14347.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,10122.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,12467.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5061.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4301.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,4301.88,15440.54,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,29753.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20388.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,25781.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23956.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20171.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,25607.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,10085.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,8573.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,8573.04,29753.49,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,19408.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,15960.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,20182.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18753.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,13158.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,16437.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6579.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,5592.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,5592.25,20182.32,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,14758.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,11098.53,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,14034.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13041.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,10005.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,12316,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5002.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,4252.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,4252.54,14758.82,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,23795.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,17015.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,21516.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19993.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,16132.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,20325.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,8066.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,6856.34,85,MS-DRG,,case rate,85% Medicare MS-DRG,6856.34,23795.53,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,21375.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,14980.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,18943.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17602.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,14492.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,18181.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,7246.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,6159.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,6159.13,21375.82,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,16666.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,12605.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,15940.93,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14812.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,11299.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,14007.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5649.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,4802.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,4802.26,16666.67,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,12810.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,10194.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,12890.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11978.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,8684.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,10588.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,4342.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,3691.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,3691.02,12890.95,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,25556.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,18164.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,22970.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21343.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,17326.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,21886.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8663.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,7363.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,7363.66,25556.23,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,16167.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,11739.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,14844.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13793.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,10961.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,13564.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,5480.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4658.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,4658.54,16167.86,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,12508.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,8630.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,10913.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10140.58,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,8480.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,10321.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,4240.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,3604.15,85,MS-DRG,,case rate,85% Medicare MS-DRG,3604.15,12508.53,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,36143.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,24533.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,31024.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28827.58,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,24504,200,MS-DRG,,case rate,200% Medicare MS-DRG,31270.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,12252,100,MS-DRG,,case rate,100% Medicare MS-DRG,10414.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,10414.2,36143.4,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,19430.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,16977.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,21469.03,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19949.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,13173.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,16457.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,6586.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,5598.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,5598.68,21469.03,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,15348.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,13717.7,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,17346.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16118.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,10406,200,MS-DRG,,case rate,200% Medicare MS-DRG,12838.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,5203,100,MS-DRG,,case rate,100% Medicare MS-DRG,4422.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,4422.55,17346.78,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,33885.65,295,MS-DRG,,case rate,295% Medicare MS-DRG,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,21141.85,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,26735.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24842.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,22973.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,29269.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,11486.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,9763.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,9763.66,33885.65,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,20910.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,14697.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,18585.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17269.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,14176.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,17768.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,7088.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,6025.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,6025.06,20910.49,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,14006.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,8592.41,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,10865.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10096.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,9496.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,11649.46,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,4748.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,4035.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,4035.89,19985.07,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,18686.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,11795.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,14916.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13860.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,12668.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,15797.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6334.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,5384.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,5384.16,24518.14,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,13798.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,7574.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,9578.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,8900.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,9354.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,11464.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,4677.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,3975.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,3975.82,31642.31,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,16180.84,295,MS-DRG,,case rate,295% Medicare MS-DRG,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,11776.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,14892.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13838.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,10970.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,13576.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,5485.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4662.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,4662.28,52817.64,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,34559.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,20821.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,26329.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24465.81,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,23430.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,29866.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,11715.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,9957.8,85,MS-DRG,,case rate,85% Medicare MS-DRG,9957.8,34559.43,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,17867.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,11795.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,14916.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13860.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,12113.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,15071.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,6056.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,5148.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,5148.19,17867.24,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,129443.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,90484.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,114422.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,106321.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,87758.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,113970.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,43879.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,37297.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,37297.22,129443.29,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,51190.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,34840.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,44057.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40938.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,34705.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,44608.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,17352.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,14749.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,14749.72,51190.2,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,201340.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,136501.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,177698.46,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,68250.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,58013.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,23268.01,201340.04,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,190993.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,142132.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,179734.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,167009.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,129486.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,168527.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,64743.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,55031.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,55031.89,190993.03,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,181509.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,127849.76,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,161672.98,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,150226.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,123057.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,160121.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,61528.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,52299.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,52299.4,181509.69,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,119342.01,295,MS-DRG,,case rate,295% Medicare MS-DRG,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,81872.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,103532.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,96202.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,80909.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,105016.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,40454.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,34386.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,34386.68,119342.01,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,106897.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,67872.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,85828.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,79751.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,72472.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,93985.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,36236.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,30800.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,30800.92,106897.32,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,144393.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,98341.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,124358.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,115553.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,97893.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,127221.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,48946.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,41604.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,41604.87,144393.38,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,98482.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,75824.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,95883.87,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,89095.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,66767.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,86527.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,33383.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,28376.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,28376.26,98482.33,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,87388.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,58582.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,74081.25,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,68836.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,59246.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,76694.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,29623.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,25179.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,10517.89,87388.91,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,94649.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,109930.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,139012.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,129170.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,64169.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,83130.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,32084.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,27272.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,27272.01,139012.55,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,60046.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,66082.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,83564.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,77648.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,40709.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,52458.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,20354.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,17301.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,17301.49,83564.8,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,151913.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,127039.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,160648.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,149274.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,102991.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,133887.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,51495.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,43771.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,12429.59,160648.38,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,111585.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,93687.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,118472.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,110085.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,75651.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,98141.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,37825.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,32151.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,16640.9,118472.82,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,146038.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,97248.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,122976.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,114269.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,99009.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,128680.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,49504.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,42078.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,29015.99,146038.78,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,97613.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,75937.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,96026.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,89228.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,66178.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,85756.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,33089.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,28125.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,28125.81,97613.11,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,110320.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,73808.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,93334.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,86726.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,74793.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,97020.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,37396.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,31787.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,31787.19,110320.24,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,76083.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,57207.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,72341.81,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,67220.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,51581.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,66673.01,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,25790.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,21922.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,21922.33,76083.39,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,90333.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,66289.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,83826.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,77892.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,61243.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,79304.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,30621.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,26028.3,85,MS-DRG,,case rate,85% Medicare MS-DRG,26028.3,90333.51,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,53152.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,37196.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,47036.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43706.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,36035.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,46347.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,18017.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,15314.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,15314.99,53152.04,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,26810.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,29319.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,37076.37,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34451.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,18176.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,22929.37,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9088.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,7725.15,85,MS-DRG,,case rate,85% Medicare MS-DRG,7725.15,37076.37,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,65174.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,53589.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,67766.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,62969,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,44185.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,57003.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,22092.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,18779.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,10249.7,67766.83,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,43257.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,38929.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,49228.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45743.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,29327,200,MS-DRG,,case rate,200% Medicare MS-DRG,37576.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14663.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,12463.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,12463.98,49228.65,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,34916.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,36046.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,45582.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42355.73,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,23672.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,30183.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11836.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,10060.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,10060.78,45582.96,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,85207.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,94855.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,119950.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,111457.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,57767.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,74760.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,28883.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24551.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,24551.31,119950.15,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,44619.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,36913.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,46679.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43374.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,30250.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,38784.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,15125.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,12856.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,12856.56,46679.05,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,30401.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,30789.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,38934.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36178.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,20611.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,26181.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,10305.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,8759.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,8759.69,38934.95,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,63288.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,60297.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,76249.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,70851.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,42907.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,55332.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,21453.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,18235.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,18235.72,76249.6,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,48347.99,295,MS-DRG,,case rate,295% Medicare MS-DRG,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,42057.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,53184.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,49418.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,32778.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,42088.86,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,16389.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13930.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,13930.78,53184.1,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,33159.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,30243.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,38243.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35536.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,22481.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,28626.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,11240.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,9554.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,9554.49,38243.94,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,52001.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,34445,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,43557.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40473.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,35255.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,45327.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,17627.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,14983.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,14983.56,52001.77,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,31384.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,21424.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,27092.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25174.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,21277.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,27052.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,10638.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,9042.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,9042.87,31384.08,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,19309.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,15262.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,19300.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17934.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,13091.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,16349.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,6545.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,5563.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,5563.81,19309.7,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,51279.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,58790.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,74343.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,69079.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,34765.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,44687.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,17382.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,14775.47,85,MS-DRG,,case rate,85% Medicare MS-DRG,14775.47,74343.36,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,35607.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,39476.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,49919.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,46385.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,24140.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,30795.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12070.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10259.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,10259.75,49919.66,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,62570.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,53532.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,67695.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,62902.58,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,42420.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,54695.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,21210.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,18028.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,18028.72,67695.35,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,35890.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,28999.38,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,36671.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34075,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,24332.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,31046.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,12166.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,10341.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,10341.26,36671.29,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,31488.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,23572.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,29808.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27698.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,21347.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,27144.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,10673.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9072.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,9072.89,31488.27,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,53449.87,295,MS-DRG,,case rate,295% Medicare MS-DRG,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,43470.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,54971.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,51079.29,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,36237.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,46611.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,18118.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,15400.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,15400.81,54971.2,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,61654.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,35462.53,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,44844.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,41669.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,41799.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,53883.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,20899.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,17764.85,85,MS-DRG,,case rate,85% Medicare MS-DRG,17764.85,61654.47,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,66644.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,61371.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,77607.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,72113.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,45182.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,58306.71,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,22591.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,19202.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,19202.7,77607.8,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,117123.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,103033.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,130291.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,121066.99,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,79405.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,103050.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,39702.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,33747.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,33747.4,130291.5,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,91699.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,83794.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,105963.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,98461.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,62169.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,80515.1,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,31084.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,26421.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,26421.95,105963.12,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,128451.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,113642.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,143706.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,133532.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,87085.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,113091.03,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,43542.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,37011.38,85,MS-DRG,,case rate,85% Medicare MS-DRG,37011.38,143706.67,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,78268.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,55888.34,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,70673.85,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,65670.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,53063.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,68609.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,26531.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,22551.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,22551.94,78268.49,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,94988.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,69134.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,87424.93,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,81235.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,64399.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,83430.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,32199.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,27369.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,27369.61,94988.64,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,65194.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,55549.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,70244.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,65271.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,44199.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,57021.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,22099.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,18784.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,13294.37,70244.94,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,46270.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,43527.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,55042.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,51145.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,31370.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,40247.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,15685.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,13332.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,13332.26,55042.68,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,73399.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,71433.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,90331.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,83936.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,49762.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,64293.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,24881.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,21148.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,21148.96,90331.95,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,61185.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,51384.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,64978.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,60378.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,41481.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,53467.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,20740.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17629.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,17629.71,64978.96,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,131822.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,89370.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,116078.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,44685.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,37982.63,85,MS-DRG,,case rate,85% Medicare MS-DRG,37982.63,131822.08,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,116455.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,78952.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,102457.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,39476.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,33554.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,33554.86,116455.09,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,89879.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,60935.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,78901.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,30467.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,25897.44,85,MS-DRG,,case rate,85% Medicare MS-DRG,25897.44,89879.36,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,83885.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,56871.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,73589.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,28435.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,24170.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,24170.53,83885.96,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,60437.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,40974.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,52804.52,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,20487.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,17414.11,85,MS-DRG,,case rate,85% Medicare MS-DRG,17414.11,60437.21,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,30393.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,23365.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,29546.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27454.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,20606,200,MS-DRG,,case rate,200% Medicare MS-DRG,26174.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,8757.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,8757.55,30393.85,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,17857.88,295,MS-DRG,,case rate,295% Medicare MS-DRG,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,15470.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,19562.79,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18177.76,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,12107.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,15062.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,6053.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,5145.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,5145.49,19562.79,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,14230.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,14094.56,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,17823.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16561.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,9647.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,11847.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,4823.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,4100.24,85,MS-DRG,,case rate,85% Medicare MS-DRG,4100.24,17823.34,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,37558.01,295,MS-DRG,,case rate,295% Medicare MS-DRG,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,37422.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,47322.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43972.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,25463.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,32524.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,12731.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,10821.8,85,MS-DRG,,case rate,85% Medicare MS-DRG,10821.8,47322.41,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,14632.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,13943.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,17632.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16384.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,9920.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,12203.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,4960.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,4216.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,4216.08,17632.72,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,9960.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,9760.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,12342.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11469.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,6752.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,8062.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,3376.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,2869.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,2869.94,12342.9,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,40986.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,28509.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,36051.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33499.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,27787.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,35563.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,13893.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,11809.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,11809.68,40986.53,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,20996.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,17768.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,22469.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20878.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,14234.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,17844.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,7117.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6049.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,6049.71,22469.8,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,49127.88,295,MS-DRG,,case rate,295% Medicare MS-DRG,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,38383.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,48537.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45101.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,33307.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,42780.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,16653.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,14155.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,14155.49,49127.88,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,28368.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,24062.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,30428.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28274.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,19233.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,24379.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,9616.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,8174.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,8174.03,30428.36,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,21061.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,24495.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,30976.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28783.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,14278.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,16914.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,7139.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,6068.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,6068.49,30976.4,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,24761.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,17957.38,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,22708.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21100.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,16787.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,21182.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,8393.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,7134.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,7134.66,24761.47,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,16806.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,12530.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,15845.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14723.77,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,11394.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,14130.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,5697.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,4842.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,4842.48,18172.48,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,11315.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,9798.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,12390.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11513.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,7671.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,9263.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,3835.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,3260.38,85,MS-DRG,,case rate,85% Medicare MS-DRG,3260.38,24813.14,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,21221.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,23384.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,29570.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27476.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,14387.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,18044.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,7193.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,6114.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,6114.61,43369.75,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,15700.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,14923.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,18871.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17535.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,10644.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,10418.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,5322.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,4523.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,4523.92,18871.78,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,30704.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,28226.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,35694.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33167.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,20816.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,26450.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,10408.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,8847.11,85,MS-DRG,,case rate,85% Medicare MS-DRG,8847.11,35694.34,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14425.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,13020.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,16465.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15299.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,9780.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,12020.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,4890.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,4156.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,4156.55,16465.15,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9048.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9176.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,11604.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10782.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6134.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,7241.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,3067.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,2607.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,2607.16,11604.24,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,30202.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,17203.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,21754.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20214.73,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,20476.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,26004.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,10238.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,8702.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,8702.31,30202.13,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,20724.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,12511.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,15821.79,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14701.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14050.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,17603.71,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,7025.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,5971.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,5971.42,20724.34,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,14075.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,9214.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,11651.89,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10826.95,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,9542.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,11710.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,4771.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,4055.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,4055.72,17022.45,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,21731.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,21725.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,27473.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25528.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,14733.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,18496.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,7366.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,6261.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,6261.56,27473.68,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,13113.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,11494.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,14535.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13506.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8890.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,10857.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,4445.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,3778.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,3778.45,35674.5,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,22250.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,16713.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,21135.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19639.07,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,15085.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,18956.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7542.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,6411.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,6411.18,48587.47,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,14889.12,295,MS-DRG,,case rate,295% Medicare MS-DRG,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,10910.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,13796.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12819.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,10094.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,12431.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,5047.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4290.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,4290.09,14889.12,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,29468.76,295,MS-DRG,,case rate,295% Medicare MS-DRG,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,29432.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,37219.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34584.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,19978.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,25354.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9989.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,8491,85,MS-DRG,,case rate,85% Medicare MS-DRG,8491,37219.34,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,18408.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,16826.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,21278.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19771.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12480.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,15551.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,6240.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,5304.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,5304.25,21278.4,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,23240.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,15733.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,19896.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18487.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,15756.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,19834.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,7878.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,6696.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,6696.5,23240.81,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,14725.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,9930.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,12557.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11668.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,9983.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,12286.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4991.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,4242.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,4242.89,14725.31,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,11157.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,8027.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,10150.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9432.07,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,7564.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,9123.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,3782.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,3214.79,85,MS-DRG,,case rate,85% Medicare MS-DRG,3214.79,11157.2,
ANGINA PECTORIS,311,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,13857.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,10552.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,13343.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12398.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,9395.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,11517.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,4697.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,3992.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,3992.98,13857.98,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,16936.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11268.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,14249.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13240.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11482.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,14246.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,5741.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,4880.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,4880.03,16936.57,
CHEST PAIN,313,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,14332.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,10514.39,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,13296.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12354.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,9717.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,11938.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,4858.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,4129.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,4129.73,14332.6,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,39830.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,28584.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,36147.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33587.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,27003.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,34539.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,13501.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,11476.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,11476.62,39830.63,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,18868.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,14414.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,18228.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16937.87,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,12792.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,15958.82,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,6396.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,5436.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,5436.72,18868.61,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,13757.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,11607.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,14678.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13638.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,9327.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,11428.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,4663.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,3964.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,3964.01,14678.05,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,82052.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,79310.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,100292.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,93191.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,55628.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,71964.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,27814.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,23642.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,23642.27,100292.05,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,42296.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,45147.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,57091.89,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,53049.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,28675.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,36725.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,14337.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,12187.24,85,MS-DRG,,case rate,85% Medicare MS-DRG,12187.24,57091.89,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,54371.18,295,MS-DRG,,case rate,295% Medicare MS-DRG,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,36861.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,47427.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,18430.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,15666.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,15666.27,54371.18,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,34803.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,23595.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,30083.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,11797.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,10028.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,10028.07,34803.3,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,77922.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,52828.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,68303.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,26414.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,22452.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,22452.2,77922.33,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,56118.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,38046.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,48976.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,19023.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,16169.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,16169.87,56118.97,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,50082.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,33954.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,43626.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,16977.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14430.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,14430.62,50082.74,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,95400.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,74071.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,93667.87,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,87036.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,64677.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,83794.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,32338.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,27488.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,27488.14,95400.02,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,47348.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,36668.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,46369.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43086.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,32100.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,41202.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,16050.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,13642.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,13642.78,47348.47,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,30594.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,22404.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,28331.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26325.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,20742.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,26352.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,10371.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8815.46,85,MS-DRG,,case rate,85% Medicare MS-DRG,8815.46,30594.83,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,84935.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,59355.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,75058.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,69744.15,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,57583.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,74519.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,28791.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,24473.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,24473.01,84935.75,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,45016.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,34558.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,43700.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40606.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,30519.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,39135.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,15259.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,12970.79,85,MS-DRG,,case rate,85% Medicare MS-DRG,12970.79,45016.26,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,31985.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,25739.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,32549.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30244.61,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,21684.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,27585.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,10842.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,9216.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,9216.09,32549.05,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,68882,295,MS-DRG,,case rate,295% Medicare MS-DRG,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,74335.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,94001.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,87346.25,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,46699.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,59849.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,23349.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,19847.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,19847.36,94001.46,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,39570.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,39815.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,50348.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,46783.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,26827.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,34308.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,13413.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,11401.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,11401.54,50348.56,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,30740.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,27020.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,34169.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31750.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,20840.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,26481.45,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,10420.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,8857.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,8857.31,34169.35,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,67405.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,44770.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,56615.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,52607.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,45698.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,58981.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,22849.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,19422.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,19422.05,67405.94,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,40050.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,30506.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,38577.53,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35846.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,27152.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,34733.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,13576.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,11539.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,11539.92,40050.32,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,28716.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,23101.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,29213.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27144.87,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,19469,200,MS-DRG,,case rate,200% Medicare MS-DRG,24688.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,9734.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,8274.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,8274.33,29213.13,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,51871.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,53419.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,67552.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,62769.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,35167.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,45212,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,17583.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,14946.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,14946.01,67552.38,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,29539.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,21066.47,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,26639.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24753.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,20026.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,25417.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,10013.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,8511.37,85,MS-DRG,,case rate,85% Medicare MS-DRG,8511.37,29539.47,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,24834.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,18805.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,23780.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22096.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,16836.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,21246.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,8418.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,7155.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,7155.59,24834.1,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,48310.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,47239.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,59736.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,55507.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,32753.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,42055.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,16376.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,13920.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,13920.04,59736.8,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,25087.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,19201.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,24280.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22561.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,17008.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,21470.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,8504.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,7228.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,7228.52,25087.21,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,19026.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,14264.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,18037.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16760.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,12899.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,16099.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,6449.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,5482.3,85,MS-DRG,,case rate,85% Medicare MS-DRG,5482.3,19026.82,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,45535.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,46089.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,58283.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54156.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,30871.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,39595.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,15435.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,13120.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,13120.41,58283.29,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,27957.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,24665.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,31190.85,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28982.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,18954.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,24014.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,9477.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,8055.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,8055.52,31190.85,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,21506.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,16016.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,20253.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18819.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14580.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,18296.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,7290.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,6196.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,6196.67,21506.09,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,55294.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,38175.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,48275.53,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44857.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,37487.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,48246.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,18743.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,15932.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,15932.28,55294.39,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,32837.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,23874.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,30190.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28052.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,22262.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,28340.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,11131.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,9461.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,9461.72,32837.72,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,26226.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,20331.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,25710.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23890.14,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,17780.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,22480.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,8890.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,7556.76,85,MS-DRG,,case rate,85% Medicare MS-DRG,7556.76,26226.39,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,80503.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,54889.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,69410.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,64496.73,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,54578.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,70591.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,27289.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,23196.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,23196.06,80503.97,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,41753.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,27963.01,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,35360.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32857.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,28307.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,36243.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,14153.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,12030.63,85,MS-DRG,,case rate,85% Medicare MS-DRG,12030.63,41753.36,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,24709.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,20972.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,26520.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24642.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,16752.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,21136,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,8376.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7119.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,7119.65,26520.56,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,31612.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,28641.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,36218.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33654.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,21432.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,27255.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,10716.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,9108.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,9108.82,36218.56,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,19259.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,15526.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,19634.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18244.18,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,13057.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,16305.29,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,6528.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,5549.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,5549.35,19634.27,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,14706.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,12134.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,15345.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14258.8,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,9970.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,12269.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,4985.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,4237.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,4237.53,15345.23,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,33394.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,22592.76,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,28569.77,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26547.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,22640.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,28834.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11320.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,9622.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,9622.08,33394.27,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,20264.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13020.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,16465.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15299.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13738.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,17196.2,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,6869.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,5838.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,5838.95,20264.58,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,14200.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,10702.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,13534.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12576.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,9627.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,11821.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,4813.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,4091.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,4091.65,14200.42,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,39933.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,27246.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,34455.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32015.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,27073.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,34629.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,13536.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,11506.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,11506.13,39933.03,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,23168.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,17034.07,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,21540.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20015.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,15707.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,19769.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,7853.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,6675.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,6675.59,23168.24,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,17455.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,13585.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,17179.99,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15963.66,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,11834.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,14706.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5917.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5029.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,5029.66,17455.89,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,34187.17,295,MS-DRG,,case rate,295% Medicare MS-DRG,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,26606.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,33645.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31263.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,23177.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,29536.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11588.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,9850.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,9850.54,34187.17,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19175.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,14735.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,18633.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17314.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,13000.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,16231.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6500.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5525.21,85,MS-DRG,,case rate,85% Medicare MS-DRG,5525.21,19175.74,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,12649.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,10420.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,13176.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12243.97,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8576.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,10446.74,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,4288.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,3644.91,85,MS-DRG,,case rate,85% Medicare MS-DRG,3644.91,13176.88,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,37131.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,26512.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,33526,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31152.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,25174.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,32146.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,12587.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,10698.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,10698.98,37131.77,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,20836.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14716.38,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,18609.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17292.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14126.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,17702.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7063.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,6003.6,85,MS-DRG,,case rate,85% Medicare MS-DRG,6003.6,20836.03,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,14956.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,11117.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,14058.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13063.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,10139.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,12490.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,5069.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,4309.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,4309.4,14956.15,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,26888.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,24910.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,31500.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29270.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,18229.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,23067.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,9114.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,7747.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,7747.67,31500.62,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,17163.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,12417.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,15702.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14590.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,11636.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,14447.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,5818.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,4945.46,85,MS-DRG,,case rate,85% Medicare MS-DRG,4945.46,17163.66,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,30028.99,295,MS-DRG,,case rate,295% Medicare MS-DRG,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,20557.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,25996.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24155.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,20358.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,25851.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10179.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,8652.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,8652.42,30028.99,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,18948.65,295,MS-DRG,,case rate,295% Medicare MS-DRG,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,13265.47,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,16774.91,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15587.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,12846.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,16029.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,6423.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,5459.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,5459.78,18948.65,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,13597.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10118.69,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12795.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11889.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,9218.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,11286.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,4609.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,3917.9,85,MS-DRG,,case rate,85% Medicare MS-DRG,3917.9,13597.41,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,27918.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17467.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,22088.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20524.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,18927.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,23980.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,9463.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,8044.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,8044.26,27918.3,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,15687.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,10118.69,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,12795.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11889.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,10635.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,13139.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,5317.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,4520.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,4520.16,15687.63,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,11268.88,295,MS-DRG,,case rate,295% Medicare MS-DRG,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,8008.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,10126.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9409.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7639.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,9222.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,3819.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,3246.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,3246.97,11268.88,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,24608.87,295,MS-DRG,,case rate,295% Medicare MS-DRG,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,16563,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,20944.81,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19461.94,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,16683.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,21046.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,8341.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,7090.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,7090.69,24608.87,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,15486.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,10175.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,12867.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11956.14,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,10499.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,12961.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,5249.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,4462.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,4462.25,15486.62,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,31009.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,21820.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,27592.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25639.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,21023.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,26720.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,10511.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,8935.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,8935.07,31009.96,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,18302.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,13265.47,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,16774.91,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15587.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,12408.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,15457.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,6204.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,5273.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,5273.69,18302.8,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,12916.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,11268.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,14249.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13240.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,8756.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,10682.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4378.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,3721.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,3721.61,14249.14,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,42680.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,28935.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,37065.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,14467.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,12297.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,12297.72,42680.31,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,29031.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,19682.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,24966.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,9841.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8364.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,8364.96,29031.33,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,21582.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14632.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,18364.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,6218.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,6218.65,21582.38,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,103332.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,76615.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,96884.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,90025.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,70056.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,90826.55,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,35028.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,29773.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,29773.89,103332.9,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,54607.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,43414.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,54899.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,51012.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,37022.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,47637.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,18511.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,15734.39,85,MS-DRG,,case rate,85% Medicare MS-DRG,15734.39,54899.71,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,40900.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,32730.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,41389.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38458.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,27729.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,35487.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13864.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,11785.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,11785.01,41389.24,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,70145.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,70868.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,89617.11,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,83272.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,47556.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,61410.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,23778.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,20211.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,20211.5,89617.11,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,37295.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,35500.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,44891.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,41713.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,25285.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,32292.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12642.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,10746.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,10746.18,44891.95,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,29997.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,29564.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,37386.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34739.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,20337.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,25823.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,10168.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,8643.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,8643.31,37386.13,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,57455.35,295,MS-DRG,,case rate,295% Medicare MS-DRG,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,71056.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,89855.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,83493.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,38952.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,47523.41,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,19476.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,16554.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,6764.78,89855.39,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,39320.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,43847.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,55447.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,51522.11,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,26658.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,33747.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,13329.04,100,MS-DRG,,case rate,100% Medicare MS-DRG,11329.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,7446.71,55447.76,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,28962.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,32051.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,40531.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37661.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,19635.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,24905.86,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,9817.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,8345.12,85,MS-DRG,,case rate,85% Medicare MS-DRG,8345.12,40531.43,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,66479.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,45053.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,56972.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,52939.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,45070.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,58159.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,22535.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,19154.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,16180.55,66479.02,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,37639.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,28829.79,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,36456.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33875.73,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,25518.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,32597.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12759.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10845.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,10845.4,37639.91,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,25790.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,22366.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,28283.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26281.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,17485.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,22094.55,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,8742.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,7431.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,7431.26,28283.84,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,44005.59,295,MS-DRG,,case rate,295% Medicare MS-DRG,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,27831.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,35193.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32702.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,29834.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,38239.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,14917.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,12679.58,85,MS-DRG,,case rate,85% Medicare MS-DRG,12679.58,44005.59,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,31291,295,MS-DRG,,case rate,295% Medicare MS-DRG,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,23497.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,29713.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27609.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,21214.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,26969.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,10607.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,9016.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,9016.05,31291,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,25306.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,19992.42,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,25281.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23491.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,17157.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,21665.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,8578.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,7291.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,7291.82,25306.9,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,60440.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,64009.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,80943.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,75212.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,40976.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,52807.82,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,20488.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,17415.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,17415.18,80943.72,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,32685.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,30205.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,38196.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35492.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,22159.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,28205.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,11079.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,9417.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,5412.4,38196.28,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,27127.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,26342.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,33311.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30953.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,18391.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,23279.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,9195.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,7816.32,85,MS-DRG,,case rate,85% Medicare MS-DRG,6553.96,33311.54,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,73658.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,77011.34,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,97385.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,90490.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,49937.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,64523.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,24968.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,21223.51,85,MS-DRG,,case rate,85% Medicare MS-DRG,9922.73,97385.04,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,40541.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,42754.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,54065.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,50237.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,27485.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,34436.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,11681.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,11681.49,54065.73,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,30680.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,28584.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,36147.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33587.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,20800.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,26428.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,10400.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,8840.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,8840.13,36147.08,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,36526.84,295,MS-DRG,,case rate,295% Medicare MS-DRG,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,27039.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,34193.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31772.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,24763.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,31610.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,12381.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10524.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,8757.5,36526.84,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,20054.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14980.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,18943.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17602.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,13596.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,17009.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,6798.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,5778.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,5778.35,20054.28,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,13325.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,9251.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,11699.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10871.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,9034.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,11045.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4517.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,3839.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,3839.59,29171.87,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,33621.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,24966.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,31572.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29336.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,22794.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,29035.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,11397.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,9687.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,9687.5,33621.33,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,21351.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,16355.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,20682.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19218.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,14475.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,18159.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,7237.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,6152.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,6152.16,21351.6,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,16333.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,13114.73,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,16584.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15410.14,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,11073.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,13711.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,5536.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,4706.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,4706.27,16584.29,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,31925.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,25965.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,32834.98,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30510.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,21644.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,27532.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,10822.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,9198.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,9198.94,32834.98,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,16782.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,12417.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,15702.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14590.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,11377.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,14109.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,5688.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,4835.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,4835.52,16782.11,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,12322.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,9346.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,11818.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10981.94,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,8354.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,10156.37,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,4177.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,3550.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,3550.52,12322.39,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,34892.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,28584.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,36147.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33587.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,23656,200,MS-DRG,,case rate,200% Medicare MS-DRG,30162.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,11828,100,MS-DRG,,case rate,100% Medicare MS-DRG,10053.8,85,MS-DRG,,case rate,85% Medicare MS-DRG,6571.17,36147.08,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,18574.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,13868.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,17537.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16295.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,12592.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,15698.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,6296.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,5351.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,5351.98,18574.53,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,14166.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,11889.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,15035.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13970.97,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,9604.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,11791.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4802.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4082.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,4082.01,15035.47,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,31263.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,21801.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,27569,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25617.14,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,21195.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,26945.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,10597.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,9008,85,MS-DRG,,case rate,85% Medicare MS-DRG,9008,31263.07,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,21092.88,295,MS-DRG,,case rate,295% Medicare MS-DRG,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,16261.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,20563.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19107.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,14300.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,17930.37,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,7150.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,6077.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,6077.61,21092.88,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,15782.59,295,MS-DRG,,case rate,295% Medicare MS-DRG,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,12737.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,16107.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14967.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,10700.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,13223.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,5350.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4547.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,4547.53,16107.73,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,165802.12,295,MS-DRG,,case rate,295% Medicare MS-DRG,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,132692.41,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,167796.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,155916.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,112408.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,146198.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,56204.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,47773.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,10951.72,167796.78,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,114707.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,83587.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,105701.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,98217.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,77767.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,100908.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,38883.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,33051.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,19418.81,114707.36,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,86588.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,68626.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,86781.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,80637.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,58704.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,75984.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,29352.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,24949.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,24949.25,86781.58,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,157761.25,295,MS-DRG,,case rate,295% Medicare MS-DRG,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,152402.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,192720.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,179076.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,106956.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,139070.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,53478.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,45456.63,85,MS-DRG,,case rate,85% Medicare MS-DRG,45456.63,192720.86,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,113944.25,295,MS-DRG,,case rate,295% Medicare MS-DRG,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,110796.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,140108.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,130189.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,77250.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,100232.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,38625.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,32831.39,85,MS-DRG,,case rate,85% Medicare MS-DRG,32831.39,140108.64,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,85200.01,295,MS-DRG,,case rate,295% Medicare MS-DRG,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,94780.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,119854.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,111369.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,57762.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,74753.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,28881.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,24549.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,24549.16,119854.84,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,124311.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,82381.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,104176.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,96800.45,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,84279.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,109421.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,42139.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,35818.63,85,MS-DRG,,case rate,85% Medicare MS-DRG,35818.63,124311.7,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,68948.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,45185.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,57139.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,53094.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,46745.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,60349.2,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,23372.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,19866.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,19866.64,68948.93,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,127777.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,105106.25,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,132912.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,123502.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,86628.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,112493.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,43314.39,100,MS-DRG,,case rate,100% Medicare MS-DRG,36817.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,6169.62,132912.58,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,53842.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,40719.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,51492.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,47846.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,36503.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,46959.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,18251.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,15513.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,7268.16,53842.57,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,106283.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,67684.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,85590.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,79530.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,72056.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,93441.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,36028.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,30623.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,9249.41,106283.04,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,56729.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,38326.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,48466.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45034.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,38460.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,49518.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,19230.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,16345.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,16345.78,56729.47,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,35685.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,26116.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,33025.61,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30687.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,24193.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,30865.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,12096.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10282.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,10282.27,35685.53,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,97402.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,60109.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,76011.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,70629.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,66035.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,85570.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,33017.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,28065.21,85,MS-DRG,,case rate,85% Medicare MS-DRG,28065.21,97402.78,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,65754.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,41473.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,52445.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,48732.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,44579.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,57518.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,22289.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,18946.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,18946.35,65754.97,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,50553.65,295,MS-DRG,,case rate,295% Medicare MS-DRG,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,34953.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,44200.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,41071.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,34273.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,44043.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17136.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,14566.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,14566.31,50553.65,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,62842.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,37855.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,47870.45,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44481.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,42604.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,54936.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,21302.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,18107.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,18107.02,62842.02,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,35888.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,25400.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,19637,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29846.07,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,24331.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,31044.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,12165.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,10340.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,10340.73,35888.43,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,92421.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,56076.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,70912.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,65891.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,62658.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,81155.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,31329.46,100,MS-DRG,,case rate,100% Medicare MS-DRG,26630.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,5370.09,92421.91,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,55873.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,38439.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,48609.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45167.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,37880.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,48759.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,18940.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,16099.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,5980.31,55873.27,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,46663.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,30129.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,38100.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35403.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,31636.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,40595.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,15818.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13445.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,7750.03,46663.54,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,80952.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,73129.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,92476.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,85929.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,54883.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,70988.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,27441.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,23325.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,13726.76,92476.47,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,40783.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,31448.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,39768.93,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36953.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,27649.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,35383.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,13824.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,11751.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,11751.22,40783.63,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,22769.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,21556.39,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,27259.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25329.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,15437.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,19416.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,7718.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,6560.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,6560.82,27259.23,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,63571.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,46221.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,58450.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54311.87,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,43099.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,55582.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,21549.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,18317.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,18317.25,63571.64,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,45232.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,33446.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,42294.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,39300.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,30665.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,39327.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,15332.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,13033.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,13033.01,45232.2,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,35558.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,22800.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,28831.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26790.61,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24107.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,30752.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,12053.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,10245.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,10245.81,35558.98,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,55752.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,50178.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,63453.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,58961.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,37798.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,48651.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,18899.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,16064.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,16064.22,63453.96,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,39484.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,33936.24,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,42914.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,39875.94,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,26769.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,34232.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,13384.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,11376.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,5441.8,42914.23,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,30429.19,295,MS-DRG,,case rate,295% Medicare MS-DRG,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,24646.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,31167.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28960.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,20629.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,26205.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10314.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,8767.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,6000.39,31167.02,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,47102.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,31599.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,39959.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37130.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,31934.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,40985.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,15967.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,13571.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,8310.77,47102.8,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,62175.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,62709.5,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,79299.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,73685.25,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,42153,200,MS-DRG,,case rate,200% Medicare MS-DRG,54345.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,21076.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,17915.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,17915.03,79299.58,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,38244.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,26775.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,33859.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31462.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,25928.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,33133.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,12964.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,11019.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,11019.69,38244.8,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,29619.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,20557.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,25996.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24155.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,20081.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,25488.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,10040.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,8534.44,85,MS-DRG,,case rate,85% Medicare MS-DRG,8534.44,29619.53,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,40074.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,28905.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,36552.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33964.29,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,27169.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,34755.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,13584.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,11546.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,11546.88,40074.48,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,23901.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,19031.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,24066.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22362.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,16204.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,20419.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8102.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,6886.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,6886.89,24066.28,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,65304.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,46692.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,59045.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54865.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,44274.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,57118.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,22137.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,18816.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,15903.76,65304.53,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,45567.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,34727.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,43915,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40805.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,30893.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,39624.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,15446.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,13129.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,13129.53,45567.2,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,35655.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,24608.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,31119.37,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28916.15,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,24173.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,30838.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,12086.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,10273.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,10273.69,39591.54,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,67521.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,63331.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,80085.91,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,74415.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,45777.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,59083.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,22888.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,19455.3,85,MS-DRG,,case rate,85% Medicare MS-DRG,19455.3,80085.91,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,37857.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,28867.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,36504.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33920.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,25666.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,32790.41,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12833.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,10908.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,10908.14,37857.67,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,27432.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,22781.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,28808.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26768.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,18598.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,23549.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9299.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,7904.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,7904.28,28808.05,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,49462.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,45769.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,57878.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,53780.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,33534.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,43077.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,16767.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,14252.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,14252.04,57878.21,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,24871.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,22102.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,27950.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25971.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,16861.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,21279.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,8430.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7166.32,85,MS-DRG,,case rate,85% Medicare MS-DRG,7166.32,27950.24,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,61222.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,48256.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,61023.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,56703.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,41506.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,53500.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,20753.45,100,MS-DRG,,case rate,100% Medicare MS-DRG,17640.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,17640.43,61222.68,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,33170.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,23817.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,30118.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27986.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,22488.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,28636.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,11244.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,9557.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,5514.22,33170.92,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,26600.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,18258.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,23089.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21454.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,18034.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,22812.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,9017.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,7664.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,7664.54,26600.45,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,50782.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,49349.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,62405.53,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,57987.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,34428.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,44246.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,17214.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,14632.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,14632.27,62405.53,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,33010.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,25720.7,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,32525.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30222.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,22380.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,28494.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,11190.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,9511.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,9511.59,42898.06,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,32612.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,23553.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,29785,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27676.25,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,22110.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,28141.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,11055.08,100,MS-DRG,,case rate,100% Medicare MS-DRG,9396.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,9396.82,32612.49,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,28087.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,25664.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,32453.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30156.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,19042.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,24130.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,9521.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8093.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,8093.05,32453.74,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,40541.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,38081.7,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,48156.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44746.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,27485.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,35169.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,13742.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,11681.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,11681.49,48156.39,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,27555.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,27963.01,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,35360.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32857.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,18681.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,23658.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,9340.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,7939.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,7939.67,35360.75,
ARTHROSCOPY,509,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,26291.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,30469.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,38529.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35802,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,17824.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,21880.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,8912.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,7575.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,7575.52,38529.88,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,51502.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,51102.22,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,64621.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,60046.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,34917.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,44885.33,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,17458.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,14839.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,14839.82,64621.54,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,37974.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,29093.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,36790.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34185.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,25745.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,32894.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,12872.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,10941.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,3393.15,37974.91,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,30901.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,21123,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,26711.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24820.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,20950.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,26624.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,10475.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,8903.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,5727.91,30901.93,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,31035.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,20576.56,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,26020.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24177.97,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,21041.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,26743.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,8942.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,8942.56,31035.95,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,20249.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,15357.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,19419.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18044.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,13728.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,17183,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6864.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,5834.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,5834.66,26003.39,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,59709.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,46372.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,58640.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54489,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,40480.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,52159.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,20240.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,17204.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,17204.41,59709.42,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,38849.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,31222.85,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,39483,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36687.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,26338.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,33669.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,13169.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,11193.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,11193.99,39483,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,28679.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,19672.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24876.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23115.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,19443.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,24655.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,9721.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,8263.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,8263.61,28679.58,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,68835.45,295,MS-DRG,,case rate,295% Medicare MS-DRG,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,36272.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,45868.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42621.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,46668.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,60248.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,23334.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,19833.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,19833.94,68835.45,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,37505.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,24552.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,31047.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28849.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,25427.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,32478.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,12713.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,10806.77,85,MS-DRG,,case rate,85% Medicare MS-DRG,10806.77,37505.86,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,27508.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,19012.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,24042.45,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22340.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,18650.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,23617.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,9325.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,7926.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,7926.27,27508.81,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,56595.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,57716.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,72985.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,67817.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,38369.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,49399.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,19184.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,16307.17,85,MS-DRG,,case rate,85% Medicare MS-DRG,5054.58,72985.16,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,40178.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,32051.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,40531.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37661.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,27239.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,34847.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,13619.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,11576.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,5745.83,40531.43,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,31229.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,27058.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,34217.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31794.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,21172.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,26915.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10586.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,8998.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,7565.74,34217.01,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,15940.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,14207.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,17966.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16694.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10807.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,13363.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,5403.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,4593.11,85,MS-DRG,,case rate,85% Medicare MS-DRG,4593.11,21710.9,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,24999.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,23214.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,29356.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27277.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,16949,200,MS-DRG,,case rate,200% Medicare MS-DRG,21393.37,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,8474.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,7203.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,7203.33,29356.1,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,15514.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,11343.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,14344.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13328.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,10518.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,12985.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,5259.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4470.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,4470.29,15514.52,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,18863.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,17429.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,22040.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20480.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,12788.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,15953.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6394.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5435.11,85,MS-DRG,,case rate,85% Medicare MS-DRG,5435.11,22040.9,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,14062.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,13548.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,17132.33,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15919.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,9534.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,11698.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4767.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4051.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,4051.98,17132.33,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,37800,295,MS-DRG,,case rate,295% Medicare MS-DRG,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,25004.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,31619.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29381.11,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,25627.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,32739.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,12813.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,10891.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,10891.53,37800,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,25027.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,15978.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,20206.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18775.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,16967.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,21418.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,8483.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7211.37,85,MS-DRG,,case rate,85% Medicare MS-DRG,7211.37,25027.68,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,16832.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,9967.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,12605.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11712.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11411.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,14153.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5705.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,4849.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,4433.6,16832.32,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,34808.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,30431.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,38482.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35757.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,23599.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,30087.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,11799.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,10029.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,5385.15,38482.22,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,21165.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,18183.5,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,22994.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21366.07,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,14349.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,17994.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,7174.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,6098.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,6098.53,22994.02,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,15149.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14490.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,18323.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17026.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,10271,200,MS-DRG,,case rate,200% Medicare MS-DRG,12662.46,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5135.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,4365.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,4365.18,18323.73,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,47270.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,45015.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,56925.09,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,52894.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,32047.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,41133.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,16023.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,13620.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,13620.26,56925.09,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,23186.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,19728.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,24947.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23181.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,15719.9,200,MS-DRG,,case rate,200% Medicare MS-DRG,19786.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,7859.95,100,MS-DRG,,case rate,100% Medicare MS-DRG,6680.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,6680.96,24947.92,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,16188.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,16487.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,20849.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19373.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,10975.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,13419.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,5487.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,4664.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,4664.43,20849.5,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,37155.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,36555.42,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,46226.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,42953.54,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,25190.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,32168.42,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,12595.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,10705.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,10705.95,46226.32,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,23315.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,18051.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,22827.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21211.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,15806.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,19900.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,7903.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6717.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,6717.95,23315.24,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,18425.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,14848.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,18776.46,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17447.11,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,12491.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,15191.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6245.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,5309.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,5309.07,18776.46,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,32541.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,20425.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,25829.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24000.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,22062.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,28078.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,11031.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,9376.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,5815.39,32541.8,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,18850,295,MS-DRG,,case rate,295% Medicare MS-DRG,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,13453.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17013.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15808.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,12779.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,15942.33,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,6389.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,5431.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,5431.36,18850,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,26019.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,24024.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,30380.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28229.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,17640.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,22297.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,8820.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,7497.21,85,MS-DRG,,case rate,85% Medicare MS-DRG,7497.21,30380.7,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,16160.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,14094.56,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,17823.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16561.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,10956.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,13558.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,5478.1,100,MS-DRG,,case rate,100% Medicare MS-DRG,4656.39,85,MS-DRG,,case rate,85% Medicare MS-DRG,4656.39,26621.79,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,26903.88,295,MS-DRG,,case rate,295% Medicare MS-DRG,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,25230.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,31905.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29646.8,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,18239.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,23081.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,9119.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7751.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,7751.97,31905.69,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,16208.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,13340.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,16870.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15675.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,10989,200,MS-DRG,,case rate,200% Medicare MS-DRG,13601.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5494.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,4670.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,4670.33,16870.22,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,29840.99,295,MS-DRG,,case rate,295% Medicare MS-DRG,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,21028.79,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,26592.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24709.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,20231.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,25684.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,10115.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,8598.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,8598.25,29840.99,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,17213.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,8724.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,11032.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10251.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,11670.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,14492.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,5835.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,4959.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,4959.95,17213.93,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,35307.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,25664.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32453.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30156.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,23937.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,30530.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,11968.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,10173.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,10173.4,35307.69,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,21936.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,15828.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,20015.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18598.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,14871.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,18677.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,7435.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,6320.57,85,MS-DRG,,case rate,85% Medicare MS-DRG,6320.57,21936.08,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,15386.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,12850.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,16250.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15100.16,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,10431.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,12871.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,5215.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,4433.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,4433.28,16250.7,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,29169.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,22705.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,28712.74,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26679.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,19775.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,25089,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,9887.82,100,MS-DRG,,case rate,100% Medicare MS-DRG,8404.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,7641.75,29169.07,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,17534.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,12737.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,16107.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14967.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,11887.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,14775.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,5943.74,100,MS-DRG,,case rate,100% Medicare MS-DRG,5052.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,5052.18,17534.03,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,29935.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,22404.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,28331.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26325.65,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,20295.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,25768.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10147.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,8625.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,8625.62,29935.98,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,19466.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,13680.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,17299.13,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16074.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,13197.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,16488.42,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,6598.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,5608.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,5608.87,19466.08,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,14833.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,11776.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,14892.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13838.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,10056.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,12381.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,5028.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,4274,85,MS-DRG,,case rate,85% Medicare MS-DRG,4274,14892.5,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,55255.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,34595.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,43748.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40650.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,37461.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,48211.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,18730.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,15921.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,15921.02,55255.3,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,32355.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,20727.3,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,26210.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24355.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,21936.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,27913.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,10968.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,9322.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,4578.45,32355.66,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,22075.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,14885.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,18824.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17491.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,14966.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,18801.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,7483.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,6360.79,85,MS-DRG,,case rate,85% Medicare MS-DRG,6360.79,22075.68,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,116602.14,295,MS-DRG,,case rate,295% Medicare MS-DRG,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,73129.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,92476.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,85929.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,79052.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,102588.2,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,39526.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,33597.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,9929.9,116602.14,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,64256.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,44412.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,56162.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,52186.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,43563.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,56189.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,21781.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,18514.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,18026.99,64256.61,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,38946.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,24590.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,31095.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28894.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,26404.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,33755.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,13202.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11221.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,11221.88,38946.52,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,106644.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,92236.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,116638.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,108380.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,72301.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,93761.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,36150.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,30727.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,30727.98,116638.06,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,50172.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,37007.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,46798.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,43484.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,34014.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,43705.7,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,17007.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,14456.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,14456.36,50172.07,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,30840.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,28660.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,36242.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33676.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,20908.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,26570.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,10454.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,8886.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,8886.26,36242.39,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,63072.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,38515.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,48704.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45256.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,42761.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,55140.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,21380.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,18173.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,18173.52,63072.8,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,33373.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,21123,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,26711.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24820.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,22626.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,28815.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11313.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9616.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,9616.18,33373.79,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,25930.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,17015.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,21516.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19993.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,17579.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,22218.29,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,8789.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,7471.47,85,MS-DRG,,case rate,85% Medicare MS-DRG,5545.06,25930.41,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,33275.14,295,MS-DRG,,case rate,295% Medicare MS-DRG,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32089.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,40579.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37706.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,22559.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,27504.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,11279.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,9587.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,6842.94,40579.08,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,29191.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,30412.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,38458.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35735.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,19790.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,25108.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,9895.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,8411.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,8411.09,38458.39,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,37319.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,34200.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,43247.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40185.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,25301.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,32313.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,12650.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,10753.15,85,MS-DRG,,case rate,85% Medicare MS-DRG,10753.15,43247.82,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,32208.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,29602.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,37433.79,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34783.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,21836.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,27783.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,10918.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,9280.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,9280.45,37433.79,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,39767.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,20689.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,26163.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24310.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,26960.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,34483.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,13480.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,11458.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,7603.75,39767.39,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,23384.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,13736.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,17370.61,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16140.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,15853.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,19961.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,7926.83,100,MS-DRG,,case rate,100% Medicare MS-DRG,6737.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,6737.81,23384.15,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,15520.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,9836.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,12438.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11557.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,10522.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,12990.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,5261.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,4471.9,85,MS-DRG,,case rate,85% Medicare MS-DRG,4471.9,20562.45,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,41347.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,38044.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,48108.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44702.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,28032.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,35883.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,14016.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11913.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,11913.73,48108.73,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19644.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,9233.07,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,11675.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10849.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,13318.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,16646.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,6659.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,5660.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,5660.36,19644.79,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,30654.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,28302.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,35789.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33255.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,20782.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,26405.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10391.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,8832.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,8832.62,35789.66,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,23177.53,295,MS-DRG,,case rate,295% Medicare MS-DRG,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,17147.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,21683.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20148.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,15713.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,19778.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,7856.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,6678.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,6678.27,23177.53,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,13387.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,13340.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,16870.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15675.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9075.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,10252.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,4537.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,3857.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,3857.29,16870.22,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,19951.91,295,MS-DRG,,case rate,295% Medicare MS-DRG,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,11701.5,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,14797.19,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13749.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,13526.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,16919.03,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,6763.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,5748.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,5748.86,19951.91,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,12655.59,295,MS-DRG,,case rate,295% Medicare MS-DRG,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,6896.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,8721.05,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,8103.61,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,8580.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,10271.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,4290.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,3646.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,3646.53,12655.59,
CELLULITIS WITH MCC,602,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,28551.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,17165.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,21707.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20170.45,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,19356.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,24541.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,9678.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,8226.6,85,MS-DRG,,case rate,85% Medicare MS-DRG,8226.6,28551.13,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,17331.19,295,MS-DRG,,case rate,295% Medicare MS-DRG,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,8328.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10531.98,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9786.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,11749.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,14596.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,5874.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4993.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,4993.73,17331.19,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,28899.2,295,MS-DRG,,case rate,295% Medicare MS-DRG,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,21236.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,26854.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24952.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,19592.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,24849.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9796.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,8326.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,8326.89,28899.2,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,17779.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,11776.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,14892.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13838.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,12054.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,14993.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,6027.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,5122.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,5122.98,17779.74,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,30380.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,27849.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,35217.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32724.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,20597.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,26163.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,10298.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,8753.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,8753.78,35217.78,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,17494.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,8498.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,10746.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9985.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,11860.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,14741.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,5930.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,5040.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,5040.92,17494.95,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,42788.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,39023.85,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,49347.79,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45854.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,29009,200,MS-DRG,,case rate,200% Medicare MS-DRG,37160.82,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14504.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,12328.83,85,MS-DRG,,case rate,85% Medicare MS-DRG,12328.83,49347.79,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,28245.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,28999.38,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,36671.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34075,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,19149.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,24270.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,9574.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,8138.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,8138.65,36671.29,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,74529.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,46240.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,58473.91,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54334.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,50528.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,65295.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,25264.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,21474.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,21474.5,74529.15,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,37801.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,24081.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,30452.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28296.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,25628.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,32740.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,12814.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,10892.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,10892.05,37801.83,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,22483.25,295,MS-DRG,,case rate,295% Medicare MS-DRG,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,19182.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,24256.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22539.54,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,15242.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,19162.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,7621.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,6478.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,6478.22,24256.9,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,49304.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,38646.99,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,48871.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,45411.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,33426.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,42705.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,16713.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,14206.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,14206.45,49304.74,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,31058.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,23892.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,30213.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28074.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,21056.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,26763.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,10528.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,8949,85,MS-DRG,,case rate,85% Medicare MS-DRG,8949,31058.31,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,29105.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,20859.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,26377.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24510.09,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,19732.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,25032.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,9866.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,8386.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,8386.42,29105.82,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,72070.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,66383.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,83946.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,78002.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,48861.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,63115.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,24430.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,20766.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,20766.04,83946.04,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,35510.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,22668.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,28665.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26635.62,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,24074.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,30709.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,12037.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,10231.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,10231.86,35510.57,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,21608.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,20124.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,25448.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23646.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,14649.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,18387.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,7324.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,6226.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,6226.16,25448.3,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,55236.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,53419.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,67552.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,62769.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,37448.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,48194.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,18724.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,15915.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,15915.66,67552.38,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,28633.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,23158.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,29284.61,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27211.29,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,19412.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,24613.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,9706.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,8250.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,8250.19,29284.61,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,23869.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,17542.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,22183.87,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20613.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,16183.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,20391.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,8091.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,6877.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,6877.78,23869.95,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,75586.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,53174.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,67242.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,62481.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,51245,200,MS-DRG,,case rate,200% Medicare MS-DRG,66232.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,25622.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,21779.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,21779.13,75586.38,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,42981.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,28697.89,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,36290.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33720.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,29140.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,37332.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,14570.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,12384.6,85,MS-DRG,,case rate,85% Medicare MS-DRG,12384.6,42981.85,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,26853.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,26041.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,32930.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30598.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,18205.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,23036.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,9102.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,7737.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,7737.48,32930.3,
DIABETES WITH MCC,637,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,27840.12,295,MS-DRG,,case rate,295% Medicare MS-DRG,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,18824.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,23804.17,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22118.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,18874.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,23911.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,9437.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,8021.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,8021.73,27840.12,
DIABETES WITH CC,638,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,17604.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,10552.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13343.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12398.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,11935.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,14838.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5967.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5072.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,5072.56,17604.77,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,12450.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,8102.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,10246.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9520.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,8441.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,10270.2,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,4220.62,100,MS-DRG,,case rate,100% Medicare MS-DRG,3587.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,3587.53,12450.83,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,25344.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,17505.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,22136.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20568.99,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,17182.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,21698.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8591.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,7302.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,7302.54,25344.1,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,15408.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,10344.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,13081.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12155.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,10446.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,12891.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,5223.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,4439.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,4439.72,15408.44,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,25122.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,11889.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,15035.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13970.97,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,17032.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,21502.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,8516.13,100,MS-DRG,,case rate,100% Medicare MS-DRG,7238.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,7238.71,25122.58,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,31484.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,23195.73,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,29332.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27255.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,21345.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,27141.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,10672.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,9071.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,9071.82,31484.55,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,20625.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,14188.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,17942.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16672.17,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,13983.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,17516.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,6991.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,5943,85,MS-DRG,,case rate,85% Medicare MS-DRG,5943,20625.69,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,15026.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,9063.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,11461.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10649.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,10187.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,12553.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,5093.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,4329.77,85,MS-DRG,,case rate,85% Medicare MS-DRG,4329.77,15026.86,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,84576.5,295,MS-DRG,,case rate,295% Medicare MS-DRG,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,85038.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,107535.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,99922.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,57340,200,MS-DRG,,case rate,200% Medicare MS-DRG,74201.19,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,28670,100,MS-DRG,,case rate,100% Medicare MS-DRG,24369.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,24369.5,107535.76,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,65235.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,69606.04,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,88020.63,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,81788.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,44227.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,57057.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,22113.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,18796.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,18796.7,88020.63,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,56785.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,75070.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,94930.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,88209.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,38498.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,49567.55,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,19249.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,16361.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,16361.86,94930.75,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,101627.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,100583.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,127193.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,118188.66,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,68900.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,89315.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,34450.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,29282.63,85,MS-DRG,,case rate,85% Medicare MS-DRG,29282.63,127193.86,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,51817.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,43169.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,54589.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,50725.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,35130.48,200,MS-DRG,,case rate,200% Medicare MS-DRG,45164.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,17565.24,100,MS-DRG,,case rate,100% Medicare MS-DRG,14930.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,14930.45,54589.95,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,40096.84,295,MS-DRG,,case rate,295% Medicare MS-DRG,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,30789.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,38934.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36178.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,27184.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,34775.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13592.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11553.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,11553.33,40096.84,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,59264.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,49255.6,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,62286.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,57876.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,40179.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,51765.13,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,20089.7,100,MS-DRG,,case rate,100% Medicare MS-DRG,17076.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,17076.25,62286.39,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,35190.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,27115.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,34288.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31860.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,23857.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,30426.2,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,11928.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,10139.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,10139.62,35190.43,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,28418.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,23384.16,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,29570.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27476.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,19267.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,24424.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,9633.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,8188.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,8188.52,29570.55,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,49051.6,295,MS-DRG,,case rate,295% Medicare MS-DRG,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,30129.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,38100.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35403.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,33255.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,42712.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,16627.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,14133.51,85,MS-DRG,,case rate,85% Medicare MS-DRG,14133.51,49051.6,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,25915.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,18315.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,23160.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21521.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,17569.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,22205.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,8784.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,7467.18,85,MS-DRG,,case rate,85% Medicare MS-DRG,7467.18,25915.51,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,20378.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,14904.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,18847.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17513.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,13815.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,17296.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,6907.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,5871.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,5871.66,20378.13,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,56641.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,56905.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,71960.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,66865.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,38401.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,49440.52,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,19200.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,16320.57,85,MS-DRG,,case rate,85% Medicare MS-DRG,16320.57,71960.56,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,28020.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,29790.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,37672.07,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,35004.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,18997.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,24071.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,9498.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,8073.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,8073.75,37672.07,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,20623.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,22084,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,27926.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25949.25,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,13982.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,17514.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6991.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,5942.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,5942.45,27926.42,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,58361.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,57339.25,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,72508.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,67375.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,39567.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,50964.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,19783.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,16816.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,16816.13,72508.6,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,32830.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,32994.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,41722.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38768.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,22257.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,28334.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,11128.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,9459.57,85,MS-DRG,,case rate,85% Medicare MS-DRG,9459.57,41722.83,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,20400.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,18711.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,23661.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21986.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,13830.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,17316.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,6915.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,5878.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,5878.1,23661.2,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,53315.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,49406.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,62477.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,58053.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,36146.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,46492.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,18073.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,15362.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,15362.19,62477.02,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,29427.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,18032.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,22803.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21188.94,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,19951.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,25318.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,9975.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,8479.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,8479.19,29427.78,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,18781.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,13397.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,16941.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15742.25,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,12732.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,15881.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,6366.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,5411.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,5411.52,18781.15,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,32727.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,32994.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,41722.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38768.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,22188.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,28243.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,11094.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,9430.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,9430.08,41722.83,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,18313.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,20538.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,25972.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24133.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,12416.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,15223,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,6208.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,5276.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,5276.89,25972.52,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,69695.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,46165.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,58378.6,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,54245.45,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,47251.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,61010.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,23625.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,20081.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,20081.71,69695.34,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,45204.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,32786.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,41460.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38525.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,30646.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,39302.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,15323.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,13024.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,13024.96,45204.27,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,30393.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,31731.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,40126.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37285.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,20606,200,MS-DRG,,case rate,200% Medicare MS-DRG,26174.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,10303,100,MS-DRG,,case rate,100% Medicare MS-DRG,8757.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,8757.55,40126.35,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,28798.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,20350.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,25734.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23912.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,19524.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,24760.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,9762.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,8297.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,8297.93,28798.7,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,17630.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,11249.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,14225.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13218.18,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,11953.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,14861.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,5976.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,5080.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,5080.07,17630.82,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,12190.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,7970.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,10079.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9365.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,8264.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,10039.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,4132.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,3512.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,3512.45,12190.26,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,35101.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,31693.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,40078.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37241.16,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,23797.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,30347.01,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,11898.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,10113.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,10113.87,40078.7,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,20320.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,17674.73,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,22350.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20768.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,13776.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,17245.69,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,6888.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,5855.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,5855.05,22350.66,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,15399.15,295,MS-DRG,,case rate,295% Medicare MS-DRG,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,13322,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,16846.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15653.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,10440.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,12883.54,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,5220.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,4437.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,4437.04,16846.4,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,22723.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,16204.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,20492.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19041.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,15405.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,19375.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,7702.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,6547.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,6547.41,22723.38,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,15883.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,9044.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11437.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10627.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,10768.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,13312.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5384.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,4576.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,4576.48,15883.07,
URINARY STONES WITH MCC,693,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,27225.87,295,MS-DRG,,case rate,295% Medicare MS-DRG,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,23761.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,30047.11,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27919.8,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,18458.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,23366.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,9229.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,7844.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,7844.74,30047.11,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,15432.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,8724.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,11032.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10251.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,10462.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,12913.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,5231.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,4446.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,4446.69,15432.63,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,23125.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,21782.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,27545.17,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25595,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,15678.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,19731.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,7839.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6663.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,6663.25,27545.17,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,13746.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,8441.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,10674.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9919.17,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,9319.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,11418.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,4659.77,100,MS-DRG,,case rate,100% Medicare MS-DRG,3960.8,85,MS-DRG,,case rate,85% Medicare MS-DRG,3960.8,13746.32,
URETHRAL STRICTURE,697,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,21582.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,18353.08,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,23208.47,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,21565.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,14632.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,18364.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,7316.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,6218.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,6218.65,23208.47,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,31657.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,22121.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,27974.07,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25993.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,21462.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,27294.82,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,10731.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,9121.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,9121.69,31657.63,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,19864.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,13529.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,17108.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15897.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,13467.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,16841.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,6733.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,5723.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,5723.65,19864.44,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,14047.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,11305.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,14296.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13284.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,9523.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,11685.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,4761.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,4047.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,4047.67,14296.8,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,37381.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,27510.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,34788.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32325.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,25343.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,32368.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,12671.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,10770.84,85,MS-DRG,,case rate,85% Medicare MS-DRG,10770.84,37381.16,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,28011.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,23365.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,29546.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27454.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,18990.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,24062.8,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,9495.37,100,MS-DRG,,case rate,100% Medicare MS-DRG,8071.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,8071.06,29546.72,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,41269.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,43093.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,54494.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,50636.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,27979.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,34976.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,13989.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,11891.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,11891.19,54494.64,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,25010.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,29734.25,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,37600.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34938.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,16956.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,20363.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,8478.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,7206.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,7206.54,37600.58,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,40377.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,40022.53,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,50610.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,47027.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,27374.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,35024.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,13687.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,11634.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,11634.31,50610.67,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,22983.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,19766.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,24995.57,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23225.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,15582.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,19606.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,7791.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,6622.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,6622.49,24995.57,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,27866.14,295,MS-DRG,,case rate,295% Medicare MS-DRG,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,20406.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,25805.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23978.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,18892.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,23934.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,9446.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,8029.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,8029.23,27866.14,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,18704.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,15978.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,20206.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18775.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,12681.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,15813.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,6340.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,5389.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,5389.52,20206.14,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,41952.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,39231.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,49609.9,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,46097.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,28442.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,36420.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14221.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,12088.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,12088.02,49609.9,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,27335.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,25362.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,32072.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29801.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,18532.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,23463.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9266.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,7876.39,85,MS-DRG,,case rate,85% Medicare MS-DRG,7876.39,32072.49,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,34622.73,295,MS-DRG,,case rate,295% Medicare MS-DRG,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,22573.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,28545.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26524.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,23473.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,29923,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,11736.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,9976.04,85,MS-DRG,,case rate,85% Medicare MS-DRG,9976.04,34622.73,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,22749.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,15168.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,19181.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17823.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,15423.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,19398.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,7711.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,6554.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,6554.93,22749.46,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,35759.99,295,MS-DRG,,case rate,295% Medicare MS-DRG,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,32541.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,41150.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38237.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,24244.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,30931.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,12122.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,10303.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,10303.73,41150.96,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,21604.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,20708.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,26186.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24332.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,14647.26,200,MS-DRG,,case rate,200% Medicare MS-DRG,18384.08,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,7323.63,100,MS-DRG,,case rate,100% Medicare MS-DRG,6225.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,6225.09,26186.97,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,15931.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,12474.07,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,15774.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14657.34,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,10801,200,MS-DRG,,case rate,200% Medicare MS-DRG,13355.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,5400.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,4590.43,85,MS-DRG,,case rate,85% Medicare MS-DRG,4590.43,15931.48,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,23961.17,295,MS-DRG,,case rate,295% Medicare MS-DRG,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,23949.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,30285.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28141.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,16244.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,20472.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,8122.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,6904.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,6904.07,30285.39,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,14468.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,14075.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,17799.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16539.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,9809.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,12058.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,4904.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,4168.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,4168.88,17799.52,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,31035.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,26757.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,33835.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31440.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,21041.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,26743.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,10520.66,100,MS-DRG,,case rate,100% Medicare MS-DRG,8942.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,8942.56,33835.76,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,15756.48,295,MS-DRG,,case rate,295% Medicare MS-DRG,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,9478.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,11985.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11136.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,10682.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,13200.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,5341.18,100,MS-DRG,,case rate,100% Medicare MS-DRG,4540,85,MS-DRG,,case rate,85% Medicare MS-DRG,4540,15756.48,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,19549.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,19596.72,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,24781.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23026.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,13254.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,16562.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,6627.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,5633.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,5633.01,24781.12,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,12434.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,11192.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,14153.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13151.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,8429.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,10255.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,4214.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,3582.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,3582.7,14153.83,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,41321.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,29583.51,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,37409.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34761.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,28014.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,35860.75,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,14007.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,11906.21,85,MS-DRG,,case rate,85% Medicare MS-DRG,11906.21,43822.5,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,24320.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,23233.42,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,29379.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27299.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,16488.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,20791.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,8244.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,7007.56,85,MS-DRG,,case rate,85% Medicare MS-DRG,7007.56,29379.92,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,73216.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,78292.67,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,99005.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,91995.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,49638.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,64132.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,24819.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,21096.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,21096.41,99005.34,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,37602.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,32070.79,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,40555.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37683.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,25493.36,200,MS-DRG,,case rate,200% Medicare MS-DRG,32564.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,12746.68,100,MS-DRG,,case rate,100% Medicare MS-DRG,10834.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,10834.68,40555.26,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,26263.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,21349.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,26997.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25085.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,17805.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,22513.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,8902.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,7567.47,85,MS-DRG,,case rate,85% Medicare MS-DRG,7567.47,26997.12,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,68174.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,70397.45,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,89021.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,82718.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,46220.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,59662.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,23110.06,100,MS-DRG,,case rate,100% Medicare MS-DRG,19643.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,19643.55,89021.41,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,34125.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,27623.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,34931.85,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32458.71,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,23136.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,29482.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,11568.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,9832.84,85,MS-DRG,,case rate,85% Medicare MS-DRG,9832.84,34931.85,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,25048.13,295,MS-DRG,,case rate,295% Medicare MS-DRG,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,19012.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,24042.45,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22340.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,16981.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,21436.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,8490.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,7217.26,85,MS-DRG,,case rate,85% Medicare MS-DRG,7217.26,25048.13,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,34030.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,23120.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,29236.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27167.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,23071.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,29398.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11535.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,9805.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,9805.49,34030.82,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,22492.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,16186.14,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,20468.25,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19019.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,15249.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,19171.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,7624.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,6480.91,85,MS-DRG,,case rate,85% Medicare MS-DRG,6480.91,22492.57,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,35901.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,19087.96,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,24137.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22428.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,24339.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,31056.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,12169.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,10344.47,85,MS-DRG,,case rate,85% Medicare MS-DRG,10344.47,35901.41,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,20145.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,13246.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,16751.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15565.12,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,13657.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,17090.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,6828.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,5804.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,5804.62,20145.46,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,32061.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,21443.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,27116.26,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25196.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,21736.66,200,MS-DRG,,case rate,200% Medicare MS-DRG,27652.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,10868.33,100,MS-DRG,,case rate,100% Medicare MS-DRG,9238.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,9238.08,32061.57,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,17377.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,14697.54,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,18585.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17269.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,11781.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,14637.31,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,5890.75,100,MS-DRG,,case rate,100% Medicare MS-DRG,5007.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,5007.14,18585.84,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,27013.71,295,MS-DRG,,case rate,295% Medicare MS-DRG,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,17731.26,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,22422.15,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20834.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,18314.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,23178.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9157.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,7783.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,7783.61,27013.71,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,47717.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,32937.56,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,41651.34,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38702.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,32350.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,41529.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,16175.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,13748.97,85,MS-DRG,,case rate,85% Medicare MS-DRG,13748.97,47717.02,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,26177.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,25362.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,32072.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29801.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,17747.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,22437.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,8873.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,7542.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,7542.81,32072.49,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,35344.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,27265.82,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,34479.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32038.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,23962.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,30563.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,11981.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10184.12,85,MS-DRG,,case rate,85% Medicare MS-DRG,10184.12,35344.89,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,21053.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,15752.75,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,19920.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18509.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,14273.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,17895.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,7136.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,6066.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,6066.35,21053.8,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,19285.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,12775.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,16155.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15011.6,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,13074.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,16328.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6537.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,5556.85,85,MS-DRG,,case rate,85% Medicare MS-DRG,5556.85,19285.54,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,28627.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,27849.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,35217.78,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32724.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,19408.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,24608.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,9704.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,8248.58,85,MS-DRG,,case rate,85% Medicare MS-DRG,8248.58,35217.78,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,19339.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,11362.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,14368.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13351.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,13111.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,16376.23,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,6555.78,100,MS-DRG,,case rate,100% Medicare MS-DRG,5572.41,85,MS-DRG,,case rate,85% Medicare MS-DRG,5572.41,19339.55,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,12891.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,9063.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,11461.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10649.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,8740.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,10661.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,4370.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,3714.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,3714.64,12891.97,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,19391.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,11192.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,14153.83,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13151.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,13146.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,16422.43,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,6573.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,5587.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,5587.42,19391.62,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,12136.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,7932.9,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,10031.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9321.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,8227.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,9991.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4113.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,3496.88,85,MS-DRG,,case rate,85% Medicare MS-DRG,3496.88,12136.24,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,23536.78,295,MS-DRG,,case rate,295% Medicare MS-DRG,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,10457.87,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,13224.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12288.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,15957.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,20096.6,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7978.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,6781.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,6781.78,23536.78,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,29600.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,19577.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,24757.29,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23004.5,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,20068.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,25471.76,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,10034.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,8529.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,8529.08,29600.92,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,15730.43,295,MS-DRG,,case rate,295% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,10928.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13820.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12841.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,10664.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,13177.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,5332.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,4532.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,4532.5,15730.43,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,14204.19,295,MS-DRG,,case rate,295% Medicare MS-DRG,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,7461.83,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,9435.89,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,8767.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,9629.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,11824.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4814.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,4092.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,4092.73,14204.19,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,19276.24,295,MS-DRG,,case rate,295% Medicare MS-DRG,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,7989.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10103.07,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9387.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,13068.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,16320.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,6534.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,5554.17,85,MS-DRG,,case rate,85% Medicare MS-DRG,5554.17,19276.24,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,33842.81,295,MS-DRG,,case rate,295% Medicare MS-DRG,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,16525.31,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,20897.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19417.66,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,22944.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,29231.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,11472.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,9751.32,85,MS-DRG,,case rate,85% Medicare MS-DRG,9751.32,33842.81,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,19925.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,13604.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,17203.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15985.8,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,13509.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,16895.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,6754.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,5741.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,5741.33,19925.8,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,16988.7,295,MS-DRG,,case rate,295% Medicare MS-DRG,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,11550.76,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,14606.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13572.43,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,11517.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,14292.49,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,5758.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,4895.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,4895.05,16988.7,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,33427.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,15978.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,20206.14,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18775.57,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,22662.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,28863.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,11331.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,9631.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,9631.72,33427.75,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,20428.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,14056.88,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,17775.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16517.19,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,13849.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,17341.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,6924.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5886.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,5886.14,20428.37,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,16778.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,12379.85,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,15655,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14546.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,11375.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,14106.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,5687.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,4834.44,85,MS-DRG,,case rate,85% Medicare MS-DRG,4834.44,16778.36,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,34728.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,23544.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,30017.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,11772.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,10006.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,10006.61,34728.82,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,112544.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,76301.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,98991.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,38150.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,32428.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,32428.09,112544.54,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,77134.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,52294.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,67605.17,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,26147.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,22225.32,85,MS-DRG,,case rate,85% Medicare MS-DRG,22225.32,77134.95,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,46885.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,31786.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,40792.1,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,15893.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,13509.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,13509.25,46885.03,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,79212.22,295,MS-DRG,,case rate,295% Medicare MS-DRG,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,53703.2,200,MS-DRG,,case rate,200% Medicare MS-DRG,69446.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,26851.6,100,MS-DRG,,case rate,100% Medicare MS-DRG,22823.86,85,MS-DRG,,case rate,85% Medicare MS-DRG,22823.86,79212.22,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,28595.8,295,MS-DRG,,case rate,295% Medicare MS-DRG,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,3843.97,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,4860.91,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,4516.76,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,19386.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,24580.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,9693.49,100,MS-DRG,,case rate,100% Medicare MS-DRG,8239.47,85,MS-DRG,,case rate,85% Medicare MS-DRG,3843.97,28595.8,
NORMAL NEWBORN,795,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,4618.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,2638.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,3335.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,3099.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,3131.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,3327.71,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,1565.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,1330.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,1330.74,4618.46,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,27264.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,22479.7,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,28426.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26414.21,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,18484.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,23401.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,9242.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,7856.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,7856.01,28426.8,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,19400.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,15790.43,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,19967.86,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18554.16,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,13153.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,16430.68,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,6576.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,5590.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,5590.1,19967.86,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,16407.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,14132.25,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,17871,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16605.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,11124.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,13383.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,5562.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,4727.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,4727.72,17871,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,93084.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,76050.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,96169.81,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,89361.08,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,63108.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,81742.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,31554.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,26820.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,26820.98,96169.81,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,53310.25,295,MS-DRG,,case rate,295% Medicare MS-DRG,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,52138.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,65932.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,61264.15,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,36142.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,46487.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,18071.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,15360.58,85,MS-DRG,,case rate,85% Medicare MS-DRG,15360.58,65932.08,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,34176.02,295,MS-DRG,,case rate,295% Medicare MS-DRG,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,30845.99,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,39006.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36244.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,23170.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,29527.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,11585.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,9847.33,85,MS-DRG,,case rate,85% Medicare MS-DRG,9847.33,39006.44,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,64721.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,65196.78,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,82444.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,76607.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,43879.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,55934.25,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,21939.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,18648.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,18648.69,82444.88,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,35450.98,295,MS-DRG,,case rate,295% Medicare MS-DRG,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,29489.3,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,37290.82,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34650.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,24034.56,200,MS-DRG,,case rate,200% Medicare MS-DRG,30657.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,12017.28,100,MS-DRG,,case rate,100% Medicare MS-DRG,10214.69,85,MS-DRG,,case rate,85% Medicare MS-DRG,10214.69,37290.82,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,23393.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,19879.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,25138.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23358.76,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,15859.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,19969.57,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,7929.98,100,MS-DRG,,case rate,100% Medicare MS-DRG,6740.48,85,MS-DRG,,case rate,85% Medicare MS-DRG,6740.48,25138.54,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,19629.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,11211.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,14177.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13173.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,13308.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,16633.61,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,6654.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,5656.07,85,MS-DRG,,case rate,85% Medicare MS-DRG,5656.07,19629.89,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,14762.57,295,MS-DRG,,case rate,295% Medicare MS-DRG,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,9346.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,11818.69,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10981.94,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,10008.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,12319.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,5004.26,100,MS-DRG,,case rate,100% Medicare MS-DRG,4253.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,4253.62,14762.57,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,13042.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,8290.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,10484.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9742.04,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,8842.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,10794.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,4421.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,3758.06,85,MS-DRG,,case rate,85% Medicare MS-DRG,3758.06,13042.69,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,41628.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,29206.65,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,36933.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,34318.55,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,28222.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,36132.97,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,14111.42,100,MS-DRG,,case rate,100% Medicare MS-DRG,11994.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,11994.71,41628.69,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,23281.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,16713.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,21135.44,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19639.07,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,15784.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,19870.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,7892.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,6708.3,85,MS-DRG,,case rate,85% Medicare MS-DRG,6708.3,23281.75,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,19561.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,12191.42,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,15416.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14325.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,13261.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,16572.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,6630.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,5636.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,5636.23,19561.04,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,26989.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,20293.91,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,25662.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23845.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,18297.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,23157.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,9148.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,7776.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,7776.64,26989.52,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,17628.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,12869.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,16274.52,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15122.3,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,11951.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,14860.04,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,5975.91,100,MS-DRG,,case rate,100% Medicare MS-DRG,5079.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,5079.52,17628.93,
COAGULATION DISORDERS,813,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,29900.58,295,MS-DRG,,case rate,295% Medicare MS-DRG,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,24835.07,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,31405.3,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29181.84,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,20271.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,25737.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,10135.79,100,MS-DRG,,case rate,100% Medicare MS-DRG,8615.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,8615.42,31405.3,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,40474.68,295,MS-DRG,,case rate,295% Medicare MS-DRG,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,28660.2,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,36242.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33676.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,27440.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,35110.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,13720.23,100,MS-DRG,,case rate,100% Medicare MS-DRG,11662.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,11662.2,40474.68,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,19369.32,295,MS-DRG,,case rate,295% Medicare MS-DRG,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,15130.93,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,19133.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,17779.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,13131.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,16402.63,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,6565.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5580.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,5580.99,19369.32,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,14083.18,295,MS-DRG,,case rate,295% Medicare MS-DRG,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,10570.92,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,13367.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12421.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,9547.92,200,MS-DRG,,case rate,200% Medicare MS-DRG,11717.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,4773.96,100,MS-DRG,,case rate,100% Medicare MS-DRG,4057.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,4057.87,14083.18,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,53293.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,24250.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,30666.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28495.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,36131.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,37203.71,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,18065.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,15355.75,85,MS-DRG,,case rate,85% Medicare MS-DRG,15355.75,53293.49,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,27501.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,14132.25,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,17871,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16605.75,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,18645,200,MS-DRG,,case rate,200% Medicare MS-DRG,19354.18,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,9322.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,7924.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,7924.13,27501.38,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,17749.97,295,MS-DRG,,case rate,295% Medicare MS-DRG,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,10118.69,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,12795.64,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11889.72,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,12033.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,14967.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,6016.94,100,MS-DRG,,case rate,100% Medicare MS-DRG,5114.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,5114.4,17749.97,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,113411.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,90540.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,114493.54,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,106387.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,76889.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,99760.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,38444.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,32678,85,MS-DRG,,case rate,85% Medicare MS-DRG,32678,114493.54,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,42410.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,32183.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,40698.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,37816.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,28752.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,36825.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,14376.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,12219.95,85,MS-DRG,,case rate,85% Medicare MS-DRG,4446.51,42410.41,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,23922.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,19898.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,25162.37,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23380.9,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,16218.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,20438.12,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,8109.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,6892.79,85,MS-DRG,,case rate,85% Medicare MS-DRG,5803.92,25162.37,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,84658.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,68720.42,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,86900.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,80748.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,57395.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,74273.79,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,28697.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,24393.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,8969.04,86900.72,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,42425.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,37799.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,47798.97,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44414.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,28762.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,36839.1,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,14381.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,12224.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,12224.25,47798.97,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,24901.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,23817.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,30118.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27986.22,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,16882.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,21305.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,8441.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,7174.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,7174.89,30118.59,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,86999.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,93216.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,117877.12,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,109531.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,58983.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,72407.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,29491.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,25067.78,85,MS-DRG,,case rate,85% Medicare MS-DRG,25067.78,117877.12,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,43994.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,41040.05,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,51897.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,48223.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,29826.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,38229.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,14913.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,12676.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,12676.35,51897.38,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,31397.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,27284.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,34502.94,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32060.17,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,21286.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,27063.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,10643.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,9046.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,9046.61,34502.94,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,59566.08,295,MS-DRG,,case rate,295% Medicare MS-DRG,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,37497.57,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,47417.72,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,44060.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,40383.78,200,MS-DRG,,case rate,200% Medicare MS-DRG,52032.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,20191.89,100,MS-DRG,,case rate,100% Medicare MS-DRG,17163.11,85,MS-DRG,,case rate,85% Medicare MS-DRG,17163.11,59566.08,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,30295.17,295,MS-DRG,,case rate,295% Medicare MS-DRG,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,27529.62,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,34812.71,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32348,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,20539.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,26087.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,10269.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,8729.12,85,MS-DRG,,case rate,85% Medicare MS-DRG,8729.12,34812.71,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,20878.83,295,MS-DRG,,case rate,295% Medicare MS-DRG,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,10043.32,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,12700.32,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11801.15,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,14155.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,16660,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7077.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,6015.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,6015.93,20878.83,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,14595.04,295,MS-DRG,,case rate,295% Medicare MS-DRG,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,7706.79,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,9745.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,9055.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,9894.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,12170.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,4947.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,4205.35,85,MS-DRG,,case rate,85% Medicare MS-DRG,4205.35,14595.04,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,10390.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,5860.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,7410.51,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,6885.85,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,7044.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,8443.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,3522.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,2993.83,85,MS-DRG,,case rate,85% Medicare MS-DRG,2993.83,10390.34,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,105078.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,143979.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,182069.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,169179.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,71239.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,92374.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,35619.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,30276.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,30276.94,182069.75,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,42473.72,295,MS-DRG,,case rate,295% Medicare MS-DRG,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,51026.84,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,64526.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,59957.83,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,28795.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,36881.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,14397.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,12238.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,12238.19,64526.22,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,27143.95,295,MS-DRG,,case rate,295% Medicare MS-DRG,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,31392.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,39697.45,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36886.91,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,18402.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,19753.44,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,9201.34,100,MS-DRG,,case rate,100% Medicare MS-DRG,7821.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,7821.14,39697.45,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,91025.94,295,MS-DRG,,case rate,295% Medicare MS-DRG,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,53627.18,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,67814.49,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,63013.29,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,61712.5,200,MS-DRG,,case rate,200% Medicare MS-DRG,78475.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,30856.25,100,MS-DRG,,case rate,100% Medicare MS-DRG,26227.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,26227.81,91025.94,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,38121.99,295,MS-DRG,,case rate,295% Medicare MS-DRG,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,28735.58,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,36337.7,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33765.03,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,25845.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,32211.32,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,12922.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,10984.3,85,MS-DRG,,case rate,85% Medicare MS-DRG,10984.3,38121.99,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,25118.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,16657.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,21063.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19572.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,17029.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,21498.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,8514.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,7237.65,85,MS-DRG,,case rate,85% Medicare MS-DRG,7237.65,25118.9,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,59033.75,295,MS-DRG,,case rate,295% Medicare MS-DRG,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,56849.33,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,71889.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,66799.4,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,40022.88,200,MS-DRG,,case rate,200% Medicare MS-DRG,51560.55,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,20011.44,100,MS-DRG,,case rate,100% Medicare MS-DRG,17009.72,85,MS-DRG,,case rate,85% Medicare MS-DRG,17009.72,71889.08,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,30151.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,28321.03,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,35813.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33277.92,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,20441.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,25960.11,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,10220.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,8687.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,8687.82,35813.48,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,20713.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,20086.64,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,25400.65,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23602.31,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,14042.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,17593.81,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,7021.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,5968.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,5968.2,25400.65,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,35495.67,295,MS-DRG,,case rate,295% Medicare MS-DRG,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,28302.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,35789.66,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33255.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,24064.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,30696.77,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,12032.43,100,MS-DRG,,case rate,100% Medicare MS-DRG,10227.57,85,MS-DRG,,case rate,85% Medicare MS-DRG,10227.57,35789.66,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,22403.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,19841.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,25090.88,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23314.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,15188.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,19091.86,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,7594.31,100,MS-DRG,,case rate,100% Medicare MS-DRG,6455.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,6455.16,25090.88,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,16962.65,295,MS-DRG,,case rate,295% Medicare MS-DRG,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,16204.98,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,20492.08,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19041.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,11500.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,14269.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,5750.05,100,MS-DRG,,case rate,100% Medicare MS-DRG,4887.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,4887.54,20492.08,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,46354.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,23855.24,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,30166.25,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,28030.51,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,31426.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,40321.89,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,15713.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,13356.4,85,MS-DRG,,case rate,85% Medicare MS-DRG,13356.4,46354.56,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,23434.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,15319.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,19372.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,18000.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,15887.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,20005.86,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,7943.86,100,MS-DRG,,case rate,100% Medicare MS-DRG,6752.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,6752.28,23434.39,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,16428.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,8856.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,11199.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10406.27,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,11137.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,12530.47,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,5568.97,100,MS-DRG,,case rate,100% Medicare MS-DRG,4733.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,4733.62,16428.46,
RADIOTHERAPY,849,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,50959.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,42264.85,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,53446.2,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,49662.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,34548.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,44403.58,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,17274.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,14683.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,14683.22,53446.2,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,93916.55,295,MS-DRG,,case rate,295% Medicare MS-DRG,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,67910.17,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,85876.11,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,79796.16,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,63672.24,200,MS-DRG,,case rate,200% Medicare MS-DRG,82480.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,31836.12,100,MS-DRG,,case rate,100% Medicare MS-DRG,27060.7,85,MS-DRG,,case rate,85% Medicare MS-DRG,27060.7,93916.55,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,38801.35,295,MS-DRG,,case rate,295% Medicare MS-DRG,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,28057.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,35479.89,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,32967.95,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,26306,200,MS-DRG,,case rate,200% Medicare MS-DRG,33626.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,13153,100,MS-DRG,,case rate,100% Medicare MS-DRG,11180.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,11180.05,38801.35,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,32539.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,20350.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,25734.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23912.28,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,22060.96,200,MS-DRG,,case rate,200% Medicare MS-DRG,28076.84,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,11030.48,100,MS-DRG,,case rate,100% Medicare MS-DRG,9375.91,85,MS-DRG,,case rate,85% Medicare MS-DRG,9375.91,32539.92,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,83290.36,295,MS-DRG,,case rate,295% Medicare MS-DRG,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,51592.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,65241.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,60622.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,56468.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,73061.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,28234.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,23998.92,85,MS-DRG,,case rate,85% Medicare MS-DRG,23998.92,83290.36,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,40616.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,25193.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,31858.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29602.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,27536.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,35235.46,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,13768.17,100,MS-DRG,,case rate,100% Medicare MS-DRG,11702.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,11702.94,40616.1,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,24752.18,295,MS-DRG,,case rate,295% Medicare MS-DRG,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,20727.3,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,26210.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,24355.1,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,16781.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,21173.94,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,8390.57,100,MS-DRG,,case rate,100% Medicare MS-DRG,7131.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,7131.98,26210.8,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,35149.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,17505.15,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,22136.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20568.99,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,23830.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,30389.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,11915.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,10127.81,85,MS-DRG,,case rate,85% Medicare MS-DRG,10127.81,35149.46,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,19579.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,11720.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,14821.02,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13771.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,13274.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,16589.06,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,6637.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,5641.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,5641.59,19579.62,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,17295.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,11155.06,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,14106.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13107.47,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,11725.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,14564.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,5862.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,4983.54,85,MS-DRG,,case rate,85% Medicare MS-DRG,4983.54,17295.82,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,31387.76,295,MS-DRG,,case rate,295% Medicare MS-DRG,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,18918.37,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,23923.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22229.56,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,21279.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,27055.59,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,10639.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,9043.93,85,MS-DRG,,case rate,85% Medicare MS-DRG,9043.93,31387.76,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,17945.41,295,MS-DRG,,case rate,295% Medicare MS-DRG,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9949.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,12581.18,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11690.45,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,12166.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,15140.51,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,6083.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,5170.71,85,MS-DRG,,case rate,85% Medicare MS-DRG,5170.71,17945.41,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,39808.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,32692.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,41341.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38414.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,26988.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,34519.43,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,13494.35,100,MS-DRG,,case rate,100% Medicare MS-DRG,11470.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,11470.2,41341.58,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,21068.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,12756.71,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,16131.56,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,14989.46,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,14283.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,17908.93,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,7141.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,6070.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,6070.64,21068.69,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,13720.21,295,MS-DRG,,case rate,295% Medicare MS-DRG,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,10872.41,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,13748.76,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12775.36,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,9301.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,11395.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,4650.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,3953.28,85,MS-DRG,,case rate,85% Medicare MS-DRG,3953.28,13748.76,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,130502.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,100923.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,127622.77,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,118587.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,88476.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,114909.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,44238.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,37602.39,85,MS-DRG,,case rate,85% Medicare MS-DRG,37602.39,130502.42,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,871,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,229179.66,295,MS-DRG,,case rate,295% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,207838.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,262822.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,244215.23,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,155376.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,202374.99,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,77688.02,100,MS-DRG,,case rate,100% Medicare MS-DRG,66034.82,85,MS-DRG,,case rate,85% Medicare MS-DRG,66034.82,262822.84,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,20033.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,13322,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,16846.4,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15653.69,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,13582.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,16991.62,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,6791.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,5772.44,85,MS-DRG,,case rate,85% Medicare MS-DRG,5772.44,20033.77,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,70318.86,295,MS-DRG,,case rate,295% Medicare MS-DRG,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,47673.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,61563.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,23836.9,100,MS-DRG,,case rate,100% Medicare MS-DRG,20261.37,85,MS-DRG,,case rate,85% Medicare MS-DRG,20261.37,70318.86,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,18632.23,295,MS-DRG,,case rate,295% Medicare MS-DRG,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,12632.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,15749.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,6316.01,100,MS-DRG,,case rate,100% Medicare MS-DRG,5368.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,5368.61,18632.23,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,17736.93,295,MS-DRG,,case rate,295% Medicare MS-DRG,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,12025.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,14955.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,6012.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,5110.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,5110.64,17736.93,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,18347.44,295,MS-DRG,,case rate,295% Medicare MS-DRG,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,12438.94,200,MS-DRG,,case rate,200% Medicare MS-DRG,15496.87,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,6219.47,100,MS-DRG,,case rate,100% Medicare MS-DRG,5286.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,5286.55,18347.44,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,35771.14,295,MS-DRG,,case rate,295% Medicare MS-DRG,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,24251.62,200,MS-DRG,,case rate,200% Medicare MS-DRG,30940.95,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,12125.81,100,MS-DRG,,case rate,100% Medicare MS-DRG,10306.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,10306.94,35771.14,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,33565.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,22756.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,28985.9,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,11378.14,100,MS-DRG,,case rate,100% Medicare MS-DRG,9671.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,9671.42,33565.51,
PSYCHOSES,885,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,26297.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,17828.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,22543.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,8914.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,7577.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,7577.13,26297.1,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,32165.77,295,MS-DRG,,case rate,295% Medicare MS-DRG,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,21807.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,27745.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,10903.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,9268.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,9268.1,32165.77,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,24979.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,16935.1,200,MS-DRG,,case rate,200% Medicare MS-DRG,21375.22,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,8467.55,100,MS-DRG,,case rate,100% Medicare MS-DRG,7197.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,7197.42,24979.27,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,11557.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,7835.52,200,MS-DRG,,case rate,200% Medicare MS-DRG,9478.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,3917.76,100,MS-DRG,,case rate,100% Medicare MS-DRG,3330.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,3330.1,60345.67,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,30808.89,295,MS-DRG,,case rate,295% Medicare MS-DRG,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,20887.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,26542.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,10443.69,100,MS-DRG,,case rate,100% Medicare MS-DRG,8877.14,85,MS-DRG,,case rate,85% Medicare MS-DRG,8877.14,30808.89,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,33960.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,23023.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,29335.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,11511.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,9785.1,85,MS-DRG,,case rate,85% Medicare MS-DRG,9785.1,33960.05,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,16789.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,11382.72,200,MS-DRG,,case rate,200% Medicare MS-DRG,14115.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,5691.36,100,MS-DRG,,case rate,100% Medicare MS-DRG,4837.66,85,MS-DRG,,case rate,85% Medicare MS-DRG,4837.66,16789.51,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,81417.85,295,MS-DRG,,case rate,295% Medicare MS-DRG,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,79121.76,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,100053.77,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,92970.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,55198.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,71401.43,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,27599.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,23459.38,85,MS-DRG,,case rate,85% Medicare MS-DRG,23459.38,100053.77,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,35944.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,23346.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,29522.89,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27432.7,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,24369,200,MS-DRG,,case rate,200% Medicare MS-DRG,31094.38,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,12184.5,100,MS-DRG,,case rate,100% Medicare MS-DRG,10356.83,85,MS-DRG,,case rate,85% Medicare MS-DRG,10356.83,35944.28,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,23972.35,295,MS-DRG,,case rate,295% Medicare MS-DRG,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,17354.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,21945.59,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20391.86,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,16252.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,20482.66,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,8126.22,100,MS-DRG,,case rate,100% Medicare MS-DRG,6907.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,6907.29,23972.35,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,61472.07,295,MS-DRG,,case rate,295% Medicare MS-DRG,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,64593.8,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,81682.38,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,75899.35,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,41675.98,200,MS-DRG,,case rate,200% Medicare MS-DRG,53721.83,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,20837.99,100,MS-DRG,,case rate,100% Medicare MS-DRG,17712.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,17712.29,81682.38,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,30341.69,295,MS-DRG,,case rate,295% Medicare MS-DRG,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,30789.46,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,38934.95,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,36178.39,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,20570.64,200,MS-DRG,,case rate,200% Medicare MS-DRG,26128.39,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,10285.32,100,MS-DRG,,case rate,100% Medicare MS-DRG,8742.52,85,MS-DRG,,case rate,85% Medicare MS-DRG,8742.52,38934.95,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,35886.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,24948.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,31548.27,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29314.68,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,24329.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,31043.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,12164.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,10340.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,10340.19,35886.54,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,70095.51,295,MS-DRG,,case rate,295% Medicare MS-DRG,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,55831.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,70602.36,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,65603.78,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,47522.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,61365.5,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,23761.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,20197.01,85,MS-DRG,,case rate,85% Medicare MS-DRG,20197.01,70602.36,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,38166.63,295,MS-DRG,,case rate,295% Medicare MS-DRG,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,25946.81,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,32811.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,30488.16,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,25875.68,200,MS-DRG,,case rate,200% Medicare MS-DRG,33064.28,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,12937.84,100,MS-DRG,,case rate,100% Medicare MS-DRG,10997.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,10997.16,38166.63,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,26109.09,295,MS-DRG,,case rate,295% Medicare MS-DRG,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,17768.95,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,22469.8,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,20878.96,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,17701.08,200,MS-DRG,,case rate,200% Medicare MS-DRG,22376.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,8850.54,100,MS-DRG,,case rate,100% Medicare MS-DRG,7522.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,7522.96,26109.09,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,28681.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,28867.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,36504.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,33920.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,19445.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,24656.74,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,9722.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,8264.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,8264.13,36504.5,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,17759.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,13736.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,17370.61,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16140.79,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,12040.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,14975.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,6020.09,100,MS-DRG,,case rate,100% Medicare MS-DRG,5117.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,5117.08,64849.54,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,33883.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,19672.09,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,24876.43,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,23115.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,22972.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,29268.02,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,11486.03,100,MS-DRG,,case rate,100% Medicare MS-DRG,9763.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,9763.13,33883.79,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,13126.47,295,MS-DRG,,case rate,295% Medicare MS-DRG,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,8818.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,11151.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10361.99,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,8899.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,10869.09,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,4449.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,3782.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,3782.2,13126.47,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,30568.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,19050.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,24090.11,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,22384.55,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,20724.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,26329.67,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,10362.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,8807.96,85,MS-DRG,,case rate,85% Medicare MS-DRG,8807.96,30568.79,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,16888.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,8988.11,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,11365.96,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,10561.26,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,11449.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,14203.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,5724.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,4866.08,85,MS-DRG,,case rate,85% Medicare MS-DRG,4866.08,16888.16,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,34827.46,295,MS-DRG,,case rate,295% Medicare MS-DRG,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,22762.34,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,28784.22,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26746.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,23611.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,30104.48,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,11805.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,10035.03,85,MS-DRG,,case rate,85% Medicare MS-DRG,10035.03,34827.46,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,20106.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13962.66,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,17656.55,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16406.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13631.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,17055.96,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,6815.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,5793.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,5793.36,20106.37,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,13852.37,295,MS-DRG,,case rate,295% Medicare MS-DRG,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,10005.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,12652.67,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,11756.87,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,9391.44,200,MS-DRG,,case rate,200% Medicare MS-DRG,11512.53,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,4695.72,100,MS-DRG,,case rate,100% Medicare MS-DRG,3991.36,85,MS-DRG,,case rate,85% Medicare MS-DRG,3991.36,13852.37,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,33342.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,26587.47,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,33621.31,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,31240.95,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,22604.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,28787.92,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,11302.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,9607.05,85,MS-DRG,,case rate,85% Medicare MS-DRG,9607.05,33621.31,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,19689.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,10910.1,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,13796.41,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,12819.64,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,13348.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,16686.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,6674.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,5673.22,85,MS-DRG,,case rate,85% Medicare MS-DRG,5673.22,26868.67,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,491480.74,295,MS-DRG,,case rate,295% Medicare MS-DRG,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,370905.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,469030.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,435823.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,333207.28,200,MS-DRG,,case rate,200% Medicare MS-DRG,434874.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,166603.64,100,MS-DRG,,case rate,100% Medicare MS-DRG,141613.09,85,MS-DRG,,case rate,85% Medicare MS-DRG,141613.09,491480.74,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,129661.11,295,MS-DRG,,case rate,295% Medicare MS-DRG,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,40324.02,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,50991.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,47381.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,87905.84,200,MS-DRG,,case rate,200% Medicare MS-DRG,114163.42,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,43952.92,100,MS-DRG,,case rate,100% Medicare MS-DRG,37359.98,85,MS-DRG,,case rate,85% Medicare MS-DRG,37359.98,129661.11,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,60714.54,295,MS-DRG,,case rate,295% Medicare MS-DRG,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,21970.94,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,27783.45,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25816.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,41162.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,53050.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,20581.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,17494.02,85,MS-DRG,,case rate,85% Medicare MS-DRG,17494.02,60714.54,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,57299.03,295,MS-DRG,,case rate,295% Medicare MS-DRG,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,50254.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,63549.28,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,59050.05,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,38846.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,50022.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,19423.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,16509.89,85,MS-DRG,,case rate,85% Medicare MS-DRG,16509.89,63549.28,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,39812.05,295,MS-DRG,,case rate,295% Medicare MS-DRG,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,32749.13,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,41413.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,38481.06,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,26991.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,34522.73,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,13495.61,100,MS-DRG,,case rate,100% Medicare MS-DRG,11471.27,85,MS-DRG,,case rate,85% Medicare MS-DRG,11471.27,41413.06,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,38855.34,295,MS-DRG,,case rate,295% Medicare MS-DRG,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,16770.27,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,21206.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19705.49,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,26342.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,33674.72,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,13171.3,100,MS-DRG,,case rate,100% Medicare MS-DRG,11195.61,85,MS-DRG,,case rate,85% Medicare MS-DRG,11195.61,38855.34,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,60710.79,295,MS-DRG,,case rate,295% Medicare MS-DRG,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,64744.55,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,81873.01,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,76076.48,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,41159.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,53047.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20579.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,17492.94,85,MS-DRG,,case rate,85% Medicare MS-DRG,17492.94,81873.01,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,41191.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,34388.48,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,43486.1,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40407.33,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,27926.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,35745.26,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,13963.15,100,MS-DRG,,case rate,100% Medicare MS-DRG,11868.68,85,MS-DRG,,case rate,85% Medicare MS-DRG,11868.68,43486.1,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,35410.06,295,MS-DRG,,case rate,295% Medicare MS-DRG,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,22121.68,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,27974.07,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25993.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,24006.82,200,MS-DRG,,case rate,200% Medicare MS-DRG,30620.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,12003.41,100,MS-DRG,,case rate,100% Medicare MS-DRG,10202.9,85,MS-DRG,,case rate,85% Medicare MS-DRG,10202.9,35410.06,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,28960.62,295,MS-DRG,,case rate,295% Medicare MS-DRG,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,19634.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,24904.21,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,9817.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,8344.59,85,MS-DRG,,case rate,85% Medicare MS-DRG,8344.59,28960.62,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,19713.61,295,MS-DRG,,case rate,295% Medicare MS-DRG,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,other,Not separately reimbursable,,,,,other,Not separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,13365.16,200,MS-DRG,,case rate,200% Medicare MS-DRG,16707.85,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,6682.58,100,MS-DRG,,case rate,100% Medicare MS-DRG,5680.19,85,MS-DRG,,case rate,85% Medicare MS-DRG,5680.19,19713.61,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,24160.29,295,MS-DRG,,case rate,295% Medicare MS-DRG,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,16487.63,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,20849.5,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19373.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,16379.86,200,MS-DRG,,case rate,200% Medicare MS-DRG,20649.3,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,8189.93,100,MS-DRG,,case rate,100% Medicare MS-DRG,6961.44,85,MS-DRG,,case rate,85% Medicare MS-DRG,6961.44,24160.29,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,15773.27,295,MS-DRG,,case rate,295% Medicare MS-DRG,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,11814.56,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,14940.16,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,13882.41,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,10693.74,200,MS-DRG,,case rate,200% Medicare MS-DRG,13215.15,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,5346.87,100,MS-DRG,,case rate,100% Medicare MS-DRG,4544.84,85,MS-DRG,,case rate,85% Medicare MS-DRG,4544.84,15773.27,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,20832.31,295,MS-DRG,,case rate,295% Medicare MS-DRG,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,17015.23,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,21516.68,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19993.32,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,14123.6,200,MS-DRG,,case rate,200% Medicare MS-DRG,17093.91,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,7061.8,100,MS-DRG,,case rate,100% Medicare MS-DRG,6002.53,85,MS-DRG,,case rate,85% Medicare MS-DRG,6002.53,21516.68,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,12750.49,295,MS-DRG,,case rate,295% Medicare MS-DRG,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,12888.61,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,16298.35,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,15144.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,8644.4,200,MS-DRG,,case rate,200% Medicare MS-DRG,10364.24,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,4322.2,100,MS-DRG,,case rate,100% Medicare MS-DRG,3673.87,85,MS-DRG,,case rate,85% Medicare MS-DRG,3673.87,16298.35,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,11845.9,295,MS-DRG,,case rate,295% Medicare MS-DRG,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,7028.44,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,8887.84,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,8258.59,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,8031.12,200,MS-DRG,,case rate,200% Medicare MS-DRG,9734.01,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,4015.56,100,MS-DRG,,case rate,100% Medicare MS-DRG,3413.23,85,MS-DRG,,case rate,85% Medicare MS-DRG,3413.23,11845.9,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,114221.52,295,MS-DRG,,case rate,295% Medicare MS-DRG,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,112775.36,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,142610.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,132513.89,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,77438.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,100478.07,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,38719.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,32911.29,85,MS-DRG,,case rate,85% Medicare MS-DRG,32911.29,142610.58,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,73049.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,85679.12,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,108345.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,100675.13,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,49525.02,200,MS-DRG,,case rate,200% Medicare MS-DRG,63983.78,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,24762.51,100,MS-DRG,,case rate,100% Medicare MS-DRG,21048.13,85,MS-DRG,,case rate,85% Medicare MS-DRG,21048.13,108345.92,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,135483.26,295,MS-DRG,,case rate,295% Medicare MS-DRG,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,125117.52,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,158217.92,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,147016.24,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,91853.06,200,MS-DRG,,case rate,200% Medicare MS-DRG,119324.1,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,45926.53,100,MS-DRG,,case rate,100% Medicare MS-DRG,39037.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,39037.55,158217.92,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,76150.33,295,MS-DRG,,case rate,295% Medicare MS-DRG,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,61597.77,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,77893.73,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,72378.93,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,51627.34,200,MS-DRG,,case rate,200% Medicare MS-DRG,66732.4,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,25813.67,100,MS-DRG,,case rate,100% Medicare MS-DRG,21941.62,85,MS-DRG,,case rate,85% Medicare MS-DRG,21941.62,77893.73,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,47999.92,295,MS-DRG,,case rate,295% Medicare MS-DRG,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,49783.21,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,62953.58,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,58496.52,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,32542.32,200,MS-DRG,,case rate,200% Medicare MS-DRG,41780.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,16271.16,100,MS-DRG,,case rate,100% Medicare MS-DRG,13830.49,85,MS-DRG,,case rate,85% Medicare MS-DRG,13830.49,62953.58,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,51757.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,43357.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,54828.23,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,50946.44,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,35090.14,200,MS-DRG,,case rate,200% Medicare MS-DRG,45111.36,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,17545.07,100,MS-DRG,,case rate,100% Medicare MS-DRG,14913.31,85,MS-DRG,,case rate,85% Medicare MS-DRG,14913.31,54828.23,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,28802.38,295,MS-DRG,,case rate,295% Medicare MS-DRG,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,21499.86,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,27187.75,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,25262.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,19527.04,200,MS-DRG,,case rate,200% Medicare MS-DRG,24763.98,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,9763.52,100,MS-DRG,,case rate,100% Medicare MS-DRG,8298.99,85,MS-DRG,,case rate,85% Medicare MS-DRG,8298.99,28802.38,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,18656.42,295,MS-DRG,,case rate,295% Medicare MS-DRG,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,14282.99,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,18061.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,16782.88,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,12648.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,15770.74,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,6324.21,100,MS-DRG,,case rate,100% Medicare MS-DRG,5375.58,85,MS-DRG,,case rate,85% Medicare MS-DRG,5375.58,18656.42,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,128784.4,295,MS-DRG,,case rate,295% Medicare MS-DRG,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,108648.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,137392.25,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,127665.01,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,87311.46,200,MS-DRG,,case rate,200% Medicare MS-DRG,113386.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,43655.73,100,MS-DRG,,case rate,100% Medicare MS-DRG,37107.37,85,MS-DRG,,case rate,85% Medicare MS-DRG,37107.37,137392.25,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,52601.1,295,MS-DRG,,case rate,295% Medicare MS-DRG,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,53853.29,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,68100.42,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,63278.98,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,35661.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,39668.56,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,17830.88,100,MS-DRG,,case rate,100% Medicare MS-DRG,15156.25,85,MS-DRG,,case rate,85% Medicare MS-DRG,15156.25,68100.42,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,55149.22,295,MS-DRG,,case rate,295% Medicare MS-DRG,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,45487,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,57520.79,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,53448.37,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,37389.3,200,MS-DRG,,case rate,200% Medicare MS-DRG,48117.35,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,18694.65,100,MS-DRG,,case rate,100% Medicare MS-DRG,15890.45,85,MS-DRG,,case rate,85% Medicare MS-DRG,15890.45,57520.79,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,26239.39,295,MS-DRG,,case rate,295% Medicare MS-DRG,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,22234.74,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,28117.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,26126.38,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,17789.42,200,MS-DRG,,case rate,200% Medicare MS-DRG,22492.16,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,8894.71,100,MS-DRG,,case rate,100% Medicare MS-DRG,7560.5,85,MS-DRG,,case rate,85% Medicare MS-DRG,7560.5,28117.04,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,16597.82,295,MS-DRG,,case rate,295% Medicare MS-DRG,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,16280.35,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,20587.39,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19129.82,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,11252.76,200,MS-DRG,,case rate,200% Medicare MS-DRG,13946.03,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,5626.38,100,MS-DRG,,case rate,100% Medicare MS-DRG,4782.42,85,MS-DRG,,case rate,85% Medicare MS-DRG,4782.42,20587.39,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,27222.16,295,MS-DRG,,case rate,295% Medicare MS-DRG,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,23610.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,29856.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27742.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,18455.7,200,MS-DRG,,case rate,200% Medicare MS-DRG,23363.27,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,9227.85,100,MS-DRG,,case rate,100% Medicare MS-DRG,7843.67,85,MS-DRG,,case rate,85% Medicare MS-DRG,7843.67,29856.48,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,89097.64,295,MS-DRG,,case rate,295% Medicare MS-DRG,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,69323.4,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,87663.21,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,81456.74,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,60405.18,200,MS-DRG,,case rate,200% Medicare MS-DRG,78208.64,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,30202.59,100,MS-DRG,,case rate,100% Medicare MS-DRG,25672.2,85,MS-DRG,,case rate,85% Medicare MS-DRG,8175.25,89097.64,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,47136.28,295,MS-DRG,,case rate,295% Medicare MS-DRG,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,34614.59,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,43772.04,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,40673.02,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,31956.8,200,MS-DRG,,case rate,200% Medicare MS-DRG,41014.82,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,15978.4,100,MS-DRG,,case rate,100% Medicare MS-DRG,13581.64,85,MS-DRG,,case rate,85% Medicare MS-DRG,10978.25,47136.28,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,31300.3,295,MS-DRG,,case rate,295% Medicare MS-DRG,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,25061.19,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,31691.24,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,29447.53,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,21220.54,200,MS-DRG,,case rate,200% Medicare MS-DRG,26978.05,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,10610.27,100,MS-DRG,,case rate,100% Medicare MS-DRG,9018.73,85,MS-DRG,,case rate,85% Medicare MS-DRG,9018.73,31691.24,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,63714.96,295,MS-DRG,,case rate,295% Medicare MS-DRG,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,47258.24,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,59760.62,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,55529.63,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,43196.58,200,MS-DRG,,case rate,200% Medicare MS-DRG,55709.88,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,21598.29,100,MS-DRG,,case rate,100% Medicare MS-DRG,18358.55,85,MS-DRG,,case rate,85% Medicare MS-DRG,18358.55,63714.96,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,32450.56,295,MS-DRG,,case rate,295% Medicare MS-DRG,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,23610.28,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,29856.48,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,27742.67,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,22000.38,200,MS-DRG,,case rate,200% Medicare MS-DRG,27997.65,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,11000.19,100,MS-DRG,,case rate,100% Medicare MS-DRG,9350.16,85,MS-DRG,,case rate,85% Medicare MS-DRG,9350.16,32450.56,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,20971.87,295,MS-DRG,,case rate,295% Medicare MS-DRG,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,16864.49,100,MS-DRG,,case rate,100% Highmark BCBS ACA DRG,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,21326.06,100,MS-DRG,,case rate,100% Highmark BCBS PPO DRG,19816.2,100,MS-DRG,,case rate,100% Highmark BCBS Trad DRG,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,14218.22,200,MS-DRG,,case rate,200% Medicare MS-DRG,17823.14,100,MS-DRG,,case rate,100% The Health Plan DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,7109.11,100,MS-DRG,,case rate,100% Medicare MS-DRG,6042.74,85,MS-DRG,,case rate,85% Medicare MS-DRG,6042.74,21326.06,
1  LIVER  TRANSPLANT  &/OR  INTESTINAL  TRANSPLANT,11,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70765.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64332.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64332.11,70765.32,
2  LIVER  TRANSPLANT  WOR  INTESTINAL  TRANSPLANT,12,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76326.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69387.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69387.42,76326.16,
3  LIVER  TRANSPLANT  84/OR  INTESTINAL  TRANSPLANT,13,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79682.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72438.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72438.52,79682.37,
4  LIVER  TRANSPLANT  WOR  INTESTINAL  TRANSPLANT,14,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,146094.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132813.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,132813.16,146094.48,
1  HEART  WOR  LUNG  TRANSPLANT,21,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83503.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75912.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75912.7,83503.97,
2  HEART  at/OR  LUNG  TRANSPLANT,22,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,107589.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97808.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,97808.96,107589.86,
3  HEART  WOR  LUNG  TRANSPLANT,23,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139776.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127069.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,127069.48,139776.43,
4  HEART  84/OR  LUNG  TRANSPLANT,24,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,196138.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178307.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,178307.29,196138.02,
1  TRACHEOSTOMY  W  MV  96+  HOURS  W  EXTENSIVE  PROCEDURE,41,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58071.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52792.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52792.4,58071.64,
2  TRACHEOSTOMY  W  MV  96+  HOURS  W  EXTENSIVE  PROCEDURE,42,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72583.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65984.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65984.95,72583.45,
3  TRACHEOSTOMY  W  MV  96+  HOURS  W  EXTENSIVE  PROCEDURE,43,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94639.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86036.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86036.21,94639.83,
TRACHEOSTOMY  W  MV  96+  HOURS  W  EXTENSIVE  PROCEDURE,44,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131045.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119132.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119132.3,131045.53,
TRACHEOSTOMY  W  MV  96+  HOURS  W/O  EXTENSIVE  PROCEDURE,51,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49116.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44651.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44651.58,49116.74,
TRACHEOSTOMY  W  MV  96+  HOURS  W/O  EXTENSIVE  PROCEDURE,52,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54575.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49613.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49613.66,54575.03,
3  TRACHEOSTOMY  W  MV  96+  HOURS  W/O  EXTENSIVE  PROCEDURE,53,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68655.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62413.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62413.97,68655.37,
4   TRACHEOSTOMY  W  MV  96+  HOURS  W/O  EXTENSIVE  PROCEDURE,54,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88060.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80055.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80055.17,88060.69,
1  PANCREAS  TRANSPLANT,61,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75561.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68691.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68691.86,75561.05,
2  PANCREAS  TRANSPLANT,62,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77495.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70450.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70450.82,77495.9,
3  PANCREAS  TRANSPLANT,63,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85488.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77716.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77716.83,85488.51,
4   PANCREAS  TRANSPLANT,64,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,122726.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111569.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,111569.42,122726.36,
1  ALLOGENEIC  BONE  MARROW  TRANSPLANT,71,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80017.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72743.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72743.27,80017.6,
2  ALLOGENEIC  BONE  MARROW  TRANSPLANT,72,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87171.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79247.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79247.05,87171.76,
3  ALLOGENEIC  BONE  MARROW  TRANSPLANT,73,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120173.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109248.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109248.29,120173.12,
ALLOGENEIC  BONE  MARROW  TRANSPLANT,74,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,186787.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169807.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,169807.21,186787.93,
AUTOLOGOUS  BONE  MARROW  TRANSPLANT  OR  T-CELL  IMMUNOTHERAFI,81,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40422.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36748.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36748.1,40422.91,
AUTOLOGOUS  BONE  MARROW  TRANSPLANT  OR  T-CELL  IMMUNOTHERAF,82,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47969.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43608.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43608.25,47969.08,
3  AUTOLOGOUS  BONE  MARROW  TRANSPLANT  OR  T-CELL  IMMUNOTHERAF,83,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62879.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57163.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57163.63,62879.99,
AUTOLOGOUS  BONE  MARROW  TRANSPLANT  OR  T-CELL  IMMUNOTHERAF,84,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99870.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90791.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,90791.78,99870.96,
EXTRACORPOREAL  MEMBRANE  OXYGENATION  (ECMO),91,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51008.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46371.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46371.81,51008.99,
2  EXTRACORPOREAL  MEMBRANE  OXYGENATION  (ECMO),92,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56676.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51523.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51523.92,56676.31,
3  EXTRACORPOREAL  MEMBRANE  OXYGENATION  (ECMO),93,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80058.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72780.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72780.56,80058.62,
4   EXTRACORPOREAL  MEMBRANE  OXYGENATION  (ECMO),94,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,141263.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128421.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128421.14,141263.25,
OPEN  CRANIOTOMY  FOR  TRAUMA,201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19985.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18168.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18168.25,19985.08,
OPEN  CRANIOTOMY  FOR  TRAUMA,202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24518.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22289.22,24518.14,
OPEN  CRANIOTOMY  FOR  TRAUMA,203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31642.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28765.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28765.74,31642.31,
OPEN  CRANIOTOMY  FOR  TRAUMA,204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52817.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48016.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48016.04,52817.64,
OPEN  CRANIOTOMY  EXCEPT  TRAUMA,211,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18635.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16941.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16941.34,18635.47,
OPEN  CRANIOTOMY  EXCEPT  TRAUMA,212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25594.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23268.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23268.01,25594.81,
OPEN  CRANIOTOMY  EXCEPT  TRAUMA,213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37289.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33899.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33899.92,37289.91,
OPEN  CRANIOTOMY  EXCEPT  TRAUMA,214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62167.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56516.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56516.12,62167.73,
1  VENTRICULAR  SHUNT  PROCEDURES,221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11569.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10517.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10517.89,11569.68,
2  VENTRICULAR  SHUNT  PROCEDURES,222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14200.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12909.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12909.3,14200.23,
3  VENTRICULAR  SHUNT  PROCEDURES,223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21927.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19934.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19934.38,21927.82,
4   VENTRICULAR  SHUNT  PROCEDURES,224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56200.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51091.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51091.53,56200.68,
1  SPINAL  PROCEDURES,231,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13672.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12429.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12429.59,13672.55,
2  SPINAL  PROCEDURES,232,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18304.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16640.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16640.9,18304.99,
3  SPINAL  PROCEDURES,233,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31917.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29015.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29015.99,31917.59,
4 SPINAL  PROCEDURES,234,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56408.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51280.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51280.11,56408.12,
OPEN  EXTRACRANIAL  VASCULAR  PROCEDURES,241,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8700.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7909.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7909.22,8700.14,
OPEN  EXTRACRANIAL  VASCULAR  PROCEDURES,242,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11274.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10249.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10249.7,11274.67,
OPEN  EXTRACRANIAL  VASCULAR  PROCEDURES,243,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20309.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.96,20309.26,
OPEN  EXTRACRANIAL  VASCULAR  PROCEDURES,244,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37316.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33924.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33924.3,37316.73,
OTHER  NERVOUS  SYSTEM  &  RELATED  PROCEDURES,261,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12948.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11771.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11771.32,12948.45,
OTHER  NERVOUS  SYSTEM  &  RELATED  PROCEDURES,262,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17163.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15603.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15603.31,17163.64,
OTHER  NERVOUS  SYSTEM  &  RELATED  PROCEDURES,263,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23053.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20957.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20957.63,23053.39,
OTHER  NERVOUS  SYSTEM  &  RELATED  PROCEDURES,264,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44044.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40040.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40040.14,44044.15,
OTHER  OPEN  CRANIOTOMY,271,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14623.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13294.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13294.37,14623.81,
OTHER  OPEN  CRANIOTOMY,272,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18359.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16690.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16690.38,18359.42,
OTHER  OPEN  CRANIOTOMY,273,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25890.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23536.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23536.91,25890.6,
OTHER  OPEN  CRANIOTOMY,274,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54479.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49526.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49526.89,54479.58,
OTHER  PERCUTANEOUS  INTRACRANIAL  PROCEDURES,291,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16355.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14868.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14868.32,16355.15,
OTHER  PERCUTANEOUS  INTRACRANIAL  PROCEDURES,292,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18172.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16520.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16520.43,18172.47,
OTHER  PERCUTANEOUS  INTRACRANIAL  PROCEDURES,293,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24813.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22557.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22557.4,24813.14,
OTHER  PERCUTANEOUS  INTRACRANIAL  PROCEDURES,294,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43369.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39427.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39427.05,43369.76,
1  PERCUTANEOUS  INTRA  &  EXTRACRANIAL  VASCULAR  PROCEDURES,301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17022.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15474.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15474.96,17022.46,
2  PERCUTANEOUS  INTRA  &  EXTRACRANIAL  VASCULAR  PROCEDURES,302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23734.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21576.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21576.46,23734.11,
3  PERCUTANEOUS  INTRA  &  EXTRACRANIAL  VASCULAR  PROCEDURES,303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35674.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32431.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32431.37,35674.51,
4  PERCUTANEOUS  INTRA  8c  EXTRACRANIAL  VASCULAR  PROCEDURES,304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48587.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44170.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44170.43,48587.47,
1  SPINAL  DISORDERS  &  INJURIES,401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9518.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8652.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8652.81,9518.09,
2  SPINAL  DISORDERS  8c  INJURIES,402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11160.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10145.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10145.74,11160.31,
3  SPINAL  DISORDERS  &  INJURIES,403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17841.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16219.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16219.27,17841.2,
4   SPINAL  DISORDERS  &  INJURIES,404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31788.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28898.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28898.4,31788.24,
1  NERVOUS  SYSTEM  MALIGNANCY,411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7441.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6764.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6764.78,7441.26,
2  NERVOUS  SYSTEM  MALIGNANCY,412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8191.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7446.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7446.71,8191.38,
NERVOUS  SYSTEM  MALIGNANCY,413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10885.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9895.48,10885.03,
NERVOUS  SYSTEM  MALIGNANCY,414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17798.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16180.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16180.55,17798.61,
DEGENERATIVE  NERVOUS  SYSTEM  DISORDERS  EXC  MULT  SCLEROSIS,421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5953.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5412.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5412.4,5953.64,
2  DEGENERATIVE  NERVOUS  SYSTEM  DISORDERS  EXC  MULT  SCLEROSIS,422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7209.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6553.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6553.96,7209.36,
3  DEGENERATIVE  NERVOUS  SYSTEM  DISORDERS  EXC  MULT  SCLEROSIS,423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10915,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9922.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9922.73,10915,
4  DEGENERATIVE  NERVOUS  SYSTEM  DISORDERS  EXC  MULT  SCLEROSIS,424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26291.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23901.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23901.18,26291.3,
1  MULTIPLE  SCLEROSIS  &  OTHER  DEMYELINATING  DISEASES,431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7304.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6640.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6640.73,7304.8,
2  MULTIPLE  SCLEROSIS  &  OTHER  DEMYELINATING  DISEASES,432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9633.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8757.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8757.5,9633.25,
3  MULTIPLE  SCLEROSIS  &  OTHER  DEMYELINATING  DISEASES,433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15375.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13977.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13977.73,15375.5,
4   MULTIPLE  SCLEROSIS  &  OTHER  DEMYELINATING  DISEASES,434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29171.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26519.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26519.89,29171.88,
1  INTRACRANIAL  HEMORRHAGE,441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7228.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6571.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6571.17,7228.29,
2  INTRACRANIAL  HEMORRHAGE,442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9103.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8275.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8275.64,9103.2,
INTRACRANIAL  HEMORRHAGE,443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12462.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11329.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11329.61,12462.57,
INTRACRANIAL  HEMORRHAGE,444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18661.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16965.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16965.02,18661.52,
CVA  &  PRECEREBRAL  OCCLUSION  W  INFARCT,451,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6523.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5930.12,6523.13,
CVA  &  PRECEREBRAL  OCCLUSION  W  INFARCT,452,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8264.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7513.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7513.4,8264.74,
CVA  &  PRECEREBRAL  OCCLUSION  W  INFARCT,453,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12046.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10951.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10951.72,12046.89,
CVA  &  PRECEREBRAL  OCCLUSION  W  INFARCT,454,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21360.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19418.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19418.81,21360.69,
1  NONSPECIFIC  CVA  &  PRECEREBRAL  OCCLUSION  W/O  INFARCT,461,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6786.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6169.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6169.62,6786.58,
2  NONSPECIFIC  CVA  &  PRECEREBRAL  OCCLUSION  W/O  INFARCT,462,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7994.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7268.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7268.16,7994.98,
3  NONSPECIFIC  CVA  8c  PRECEREBRAL  OCCLUSION  W/O  INFARCT,463,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10174.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9249.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9249.41,10174.35,
4   NONSPECIFIC  CVA  &  PRECEREBRAL  OCCLUSION  W/O  INFARCT,464,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21680.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19709.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19709.93,21680.92,
1  TRANSIENT  ISCHEMIA,471,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5907.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5370.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5370.09,5907.1,
2  TRANSIENT  ISCHEMIA,472,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6578.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5980.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5980.31,6578.34,
3  TRANSIENT  ISCHEMIA,473,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8525.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7750.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7750.03,8525.03,
4 TRANSIENT  ISCHEMIA,474,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15099.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13726.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13726.76,15099.44,
"PERIPHERAL,  CRANIAL  &  AUTONOMIC  NERVE  DISORDERS",481,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5985.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5441.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5441.8,5985.98,
"2  PERIPHERAL,  CRANIAL  &  AUTONOMIC  NERVE  DISORDERS",482,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6600.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000.39,6600.43,
"PERIPHERAL,  CRANIAL  &  AUTONOMIC  NERVE  DISORDERS",483,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9141.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8310.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8310.77,9141.85,
"PERIPHERAL,  CRANIAL  &  AUTONOMIC  NERVE  DISORDERS",484,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21486.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19532.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19532.82,21486.1,
1  BACTERIAL  &  TUBERCULOUS  INFECTIONS  OF  NERVOUS  SYSTEM,491,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10635.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9668.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9668.89,10635.78,
2  BACTERIAL  &  TUBERCULOUS  INFECTIONS  OF  NERVOUS  SYSTEM,492,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17494.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15903.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15903.76,17494.14,
3  BACTERIAL  &  TUBERCULOUS  INFECTIONS  OF  NERVOUS  SYSTEM,493,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20430.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18573.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18573.39,20430.73,
4   BACTERIAL  &  TUBERCULOUS  INFECTIONS  OF  NERVOUS  SYSTEM,494,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39591.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35992.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35992.31,39591.54,
1  NON-BACTERIAL  INFECTIONS  OF  NERVOUS  SYSTEM  EXC  VIRAL  MENINGIT,501,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6065.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5514.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5514.22,6065.64,
2  NON-BACTERIAL  INFECTIONS  OF  NERVOUS  SYSTEM  EXC  VIRAL  MENINGIT,502,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12591.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11446.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11446.49,12591.14,
NON-BACTERIAL  INFECTIONS  OF  NERVOUS  SYSTEM  EXC  VIRAL  MENINGIT,503,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20616.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18741.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18741.9,20616.09,
NON-BACTERIAL  INFECTIONS  OF  NERVOUS  SYSTEM  EXC  VIRAL  MENINGIT,504,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42898.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38998.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38998.24,42898.06,
1  VIRAL  MENINGITIS,511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3732.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3393.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3393.15,3732.47,
2  VIRAL  MENINGITIS,512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6300.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5727.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5727.91,6300.7,
3  VIRAL  MENINGITIS,513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12354.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11231.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11231.37,12354.51,
4   VIRAL  MENINGITIS,514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26003.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23639.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23639.45,26003.4,
1  ALTERATION  IN  CONSCIOUSNESS,521,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5560.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5054.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5054.58,5560.04,
2  ALTERATION  IN  CONSCIOUSNESS,522,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6320.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5745.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5745.83,6320.41,
3  ALTERATION  IN  CONSCIOUSNESS,523,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8295.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7541.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7541.36,8295.5,
4   ALTERATION  IN  CONSCIOUSNESS,524,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19139.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17399.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17399.56,19139.52,
1  SEIZURE,531,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4905.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4459.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4459.42,4905.36,
2  SEIZURE,532,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6161.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5601.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5601.7,6161.87,
3  SEIZURE,533,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8322.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7565.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7565.74,8322.31,
4   SEIZURE,534,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21710.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19737.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19737.18,21710.9,
MIGRAINE  &  OTHER  HEADACHES,541,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4876.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4433.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4433.6,4876.96,
MIGRAINE  &  OTHER  HEADACHES,542,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5923.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5385.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5385.15,5923.67,
MIGRAINE  &  OTHER  HEADACHES,543,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7750.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7045.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7045.87,7750.46,
MIGRAINE  &  OTHER  HEADACHES,544,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16968.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15426.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15426.2,16968.82,
HEAD  TRAUMA  W  COMA  >1  HR  OR  HEMORRHAGE,551,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6396.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5815.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5815.39,6396.93,
2  HEAD  TRAUMA  W  COMA  >1  HR  OR  HEMORRHAGE,552,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8769.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7972.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7972.32,8769.55,
3  HEAD  TRAUMA  W  COMA  >1  HR  OR  HEMORRHAGE,553,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12953.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11775.63,12953.19,
4   HEAD  TRAUMA  W  COMA  >1  HR  OR  HEMORRHAGE,554,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26621.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24201.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24201.63,26621.79,
"1  BRAIN  CONTUSION/LACERATION  &  COMPLICATED  SKULL  FX,  COMA  <  1  H",561,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6145.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5586.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5586.65,6145.32,
"2  BRAIN  CONTUSION/LACERATION  &  COMPLICATED  SKULL  FX,  COMA  <  1  H",562,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8405.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7641.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7641.75,8405.93,
"3  BRAIN  CONTUSION/LACERATION  &  COMPLICATED  SKULL  FX,  COMA  <  1  H",563,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12438.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11307.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11307.38,12438.12,
"4  BRAIN  CONTUSION/LACERATION  &  COMPLICATED  SKULL  FX,  COMA  <  1  H",564,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24375.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22159.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22159.43,24375.37,
"CONCUSSION,  CLOSED  SKULL  FX  NOS,UNCOMPLICATED  INTRACRANIAL  IN",571,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5036.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4578.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4578.45,5036.3,
"CONCUSSION,  CLOSED  SKULL  FX  NOS,UNCOMPLICATED  INTRACRANIAL  IN",572,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7580.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6890.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6890.99,7580.09,
"CONCUSSION,  CLOSED  SKULL  FX  NOS,UNCOMPLICATED  INTRACRANIAL  IN",573,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10922.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9929.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9929.9,10922.89,
"CONCUSSION,  CLOSED  SKULL  FX  NOS,UNCOMPLICATED  INTRACRANIAL  IN",574,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19829.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18026.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18026.99,19829.69,
OTHER  DISORDERS  OF  NERVOUS  SYSTEM,581,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6099.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5545.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5545.06,6099.57,
OTHER  DISORDERS  OF  NERVOUS  SYSTEM,582,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7527.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6842.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6842.94,7527.23,
OTHER  DISORDERS  OF  NERVOUS  SYSTEM,583,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10765.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9786.49,10765.14,
OTHER  DISORDERS  OF  NERVOUS  SYSTEM,584,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22035.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20031.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20031.9,22035.09,
1  ANOXIC  &  OTHER  SEVERE  BRAIN  DAMAGE,591,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6343.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5766.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5766.63,6343.29,
2  ANOXIC  &  OTHER  SEVERE  BRAIN  DAMAGE,592,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8364.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7603.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7603.75,8364.13,
3  ANOXIC  &  OTHER  SEVERE  BRAIN  DAMAGE,593,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12598.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11452.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11452.95,12598.25,
4   ANOXIC  &  OTHER  SEVERE  BRAIN  DAMAGE,594,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20562.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18693.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18693.14,20562.45,
1 ORBIT  &  EYE  PROCEDURES,731,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8880.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8073.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8073.42,8880.76,
2  ORBIT  &  EYE  PROCEDURES,732,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11932.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10847.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10847.74,11932.51,
3  ORBIT  &  EYE  PROCEDURES,733,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19692.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17902.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17902.22,19692.44,
4   ORBIT  &  EYE  PROCEDURES,734,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43822.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39838.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39838.64,43822.5,
1  EYE  INFECTIONS  &  OTHER  EYE  DISORDERS,821,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4891.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4446.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4446.51,4891.16,
2  EYE  INFECTIONS  &  OTHER  EYE  DISORDERS,822,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6384.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5803.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5803.92,6384.31,
3  EYE  INFECTIONS  &  OTHER  EYE  DISORDERS,823,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9865.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8969.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8969.04,9865.94,
4   EYE  INFECTIONS  &  OTHER  EYE  DISORDERS,824,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26662.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24238.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24238.91,26662.8,
1  MAJOR  CRANIAL/FACIAL  BONE  PROCEDURES,891,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16239.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14763.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14763.63,16239.99,
2  MAJOR  CRANIAL/FACIAL  BONE  PROCEDURES,892,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21629.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19663.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19663.33,21629.66,
3  MAJOR  CRANIAL/FACIAL  BONE  PROCEDURES,893,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34750.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31591.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31591.69,34750.86,
4   MAJOR  CRANIAL/FACIAL  BONE  PROCEDURES,894,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60345.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54859.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54859.7,60345.67,
OTHER  MAJOR  HEAD  &  NECK  PROCEDURES,911,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12102.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11001.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11001.91,12102.1,
OTHER  MAJOR  HEAD  &  NECK  PROCEDURES,912,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19546.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17769.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17769.56,19546.52,
OTHER  MAJOR  HEAD  &  NECK  PROCEDURES,913,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34085.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30986.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30986.49,34085.14,
OTHER  MAJOR  HEAD  &  NECK  PROCEDURES,914,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64849.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58954.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58954.13,64849.54,
1  FACIAL  BONE  PROCEDURES  EXCEPT  MAJOR  CRANIAL/FACIAL  BONE  PROCE,921,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11023.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10021.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10021.69,11023.86,
2  FACIAL  BONE  PROCEDURES  EXCEPT  MAJOR  CRANIAL/FACIAL  BONE  PROCE,922,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15701.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14273.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14273.88,15701.27,
3  FACIAL  BONE  PROCEDURES  EXCEPT  MAJOR  CRANIAL/FACIAL  BONE  PROCE,923,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26868.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24426.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24426.07,26868.68,
4   FACIAL  BONE  PROCEDURES  EXCEPT  MAJOR  CRANIAL/FACIAL  BONE  PROC,924,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59344.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53949.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53949.74,59344.71,
CLEFT  LIP  &  PALATE  REPAIR,951,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7647.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6952.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6952.65,7647.92,
CLEFT  LIP  &  PALATE  REPAIR,952,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8965.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8150.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8150.87,8965.96,
CLEFT  LIP  &  PALATE  REPAIR,953,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13495.14,14844.65,
CLEFT  LIP  &  PALATE  REPAIR,954,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33255.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30232.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30232.14,33255.35,
1  TONSIL  &  ADENOID  PROCEDURES,971,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5272.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4792.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4792.85,5272.14,
2  TONSIL  &  ADENOID  PROCEDURES,972,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7556.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6869.47,7556.42,
3  TONSIL  &  ADENOID  PROCEDURES,973,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13200.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12000.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12000.07,13200.08,
4   TONSIL  &  ADENOID  PROCEDURES,974,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32173.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29249.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29249.04,32173.94,
"1  OTHER  EAR,  NOSE,  MOUTH  &  THROAT  PROCEDURES",981,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8992.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8175.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8175.25,8992.78,
"2  OTHER  EAR,  NOSE,  MOUTH  &  THROAT  PROCEDURES",982,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12076.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10978.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10978.25,12076.08,
"3  OTHER  EAR,  NOSE,  MOUTH  &  THROAT  PROCEDURES",983,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20922.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19020.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19020.84,20922.92,
"4   OTHER  EAR,  NOSE,  MOUTH  &  THROAT  PROCEDURES",984,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39454.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35867.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35867.54,39454.29,
"1  EAR,  NOSE,  MOUTH,  THROAT,  CRANIAL/FACIAL  MALIGNANCIES",1101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7879.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7163.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7163.47,7879.82,
"2  EAR,  NOSE,  MOUTH,  THROAT,  CRANIAL/FACIAL  MALIGNANCIES",1102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8970.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8155.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8155.17,8970.69,
"3  EAR,  NOSE,  MOUTH,  THROAT,  CRANIAL/FACIAL  MALIGNANCIES",1103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12793.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11630.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11630.06,12793.07,
"4   EAR,  NOSE,  MOUTH,  THROAT,  CRANIAL/FACIAL  MALIGNANCIES",1104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21722.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19747.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19747.93,21722.72,
1  VERTIGO  &  OTHER  LABYRINTH  DISORDERS,1111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5403.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4912.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4912.6,5403.86,
2  VERTIGO  &  OTHER  LABYRINTH  DISORDERS,1112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5885.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5350.73,5885.8,
3  VERTIGO  &  OTHER  LABYRINTH  DISORDERS,1113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7497.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6815.69,7497.26,
4   VERTIGO  &  OTHER  LABYRINTH  DISORDERS,1114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12063.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10966.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10966.78,12063.46,
1  INFECTIONS  OF  UPPER  RESPIRATORY  TRACT,1131,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3191.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2901.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2901.24,3191.36,
2  INFECTIONS  OF  UPPER  RESPIRATORY  TRACT,1132,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4670.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4245.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4245.74,4670.31,
INFECTIONS  OF  UPPER  RESPIRATORY  TRACT,1133,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7518.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6835.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6835.05,7518.56,
INFECTIONS  OF  UPPER  RESPIRATORY  TRACT,1134,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15714.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14286.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14286.07,15714.68,
1  DENTAL  DISEASES  &  DISORDERS,1141,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4037.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3670.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3670.65,4037.72,
2  DENTAL  DISEASES  &  DISORDERS,1142,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5690.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5173.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5173.62,5690.98,
3  DENTAL  DISEASES  &  DISORDERS,1143,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9801.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8910.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8910.24,9801.26,
4  DENTAL  DISEASES  &  DISORDERS,1144,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22886.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20805.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20805.61,22886.17,
"OTHER  EAR,  NOSE,  MOUTH,THROAT  &  CRANIAL/FACIAL  DIAGNOSES",1151,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4624.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4204.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4204.14,4624.55,
"OTHER  EAR,  NOSE,  MOUTH,THROAT  &  CRANIAL/FACIAL  DIAGNOSES",1152,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6411.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5828.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5828.3,6411.13,
"OTHER  EAR,  NOSE,  MOUTH,THROAT  &  CRANIAL/FACIAL  DIAGNOSES",1153,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10280.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9346.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9346.2,10280.82,
"OTHER  EAR,  NOSE,  MOUTH,THROAT  &  CRANIAL/FACIAL  DIAGNOSES",1154,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21042.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19129.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19129.12,21042.03,
MAJOR  RESPIRATORY  &  CHEST  PROCEDURES,1201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16420.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14927.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14927.84,16420.62,
MAJOR  RESPIRATORY  &  CHEST  PROCEDURES,1202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20098.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18271.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18271.5,20098.65,
3  MAJOR  RESPIRATORY  &  CHEST  PROCEDURES,1203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30634.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27849.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27849.33,30634.26,
MAJOR  RESPIRATORY  &  CHEST  PROCEDURES,1204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57406.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52187.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52187.92,57406.71,
OTHER  RESPIRATORY  &  CHEST  PROCEDURES,1211,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12268.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11153.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11153.21,12268.53,
OTHER  RESPIRATORY  &  CHEST  PROCEDURES,1212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15664.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14240.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14240.89,15664.98,
OTHER  RESPIRATORY  &  CHEST  PROCEDURES,1213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24876.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22614.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22614.76,24876.24,
OTHER  RESPIRATORY  &  CHEST  PROCEDURES,1214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45762.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41602.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41602.62,45762.88,
1  RESPIRATORY  SYSTEM  DIAGNOSIS  W  VENTILATOR  SUPPORT  96+  HOURS,1301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28909.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26281.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26281.11,28909.22,
2  RESPIRATORY  SYSTEM  DIAGNOSIS  W  VENTILATOR  SUPPORT  96+  HOURS,1302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32169.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29244.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29244.74,32169.21,
3  RESPIRATORY  SYSTEM  DIAGNOSIS  W  VENTILATOR  SUPPORT  96+  HOURS,1303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39255.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35686.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35686.83,39255.51,
4   RESPIRATORY  SYSTEM  DIAGNOSIS  W  VENTILATOR  SUPPORT  96+  HOURS,1304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51851.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47137.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47137.64,51851.4,
1  CYSTIC  FIBROSIS  -  PULMONARY  DISEASE,1311,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12180.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11073.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11073.62,12180.98,
2  CYSTIC  FIBROSIS  -  PULMONARY  DISEASE,1312,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18021.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16382.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16382.76,18021.04,
3  CYSTIC  FIBROSIS  -  PULMONARY  DISEASE,1313,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24201.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22001.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22001.67,24201.84,
4   CYSTIC  FIBROSIS  -  PULMONARY  DISEASE,1314,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35736.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32487.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32487.3,35736.03,
1  BPD  &  0TH  CHRONIC  RESPIRATORY  DISEASES  ARISING  IN  PERINATAL  PERI,1321,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4399.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3999.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3999.78,4399.76,
2  BPD  &  0TH  CHRONIC  RESPIRATORY  DISEASES  ARISING  IN  PERINATAL  PERI,1322,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6260.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.34,6260.47,
3  BPD  &  0TH  CHRONIC  RESPIRATORY  DISEASES  ARISING  IN  PERINATAL  PERI,1323,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11269.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10245.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10245.41,11269.95,
4   BPD  &  0TH  CHRONIC  RESPIRATORY  DISEASES  ARISING  IN  PERINATAL  PERI,1324,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18765.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17059.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17059.66,18765.63,
1  RESPIRATORY  FAILURE,1331,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4143.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3766.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3766.74,4143.41,
2  RESPIRATORY  FAILURE,1332,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6900.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6272.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6272.88,6900.17,
3  RESPIRATORY  FAILURE,1333,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10204.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9276.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9276.66,10204.33,
4  RESPIRATORY  FAILURE,1334,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17202.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15638.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15638.45,17202.3,
1  PULMONARY  EMBOLISM,1341,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5601.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5091.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5091.87,5601.06,
2  PULMONARY  EMBOLISM,1342,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7404.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6731.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6731.8,7404.98,
PULMONARY  EMBOLISM,1343,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10550.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9591.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9591.45,10550.6,
4 PULMONARY  EMBOLISM,1344,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15782.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14347.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14347.73,15782.5,
MAJOR  CHEST  &  RESPIRATORY  TRAUMA,1351,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6920.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6291.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6291.52,6920.67,
2  MAJOR  CHEST  &  RESPIRATORY  TRAUMA,1352,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7445.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6769.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6769.08,7445.99,
3  MAJOR  CHEST  &  RESPIRATORY  TRAUMA,1353,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11128.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10117.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10117.06,11128.77,
4   MAJOR  CHEST  &  RESPIRATORY  TRAUMA,1354,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19368.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17607.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17607.5,19368.25,
1  RESPIRATORY  MALIGNANCY,1361,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8093.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7357.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7357.79,8093.57,
2  RESPIRATORY  MALIGNANCY,1362,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8892.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8084.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8084.18,8892.6,
3  RESPIRATORY  MALIGNANCY,1363,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12159.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11054.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11054.26,12159.69,
4  RESPIRATORY  MALIGNANCY,1364,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17731.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16119.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16119.6,17731.56,
1  MAJOR  RESPIRATORY  INFECTIONS  &  INFLAMMATIONS,1371,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5985.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5441.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5441.8,5985.98,
2  MAJOR  RESPIRATORY  INFECTIONS  &  INFLAMMATIONS,1372,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7651.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6955.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6955.52,7651.07,
3  MAJOR  RESPIRATORY  INFECTIONS  &  INFLAMMATIONS,1373,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10973.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9975.79,10973.37,
4   MAJOR  RESPIRATORY  INFECTIONS  &  INFLAMMATIONS,1374,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16103.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14639.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14639.58,16103.54,
1  BRONCHIOLITIS  &  RSV  PNEUMONIA,1381,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3340.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3036.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3036.77,3340.45,
2  BRONCHIOLITIS  &  RSV  PNEUMONIA,1382,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4924.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4476.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4476.63,4924.29,
3  BRONCHIOLITIS  &  RSV  PNEUMONIA,1383,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8962.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8147.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8147.28,8962.01,
4   BRONCHIOLITIS  &  RSV  PNEUMONIA,1384,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19388.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17626.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17626.15,19388.77,
OTHER  PNEUMONIA,1391,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4173.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3793.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3793.99,4173.39,
OTHER  PNEUMONIA,1392,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5776.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5251.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5251.06,5776.17,
OTHER  PNEUMONIA,1393,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8575.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7795.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7795.92,8575.51,
OTHER  PNEUMONIA,1394,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13629.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12390.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12390.87,13629.96,
CHRONIC  OBSTRUCTIVE  PULMONARY  DISEASE,1401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4849.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4408.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4408.51,4849.36,
CHRONIC  OBSTRUCTIVE  PULMONARY  DISEASE,1402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6092.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5538.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5538.6,6092.46,
CHRONIC  OBSTRUCTIVE  PULMONARY  DISEASE,1403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7599.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6908.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6908.91,7599.8,
CHRONIC  OBSTRUCTIVE  PULMONARY  DISEASE,1404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11831.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10755.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10731.58,11831.56,
1  ASTHMA,1411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3732.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3393.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3393.15,3732.47,
2  ASTHMA,1412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5377.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4888.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4888.93,5377.82,
3  ASTHMA,1413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7666.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6969.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6969.86,7666.85,
4   ASTHMA,1414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13390.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12172.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12172.88,13390.17,
1  INTERSTITIAL  &  ALVEOLAR  LUNG  DISEASES,1421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5765.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5241.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5241.74,5765.91,
2  INTERSTITIAL  &  ALVEOLAR  LUNG  DISEASES,1422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7069.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6427.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6427.04,7069.74,
3  INTERSTITIAL  &  ALVEOLAR  LUNG  DISEASES,1423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8945.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8945.37,9839.91,
4  INTERSTITIAL  &  ALVEOLAR  LUNG  DISEASES,1424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15225.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13841.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13841.49,15225.64,
"OTHER  RESPIRATORY  DIAGNOSES  EXCEPT  SIGNS,  SYMPTOMS  &  MINOR  D",1431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4682.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4256.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4256.49,4682.14,
"OTHER  RESPIRATORY  DIAGNOSES  EXCEPT  SIGNS,  SYMPTOMS  &  MINOR  D",1432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6673.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6067.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6067.08,6673.79,
"OTHER  RESPIRATORY  DIAGNOSES  EXCEPT  SIGNS,  SYMPTOMS  &  MINOR  D",1433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10127.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9206.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9206.37,10127.01,
"OTHER  RESPIRATORY  DIAGNOSES  EXCEPT  SIGNS,  SYMPTOMS  &  MINOR  D",1434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15892.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14448.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14448.12,15892.93,
"1  RESPIRATORY  SIGNS,  SYMPTOMS  &  MINOR  DIAGNOSES",1441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4917.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4470.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4470.18,4917.2,
"2  RESPIRATORY  SIGNS,  SYMPTOMS  &  MINOR  DIAGNOSES",1442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6427.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5843.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5843.35,6427.69,
"RESPIRATORY  SIGNS,  SYMPTOMS  &  MINOR  DIAGNOSES",1443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9362.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8511.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8511.54,9362.69,
"RESPIRATORY  SIGNS,  SYMPTOMS  &  MINOR  DIAGNOSES",1444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15362.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13965.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13965.54,15362.09,
1  ACUTE  BRONCHITIS  &  RELATED  SYMPTOMS,1451,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4656.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4232.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4232.83,4656.11,
2  ACUTE  BRONCHITIS  &  RELATED  SYMPTOMS,1452,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5614.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5104.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5104.06,5614.47,
3  ACUTE  BRONCHITIS  &  RELATED  SYMPTOMS,1453,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7805.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7096.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7096.07,7805.68,
4   ACUTE  BRONCHITIS  &  RELATED  SYMPTOMS,1454,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13718.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12471.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12471.18,13718.3,
1  MAJOR  CARDIOTHORACIC  REPAIR  OF  HEART  ANOMALY,1601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33443.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30403.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30403.51,33443.86,
2  MAJOR  CARDIOTHORACIC  REPAIR  OF  HEART  ANOMALY,1602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38774.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35249.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35249.43,38774.37,
3  MAJOR  CARDIOTHORACIC  REPAIR  OF  HEART  ANOMALY,1603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55378.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50344.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50344.35,55378.79,
MAJOR  CARDIOTHORACIC  REPAIR  OF  HEART  ANOMALY,1604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,108855.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98959.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,98959.85,108855.84,
IMPLANTABLE  HEART  ASSIST  SYSTEMS,1612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116957.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106324.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106324.82,116957.3,
IMPLANTABLE  HEART  ASSIST  SYSTEMS,1613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,162032.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147302.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147302.16,162032.38,
IMPLANTABLE  HEART  ASSIST  SYSTEMS,1614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,202825.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184386.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,184386.55,202825.21,
CARDIAC  VALVE  PROCEDURES  W  AMI  OR  COMPLEX  PDX,1621,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42233.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38394.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38394.47,42233.92,
CARDIAC  VALVE  PROCEDURES  W  AMI  OR  COMPLEX  PDX,1622,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46573.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42339.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42339.76,46573.74,
CARDIAC  VALVE  PROCEDURES  W  AMI  OR  COMPLEX  PDX,1623,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62458,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56780,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56780,62458,
CARDIAC  VALVE  PROCEDURES  W  AMI  OR  COMPLEX  PDX,1624,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94364.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85785.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85785.95,94364.55,
CARDIAC  VALVE  PROCEDURES  W/O  AMI  OR  COMPLEX  PDX,1631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34347.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31225.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31225.27,34347.8,
CARDIAC  VALVE  PROCEDURES  W/O  AMI  OR  COMPLEX  PDX,1632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38004.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34549.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34549.58,38004.54,
CARDIAC  VALVE  PROCEDURES  W/O  AMI  OR  COMPLEX  PDX,1633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49694.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45177.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45177.18,49694.9,
CARDIAC  VALVE  PROCEDURES  W/O  AMI  OR  COMPLEX  PDX,1634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79405.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72186.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72186.83,79405.51,
CORONARY  BYPASS  W  AMI  OR  COMPLEX  PDX,1651,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32020.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29109.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29109.21,32020.13,
CORONARY  BYPASS  W  AMI  OR  COMPLEX  PDX,1652,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37074.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33704.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33704.16,37074.58,
CORONARY  BYPASS  W  AMI  OR  COMPLEX  PDX,1653,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47915.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43559.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43559.49,47915.44,
CORONARY  BYPASS  W  AMI  OR  COMPLEX  PDX,1654,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69576.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63251.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63251.5,69576.65,
CORONARY  BYPASS  W/O  AMI  OR  COMPLEX  PDX,1661,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28622.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26020.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26020.82,28622.9,
CORONARY  BYPASS  W/O  AMI  OR  COMPLEX  PDX,1662,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31636.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28760.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28760.72,31636.79,
CORONARY  BYPASS  W/O  AMI  OR  COMPLEX  PDX,1663,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39631.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36028.87,39631.76,
CORONARY  BYPASS  W/O  AMI  OR  COMPLEX  PDX,1664,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63252.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57502.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57502.08,63252.29,
OTHER  CARDIOTHORACIC  &  THORACIC  VASCULAR  PROCEDURES,1671,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28018.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25471.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25471.55,28018.71,
OTHER  CARDIOTHORACIC  &  THORACIC  VASCULAR  PROCEDURES,1672,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31648.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28771.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28771.48,31648.63,
OTHER  CARDIOTHORACIC  &  THORACIC  VASCULAR  PROCEDURES,1673,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39798.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36180.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36180.18,39798.2,
OTHER  CARDIOTHORACIC  &  THORACIC  VASCULAR  PROCEDURES,1674,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76912.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69920.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69920.19,76912.21,
1  MAJOR  ABDOMINAL  VASCULAR  PROCEDURES,1691,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17602.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16002,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16002,17602.2,
2  MAJOR  ABDOMINAL  VASCULAR  PROCEDURES,1692,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23138.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21035.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21035.07,23138.58,
3  MAJOR  ABDOMINAL  VASCULAR  PROCEDURES,1693,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36684.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33349.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33349.21,36684.13,
MAJOR  ABDOMINAL  VASCULAR  PROCEDURES,1694,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62214.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56558.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56558.42,62214.26,
"PERMANENT  CARDIAC  PACEMAKER  IMPLANT  W  AMI,  HEART  FAILURE  OR",1701,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18797.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17089.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17089.07,18797.98,
"2  PERMANENT  CARDIAC  PACEMAKER  IMPLANT  W  AMI,  HEART  FAILURE  OR",1702,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20550.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18682.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18682.39,20550.63,
"3  PERMANENT  CARDIAC  PACEMAKER  IMPLANT  W  AMI,  HEART  FAILURE  OR",1703,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26515.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24104.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24104.82,26515.3,
"4   PERMANENT  CARDIAC  PACEMAKER  IMPLANT  W  AMI,  HEART  FAILURE  OR",1704,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37888.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34444.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34444.17,37888.59,
"1  PERM  CARDIAC  PACEMAKER  IMPLANT  W/O  AMI,  HEART  FAILURE  OR  SHO",1711,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14623.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13294.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13294.37,14623.81,
"2  PERM  CARDIAC  PACEMAKER  IMPLANT  W/O  AMI,  HEART  FAILURE  OR  SHO",1712,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16815.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15287.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15287.09,16815.8,
"3  PERM  CARDIAC  PACEMAKER  IMPLANT  W/O  AMI,  HEART  FAILURE  OR  SHO",1713,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21150.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19228.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19228.07,21150.88,
"4   PERM  CARDIAC  PACEMAKER  IMPLANT  W/O  AMI,  HEART  FAILURE  OR  SHO",1714,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34197.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31088.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31088.31,34197.14,
1  PERCUTANEOUS  CARDIAC  INTERVENTION  W  AMI,1741,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16907.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15370.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15370.27,16907.3,
2  PERCUTANEOUS  CARDIAC  INTERVENTION  W  AMI,1742,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19029.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17299.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17299.16,19029.08,
3  PERCUTANEOUS  CARDIAC  INTERVENTION  W  AMI,1743,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24516.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22287.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22287.78,24516.56,
PERCUTANEOUS  CARDIAC  INTERVENTION  W  AMI,1744,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34607.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31461.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31461.18,34607.3,
1  PERCUTANEOUS  CARDIAC  INTERVENTION  W/O  AMI,1751,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20011.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18191.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18191.91,20011.1,
2  PERCUTANEOUS  CARDIAC  INTERVENTION  W/O  AMI,1752,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21635.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19668.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19668.34,21635.17,
3  PERCUTANEOUS  CARDIAC  INTERVENTION  W/O  AMI,1753,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26679.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24253.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24253.97,26679.37,
4   PERCUTANEOUS  CARDIAC  INTERVENTION  W/O  AMI,1754,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40787.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37079.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37079.37,40787.31,
"1  INSERTION,  REVISION  &  REPLACEMENTS  OF  PACEMAKER  &  OTHER  CARDI",1761,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16513.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15012.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15012.45,16513.7,
"2  INSERTION,  REVISION  &  REPLACEMENTS  OF  PACEMAKER  &  OTHER  CARDI",1762,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19944.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18131.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18131.68,19944.85,
"3  INSERTION,  REVISION  &  REPLACEMENTS  OF  PACEMAKER  &  OTHER  CARDI",1763,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29645.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26950.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26950.13,29645.14,
"4   INSERTION,  REVISION  &  REPLACEMENTS  OF  PACEMAKER  &  OTHER  CARDI",1764,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50114.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45558.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45558.66,50114.53,
CARDIAC  PACEMAKER  &  DEFIBRILLATOR  REVISION  EXCEPT  DEVICE  REPLA(,1771,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11881.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10801.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10801.14,11881.25,
CARDIAC  PACEMAKER  &  DEFIBRILLATOR  REVISION  EXCEPT  DEVICE  REPLA(,1772,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17074.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15522.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15522.28,17074.51,
CARDIAC  PACEMAKER  &  DEFIBRILLATOR  REVISION  EXCEPT  DEVICE  REPLA(,1773,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21198.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19271.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19271.81,21198.99,
CARDIAC  PACEMAKER  &  DEFIBRILLATOR  REVISION  EXCEPT  DEVICE  REPLA(,1774,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30876.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28069.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28069.47,30876.42,
1  EXTERNAL  HEART  ASSIST  SYSTEMS,1781,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45170.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41064.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41064.1,45170.51,
2  EXTERNAL  HEART  ASSIST  SYSTEMS,1782,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48575.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44159.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44159.67,48575.64,
3  EXTERNAL  HEART  ASSIST  SYSTEMS,1783,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55866.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50787.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50787.49,55866.24,
4  EXTERNAL  HEART  ASSIST  SYSTEMS,1784,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80175.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72886.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72886.69,80175.36,
1  DEFIBRILLATOR  IMPLANTS,1791,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35275.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32068.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32068.54,35275.39,
2  DEFIBRILLATOR  IMPLANTS,1792,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38893.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35357.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35357.71,38893.48,
3  DEFIBRILLATOR  IMPLANTS,1793,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46205.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42004.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42004.89,46205.38,
4  DEFIBRILLATOR  IMPLANTS,1794,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64182.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58347.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58347.5,64182.25,
OTHER  CIRCULATORY  SYSTEM  PROCEDURES,1801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11400.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10363.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10363.73,11400.1,
OTHER  CIRCULATORY  SYSTEM  PROCEDURES,1802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14374.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13067.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13067.77,14374.55,
OTHER  CIRCULATORY  SYSTEM  PROCEDURES,1803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20585.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18713.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18713.93,20585.32,
OTHER  CIRCULATORY  SYSTEM  PROCEDURES,1804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37553.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34139.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34139.42,37553.36,
1  LOWER  EXTREMITY  ARTERIAL  PROCEDURES,1811,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13449.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12226.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12226.66,13449.33,
2  LOWER  EXTREMITY  ARTERIAL  PROCEDURES,1812,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18927.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17206.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17206.66,18927.33,
LOWER  EXTREMITY  ARTERIAL  PROCEDURES,1813,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30534.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27758.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27758.26,30534.09,
LOWER  EXTREMITY  ARTERIAL  PROCEDURES,1814,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49724.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45204.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45204.43,49724.87,
OTHER  PERIPHERAL  VASCULAR  PROCEDURES,1821,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22222.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20201.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20201.84,22222.02,
OTHER  PERIPHERAL  VASCULAR  PROCEDURES,1822,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22555.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20505.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20505.16,22555.68,
OTHER  PERIPHERAL  VASCULAR  PROCEDURES,1823,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25549.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23227.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23227.14,25549.85,
OTHER  PERIPHERAL  VASCULAR  PROCEDURES,1824,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47776.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43433.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43433.28,47776.61,
1  PERCUTANEOUS  STRUCTURAL  CARDIAC  PROCEDURES,1831,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40662.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36966.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36966.08,40662.69,
2  PERCUTANEOUS  STRUCTURAL  CARDIAC  PROCEDURES,1832,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42708.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38826.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38826.15,42708.77,
PERCUTANEOUS  STRUCTURAL  CARDIAC  PROCEDURES,1833,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50758.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46143.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46143.79,50758.17,
PERCUTANEOUS  STRUCTURAL  CARDIAC  PROCEDURES,1834,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75002.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68184.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68184.17,75002.59,
ACUTE  MYOCARDIAL  INFARCTION,1901,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6206.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5642.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5642.58,6206.84,
2  ACUTE  MYOCARDIAL  INFARCTION,1902,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7543.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6857.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6857.28,7543.01,
3  ACUTE  MYOCARDIAL  INFARCTION,1903,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10403.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9457.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9457.36,10403.1,
4   ACUTE  MYOCARDIAL  INFARCTION,1904,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15653.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14230.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14230.14,15653.15,
CARDIAC  CATHETERIZATION  FOR  CORONARY  ARTERY  DISEASE,1911,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8649.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7863.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7863.32,8649.65,
CARDIAC  CATHETERIZATION  FOR  CORONARY  ARTERY  DISEASE,1912,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10052.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9138.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9138.98,10052.88,
CARDIAC  CATHETERIZATION  FOR  CORONARY  ARTERY  DISEASE,1913,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13191.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11992.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11992.18,13191.4,
CARDIAC  CATHETERIZATION  FOR  CORONARY  ARTERY  DISEASE,1914,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19546.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17769.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17769.56,19546.52,
CARDIAC  CATHETERIZATION  FOR  OTHER  NON-CORONARY  CONDITIONS,1921,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9353.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8502.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8502.94,9353.23,
CARDIAC  CATHETERIZATION  FOR  OTHER  NON-CORONARY  CONDITIONS,1922,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11508.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10461.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10461.95,11508.15,
CARDIAC  CATHETERIZATION  FOR  OTHER  NON-CORONARY  CONDITIONS,1923,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16820.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15291.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15291.39,16820.53,
CARDIAC  CATHETERIZATION  FOR  OTHER  NON-CORONARY  CONDITIONS,1924,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27549.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25044.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25044.89,27549.38,
ACUTE  &  SUBACUTE  ENDOCARDITIS,1931,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7944.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7222.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7222.27,7944.5,
ACUTE  &  SUBACUTE  ENDOCARDITIS,1932,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9599.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8726.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8726.67,9599.34,
3  ACUTE  &  SUBACUTE  ENDOCARDITIS,1933,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14631.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13301.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13301.54,14631.69,
ACUTE  &  SUBACUTE  ENDOCARDITIS,1934,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23212.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21102.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21102.48,23212.73,
HEART  FAILURE,1941,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4692.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4265.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4265.81,4692.39,
2  HEART  FAILURE,1942,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6202.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5638.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5638.27,6202.1,
3  HEART  FAILURE,1943,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8971.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8155.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8155.89,8971.48,
4  HEART  FAILURE,1944,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14675.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13340.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13340.98,14675.08,
CARDIAC  ARREST  &  SHOCK,1961,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4133.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3758.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3758.13,4133.94,
CARDIAC  ARREST  &  SHOCK,1962,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5247.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4770.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4770.63,5247.69,
CARDIAC  ARREST  &  SHOCK,1963,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7988.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7262.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7262.42,7988.66,
CARDIAC  ARREST  &  SHOCK,1964,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15702.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14275.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14275.31,15702.84,
1  PERIPHERAL  &  OTHER  VASCULAR  DISORDERS,1971,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5037.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4579.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4579.17,5037.09,
2  PERIPHERAL  &  OTHER  VASCULAR  DISORDERS,1972,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6575.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5978.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5978.16,6575.98,
3  PERIPHERAL  &  OTHER  VASCULAR  DISORDERS,1973,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9127.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8297.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8297.86,9127.65,
4   PERIPHERAL  &  OTHER  VASCULAR  DISORDERS,1974,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17884.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16258.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16258.71,17884.58,
1  ANGINA  PECTORIS  &  CORONARY  ATHEROSCLEROSIS,1981,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4824.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4385.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4385.56,4824.12,
2  ANGINA  PECTORIS  &  CORONARY  ATHEROSCLEROSIS,1982,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5559.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5053.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5053.87,5559.26,
3  ANGINA  PECTORIS  &  CORONARY  ATHEROSCLEROSIS,1983,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7270.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6609.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6609.9,7270.89,
4   ANGINA  PECTORIS  &  CORONARY  ATHEROSCLEROSIS,1984,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13216.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12015.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12015.12,13216.63,
1  HYPERTENSION,1991,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4790.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4354.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4354.72,4790.19,
2  HYPERTENSION,1992,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5543.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5039.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5039.53,5543.48,
3  HYPERTENSION,1993,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7356.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6687.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6687.34,7356.07,
4  HYPERTENSION,1994,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13189.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11990.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11990.03,13189.03,
CARDIAC  STRUCTURAL  &  VALVULAR  DISORDERS,2001,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5368.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4880.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4880.34,5368.37,
CARDIAC  STRUCTURAL  &  VALVULAR  DISORDERS,2002,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6566.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5969.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5969.56,6566.52,
CARDIAC  STRUCTURAL  &  VALVULAR  DISORDERS,2003,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9854.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8958.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8958.28,9854.11,
CARDIAC  STRUCTURAL  &  VALVULAR  DISORDERS,2004,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20514.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18649.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18649.4,20514.34,
CARDIAC  ARRHYTHMIA  &  CONDUCTION  DISORDERS,2011,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4230.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3846.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3846.33,4230.96,
CARDIAC  ARRHYTHMIA  &  CONDUCTION  DISORDERS,2012,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5541.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5037.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5037.37,5541.11,
CARDIAC  ARRHYTHMIA  &  CONDUCTION  DISORDERS,2013,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8175.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7432.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7432.37,8175.61,
CARDIAC  ARRHYTHMIA  &  CONDUCTION  DISORDERS,2014,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14650.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13318.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13318.75,14650.63,
CHEST  PAIN,2031,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5264.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4785.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4785.68,5264.25,
CHEST  PAIN,2032,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5737.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5215.92,5737.51,
CHEST  PAIN,2033,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6971.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6338.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6338.13,6971.94,
CHEST  PAIN,2034,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10567.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9607.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9607.21,10567.93,
1  SYNCOPE  &  COLLAPSE,2041,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5720.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5200.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5200.87,5720.96,
2  SYNCOPE  &  COLLAPSE,2042,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5732.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5732.21,6305.43,
3  SYNCOPE  &  COLLAPSE,2043,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7789.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7081.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7081.72,7789.89,
4 SYNCOPE  &  COLLAPSE,2044,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13484.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12258.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12258.21,13484.03,
CARDIOMYOPATHY,2051,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5442.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4947.74,5442.51,
2  CARDIOMYOPATHY,2052,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6150.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5590.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5590.95,6150.05,
3  CARDIOMYOPATHY,2053,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10317.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9379.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9379.91,10317.9,
4   CARDIOMYOPATHY,2054,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25123.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22839.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22839.21,25123.13,
"1  MALFUNCTION,REACTION,COMPLICATION  OF  CARDIAC/VASC  DEVICE  OR",2061,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7178.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6526,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6526,7178.6,
"2  MALFUNCTION,REACTION,COMPLICATION  OF  CARDIAC/VASC  DEVICE  OR",2062,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7229.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6571.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6571.89,7229.08,
"3  MALFUNCTION,REACTION,COMPLICATION  OF  CARDIAC/VASC  DEVICE  OR",2063,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10850.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9863.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9863.93,10850.32,
"4   MALFUNCTION,REACTION,COMPLICATION  OF  CARDIAC/VASC  DEVICE  OR",2064,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21607.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19643.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19643.25,21607.58,
OTHER  CIRCULATORY  SYSTEM  DIAGNOSES,2071,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5310.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4827.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4827.99,5310.79,
OTHER  CIRCULATORY  SYSTEM  DIAGNOSES,2072,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6640.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6036.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6036.96,6640.66,
OTHER  CIRCULATORY  SYSTEM  DIAGNOSES,2073,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9124.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8295,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8295,9124.5,
OTHER  CIRCULATORY  SYSTEM  DIAGNOSES,2074,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18469.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16790.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16790.77,18469.85,
"MAJOR  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12778.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11617.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11617.15,12778.87,
"MAJOR  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18969.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17244.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17244.66,18969.13,
"3  MAJOR  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30517.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27743.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27743.21,30517.53,
"4   MAJOR  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55928.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50844.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50844.14,55928.55,
"OTHER  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6588.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5989.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5989.64,6588.6,
"OTHER  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11482.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10438.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10438.29,11482.12,
"OTHER  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18242.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16584.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16584.25,18242.68,
"OTHER  STOMACH,  ESOPHAGEAL  &  DUODENAL  PROCEDURES",2224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38598.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35089.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35089.53,38598.48,
OTHER  SMALL  &  LARGE  BOWEL  PROCEDURES,2231,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9477.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8616.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8616.24,9477.86,
OTHER  SMALL  &  LARGE  BOWEL  PROCEDURES,2232,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13677.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12433.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12433.89,13677.28,
OTHER  SMALL  &  LARGE  BOWEL  PROCEDURES,2233,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21762.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19783.8,21762.18,
OTHER  SMALL  &  LARGE  BOWEL  PROCEDURES,2234,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38118.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34653.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34653.55,38118.91,
1  PERITONEAL  ADHESIOLYSIS,2241,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11574.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10522.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10522.2,11574.42,
2  PERITONEAL  ADHESIOLYSIS,2242,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14778.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13434.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13434.91,14778.4,
PERITONEAL  ADHESIOLYSIS,2243,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22198.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20180.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20180.33,22198.36,
4 PERITONEAL  ADHESIOLYSIS,2244,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38462.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34965.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34965.47,38462.02,
1  ANAL  PROCEDURES,2261,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7779.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7072.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7072.4,7779.64,
2  ANAL  PROCEDURES,2262,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11307.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10279.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10279.11,11307.02,
3  ANAL  PROCEDURES,2263,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15799.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14362.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14362.79,15799.07,
4   ANAL  PROCEDURES,2264,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32645.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29677.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29677.84,32645.62,
"1  HERNIA  PROCEDURES  EXCEPT  INGUINAL,  FEMORAL  &  UMBILICAL",2271,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10404.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9458.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9458.79,10404.67,
"2  HERNIA  PROCEDURES  EXCEPT  INGUINAL,  FEMORAL  &  UMBILICAL",2272,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13428.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12208.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12208.01,13428.81,
"3  HERNIA  PROCEDURES  EXCEPT  INGUINAL,  FEMORAL  &  UMBILICAL",2273,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20910.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19009.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19009.37,20910.31,
"HERNIA  PROCEDURES  EXCEPT  INGUINAL,  FEMORAL  &  UMBILICAL",2274,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38921.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35382.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35382.81,38921.09,
"INGUINAL,  FEMORAL  &  UMBILICAL  HERNIA  PROCEDURES",2281,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7782.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7074.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7074.55,7782.01,
"2  INGUINAL,  FEMORAL  &  UMBILICAL  HERNIA  PROCEDURES",2282,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10520.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9564.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9564.2,10520.62,
"INGUINAL,  FEMORAL  &  UMBILICAL  HERNIA  PROCEDURES",2283,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15243.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13857.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13857.98,15243.78,
"INGUINAL,  FEMORAL  &  UMBILICAL  HERNIA  PROCEDURES",2284,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32243.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29312.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29312.14,32243.35,
OTHER  DIGESTIVE  SYSTEM  &  ABDOMINAL  PROCEDURES,2291,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10264.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9331.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9331.15,10264.27,
OTHER  DIGESTIVE  SYSTEM  &  ABDOMINAL  PROCEDURES,2292,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13638.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12398.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12398.75,13638.63,
OTHER  DIGESTIVE  SYSTEM  &  ABDOMINAL  PROCEDURES,2293,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20026.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18205.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18205.54,20026.09,
OTHER  DIGESTIVE  SYSTEM  &  ABDOMINAL  PROCEDURES,2294,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37397.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33998.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33998.16,37397.98,
1  MAJOR  SMALL  BOWEL  PROCEDURES,2301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12279.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11163.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11163.25,12279.58,
2  MAJOR  SMALL  BOWEL  PROCEDURES,2302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17197.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15634.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15634.15,17197.57,
3  MAJOR  SMALL  BOWEL  PROCEDURES,2303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26505.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24096.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24096.22,26505.84,
4   MAJOR  SMALL  BOWEL  PROCEDURES,2304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50732.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46120.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46120.12,50732.13,
MAJOR  LARGE  BOWEL  PROCEDURES,2311,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12454.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11322.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11322.44,12454.68,
MAJOR  LARGE  BOWEL  PROCEDURES,2312,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16270.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14791.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14791.6,16270.76,
3  MAJOR  LARGE  BOWEL  PROCEDURES,2313,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25439.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23126.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23126.75,25439.43,
MAJOR  LARGE  BOWEL  PROCEDURES,2314,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43551.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39592.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39592.69,43551.96,
GASTRIC  FUNDOPLICATION,2321,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9815.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8923.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8923.14,9815.45,
2  GASTRIC  FUNDOPLICATION,2322,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13051.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11865.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11865.26,13051.79,
3  GASTRIC  FUNDOPLICATION,2323,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19929.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18118.06,19929.87,
4   GASTRIC  FUNDOPLICATION,2324,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54981.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49982.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49982.95,54981.25,
1  APPENDECTOMY  WITH  COMPLEX  PRINCIPAL  DIAGNOSIS,2331,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9527.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8661.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8661.42,9527.56,
2  APPENDECTOMY  WITH  COMPLEX  PRINCIPAL  DIAGNOSIS,2332,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12486.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11351.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11351.12,12486.23,
3  APPENDECTOMY  WITH  COMPLEX  PRINCIPAL  DIAGNOSIS,2333,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19508.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17735.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17735.14,19508.65,
4   APPENDECTOMY  WITH  COMPLEX  PRINCIPAL  DIAGNOSIS,2334,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33316.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30288.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30288.07,33316.88,
1  APPENDECTOMY  WITHOUT  COMPLEX  PRINCIPAL  DIAGNOSIS,2341,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6873.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6248.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6248.5,6873.35,
2  APPENDECTOMY  WITHOUT  COMPLEX  PRINCIPAL  DIAGNOSIS,2342,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9554.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8685.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8685.79,9554.37,
3  APPENDECTOMY  WITHOUT  COMPLEX  PRINCIPAL  DIAGNOSIS,2343,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15846.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14405.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14405.82,15846.4,
4   APPENDECTOMY  WITHOUT  COMPLEX  PRINCIPAL  DIAGNOSIS,2344,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26027.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23660.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23660.96,26027.06,
1  DIGESTIVE  MALIGNANCY,2401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7430.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.74,7430.21,
2  DIGESTIVE  MALIGNANCY,2402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8259.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7508.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7508.38,8259.22,
3  DIGESTIVE  MALIGNANCY,2403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11737.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10670.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10670.63,11737.69,
4  DIGESTIVE  MALIGNANCY,2404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20764.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18876.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18876.71,20764.38,
1  PEPTIC  ULCER  &  GASTRITIS,2411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5815.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5286.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5286.91,5815.6,
2  PEPTIC  ULCER  &  GASTRITIS,2412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7242.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6584.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6584.08,7242.49,
PEPTIC  ULCER  &  GASTRITIS,2413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10739.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9763.54,10739.89,
4   PEPTIC  ULCER  &  GASTRITIS,2414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22821.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20746.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20746.81,22821.49,
1  MAJOR  ESOPHAGEAL  DISORDERS,2421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5310,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4827.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4827.27,5310,
2  MAJOR  ESOPHAGEAL  DISORDERS,2422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6911.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6282.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6282.91,6911.2,
3  MAJOR  ESOPHAGEAL  DISORDERS,2423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10076.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9160.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9160.49,10076.54,
4   MAJOR  ESOPHAGEAL  DISORDERS,2424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22091.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20083.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20083.53,22091.88,
OTHER  ESOPHAGEAL  DISORDERS,2431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5056.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4597.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4597.1,5056.81,
OTHER  ESOPHAGEAL  DISORDERS,2432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6463.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5876.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5876.34,6463.97,
OTHER  ESOPHAGEAL  DISORDERS,2433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9673.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8794.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8794.07,9673.48,
OTHER  ESOPHAGEAL  DISORDERS,2434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20970.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19063.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19063.86,20970.25,
1  DIVERTICULITIS  &  DIVERTICULOSIS,2441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4669.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4245.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4245.02,4669.52,
2  DIVERTICULITIS  &  DIVERTICULOSIS,2442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5732.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5732.21,6305.43,
3  DIVERTICULITIS  &  DIVERTICULOSIS,2443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9828.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8935.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8935.33,9828.86,
4   DIVERTICULITIS  &  DIVERTICULOSIS,2444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19522.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17747.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17747.33,19522.06,
1  INFLAMMATORY  BOWEL  DISEASE,2451,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5621.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5110.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5110.52,5621.57,
2  INFLAMMATORY  BOWEL  DISEASE,2452,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7326.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6660.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6660.81,7326.89,
INFLAMMATORY  BOWEL  DISEASE,2453,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11194.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10176.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10176.57,11194.23,
INFLAMMATORY  BOWEL  DISEASE,2454,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24676.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22433.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22433.35,24676.69,
GASTROINTESTINAL  VASCULAR  INSUFFICIENCY,2461,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5621.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5110.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5110.52,5621.57,
GASTROINTESTINAL  VASCULAR  INSUFFICIENCY,2462,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6935.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6305.14,6935.65,
GASTROINTESTINAL  VASCULAR  INSUFFICIENCY,2463,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10568.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9607.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9607.94,10568.73,
GASTROINTESTINAL  VASCULAR  INSUFFICIENCY,2464,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18870.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17155.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17155.04,18870.54,
1  INTESTINAL  OBSTRUCTION,2471,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4387.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3988.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3988.31,4387.14,
2  INTESTINAL  OBSTRUCTION,2472,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5911.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5374.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5374.39,5911.83,
3  INTESTINAL  OBSTRUCTION,2473,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9537.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8670.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8670.74,9537.81,
4  INTESTINAL  OBSTRUCTION,2474,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18417,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16742.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16742.73,18417,
1  MAJOR  GASTROINTESTINAL  &  PERITONEAL  INFECTIONS,2481,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4912.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4465.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4465.87,4912.46,
2  MAJOR  GASTROINTESTINAL  &  PERITONEAL  INFECTIONS,2482,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6825.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6204.75,6825.23,
3  MAJOR  GASTROINTESTINAL  &  PERITONEAL  INFECTIONS,2483,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10109.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9190.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9190.61,10109.67,
4   MAJOR  GASTROINTESTINAL  &  PERITONEAL  INFECTIONS,2484,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21272.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19338.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19338.5,21272.35,
"OTHER  GASTROENTERITIS,  NAUSEA  &  VOMITING",2491,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4250.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3864.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3864.26,4250.69,
"OTHER  GASTROENTERITIS,  NAUSEA  &  VOMITING",2492,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5234.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4758.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4758.43,5234.27,
"OTHER  GASTROENTERITIS,  NAUSEA  &  VOMITING",2493,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7959.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7235.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7235.89,7959.48,
"OTHER  GASTROENTERITIS,  NAUSEA  &  VOMITING",2494,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17642.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16038.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16038.57,17642.43,
1  ABDOMINAL  PAIN,2511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4752.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320.31,4752.34,
2  ABDOMINAL  PAIN,2512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5466.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5466.9,6013.59,
3  ABDOMINAL  PAIN,2513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8058.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7325.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7325.53,8058.08,
4   ABDOMINAL  PAIN,2514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14885.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13532.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13532.43,14885.67,
"1  MALFUNCTION,  REACTION  &  COMPLICATION  OF  GI  DEVICE  OR  PROCEDU",2521,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.35,5332.09,
"2  MALFUNCTION,  REACTION  &  COMPLICATION  OF  GI  DEVICE  OR  PROCEDUI",2522,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6878.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6252.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6252.8,6878.08,
"3  MALFUNCTION,  REACTION  &  COMPLICATION  OF  GI  DEVICE  OR  PROCEDUI",2523,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10598.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9635.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9635.19,10598.71,
"4   MALFUNCTION,  REACTION  &  COMPLICATION  OF  GI  DEVICE  OR  PROCEDUI",2524,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23170.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21064.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21064.47,23170.92,
OTHER  &  UNSPECIFIED  GASTROINTESTINAL  HEMORRHAGE,2531,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5372.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4883.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4883.92,5372.31,
OTHER  &  UNSPECIFIED  GASTROINTESTINAL  HEMORRHAGE,2532,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6933.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6302.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6302.99,6933.29,
OTHER  &  UNSPECIFIED  GASTROINTESTINAL  HEMORRHAGE,2533,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10225.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9296.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9296.02,10225.62,
OTHER  &  UNSPECIFIED  GASTROINTESTINAL  HEMORRHAGE,2534,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18664.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16967.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16967.89,18664.68,
OTHER  DIGESTIVE  SYSTEM  DIAGNOSES,2541,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4849.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4408.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4408.51,4849.36,
OTHER  DIGESTIVE  SYSTEM  DIAGNOSES,2542,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6485.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5895.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5895.7,6485.27,
OTHER  DIGESTIVE  SYSTEM  DIAGNOSES,2543,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9839.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8945.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8945.37,9839.91,
OTHER  DIGESTIVE  SYSTEM  DIAGNOSES,2544,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19603.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17821.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17821.18,19603.3,
"1  MAJOR  PANCREAS,  LIVER  &  SHUNT  PROCEDURES",2601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17255.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15686.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15686.49,17255.14,
"2  MAJOR  PANCREAS,  LIVER  &  SHUNT  PROCEDURES",2602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21407.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19461.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19461.12,21407.23,
"3  MAJOR  PANCREAS,  LIVER  &  SHUNT  PROCEDURES",2603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32399.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29454.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29454.12,32399.53,
"MAJOR  PANCREAS,  LIVER  &  SHUNT  PROCEDURES",2604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64474.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58612.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58612.81,64474.09,
MAJOR  BILIARY  TRACT  PROCEDURES,2611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12418.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11289.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11289.46,12418.41,
MAJOR  BILIARY  TRACT  PROCEDURES,2612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18911.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17192.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17192.33,18911.56,
3  MAJOR  BILIARY  TRACT  PROCEDURES,2613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27889.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25353.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25353.95,27889.35,
MAJOR  BILIARY  TRACT  PROCEDURES,2614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54638.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49671.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49671.02,54638.12,
CHOLECYSTECTOMY,2631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9574.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8704.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8704.44,9574.88,
CHOLECYSTECTOMY,2632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12527.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11388.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11388.41,12527.25,
CHOLECYSTECTOMY,2633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16854.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15322.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15322.22,16854.44,
CHOLECYSTECTOMY,2634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32603.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29639.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29639.12,32603.03,
"OTHER  HEPATOBILIARY,  PANCREAS  &  ABDOMINAL  PROCEDURES",2641,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13408.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12189.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12189.37,13408.31,
"OTHER  HEPATOBILIARY,  PANCREAS  &  ABDOMINAL  PROCEDURES",2642,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14612.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13284.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13284.33,14612.76,
"OTHER  HEPATOBILIARY,  PANCREAS  &  ABDOMINAL  PROCEDURES",2643,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23188.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21080.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21080.25,23188.28,
"OTHER  HEPATOBILIARY,  PANCREAS  &  ABDOMINAL  PROCEDURES",2644,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57797.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52542.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52542.86,57797.15,
1  HEPATIC  COMA  &  OTHER  MAJOR  ACUTE  LIVER  DISORDERS,2791,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4498.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4089.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4089.42,4498.36,
2  HEPATIC  COMA  &  OTHER  MAJOR  ACUTE  LIVER  DISORDERS,2792,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6180.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5618.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5618.2,6180.02,
HEPATIC  COMA  &  OTHER  MAJOR  ACUTE  LIVER  DISORDERS,2793,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9467.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8606.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8606.92,9467.61,
HEPATIC  COMA  &  OTHER  MAJOR  ACUTE  LIVER  DISORDERS,2794,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22506.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20460.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20460.7,22506.77,
ALCOHOLIC  LIVER  DISEASE,2801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4579.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4163.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4163.27,4579.6,
2  ALCOHOLIC  LIVER  DISEASE,2802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5897.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5361.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5361.49,5897.64,
3  ALCOHOLIC  LIVER  DISEASE,2803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9083.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8257.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8257.7,9083.47,
4   ALCOHOLIC  LIVER  DISEASE,2804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20463.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18602.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18602.79,20463.07,
1  MALIGNANCY  OF  HEPATOBILIARY  SYSTEM  &  PANCREAS,2811,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6662.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6057.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6057.04,6662.74,
2  MALIGNANCY  OF  HEPATOBILIARY  SYSTEM  gt  PANCREAS,2812,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8465.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7696.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7696.25,8465.88,
3  MALIGNANCY  OF  HEPATOBILIARY  SYSTEM  &  PANCREAS,2813,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11083.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10075.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10075.46,11083.01,
MALIGNANCY  OF  HEPATOBILIARY  SYSTEM  &  PANCREAS,2814,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18282.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16620.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16620.83,18282.91,
DISORDERS  OF  PANCREAS  EXCEPT  MALIGNANCY,2821,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4564.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4149.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4149.64,4564.6,
2  DISORDERS  OF  PANCREAS  EXCEPT  MALIGNANCY,2822,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6153.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5594.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5594.53,6153.98,
DISORDERS  OF  PANCREAS  EXCEPT  MALIGNANCY,2823,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10278.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9344.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9344.06,10278.47,
DISORDERS  OF  PANCREAS  EXCEPT  MALIGNANCY,2824,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25285.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22986.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22986.92,25285.61,
1  OTHER  DISORDERS  OF  THE  LIVER,2831,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4976.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4523.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4523.96,4976.36,
2  OTHER  DISORDERS  OF  THE  LIVER,2832,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6286.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5715,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5715,6286.5,
OTHER  DISORDERS  OF  THE  LIVER,2833,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9464.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8604.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8604.04,9464.44,
4   OTHER  DISORDERS  OF  THE  LIVER,2834,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20219.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18381.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18381.22,20219.34,
1  DISORDERS  OF  GALLBLADDER  &  BILIARY  TRACT,2841,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6237.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5670.54,6237.59,
2  DISORDERS  OF  GALLBLADDER  &  BILIARY  TRACT,2842,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7846.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7133.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7133.35,7846.69,
3  DISORDERS  OF  GALLBLADDER  &  BILIARY  TRACT,2843,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11203.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10185.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10185.18,11203.7,
4   DISORDERS  OF  GALLBLADDER  &  BILIARY  TRACT,2844,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20945.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19041.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19041.63,20945.79,
1  HIP  JOINT  REPLACEMENT,3011,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13833.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12575.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12575.87,13833.46,
2  HIP  JOINT  REPLACEMENT,3012,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14658.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13325.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13325.92,14658.51,
3  HIP  JOINT  REPLACEMENT,3013,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20999.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19090.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19090.39,20999.43,
4 HIP  JOINT  REPLACEMENT,3014,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31072.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28248.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28248.02,31072.82,
1  KNEE  JOINT  REPLACEMENT,3021,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12680.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11527.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11527.52,12680.27,
2  KNEE  JOINT  REPLACEMENT,3022,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14319.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13017.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13017.58,14319.34,
3  KNEE  JOINT  REPLACEMENT,3023,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20383.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18530.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18530.37,20383.41,
4 KNEE  JOINT  REPLACEMENT,3024,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32258.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29325.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29325.77,32258.35,
1  DORSAL  &  LUMBAR  FUSION  PROC  FOR  CURVATURE  OF  BACK,3031,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39728.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36117.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36117.08,39728.79,
2  DORSAL  &  LUMBAR  FUSION  PROC  FOR  CURVATURE  OF  BACK,3032,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49270.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44791.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44791.4,49270.54,
3  DORSAL  &  LUMBAR  FUSION  PROC  FOR  CURVATURE  OF  BACK,3033,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71451.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64955.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64955.96,71451.56,
DORSAL  &  LUMBAR  FUSION  PROC  FOR  CURVATURE  OF  BACK,3034,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88679.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80618.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80618.07,88679.88,
1  DORSAL  &  LUMBAR  FUSION  PROC  EXCEPT  FOR  CURVATURE  OF  BACK,3041,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24171.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21974.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21974.43,24171.87,
2  DORSAL  &  LUMBAR  FUSION  PROC  EXCEPT  FOR  CURVATURE  OF  BACK,3042,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29469.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26790.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26790.23,29469.25,
3  DORSAL  &  LUMBAR  FUSION  PROC  EXCEPT  FOR  CURVATURE  OF  BACK,3043,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45899.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41726.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41726.67,45899.34,
DORSAL  &  LUMBAR  FUSION  PROC  EXCEPT  FOR  CURVATURE  OF  BACK,3044,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,70030.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63663.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63663.81,70030.19,
1  AMPUTATION  OF  LOWER  LIMB  EXCEPT  TOES,3051,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8783.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7985.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7985.22,8783.74,
2  AMPUTATION  OF  LOWER  LIMB  EXCEPT  TOES,3052,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12536.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11397.02,12536.72,
3  AMPUTATION  OF  LOWER  LIMB  EXCEPT  TOES,3053,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20308.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.25,20308.48,
4   AMPUTATION  OF  LOWER  LIMB  EXCEPT  TOES,3054,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41385.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37622.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37622.91,41385.2,
1  HIP  &  FEMUR  FRACTURE  REPAIR,3081,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11752.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10684.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10684.25,11752.68,
2  HIP  &  FEMUR  FRACTURE  REPAIR,3082,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13892.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12629.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12629.65,13892.62,
3  HIP  &  FEMUR  FRACTURE  REPAIR,3083,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18225.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16568.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16568.48,18225.33,
HIP  &  FEMUR  FRACTURE  REPAIR,3084,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28177.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25615.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25615.68,28177.25,
1  OTHER  SIGNIFICANT  HIP  &  FEMUR  SURGERY,3091,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12687.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11533.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11533.97,12687.37,
2  OTHER  SIGNIFICANT  HIP  &  FEMUR  SURGERY,3092,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16573.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15066.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15066.95,16573.65,
3  OTHER  SIGNIFICANT  HIP  &  FEMUR  SURGERY,3093,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22945.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20859.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20859.39,22945.33,
4   OTHER  SIGNIFICANT  HIP  &  FEMUR  SURGERY,3094,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39652.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36047.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36047.51,39652.26,
1  INTERVERTEBRAL  DISC  EXCISION  &  DECOMPRESSION,3101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10083.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9166.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9166.95,10083.65,
2  INTERVERTEBRAL  DISC  EXCISION  &  DECOMPRESSION,3102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12886.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11715.39,12886.93,
3  INTERVERTEBRAL  DISC  EXCISION  &  DECOMPRESSION,3103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17872.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16247.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16247.95,17872.75,
INTERVERTEBRAL  DISC  EXCISION  &  DECOMPRESSION,3104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35642.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32401.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32401.97,35642.17,
"1  SKIN  GRAFT,  EXCEPT  HAND,  FOR  MUSCULOSKELETAL  &  CONNECTIVE  TISS",3121,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11409.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10372.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10372.33,11409.56,
"2  SKIN  GRAFT,  EXCEPT  HAND,  FOR  MUSCULOSKELETAL  &  CONNECTIVE  TISS",3122,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15859.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14418.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14418.01,15859.81,
"3  SKIN  GRAFT,  EXCEPT  HAND,  FOR  MUSCULOSKELETAL  &  CONNECTIVE  TISS",3123,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26345.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23950.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23950.65,26345.72,
"4   SKIN  GRAFT,  EXCEPT  HAND,  FOR  MUSCULOSKELETAL  &  CONNECTIVE  TISS",3124,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58371.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53064.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53064.89,58371.38,
1  KNEE  &  LOWER  LEG  PROCEDURES  EXCEPT  FOOT,3131,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10625.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9659.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9659.57,10625.53,
2  KNEE  &  LOWER  LEG  PROCEDURES  EXCEPT  FOOT,3132,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14320.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13018.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13018.3,14320.13,
3  KNEE  &  LOWER  LEG  PROCEDURES  EXCEPT  FOOT,3133,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21003.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19093.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19093.98,21003.38,
KNEE  &  LOWER  LEG  PROCEDURES  EXCEPT  FOOT,3134,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35889.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32627.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32627.13,35889.84,
1  FOOT  &  TOE  PROCEDURES,3141,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10248.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9316.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9316.81,10248.49,
2  FOOT  &  TOE  PROCEDURES,3142,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10354.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9412.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9412.9,10354.19,
3  FOOT  &  TOE  PROCEDURES,3143,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14813.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13467.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13467.18,14813.9,
4 FOOT  &  TOE  PROCEDURES,3144,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29078.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26434.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26434.56,29078.02,
"1  SHOULDER,  UPPER  ARM  &  FOREARM  PROCEDURES  EXCEPT  JOINT  REPLACI",3151,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8045.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7314.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7314.05,8045.46,
"2  SHOULDER,  UPPER  ARM  &  FOREARM  PROCEDURES  EXCEPT  JOINT  REPLAC",3152,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13008.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11825.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11825.82,13008.4,
"3  SHOULDER,  UPPER  ARM  &  FOREARM  PROCEDURES  EXCEPT  JOINT  REPLAC",3153,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18980.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17254.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17254.71,18980.18,
"4   SHOULDER,  UPPER  ARM  &  FOREARM  PROCEDURES  EXCEPT  JOINT  REPLAC",3154,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33284.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30258.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30258.67,33284.54,
1  HAND  &  WRIST  PROCEDURES,3161,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7719.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7017.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7017.91,7719.7,
2  HAND  &  WRIST  PROCEDURES,3162,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10157.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9234.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9234.35,10157.79,
3  HAND  &  WRIST  PROCEDURES,3163,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16470.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14973.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14973.01,16470.31,
4 HAND  &  WRIST  PROCEDURES,3164,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35023.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31839.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31839.79,35023.77,
"1  TENDON,  MUSCLE  &  OTHER  SOFT  TISSUE  PROCEDURES",3171,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8749.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7953.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7953.67,8749.04,
"2  TENDON,  MUSCLE  &  OTHER  SOFT  TISSUE  PROCEDURES",3172,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11826.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10751.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10751.66,11826.83,
"3  TENDON,  MUSCLE  &  OTHER  SOFT  TISSUE  PROCEDURES",3173,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18891.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17174.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17174.4,18891.84,
"4   TENDON,  MUSCLE  &  OTHER  SOFT  TISSUE  PROCEDURES",3174,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37596.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34178.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34178.86,37596.75,
1  OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  PROCEDURES,3201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9597.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8725.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8725.23,9597.75,
2  OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  PROCEDURES,3202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13499.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12272.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12272.55,13499.81,
3  OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  PROCEDURES,3203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20714.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18831.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18831.53,20714.68,
4   OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  PROCEDURES,3204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36288.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32989.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32989.25,36288.18,
1  CERVICAL  SPINAL  FUSION  &  OTHER  BACK/NECK  PROC  EXC  DISC  EXCIS/DE(,3211,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15027.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13661.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13661.5,15027.65,
2  CERVICAL  SPINAL  FUSION  &  OTHER  BACK/NECK  PROC  EXC  DISC  EXCIS/DE(,3212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18884.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17167.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17167.95,18884.75,
CERVICAL  SPINAL  FUSION  &  OTHER  BACK/NECK  PROC  EXC  DISC  EXCIS/DE(,3213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28338.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25761.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25761.96,28338.16,
CERVICAL  SPINAL  FUSION  &  OTHER  BACK/NECK  PROC  EXC  DISC  EXCIS/DE(,3214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49070.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44609.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44609.99,49070.99,
1  SHOULDER  &  ELBOW  JOINT  REPLACEMENT,3221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14978.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13617.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13617.05,14978.76,
2  SHOULDER  &  ELBOW  JOINT  REPLACEMENT,3222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16761.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15237.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15237.61,16761.37,
SHOULDER  &  ELBOW  JOINT  REPLACEMENT,3223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22720.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20655.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20655.03,22720.53,
SHOULDER  &  ELBOW  JOINT  REPLACEMENT,3224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34110.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31009.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31009.43,34110.37,
FRACTURE  OF  FEMUR,3401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4127.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3752.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3752.4,4127.64,
2  FRACTURE  OF  FEMUR,3402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4936.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4487.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4487.39,4936.13,
3  FRACTURE  OF  FEMUR,3403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7448.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6771.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6771.24,7448.36,
4   FRACTURE  OF  FEMUR,3404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13581.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12346.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12346.41,13581.05,
1  FRACTURE  OF  PELVIS  OR  DISLOCATION  OF  HIP,3411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4694.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4267.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4267.96,4694.76,
2  FRACTURE  OF  PELVIS  OR  DISLOCATION  OF  HIP,3412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5529.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5026.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5026.62,5529.28,
3  FRACTURE  OF  PELVIS  OR  DISLOCATION  OF  HIP,3413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7110.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6464.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6464.33,7110.76,
4   FRACTURE  OF  PELVIS  OR  DISLOCATION  OF  HIP,3414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16766.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15241.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15241.91,16766.1,
"1  FRACTURES  &  DISLOCATIONS  EXCEPT  FEMUR,  PELVIS  &  BACK",3421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4952.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4502.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4502.43,4952.67,
"2  FRACTURES  &  DISLOCATIONS  EXCEPT  FEMUR,  PELVIS  &  BACK",3422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6053.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5503.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5503.47,6053.82,
"FRACTURES  &  DISLOCATIONS  EXCEPT  FEMUR,  PELVIS  &  BACK",3423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8624.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7840.38,8624.42,
"FRACTURES  &  DISLOCATIONS  EXCEPT  FEMUR,  PELVIS  &  BACK",3424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16641.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15128.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15128.62,16641.48,
MUSCULOSKELETAL  MALIGNANCY  &  PATHOL  FRACTURE  D/T  MUSCSKEL  N,3431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7722.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7020.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7020.77,7722.85,
2  MUSCULOSKELETAL  MALIGNANCY  &  PATHOL  FRACTURE  D/T  MUSCSKEL  N,3432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9083.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8257.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8257.7,9083.47,
3  MUSCULOSKELETAL  MALIGNANCY  &  PATHOL  FRACTURE  D/T  MUSCSKEL  N,3433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13525.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12296.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12296.21,13525.83,
4   MUSCULOSKELETAL  MALIGNANCY  &  PATHOL  FRACTURE  D/T  MUSCSKEL  N,3434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24093.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21903.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21903.44,24093.78,
"OSTEOMYELITIS,  SEPTIC  ARTHRITIS  &  OTHER  MUSCULOSKELETAL  INFECTI1",3441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6302.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5729.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5729.34,6302.27,
"OSTEOMYELITIS,  SEPTIC  ARTHRITIS  &  OTHER  MUSCULOSKELETAL  INFECT!'",3442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7918.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7198.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7198.61,7918.47,
"OSTEOMYELITIS,  SEPTIC  ARTHRITIS  &  OTHER  MUSCULOSKELETAL  INFECTI1",3443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11422.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10383.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10383.79,11422.17,
"OSTEOMYELITIS,  SEPTIC  ARTHRITIS  &  OTHER  MUSCULOSKELETAL  INFECT!'",3444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21610.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19646.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19646.12,21610.73,
CONNECTIVE  TISSUE  DISORDERS,3461,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6556.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5960.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5960.24,6556.26,
CONNECTIVE  TISSUE  DISORDERS,3462,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8540.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7763.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7763.65,8540.02,
CONNECTIVE  TISSUE  DISORDERS,3463,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13591.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12355.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12355.73,13591.3,
CONNECTIVE  TISSUE  DISORDERS,3464,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31023.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28202.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28202.84,31023.12,
"OTHER  BACK  &  NECK  DISORDERS,  FRACTURES  &  INJURIES",3471,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5923.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5385.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5385.15,5923.67,
"OTHER  BACK  &  NECK  DISORDERS,  FRACTURES  &  INJURIES",3472,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7063.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6421.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6421.31,7063.44,
"OTHER  BACK  &  NECK  DISORDERS,  FRACTURES  &  INJURIES",3473,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9489.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8627,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8627,9489.7,
"OTHER  BACK  &  NECK  DISORDERS,  FRACTURES  &  INJURIES",3474,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19638.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17852.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17852.74,19638.01,
"1  MALFUNCTION,  REACTION,  COMPLIC  OF  ORTHOPEDIC  DEVICE  OR  PROCEE",3491,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4650.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4227.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4227.81,4650.59,
"2  MALFUNCTION,  REACTION,  COMPLIC  OF  ORTHOPEDIC  DEVICE  OR  PROCEE",3492,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6659.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6054.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6054.17,6659.59,
"3  MALFUNCTION,  REACTION,  COMPLIC  OF  ORTHOPEDIC  DEVICE  OR  PROCEE",3493,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10035.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9123.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9123.2,10035.52,
"4   MALFUNCTION,  REACTION,  COMPLIC  OF  ORTHOPEDIC  DEVICE  OR  PROCEE",3494,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18210.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16554.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16554.86,18210.35,
OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  DIAGNOSES,3511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4903,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4457.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4457.27,4903,
OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  DIAGNOSES,3512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5775.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5250.34,5775.37,
OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  DIAGNOSES,3513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9652.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8774.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8774.7,9652.17,
OTHER  MUSCULOSKELETAL  SYSTEM  &  CONNECTIVE  TISSUE  DIAGNOSES,3514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18551.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16865.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16865.34,18551.87,
SKIN  GRAFT  FOR  SKIN  &  SUBCUTANEOUS  TISSUE  DIAGNOSES,3611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10253.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9321.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9321.11,10253.22,
SKIN  GRAFT  FOR  SKIN  &  SUBCUTANEOUS  TISSUE  DIAGNOSES,3612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11587.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11587.75,12746.53,
3  SKIN  GRAFT  FOR  SKIN  &  SUBCUTANEOUS  TISSUE  DIAGNOSES,3613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20887.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18988.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18988.57,20887.43,
4   SKIN  GRAFT  FOR  SKIN  &  SUBCUTANEOUS  TISSUE  DIAGNOSES,3614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48103.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43730.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43730.15,48103.17,
1  MASTECTOMY  PROCEDURES,3621,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9791.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8901.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8901.62,9791.78,
2  MASTECTOMY  PROCEDURES,3622,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12423.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11294.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11294.48,12423.93,
3  MASTECTOMY  PROCEDURES,3623,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16628.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15116.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15116.43,16628.07,
4   MASTECTOMY  PROCEDURES,3624,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32715.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29741.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29741.66,32715.83,
1  BREAST  PROCEDURES  EXCEPT  MASTECTOMY,3631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10215.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9286.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9286.7,10215.37,
2  BREAST  PROCEDURES  EXCEPT  MASTECTOMY,3632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13933.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12666.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12666.94,13933.63,
3  BREAST  PROCEDURES  EXCEPT  MASTECTOMY,3633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19805.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18004.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18004.75,19805.23,
BREAST  PROCEDURES  EXCEPT  MASTECTOMY,3634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24481.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22255.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22255.52,24481.07,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  RELATED  PROCEDURES",3641,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6801.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6183.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6183.24,6801.56,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  RELATED  PROCEDURES",3642,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10105.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9187.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9187.02,10105.72,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  RELATED  PROCEDURES",3643,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16490.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14990.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14990.94,16490.03,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  RELATED  PROCEDURES",3644,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33070.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30064.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30064.34,33070.77,
1  SKIN  ULCERS,3801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5158.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4689.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4689.6,5158.56,
2  SKIN  ULCERS,3802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6493.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5903.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5903.59,6493.95,
3  SKIN  ULCERS,3803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9417.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8561.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8561.74,9417.91,
4   SKIN  ULCERS,3804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19596.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17814.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17814.74,19596.21,
1  MAJOR  SKIN  DISORDERS,3811,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3928.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3571.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3571.7,3928.87,
2  MAJOR  SKIN  DISORDERS,3812,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6707.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6097.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6097.91,6707.7,
3  MAJOR  SKIN  DISORDERS,3813,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13488.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12262.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12262.51,13488.76,
4 MAJOR  SKIN  DISORDERS,3814,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34283.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31167.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31167.19,34283.91,
MALIGNANT  BREAST  DISORDERS,3821,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6195,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5631.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5631.82,6195,
MALIGNANT  BREAST  DISORDERS,3822,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7549.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6863.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6863.02,7549.32,
3  MALIGNANT  BREAST  DISORDERS,3823,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10844.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9858.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9858.2,10844.02,
4   MALIGNANT  BREAST  DISORDERS,3824,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17702.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16093.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16093.07,17702.38,
CELLULITIS  &  OTHER  SKIN  INFECTIONS,3831,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3984.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3621.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3621.89,3984.08,
CELLULITIS  &  OTHER  SKIN  INFECTIONS,3832,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5530.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5028.05,5530.86,
CELLULITIS  &  OTHER  SKIN  INFECTIONS,3833,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8476.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7706.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7706.29,8476.92,
CELLULITIS  &  OTHER  SKIN  INFECTIONS,3834,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17252.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15684.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15684.34,17252.77,
"CONTUSION,  OPEN  WOUND  &  OTHER  TRAUMA  TO  SKIN  &  SUBCUTANE01",3841,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5020.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4564.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4564.1,5020.51,
"CONTUSION,  OPEN  WOUND  &  OTHER  TRAUMA  TO  SKIN  &  SUBCUTANE01",3842,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6453.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5867.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5867.02,6453.72,
"CONTUSION,  OPEN  WOUND  &  OTHER  TRAUMA  TO  SKIN  &  SUBCUTANE01",3843,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9869.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8972.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8972.62,9869.88,
"CONTUSION,  OPEN  WOUND  &  OTHER  TRAUMA  TO  SKIN  &  SUBCUTANE01",3844,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18282.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16620.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16620.83,18282.91,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  BREAST  DISORDERS",3851,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3979.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3617.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3617.59,3979.35,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  BREAST  DISORDERS",3852,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5535.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5032.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5032.35,5535.59,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  &  BREAST  DISORDERS",3853,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8746.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7951.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7951.52,8746.67,
"OTHER  SKIN,  SUBCUTANEOUS  TISSUE  gt  BREAST  DISORDERS",3854,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19179.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17436.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17436.13,19179.74,
1  ADRENAL  PROCEDURES,4011,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12748.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11589.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11589.91,12748.9,
2  ADRENAL  PROCEDURES,4012,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22706.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20642.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20642.12,22706.33,
3  ADRENAL  PROCEDURES,4013,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27465.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24968.89,27465.78,
4   ADRENAL  PROCEDURES,4014,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40620.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36928.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36928.08,40620.89,
1  PROCEDURES  FOR  OBESITY,4031,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9261.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8419.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8419.77,9261.75,
2  PROCEDURES  FOR  OBESITY,4032,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11302.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10274.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10274.81,11302.29,
3  PROCEDURES  FOR  OBESITY,4033,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17999.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16363.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16363.4,17999.74,
4  PROCEDURES  FOR  OBESITY,4034,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55486.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50442.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50442.58,55486.84,
"THYROID,  PARATHYROID  8c  THYROGLOSSAL  PROCEDURES",4041,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8496.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7724.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7724.21,8496.63,
"THYROID,  PARATHYROID  &  THYROGLOSSAL  PROCEDURES",4042,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12951.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11774.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11774.19,12951.61,
"3  THYROID,  PARATHYROID  &  THYROGLOSSAL  PROCEDURES",4043,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21147.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19225.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19225.2,21147.72,
"THYROID,  PARATHYROID  8c  THYROGLOSSAL  PROCEDURES",4044,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49093.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44630.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44630.06,49093.07,
"OTHER  PROCEDURES  FOR  ENDOCRINE,  NUTRITIONAL  &  METABOLIC  DISO",4051,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12864.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11694.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11694.6,12864.06,
"OTHER  PROCEDURES  FOR  ENDOCRINE,  NUTRITIONAL  &  METABOLIC  DISO",4052,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16161.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14692.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14692.64,16161.9,
"OTHER  PROCEDURES  FOR  ENDOCRINE,  NUTRITIONAL  &  METABOLIC  DISO",4053,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23845.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21677.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21677.56,23845.32,
"OTHER  PROCEDURES  FOR  ENDOCRINE,  NUTRITIONAL  &  METABOLIC  DISO",4054,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50878.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46253.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46253.5,50878.85,
1  DIABETES,4201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4190.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3809.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3809.76,4190.74,
2  DIABETES,4202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5053.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4594.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4594.22,5053.64,
3  DIABETES,4203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7655.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6959.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6959.11,7655.02,
4  DIABETES,4204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16545.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15041.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15041.13,16545.24,
"1  MALNUTRITION,  FAILURE  TO  THRIVE  &  OTHER  NUTRITIONAL  DISORDERS",4211,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4409.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4008.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4008.39,4409.23,
"2  MALNUTRITION,  FAILURE  TO  THRIVE  &  OTHER  NUTRITIONAL  DISORDERS",4212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6292.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5720.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5720.74,6292.81,
"3  MALNUTRITION,  FAILURE  TO  THRIVE  &  OTHER  NUTRITIONAL  DISORDERS",4213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10186.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9260.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9260.16,10186.18,
"4   MALNUTRITION,  FAILURE  TO  THRIVE  &  OTHER  NUTRITIONAL  DISORDERS",4214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22713.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20648.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20648.57,22713.43,
1  HYPOVOLEMIA  &  RELATED  ELECTROLYTE  DISORDERS,4221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3618.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3289.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3289.17,3618.09,
2  HYPOVOLEMIA  &  RELATED  ELECTROLYTE  DISORDERS,4222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4800.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4364.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4364.05,4800.46,
3  HYPOVOLEMIA  &  RELATED  ELECTROLYTE  DISORDERS,4223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7204.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6549.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6549.66,7204.63,
4  HYPOVOLEMIA  &  RELATED  ELECTROLYTE  DISORDERS,4224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14418.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13107.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13107.93,14418.72,
1  INBORN  ERRORS  OF  METABOLISM,4231,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10068.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9153.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9153.32,10068.65,
2  INBORN  ERRORS  OF  METABOLISM,4232,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11522.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10474.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10474.87,11522.36,
3  INBORN  ERRORS  OF  METABOLISM,4233,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17035.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15487.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15487.15,17035.87,
4   INBORN  ERRORS  OF  METABOLISM,4234,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58711.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53373.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53373.94,58711.33,
OTHER  ENDOCRINE  DISORDERS,4241,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5160.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4691.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4691.75,5160.93,
OTHER  ENDOCRINE  DISORDERS,4242,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6899.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6272.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6272.16,6899.38,
OTHER  ENDOCRINE  DISORDERS,4243,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10899.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9908.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9908.39,10899.23,
OTHER  ENDOCRINE  DISORDERS,4244,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23281.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21164.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21164.86,23281.35,
OTHER  NON-HYPOVOLEMIC  ELECTROLYTE  DISORDERS,4251,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4171.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3791.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3791.83,4171.01,
OTHER  NON-HYPOVOLEMIC  ELECTROLYTE  DISORDERS,4252,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5361.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4873.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4873.88,5361.27,
OTHER  NON-HYPOVOLEMIC  ELECTROLYTE  DISORDERS,4253,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7473.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6794.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6794.18,7473.6,
OTHER  NON-HYPOVOLEMIC  ELECTROLYTE  DISORDERS,4254,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15317.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13924.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13924.67,15317.14,
1  NON-HYPOVOLEMIC  SODIUM  DISORDERS,4261,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4499.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4090.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4090.85,4499.94,
2  NON-HYPOVOLEMIC  SODIUM  DISORDERS,4262,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5821.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5291.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5291.93,5821.12,
3  NON-HYPOVOLEMIC  SODIUM  DISORDERS,4263,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8676.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7887.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7887.7,8676.47,
4  NON-HYPOVOLEMIC  SODIUM  DISORDERS,4264,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17463.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15875.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15875.8,17463.38,
1  THYROID  DISORDERS,4271,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4432.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4029.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4029.9,4432.89,
2  THYROID  DISORDERS,4272,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6264.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5694.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5694.92,6264.41,
3  THYROID  DISORDERS,4273,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9805.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8913.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8913.82,9805.2,
4   THYROID  DISORDERS,4274,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19661.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17874.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17874.25,19661.68,
1  KIDNEY  TRANSPLANT,4401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46896.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42633.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42633.04,46896.34,
2  KIDNEY  TRANSPLANT,4402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50174.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45613.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45613.16,50174.48,
3  KIDNEY  TRANSPLANT,4403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57059.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51872.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51872.41,57059.65,
4  KIDNEY  TRANSPLANT,4404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88271.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80246.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80246.63,88271.29,
1  MAJOR  BLADDER  PROCEDURES,4411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12746.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11587.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11587.75,12746.53,
2  MAJOR  BLADDER  PROCEDURES,4412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20821.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18928.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18928.34,20821.17,
3  MAJOR  BLADDER  PROCEDURES,4413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28253.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25685.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25685.23,28253.75,
4   MAJOR  BLADDER  PROCEDURES,4414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60547.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55043.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55043.27,60547.6,
1  KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  MALIGNANCY,4421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12612.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11465.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11465.85,12612.44,
2  KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  MALIGNANCY,4422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14806.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13460.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13460.73,14806.8,
3  KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  MALIGNANCY,4423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23148.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21043.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21043.68,23148.05,
KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  MALIGNANCY,4424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40833.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37121.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37121.69,40833.86,
KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  NONMALIGNANCY,4431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10320.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9382.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9382.07,10320.28,
2  KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  NONMALIGNANCY,4432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12768.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11607.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11607.83,12768.61,
KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  NONMALIGNANCY,4433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20308.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18462.25,20308.48,
KIDNEY  &  URINARY  TRACT  PROCEDURES  FOR  NONMALIGNANCY,4434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41707.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37916.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37916.19,41707.81,
1  RENAL  DIALYSIS  ACCESS  DEVICE  PROCEDURES  &  VESSEL  REPAIR,4441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10209.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9280.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9280.95,10209.05,
2  RENAL  DIALYSIS  ACCESS  DEVICE  PROCEDURES  &  VESSEL  REPAIR,4442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14501.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13183.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13183.22,14501.54,
3  RENAL  DIALYSIS  ACCESS  DEVICE  PROCEDURES  &  VESSEL  REPAIR,4443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22243.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20221.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20221.2,22243.32,
4   RENAL  DIALYSIS  ACCESS  DEVICE  PROCEDURES  &  VESSEL  REPAIR,4444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47898.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43543.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43543.71,47898.08,
OTHER  BLADDER  PROCEDURES,4451,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8889.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8081.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8081.31,8889.44,
OTHER  BLADDER  PROCEDURES,4452,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12300.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11182.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11182.61,12300.87,
3  OTHER  BLADDER  PROCEDURES,4453,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17587.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15988.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15988.38,17587.22,
4   OTHER  BLADDER  PROCEDURES,4454,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34866.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31697.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31697.1,34866.81,
1  URETHRAL  &  TRANSURETHRAL  PROCEDURES,4461,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7453.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6775.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6775.54,7453.09,
2  URETHRAL  &  TRANSURETHRAL  PROCEDURES,4462,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9798.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8908.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8908.09,9798.9,
3  URETHRAL  &  TRANSURETHRAL  PROCEDURES,4463,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15938.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14489.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14489.71,15938.68,
4   URETHRAL  &  TRANSURETHRAL  PROCEDURES,4464,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29999.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27272.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27272.1,29999.31,
"1  OTHER  KIDNEY,  URINARY  TRACT  &  RELATED  PROCEDURES",4471,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12340.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11218.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11218.47,12340.32,
"2  OTHER  KIDNEY,  URINARY  TRACT  &  RELATED  PROCEDURES",4472,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14569.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13244.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13244.89,14569.38,
"3  OTHER  KIDNEY,  URINARY  TRACT  &  RELATED  PROCEDURES",4473,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20334.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18485.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18485.91,20334.5,
"4   OTHER  KIDNEY,  URINARY  TRACT  &  RELATED  PROCEDURES",4474,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47047.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42770.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42770.72,47047.79,
1  KIDNEY  &  URINARY  TRACT  MALIGNANCY,4611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7074.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6431.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6431.35,7074.49,
2  KIDNEY  &  URINARY  TRACT  MALIGNANCY,4612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8113.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7375.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7375.72,8113.29,
3  KIDNEY  &  URINARY  TRACT  MALIGNANCY,4613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11996.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10905.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10905.83,11996.41,
KIDNEY  &  URINARY  TRACT  MALIGNANCY,4614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20108.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18280.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18280.11,20108.12,
NEPHRITIS  &  NEPHROSIS,4621,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4542.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4129.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4129.57,4542.53,
2  NEPHRITIS  &  NEPHROSIS,4622,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6271.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5701.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5701.38,6271.52,
NEPHRITIS  &  NEPHROSIS,4623,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12670.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11518.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11518.2,12670.02,
NEPHRITIS  &  NEPHROSIS,4624,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39731.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36119.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36119.23,39731.15,
KIDNEY  &  URINARY  TRACT  INFECTIONS,4631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4499.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4090.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4090.85,4499.94,
2  KIDNEY  &  URINARY  TRACT  INFECTIONS,4632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5500.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5000.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5000.09,5500.1,
3  KIDNEY  &  URINARY  TRACT  INFECTIONS,4633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7563.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6875.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6875.93,7563.52,
4   KIDNEY  &  URINARY  TRACT  INFECTIONS,4634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14227.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12933.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12933.68,14227.05,
1  URINARY  STONES  &  ACQUIRED  UPPER  URINARY  TRACT  OBSTRUCTION,4651,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5024.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4567.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4567.7,5024.47,
2  URINARY  STONES  &  ACQUIRED  UPPER  URINARY  TRACT  OBSTRUCTION,4652,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6069.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5517.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5517.81,6069.59,
3  URINARY  STONES  &  ACQUIRED  UPPER  URINARY  TRACT  OBSTRUCTION,4653,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9925.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9022.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9022.82,9925.1,
URINARY  STONES  &  ACQUIRED  UPPER  URINARY  TRACT  OBSTRUCTION,4654,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18861.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17146.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17146.43,18861.07,
"MALFUNCTION,  REACTION,  COMPLIC  OF  GENITOURINARY  DEVICE  OR  PRC",4661,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4600.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4182.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4182.63,4600.89,
"2  MALFUNCTION,  REACTION,  COMPLIC  OF  GENITOURINARY  DEVICE  OR  PRC",4662,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6048.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5498.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5498.45,6048.3,
"3  MALFUNCTION,  REACTION,  COMPLIC  OF  GENITOURINARY  DEVICE  OR  PRC",4663,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9349.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8499.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8499.36,9349.3,
"4   MALFUNCTION,  REACTION,  COMPLIC  OF  GENITOURINARY  DEVICE  OR  PRC",4664,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15703.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14276.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14276.03,15703.63,
"OTHER  KIDNEY  &  URINARY  TRACT  DIAGNOSES,  SIGNS  &  SYMPTOMS",4681,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4814.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4376.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4376.96,4814.66,
"OTHER  KIDNEY  &  URINARY  TRACT  DIAGNOSES,  SIGNS  &  SYMPTOMS",4682,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6232.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5666.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5666.24,6232.86,
"OTHER  KIDNEY  &  URINARY  TRACT  DIAGNOSES,  SIGNS  &  SYMPTOMS",4683,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8942.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8129.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8129.35,8942.29,
"OTHER  KIDNEY  &  URINARY  TRACT  DIAGNOSES,  SIGNS  &  SYMPTOMS",4684,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18585.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16895.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16895.46,18585.01,
1  ACUTE  KIDNEY  INJURY,4691,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4396.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3996.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3996.91,4396.6,
2  ACUTE  KIDNEY  INJURY,4692,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5837.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5306.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5306.99,5837.69,
3  ACUTE  KIDNEY  INJURY,4693,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9279.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8436.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8436.26,9279.89,
4   ACUTE  KIDNEY  INJURY,4694,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18299.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16635.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16635.88,18299.47,
CHRONIC  KIDNEY  DISEASE,4701,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4682.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4257.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4257.21,4682.93,
CHRONIC  KIDNEY  DISEASE,4702,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6038.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5489.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5489.84,6038.82,
CHRONIC  KIDNEY  DISEASE,4703,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8599.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7817.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7817.43,8599.17,
CHRONIC  KIDNEY  DISEASE,4704,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16329.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.66,16329.13,
1  MAJOR  MALE  PELVIC  PROCEDURES,4801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10898.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9907.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9907.67,10898.44,
2  MAJOR  MALE  PELVIC  PROCEDURES,4802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12010.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10918.73,12010.6,
3  MAJOR  MALE  PELVIC  PROCEDURES,4803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20123.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18294.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18294.45,20123.9,
4   MAJOR  MALE  PELVIC  PROCEDURES,4804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42013.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38193.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38193.69,42013.06,
1  TRANSURETHRAL  PROSTATECTOMY,4821,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7122.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6475.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6475.09,7122.6,
2  TRANSURETHRAL  PROSTATECTOMY,4822,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8640.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7854.72,8640.19,
3  TRANSURETHRAL  PROSTATECTOMY,4823,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16056.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14596.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14596.55,16056.21,
4   TRANSURETHRAL  PROSTATECTOMY,4824,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27718.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25199.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25199.06,27718.97,
"1  PENIS,  TESTES  &  SCROTAL  PROCEDURES",4831,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10030.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9118.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9118.9,10030.79,
"2  PENIS,  TESTES  &  SCROTAL  PROCEDURES",4832,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12025.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10932.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10932.36,12025.6,
"PENIS,  TESTES  &  SCROTAL  PROCEDURES",4833,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16026.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14569.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14569.31,16026.24,
"PENIS,  TESTES  &  SCROTAL  PROCEDURES",4834,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35164.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31967.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31967.43,35164.17,
OTHER  MALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,4841,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11121.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10110.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10110.6,11121.66,
2  OTHER  MALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,4842,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12205.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11095.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11095.85,12205.44,
3  OTHER  MALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,4843,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15388.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13989.92,15388.91,
4   OTHER  MALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,4844,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42900.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39000.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39000.39,42900.43,
"1  MALIGNANCY,  MALE  REPRODUCTIVE  SYSTEM",5001,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6118.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5562.27,6118.5,
"2  MALIGNANCY,  MALE  REPRODUCTIVE  SYSTEM",5002,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7379.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6708.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6708.85,7379.74,
"3  MALIGNANCY,  MALE  REPRODUCTIVE  SYSTEM",5003,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10474.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9522.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9522.61,10474.87,
"4   MALIGNANCY,  MALE  REPRODUCTIVE  SYSTEM",5004,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18419.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16744.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16744.88,18419.37,
1  MALE  REPRODUCTIVE  SYSTEM  DIAGNOSES  EXCEPT  MALIGNANCY,5011,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4317.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3925.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3925.21,4317.73,
2  MALE  REPRODUCTIVE  SYSTEM  DIAGNOSES  EXCEPT  MALIGNANCY,5012,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5665.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5150.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5150.67,5665.74,
3  MALE  REPRODUCTIVE  SYSTEM  DIAGNOSES  EXCEPT  MALIGNANCY,5013,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8789.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7990.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7990.24,8789.26,
4   MALE  REPRODUCTIVE  SYSTEM  DIAGNOSES  EXCEPT  MALIGNANCY,5014,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18558.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16871.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16871.08,18558.19,
"1  PELVIC  EVISCERATION,  RADICAL  HYSTERECTOMY  &  OTHER  RADICAL  GYN  I",5101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11721.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10656.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10656.29,11721.92,
"2  PELVIC  EVISCERATION,  RADICAL  HYSTERECTOMY  &  OTHER  RADICAL  GYN  I",5102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14576.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13251.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13251.34,14576.47,
"3  PELVIC  EVISCERATION,  RADICAL  HYSTERECTOMY  &  OTHER  RADICAL  GYN",5103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24346.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22132.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22132.9,24346.19,
"PELVIC  EVISCERATION,  RADICAL  HYSTERECTOMY  &  OTHER  RADICAL  GYN",5104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41205.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37459.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37459.42,41205.36,
UTERINE  &  ADNEXA  PROCEDURES  FOR  OVARIAN  &  ADNEXAL  MALIGNAN1,5111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12172.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11065.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11065.73,12172.3,
2  UTERINE  &  ADNEXA  PROCEDURES  FOR  OVARIAN  &  ADNEXAL  MALIGNAN,5112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14724.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13386.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13386.15,14724.77,
3  UTERINE  &  ADNEXA  PROCEDURES  FOR  OVARIAN  &  ADNEXAL  MALIGNAN,5113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21950.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19955.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19955.16,21950.68,
UTERINE  &  ADNEXA  PROCEDURES  FOR  OVARIAN  &  ADNEXAL  MALIGNANI,5114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44433.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40394.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40394.37,44433.81,
1  UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-OVARIAN  &  NON-ADNEXAL,5121,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11254.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10231.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10231.07,11254.18,
2  UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-OVARIAN  &  NON-ADNEXAL,5122,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12967.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11788.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11788.53,12967.38,
UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-OVARIAN  &  NON-ADNEXAL,5123,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19884.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18076.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18076.47,19884.12,
UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-OVARIAN  &  NON-ADNEXAL  ii,5124,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37812.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34374.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34374.61,37812.07,
UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-MALIGNANCY  EXCEPT  LEION,5131,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7999.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7272.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7272.46,7999.71,
2  UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-MALIGNANCY  EXCEPT  LEION,5132,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9415.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8559.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8559.59,9415.55,
3  UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-MALIGNANCY  EXCEPT  LEION,5133,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16360.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14873.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14873.34,16360.67,
UTERINE  &  ADNEXA  PROCEDURES  FOR  NON-MALIGNANCY  EXCEPT  LEION4,5134,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31210.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28372.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28372.79,31210.07,
1  FEMALE  REPRODUCTIVE  SYSTEM  RECONSTRUCTIVE  PROCEDURES,5141,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7046.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6406.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6406.25,7046.88,
2  FEMALE  REPRODUCTIVE  SYSTEM  RECONSTRUCTIVE  PROCEDURES,5142,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10719.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9744.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9744.9,10719.39,
3  FEMALE  REPRODUCTIVE  SYSTEM  RECONSTRUCTIVE  PROCEDURES,5143,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22162.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20147.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20147.34,22162.07,
FEMALE  REPRODUCTIVE  SYSTEM  RECONSTRUCTIVE  PROCEDURES,5144,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40193.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36539.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36539.43,40193.37,
DILATION  &  CURETTAGE  FOR  NON-OBSTETRIC  DIAGNOSES,5171,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6266.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5697.07,6266.78,
2  DILATION  &  CURETTAGE  FOR  NON-OBSTETRIC  DIAGNOSES,5172,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8662.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7874.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7874.8,8662.28,
DILATION  &  CURETTAGE  FOR  NON-OBSTETRIC  DIAGNOSES,5173,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14059.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12780.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12780.95,14059.05,
DILATION  &  CURETTAGE  FOR  NON-OBSTETRIC  DIAGNOSES,5174,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29675.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26977.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26977.38,29675.12,
1  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,5181,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7251.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6592.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6592.69,7251.96,
2  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,5182,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10836.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9851.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9851.03,10836.13,
3  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,5183,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20508.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18643.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18643.66,20508.03,
4   OTHER  FEMALE  REPRODUCTIVE  SYSTEM  &  RELATED  PROCEDURES,5184,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36997.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33633.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33633.89,36997.28,
1  UTERINE  &  ADNEXA  PROCEDURES  FOR  LEIOMYOMA,5191,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5497.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4997.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4997.93,5497.72,
2  UTERINE  &  ADNEXA  PROCEDURES  FOR  LEIOMYOMA,5192,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7087.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6442.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6442.82,7087.1,
3  UTERINE  &  ADNEXA  PROCEDURES  FOR  LEIOMYOMA,5193,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15355.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13959.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13959.8,15355.78,
UTERINE  &  ADNEXA  PROCEDURES  FOR  LEIOMYOMA,5194,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29694.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26995.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26995.31,29694.84,
1  FEMALE  REPRODUCTIVE  SYSTEM  MALIGNANCY,5301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6142.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5584.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5584.49,6142.94,
2  FEMALE  REPRODUCTIVE  SYSTEM  MALIGNANCY,5302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7281.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6619.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6619.22,7281.14,
3  FEMALE  REPRODUCTIVE  SYSTEM  MALIGNANCY,5303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10664.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9694.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9694.7,10664.17,
4   FEMALE  REPRODUCTIVE  SYSTEM  MALIGNANCY,5304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18241.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16583.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16583.54,18241.89,
FEMALE  REPRODUCTIVE  SYSTEM  INFECTIONS,5311,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3940.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3582.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3582.45,3940.7,
2  FEMALE  REPRODUCTIVE  SYSTEM  INFECTIONS,5312,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5455.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4959.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4959.93,5455.92,
FEMALE  REPRODUCTIVE  SYSTEM  INFECTIONS,5313,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9783.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8894.45,9783.9,
4   FEMALE  REPRODUCTIVE  SYSTEM  INFECTIONS,5314,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14674.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13340.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13340.26,14674.29,
1  MENSTRUAL  &  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  DISORDERS,5321,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4305.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3913.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3913.74,4305.11,
2  MENSTRUAL  &  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  DISORDERS,5322,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4979.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4526.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4526.83,4979.51,
3  MENSTRUAL  &  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  DISORDERS,5323,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8343.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7585.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7585.1,8343.61,
4   MENSTRUAL  &  OTHER  FEMALE  REPRODUCTIVE  SYSTEM  DISORDERS,5324,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19175.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17431.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17431.83,19175.01,
CESAREAN  SECTION  W  STERILIZATION,5391,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4489.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4081.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4081.53,4489.68,
CESAREAN  SECTION  W  STERILIZATION,5392,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5158.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4689.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4689.6,5158.56,
CESAREAN  SECTION  W  STERILIZATION,5393,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8954.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8140.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8140.11,8954.12,
CESAREAN  SECTION  W  STERILIZATION,5394,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19978.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18162.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18162.5,19978.75,
CESAREAN  SECTION  W/O  STERILIZATION,5401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4281.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3892.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3892.22,4281.44,
CESAREAN  SECTION  W/O  STERILIZATION,5402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5056.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4597.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4597.1,5056.81,
CESAREAN  SECTION  W/O  STERILIZATION,5403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7403.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6730.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6730.36,7403.4,
CESAREAN  SECTION  W/O  STERILIZATION,5404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14512.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13193.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13193.26,14512.59,
VAGINAL  DELIVERY  W  STERILIZATION  &/OR  D&C,5411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4787.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4351.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4351.85,4787.04,
VAGINAL  DELIVERY  W  STERILIZATION  St/OR  D&C,5412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4806.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4369.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4369.79,4806.77,
3  VAGINAL  DELIVERY  W  STERILIZATION  84/OR  D&C,5413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6260.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5691.34,6260.47,
4   VAGINAL  DELIVERY  W  STERILIZATION  at/OR  D&C,5414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15411,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14010,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14010,15411,
1  VAGINAL  DELIVERY  W  O.R.  PROCEDURE  EXCEPT  STERILIZATION  84/OR  D&C,5421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3107.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2825.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2825.23,3107.75,
2  VAGINAL  DELIVERY  W  O.R.  PROCEDURE  EXCEPT  STERILIZATION  &MR  D&C,5422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3633.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3303.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3303.51,3633.86,
3  VAGINAL  DELIVERY  W  O.R.  PROCEDURE  EXCEPT  STERILIZATION  84/OR  D&C,5423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5938.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5398.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5398.77,5938.65,
4   VAGINAL  DELIVERY  W  O.R.  PROCEDURE  EXCEPT  STERILIZATION  &MR  D&C,5424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16236.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14760.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14760.05,16236.06,
"1  ABORTION  W  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3687.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3352.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3352.27,3687.5,
"2  ABORTION  W  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4346.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3951.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3951.74,4346.91,
"3  ABORTION  W  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6180.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5618.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5618.2,6180.02,
"ABORTION  W  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24619.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22381,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22381,24619.1,
ANTEPARTUM  W  O.R.  PROCEDURE,5471,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4761.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4328.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4328.92,4761.81,
2  ANTEPARTUM  W  O.R.  PROCEDURE,5472,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5849.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5317.75,5849.53,
3  ANTEPARTUM  W  O.R.  PROCEDURE,5473,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8664.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7876.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7876.95,8664.65,
4   ANTEPARTUM  W  O.R.  PROCEDURE,5474,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27758.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25234.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25234.92,27758.41,
1  POSTPARTUM  &  POST  ABORTION  DIAGNOSIS  W  O.R.  PROCEDURE,5481,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3209.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2917.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2917.73,3209.5,
2  POSTPARTUM  &  POST  ABORTION  DIAGNOSIS  W  O.R.  PROCEDURE,5482,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5444.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4949.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4949.18,5444.1,
3  POSTPARTUM  &  POST  ABORTION  DIAGNOSIS  W  O.R.  PROCEDURE,5483,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10425.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9478.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9478.15,10425.97,
4   POSTPARTUM  &  POST  ABORTION  DIAGNOSIS  W  O.R.  PROCEDURE,5484,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25985.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23622.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23622.96,25985.26,
1  VAGINAL  DELIVERY,5601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2689.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2445.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2445.19,2689.71,
2  VAGINAL  DELIVERY,5602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2889.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2626.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2626.61,2889.27,
3  VAGINAL  DELIVERY,5603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4088.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3716.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3716.54,4088.19,
4   VAGINAL  DELIVERY,5604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6277.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5706.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5706.4,6277.04,
1  POSTPARTUM  &  POST  ABORTION  DIAGNOSES  W/O  PROCEDURE,5611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2508.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2280.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2280.26,2508.29,
2  POSTPARTUM  &  POST  ABORTION  DIAGNOSES  W/O  PROCEDURE,5612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3192.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2902.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2902.68,3192.95,
3  POSTPARTUM  &  POST  ABORTION  DIAGNOSES  W/O  PROCEDURE,5613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5099.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4635.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4635.82,5099.4,
4   POSTPARTUM  &  POST  ABORTION  DIAGNOSES  W/O  PROCEDURE,5614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11109.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10099.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10099.12,11109.03,
"1  ABORTION  W/O  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5641,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2822.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2565.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2565.65,2822.22,
"2  ABORTION  W/O  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5642,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2905.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2641.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2641.66,2905.83,
"3  ABORTION  W/O  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5643,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4227.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3842.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3842.75,4227.03,
"4   ABORTION  W/O  D&C,  ASPIRATION  CURETTAGE  OR  HYSTEROTOMY",5644,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6463.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5875.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5875.62,6463.18,
1  ANTEPARTUM  W/O  O.R.  PROCEDURE,5661,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2615.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2377.78,2615.56,
2  ANTEPARTUM  W/O  O.R.  PROCEDURE,5662,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3308.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3008.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3008.08,3308.89,
3  ANTEPARTUM  W/O  O.R.  PROCEDURE,5663,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4948.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4498.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4498.85,4948.74,
ANTEPARTUM  W/O  O.R.  PROCEDURE,5664,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9981.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9073.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9073.73,9981.1,
"NEONATE,  TRANSFERRED  <5  DAYS  OLD,  NOT  BORN  HERE",5801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2781.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2528.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2528.37,2781.21,
"2  NEONATE,  TRANSFERRED  <5  DAYS  OLD,  NOT  BORN  HERE",5802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4224.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3840.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3840.59,4224.65,
"NEONATE,  TRANSFERRED  <5  DAYS  OLD,  NOT  BORN  HERE",5803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6564.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5967.41,6564.15,
"NEONATE,  TRANSFERRED  <5  DAYS  OLD,  NOT  BORN  HERE",5804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12017.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10925.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10925.19,12017.71,
"1  NEONATE,  TRANSFERRED  <  5  DAYS  OLD,  BORN  HERE",5811,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1210.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1100.69,1210.76,
"2  NEONATE,  TRANSFERRED  <  5  DAYS  OLD,  BORN  HERE",5812,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1407.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1279.24,1407.16,
"3  NEONATE,  TRANSFERRED  <  5  DAYS  OLD,  BORN  HERE",5813,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2531.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2301.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2301.78,2531.96,
"4   NEONATE,  TRANSFERRED  <  5  DAYS  OLD,  BORN  HERE",5814,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3963.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3603.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3603.25,3963.58,
1  NEONATE  W  ECMO,5831,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153221,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139291.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139291.82,153221,
2  NEONATE  W  ECMO,5832,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,153551.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139592.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139592.28,153551.51,
3  NEONATE  W  ECMO,5833,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259881.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236256.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,236256.1,259881.71,
4 NEONATE  W  ECM(),5834,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,285870.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259881.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,259881.92,285870.11,
NEONATE  BWT  <1500G  W  MAJOR  PROCEDURE,5881,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126897.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115361.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,115361.26,126897.39,
2  NEONATE  BWT  <1500G  W  MAJOR  PROCEDURE,5882,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,140996.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128178.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,128178.78,140996.66,
NEONATE  BWT  <1500G  W  MAJOR  PROCEDURE,5883,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156415.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142195.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142195.94,156415.53,
NEONATE  BWT  <1500G  W  MAJOR  PROCEDURE,5884,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,227993.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207266.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,207266.63,227993.29,
"1  NEONATE  BWT  <  500G,  OR  BWT  500-999G  &  GESTATIONAL  AGE  <24  WKS",5891,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,172631.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156938.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156938.06,172631.87,
"2  NEONATE  BWT  <  500G,  OR  BWT  500-999G  &  GESTATIONAL  AGE  <24  WKS",5892,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,121092.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110084.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110084.38,121092.82,
"3  NEONATE  BWT  <  500G,  OR  BWT  500-999G  &  GESTATIONAL  AGE  <24  WKS",5893,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110083.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100076.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100076.32,110083.95,
"NEONATE  BWT  <  500G,  OR  BWT  500-999G  &  GESTATIONAL  AGE  <24  WKSI",5894,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20858.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18962.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18962.04,20858.24,
1  NEONATE  BIRTHWT  500-749G  W/O  MAJOR  PROCEDURE,5911,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,109472.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99520.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,99520.6,109472.66,
2  NEONATE  BIRTHWT  500-749G  W/O  MAJOR  PROCEDURE,5912,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,151835.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138031.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,138031.95,151835.15,
3  NEONATE  BIRTHWT  500-749G  W/O  MAJOR  PROCEDURE,5913,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,156713.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142466.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,142466.99,156713.69,
4   NEONATE  BIRTHWT  500-749G  W/O  MAJOR  PROCEDURE,5914,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,195781.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177983.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,177983.17,195781.49,
1  NEONATE  BIRTHWT  750-999G  W/O  MAJOR  PROCEDURE,5931,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29384.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26713.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26713.5,29384.85,
NEONATE  BIRTHWT  750-999G  W/O  MAJOR  PROCEDURE,5932,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,112537.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102306.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102306.39,112537.03,
NEONATE  BIRTHWT  750-999G  W/O  MAJOR  PROCEDURE,5933,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131255.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119323.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,119323.03,131255.33,
NEONATE  BIRTHWT  750-999G  W/O  MAJOR  PROCEDURE,5934,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,171363.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155785.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,155785.01,171363.51,
NEONATE  BWT  1000-1249G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6021,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53324.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48477.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48477.11,53324.82,
2  NEONATE  BWT  1000-1249G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6022,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,81330.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73937.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73937.19,81330.91,
3  NEONATE  BWT  1000-1249G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6023,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,101936.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92669.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92669.77,101936.75,
NEONATE  BWT  1000-1249G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6024,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,144671.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131519.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,131519.57,144671.53,
1  NEONATE  BIRTHWT  1000-1249G  W  OR  W/O  OTHER  SIGNIFICANT  CONDIT,6031,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30127.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27388.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27388.26,30127.09,
2  NEONATE  BIRTHWT  1000-1249G  W  OR  W/O  OTHER  SIGNIFICANT  CONDIT,6032,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57157.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51961.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51961.33,57157.46,
3  NEONATE  BIRTHWT  1000-1249G  W  OR  W/O  OTHER  SIGNIFICANT  CONDIT,6033,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,87926.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79933.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,79933.28,87926.61,
NEONATE  BIRTHWT  1000-1249G  W  OR  W/O  OTHER  SIGNIFICANT  CONDIT',6034,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,113203.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102912.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102912.31,113203.54,
NEONATE  BWT  1250-1499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6071,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44007.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40007.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40007.15,44007.87,
2  NEONATE  BWT  1250-1499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6072,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57241.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52037.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52037.33,57241.06,
NEONATE  BWT  1250-1499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6073,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,74615.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67832.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67832.1,74615.31,
NEONATE  BWT  1250-1499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  OR  MAJ  A,6074,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,116898.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106271.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,106271.04,116898.14,
NEONATE  BWT  1250-1499G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6081,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28427.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25842.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25842.99,28427.29,
2  NEONATE  BWT  1250-1499G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6082,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42888.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38989.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38989.64,42888.6,
3  NEONATE  BWT  1250-1499G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6083,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61151.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55592.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55592.54,61151.79,
NEONATE  BWT  1250-1499G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6084,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110285.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100259.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,100259.89,110285.88,
1  NEONATE  BWT  1500-2499G  W  MAJOR  PROCEDURE,6091,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47985.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43623.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43623.31,47985.64,
2  NEONATE  BWT  1500-2499G  W  MAJOR  PROCEDURE,6092,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51622.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46929.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46929.69,51622.66,
3  NEONATE  BWT  1500-2499G  W  MAJOR  PROCEDURE,6093,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88989.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80899.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80899.16,88989.08,
NEONATE  BWT  1500-2499G  W  MAJOR  PROCEDURE,6094,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,180362.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163966.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,163966.01,180362.61,
1  NEONATE  BIRTHWT  1500-1999G  W  MAJOR  ANOMALY,6111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20932.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19029.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19029.43,20932.37,
2  NEONATE  BIRTHWT  1500-1999G  W  MAJOR  ANOMALY,6112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35095.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31905.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31905.05,35095.56,
NEONATE  BIRTHWT  1500-1999G  W  MAJOR  ANOMALY,6113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58376.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53069.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53069.19,58376.11,
NEONATE  BIRTHWT  1500-1999G  W  MAJOR  ANOMALY,6114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,102222.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92929.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92929.34,102222.27,
NEONATE  BWT  1500-1999G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6121,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28496.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25906.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25906.09,28496.7,
2  NEONATE  BWT  1500-1999G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6122,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38732.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35211.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35211.43,38732.57,
3  NEONATE  BWT  1500-1999G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6123,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51775.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47068.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47068.8,51775.68,
NEONATE  BWT  1500-1999G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6124,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,75016.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68196.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68196.37,75016.01,
1  NEONATE  BIRTHWT  1500-1999G  W  CONGENITAL/PERINATAL  INFECTION,6131,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23231.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21119.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21119.69,23231.66,
2  NEONATE  BIRTHWT  1500-1999G  W  CONGENITAL/PERINATAL  INFECTION,6132,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36366.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33060.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33060.24,36366.26,
3  NEONATE  BIRTHWT  1500-1999G  W  CONGENITAL/PERINATAL  INFECTION,6133,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50912.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46284.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46284.33,50912.76,
NEONATE  BIRTHWT  1500-1999G  W  CONGENITAL/PERINATAL  INFECTION,6134,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,88159.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80144.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80144.81,88159.29,
NEONATE  BWT  1500-1999G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6141,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15768.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14334.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14334.83,15768.31,
2  NEONATE  BWT  1500-1999G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6142,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26647.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24224.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24224.57,26647.03,
NEONATE  BWT  1500-1999G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6143,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45487.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41352.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41352.36,45487.6,
NEONATE  BWT  1500-1999G  W  OR  W/O  OTHER  SIGNIFICANT  CONDITION,6144,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,80957.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73598,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,73598,80957.8,
NEONATE  BWT  2000-2499G  W  MAJOR  ANOMALY,61.__1,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12229.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11117.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11117.36,12229.1,
2  NEONATE  BWT  2000-2499G  W  MAJOR  ANOMALY,6212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26307.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23916.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23916.24,26307.86,
3  NEONATE  BWT  2000-2499G  W  MAJOR  ANOMALY,6213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47991.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43629.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43629.04,47991.94,
NEONATE  BWT  2000-2499G  W  MAJOR  ANOMALY,6214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,91762.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83420.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,83420.36,91762.4,
1  NEONATE  BWT  2000-2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17743.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16130.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16130.35,17743.39,
2  NEONATE  BWT  2000-2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23945.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21768.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21768.63,23945.49,
3  NEONATE  BWT  2000-2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31098.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28270.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28270.97,31098.07,
NEONATE  BWT  2000-2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND,6224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60365.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54877.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54877.62,60365.38,
NEONATE  BWT  2000-2499G  W  CONGENITAL/PERINATAL  INFECTION,6231,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13933.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12666.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12666.94,13933.63,
NEONATE  BWT  2000-2499G  W  CONGENITAL/PERINATAL  INFECTION,6232,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20117.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18288.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18288.72,20117.59,
NEONATE  BWT  2000-2499G  W  CONGENITAL/PERINATAL  INFECTION,6233,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34803.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31639.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31639.73,34803.7,
NEONATE  BWT  2000-2499G  W  CONGENITAL/PERINATAL  INFECTION,6234,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51624.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46931.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46931.12,51624.23,
1  NEONATE  BWT  2000-2499G  W  OTHER  SIGNIFICANT  CONDITION,6251,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14921.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13564.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13564.7,14921.17,
2  NEONATE  BWT  2000-2499G  W  OTHER  SIGNIFICANT  CONDITION,6252,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21090.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19173.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19173.57,21090.93,
3  NEONATE  BWT  2000-2499G  W  OTHER  SIGNIFICANT  CONDITION,6253,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31225.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28386.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28386.41,31225.05,
4  NEONATE  BWT  2000-2499G  W  OTHER  SIGNIFICANT  CONDITION,6254,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46153.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41957.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41957.57,46153.33,
"1  NEONATE  BWT  2000-2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6261,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1790.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1627.74,1790.51,
"2  NEONATE  BWT  2000-2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6262,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3226.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2933.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2933.51,3226.86,
"3  NEONATE  BWT  2000-2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6263,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9021.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8201.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8201.06,9021.17,
"4  NEONATE  BWT  2000-2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEFI",6264,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31266.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28424.42,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28424.42,31266.86,
1  NEONATE  BIRTHWT  >2499G  W  MAJOR  CARDIOVASCULAR  PROCEDURE,6301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28353.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25776.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25776.3,28353.93,
2  NEONATE  BIRTHWT  >2499G  W  MAJOR  CARDIOVASCULAR  PROCEDURE,6302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51519.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46835.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46835.75,51519.33,
3  NEONATE  BIRTHWT  >2499G  W  MAJOR  CARDIOVASCULAR  PROCEDURE,6303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84127.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76479.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,76479.17,84127.09,
4  NEONATE  BIRTHWT  >2499G  W  MAJOR  CARDIOVASCULAR  PROCEDURE,6304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,147556.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134142.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,134142.6,147556.86,
1  NEONATE  BIRTHWT  >2499G  W  OTHER  MAJOR  PROCEDURE,6311,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19400.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17636.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17636.91,19400.6,
2  NEONATE  BIRTHWT  >2499G  W  OTHER  MAJOR  PROCEDURE,6312,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35952.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32684.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32684.49,35952.94,
3  NEONATE  BIRTHWT  >2499G  W  OTHER  MAJOR  PROCEDURE,6313,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63189.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57445.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57445.43,63189.97,
4   NEONATE  BIRTHWT  >2499G  W  OTHER  MAJOR  PROCEDURE,6314,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,137673.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125157.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,125157.78,137673.56,
1  NEONATE  BIRTHWT  >2499G  W  MAJOR  ANOMALY,6331,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4779.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4345.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4345.41,4779.95,
2  NEONATE  BIRTHWT  >2499G  W  MAJOR  ANOMALY,6332,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15041.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13673.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13673.69,15041.06,
3  NEONATE  BIRTHWT  >2499G  W  MAJOR  ANOMALY,6333,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33936.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30850.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30850.96,33936.06,
4   NEONATE  BIRTHWT  >2499G  W  MAJOR  ANOMALY,6334,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78511.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71374.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71374.39,78511.83,
"1  NEONATE,  BIRTHWT  >2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND",6341,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7887.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7170.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7170.64,7887.7,
"2  NEONATE,  BIRTHWT  >2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND",6342,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14056.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12778.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12778.8,14056.68,
"3  NEONATE,  BIRTHWT  >2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND",6343,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20994.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19086.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19086.09,20994.7,
"4   NEONATE,  BIRTHWT  >2499G  W  RESP  DIST  SYND/OTH  MAJ  RESP  COND",6344,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,52503.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47730.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47730.65,52503.72,
1  NEONATE  BIRTHWT  >2499G  W  CONGENITAL/PERINATAL  INFECTION,6361,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7693.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6994.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6994.24,7693.66,
2  NEONATE  BIRTHWT  >2499G  W  CONGENITAL/PERINATAL  INFECTION,6362,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11676.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10614.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10614.7,11676.17,
3  NEONATE  BIRTHWT  >2499G  W  CONGENITAL/PERINATAL  INFECTION,6363,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23394.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21268.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21268.12,23394.93,
4   NEONATE  BIRTHWT  >2499G  W  CONGENITAL/PERINATAL  INFECTION,6364,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41447.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37679.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37679.56,41447.52,
1  NEONATE  BIRTHWT  >2499G  W  OTHER  SIGNIFICANT  CONDITION,6391,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7331.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6665.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6665.11,7331.62,
2  NEONATE  BIRTHWT  >2499G  W  OTHER  SIGNIFICANT  CONDITION,6392,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13034.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11849.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11849.48,13034.43,
3  NEONATE  BIRTHWT  >2499G  W  OTHER  SIGNIFICANT  CONDITION,6393,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20596.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18723.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18723.98,20596.38,
4   NEONATE  BIRTHWT  >2499G  W  OTHER  SIGNIFICANT  CONDITION,6394,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35177.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31979.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31979.62,35177.58,
"1  NEONATE  BIRTHWT  >2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1007.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,915.69,1007.26,
"2  NEONATE  BIRTHWT  >2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1592.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1447.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1447.75,1592.53,
"3  NEONATE  BIRTHWT  >2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEF",6403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3961.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3601.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3601.1,3961.21,
"4  NEONATE  BIRTHWT  >2499G,  NORMAL  NEWBORN  OR  NEONATE  W  OTHEFI",6404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37155.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33777.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33777.3,37155.03,
1  SPLENECTOMY,6501,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11373.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10339.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10339.35,11373.29,
2  SPLENECTOMY,6502,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15739.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14308.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14308.3,15739.13,
3  SPLENECTOMY,6503,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27251.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24773.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24773.84,27251.22,
4   SPLENECTOMY,6504,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42487.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38624.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38624.65,42487.12,
OTHER  PROCEDURES  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9644.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8767.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8767.54,9644.29,
OTHER  PROCEDURES  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13552.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12320.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12320.59,13552.65,
OTHER  PROCEDURES  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23027.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20933.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20933.97,23027.37,
OTHER  PROCEDURES  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72896.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66269.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66269.62,72896.58,
1  MAJOR  HEMATOLOGIC/IMMUNOLOGIC  DIAG  EXC  SICKLE  CELL  CRISIS  &  C(,6601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6786.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6169.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6169.62,6786.58,
2  MAJOR  HEMATOLOGIC/IMMUNOLOGIC  DIAG  EXC  SICKLE  CELL  CRISIS  8c  C(,6602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8043.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7312.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7312.62,8043.88,
3  MAJOR  HEMATOLOGIC/IMMUNOLOGIC  DIAG  EXC  SICKLE  CELL  CRISIS  &  C(,6603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13209.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12008.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12008.67,13209.54,
4   MAJOR  HEMATOLOGIC/IMMUNOLOGIC  DIAG  EXC  SICKLE  CELL  CRISIS  &  C(,6604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34628.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31480.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31480.54,34628.59,
COAGULATION  &  PLATELET  DISORDERS,6611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7220.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6564,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6564,7220.4,
COAGULATION  &  PLATELET  DISORDERS,6612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10190.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9264.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9264.46,10190.91,
COAGULATION  &  PLATELET  DISORDERS,6613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19385.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17623.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17623.28,19385.61,
COAGULATION  &  PLATELET  DISORDERS,6614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31581.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28710.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28710.53,31581.58,
1  SICKLE  CELL  ANEMIA  CRISIS,6621,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5053.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4594.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4594.22,5053.64,
2  SICKLE  CELL  ANEMIA  CRISIS,6622,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6818.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6199.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6199.02,6818.92,
3  SICKLE  CELL  ANEMIA  CRISIS,6623,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10310.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9373.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9373.45,10310.8,
4   SICKLE  CELL  ANEMIA  CRISIS,6624,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21718.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19744.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19744.36,21718.8,
1  OTHER  ANEMIA  &  DISORDERS  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4979.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4526.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4526.83,4979.51,
OTHER  ANEMIA  &  DISORDERS  OF  BLOOD  8c  BLOOD-FORMING  ORGANS,6632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6320.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5745.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5745.83,6320.41,
3  OTHER  ANEMIA  &  DISORDERS  OF  BLOOD  &  BLOOD-FORMING  ORGANS,6633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9021.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8201.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8201.78,9021.96,
4   OTHER  ANEMIA  &  DISORDERS  OF  BLOOD  8c  BLOOD-FORMING  ORGANS,6634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16465.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14968.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14968.71,16465.58,
1  MAJOR  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEC,6801,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14252.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12956.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12956.63,14252.29,
2  MAJOR  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEJ,6802,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19927.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18115.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18115.9,19927.49,
3  MAJOR  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NE,6803,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32913.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29920.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29920.93,32913.02,
MAJOR  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEC,6804,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68934.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62667.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62667.81,68934.59,
OTHER  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEO,6811,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11239.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10217.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10217.44,11239.18,
OTHER  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEO,6812,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15679.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14253.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14253.8,15679.18,
OTHER  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEO,6813,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29458.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26780.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26780.19,29458.21,
OTHER  O.R.  PROCEDURES  FOR  LYMPHATIC/HEMATOPOIETIC/OTHER  NEO,6814,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65155.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59232.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59232.35,65155.59,
1  ACUTE  LEUKEMIA,6901,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15781.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14347.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14347.02,15781.72,
2  ACUTE  LEUKEMIA,6902,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22281.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20256.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20256.34,22281.97,
3  ACUTE  LEUKEMIA,6903,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37975.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34523.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34523.05,37975.36,
4   ACUTE  LEUKEMIA,6904,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,64690.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58809.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,58809.29,64690.22,
"1  LYMPHOMA,  MYELOMA  &  NON-ACUTE  LEUKEMIA",6911,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10442.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9493.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9493.2,10442.52,
"2  LYMPHOMA,  MYELOMA  &  NON-ACUTE  LEUKEMIA",6912,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11958.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10871.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10871.41,11958.55,
"LYMPHOMA,  MYELOMA  &  NON-ACUTE  LEUKEMIA",6913,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19009.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17281.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17281.24,19009.36,
"LYMPHOMA,  MYELOMA  &  NON-ACUTE  LEUKEMIA",6914,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38358.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34871.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34871.54,38358.69,
RADIOTHERAPY,6921,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9714.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8831.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8831.36,9714.5,
2  RADIOTHERAPY,6922,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16329.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14844.66,16329.13,
3  RADIOTHERAPY,6923,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21695.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19722.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19722.84,21695.12,
4   RADIOTHERAPY,6924,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46095.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41905.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41905.22,46095.74,
1  LYMPHATIC  &  OTHER  MALIGNANCIES  &  NEOPLASMS  OF  UNCERTAIN  BEH,6941,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6667.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6061.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6061.34,6667.47,
2  LYMPHATIC  &  OTHER  MALIGNANCIES  &  NEOPLASMS  OF  UNCERTAIN  BEH,6942,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7994.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7268.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7268.16,7994.98,
3  LYMPHATIC  &  OTHER  MALIGNANCIES  &  NEOPLASMS  OF  UNCERTAIN  BEH,6943,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11953.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10867.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10867.1,11953.81,
4   LYMPHATIC  &  OTHER  MALIGNANCIES  &  NEOPLASMS  OF  UNCERTAIN  BEH,6944,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22994.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20903.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20903.84,22994.22,
CHEMOTHERAPY  FOR  ACUTE  LEUKEMIA,6951,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6251.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5683.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5683.45,6251.8,
CHEMOTHERAPY  FOR  ACUTE  LEUKEMIA,6952,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8892.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8084.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8084.18,8892.6,
CHEMOTHERAPY  FOR  ACUTE  LEUKEMIA,6953,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24314.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22104.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22104.21,24314.63,
CHEMOTHERAPY  FOR  ACUTE  LEUKEMIA,6954,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63451.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57683.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57683.5,63451.85,
OTHER  CHEMOTHERAPY,6961,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7660.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6964.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6964.13,7660.54,
OTHER  CHEMOTHERAPY,6962,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9794.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8903.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8903.78,9794.16,
OTHER  CHEMOTHERAPY,6963,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16325.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14841.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14841.79,16325.97,
OTHER  CHEMOTHERAPY,6964,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,36050.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32773.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32773.41,36050.75,
1  INFECTIOUS  &  PARASITIC  DISEASES  INCLUDING  HIV  W  O.R.  PROCEDURE,7101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9844.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8949.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8949.68,9844.65,
2  INFECTIOUS  &  PARASITIC  DISEASES  INCLUDING  HIV  W  O.R.  PROCEDURE,7102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14989.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13626.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13626.37,14989.01,
3  INFECTIOUS  &  PARASITIC  DISEASES  INCLUDING  HIV  W  O.R.  PROCEDURE,7103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23945.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21768.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21768.63,23945.49,
4  INFECTIOUS  &  PARASITIC  DISEASES  INCLUDING  HIV  W  O.R.  PROCEDURE,7104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45661.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41510.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41510.83,45661.91,
"1  POST-OP,  POST-TRAUMA,  OTHER  DEVICE  INFECTIONS  W  O.R.  PROCEDUR1",7111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9637.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8761.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8761.09,9637.2,
"2  POST-OP,  POST-TRAUMA,  OTHER  DEVICE  INFECTIONS  W  O.R.  PROCEDUR",7112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13244.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12040.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12040.22,13244.24,
"POST-OP,  POST-TRAUMA,  OTHER  DEVICE  INFECTIONS  W  O.R.  PROCEDUR",7113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23540.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21400.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21400.78,23540.86,
"POST-OP,  POST-TRAUMA,  OTHER  DEVICE  INFECTIONS  W  O.R.  PROCEDURE'",7114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46081.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41892.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41892.31,46081.54,
SEPTICEMIA  &  DISSEMINATED  INFECTIONS,7201,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5188.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4716.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4716.85,5188.54,
2  SEPTICEMIA  &  DISSEMINATED  INFECTIONS,7202,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6938.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6308.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6308.01,6938.81,
3  SEPTICEMIA  &  DISSEMINATED  INFECTIONS,7203,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10735.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9759.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9759.95,10735.95,
4   SEPTICEMIA  &  DISSEMINATED  INFECTIONS,7204,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20212.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18374.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18374.77,20212.25,
"1  POST-OPERATIVE,  POST-TRAUMATIC,  OTHER  DEVICE  INFECTIONS",7211,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5239.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4762.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4762.74,5239.01,
"2  POST-OPERATIVE,  POST-TRAUMATIC,  OTHER  DEVICE  INFECTIONS",7212,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7252.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6593.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6593.4,7252.74,
"3  POST-OPERATIVE,  POST-TRAUMATIC,  OTHER  DEVICE  INFECTIONS",7213,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12047.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10952.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10952.44,12047.68,
"4   POST-OPERATIVE,  POST-TRAUMATIC,  OTHER  DEVICE  INFECTIONS",7214,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22960.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20873.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20873.02,22960.32,
1  FEVER  &  INFLAMMATORY  CONDITIONS,7221,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3730.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3391.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3391.71,3730.88,
2  FEVER  &  INFLAMMATORY  CONDITIONS,7222,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5504.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5003.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5003.67,5504.04,
FEVER  &  INFLAMMATORY  CONDITIONS,7223,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7817.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7106.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7106.82,7817.5,
FEVER  &  INFLAMMATORY  CONDITIONS,7224,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14382.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13074.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13074.94,14382.43,
1  VIRAL  ILLNESS,7231,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3533.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3212.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3212.45,3533.7,
2  VIRAL  ILLNESS,7232,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5160.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4691.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4691.75,5160.93,
3  VIRAL  ILLNESS,7233,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8444.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7676.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7676.89,8444.58,
4   VIRAL  ILLNESS,7234,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21896.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19905.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19905.7,21896.27,
OTHER  INFECTIOUS  &  PARASITIC  DISEASES,7241,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5619.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5109.08,5619.99,
OTHER  INFECTIOUS  &  PARASITIC  DISEASES,7242,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6664.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6058.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6058.47,6664.32,
OTHER  INFECTIOUS  &  PARASITIC  DISEASES,7243,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11948.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10862.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10862.09,11948.3,
OTHER  INFECTIOUS  &  PARASITIC  DISEASES,7244,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27666.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25151.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25151.74,27666.91,
1  MENTAL  ILLNESS  DIAGNOSIS  W  O.R.  PROCEDURE,7401,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12862.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11693.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11693.16,12862.48,
2  MENTAL  ILLNESS  DIAGNOSIS  W  O.R.  PROCEDURE,7402,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13658.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12416.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12416.68,13658.35,
3  MENTAL  ILLNESS  DIAGNOSIS  W  O.R.  PROCEDURE,7403,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25131.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22847.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22847.09,25131.8,
4   MENTAL  ILLNESS  DIAGNOSIS  W  O.R.  PROCEDURE,7404,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56735.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51577.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51577.7,56735.47,
1  SCHIZOPHRENIA,7501,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4369.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3972.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3972.53,4369.78,
2  SCHIZOPHRENIA,7502,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4802.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4365.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4365.49,4802.04,
3 SCHIZOPHRENIA,7503,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9194.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8358.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8358.82,9194.7,
4 SCHIZOPHRENIA,7504,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24287.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22079.83,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22079.83,24287.81,
MAJOR  DEPRESSIVE  DISORDERS  &  OTHER/UNSPECIFIED  PSYCHOSES,7511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3366.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3060.43,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3060.43,3366.47,
2  MAJOR  DEPRESSIVE  DISORDERS  &  OTHER/UNSPECIFIED  PSYCHOSES,7512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4069.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3699.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3699.33,4069.26,
3  MAJOR  DEPRESSIVE  DISORDERS  &  OTHER/UNSPECIFIED  PSYCHOSES,7513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8230.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7482.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7482.56,8230.82,
4   MAJOR  DEPRESSIVE  DISORDERS  &  OTHER/UNSPECIFIED  PSYCHOSES,7514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15435.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14032.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14032.23,15435.45,
1  DISORDERS  OF  PERSONALITY  &  IMPULSE  CONTROL,7521,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3419.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3108.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3108.47,3419.32,
2  DISORDERS  OF  PERSONALITY  &  IMPULSE  CONTROL,7522,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3756.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3414.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3414.66,3756.13,
3  DISORDERS  OF  PERSONALITY  &  IMPULSE  CONTROL,7523,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8177.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7434.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7434.52,8177.97,
4  DISORDERS  OF  PERSONALITY  &  IMPULSE  CONTROL,7524,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37922.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34475,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34475,37922.5,
1  BIPOLAR  DISORDERS,7531,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3351.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3046.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3046.8,3351.48,
2  BIPOLAR  DISORDERS,7532,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3941.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3583.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3583.17,3941.49,
BIPOLAR  DISORDERS,7533,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7350.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6682.32,7350.55,
4 BIPOLAR  DISORDERS,7534,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17527.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15933.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15933.88,17527.27,
DEPRESSION  EXCEPT  MAJOR  DEPRESSIVE  DISORDER,7541,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2991.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2719.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2719.82,2991.8,
2  DEPRESSION  EXCEPT  MAJOR  DEPRESSIVE  DISORDER,7542,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3607.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3279.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3279.85,3607.84,
3  DEPRESSION  EXCEPT  MAJOR  DEPRESSIVE  DISORDER,7543,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6264.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5694.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5694.92,6264.41,
4  DEPRESSION  EXCEPT  MAJOR  DEPRESSIVE  DISORDER,7544,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16002.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14547.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14547.79,16002.57,
1  ADJUSTMENT  DISORDERS  &  NEUROSES  EXCEPT  DEPRESSIVE  DIAGNOSES,7551,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2927.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2661.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2661.74,2927.91,
2  ADJUSTMENT  DISORDERS  &  NEUROSES  EXCEPT  DEPRESSIVE  DIAGNOSES,7552,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4632.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4211.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4211.32,4632.45,
3  ADJUSTMENT  DISORDERS  &  NEUROSES  EXCEPT  DEPRESSIVE  DIAGNOSES,7553,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6447.41,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5861.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5861.28,6447.41,
4   ADJUSTMENT  DISORDERS  &  NEUROSES  EXCEPT  DEPRESSIVE  DIAGNOSES,7554,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11174.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10158.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10158.65,11174.52,
1  ACUTE  ANXIETY  &  DELIRIUM  STATES,7561,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4569.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4153.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4153.95,4569.35,
2  ACUTE  ANXIETY  &  DELIRIUM  STATES,7562,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5501.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5001.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5001.52,5501.67,
3  ACUTE  ANXIETY  &  DELIRIUM  STATES,7563,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6325.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5750.14,6325.15,
4   ACUTE  ANXIETY  &  DELIRIUM  STATES,7564,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14746.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13405.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13405.51,14746.06,
ORGANIC  MENTAL  HEALTH  DISTURBANCES,7571,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4503.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4093.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4093.72,4503.09,
ORGANIC  MENTAL  HEALTH  DISTURBANCES,7572,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6071.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5519.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5519.96,6071.96,
ORGANIC  MENTAL  HEALTH  DISTURBANCES,7573,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12402.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11275.11,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11275.11,12402.62,
ORGANIC  MENTAL  HEALTH  DISTURBANCES,7574,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31629.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28754.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28754.27,31629.7,
1  BEHAVIORAL  DISORDERS,7581,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4154.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3776.78,4154.46,
2  BEHAVIORAL  DISORDERS,7582,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5507.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5006.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5006.54,5507.19,
3  BEHAVIORAL  DISORDERS,7583,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8648.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7861.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7861.89,8648.08,
4  BEHAVIORAL  DISORDERS,7584,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13297.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12088.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12088.26,13297.09,
1  EATING  DISORDERS,7591,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7691.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6992.09,7691.3,
2  EATING  DISORDERS,7592,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12040.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10945.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10945.98,12040.58,
EATING  DISORDERS,7593,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18543.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16858.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16858.16,18543.98,
4 EATING  DISORDERS,7594,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30711.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27919.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27919.6,30711.56,
OTHER  MENTAL  HEALTH  DISORDERS,7601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4796.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4360.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4360.47,4796.52,
OTHER  MENTAL  HEALTH  DISORDERS,7602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8006.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7278.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7278.92,8006.81,
OTHER  MENTAL  HEALTH  DISORDERS,7603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12826.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11660.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11660.18,12826.2,
OTHER  MENTAL  HEALTH  DISORDERS,7604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23904.47,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21731.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21731.34,23904.47,
"1  DRUG  &  ALCOHOL  ABUSE  OR  DEPENDENCE,  LEFT  AGAINST  MEDICAL  ADV",7701,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1926.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1751.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1751.79,1926.97,
"2  DRUG  &  ALCOHOL  ABUSE  OR  DEPENDENCE,  LEFT  AGAINST  MEDICAL  ADV",7702,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3021,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2746.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2746.36,3021,
"3  DRUG  &  ALCOHOL  ABUSE  OR  DEPENDENCE,  LEFT  AGAINST  MEDICAL  ADV",7703,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5542.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5038.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5038.81,5542.69,
"4  DRUG  &  ALCOHOL  ABUSE  OR  DEPENDENCE,  LEFT  AGAINST  MEDICAL  ADV",7704,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12152.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11047.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11047.81,12152.59,
OPIOID  ABUSE  &  DEPENDENCE,7731,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2409.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2190.63,2409.69,
OPIOID  ABUSE  &  DEPENDENCE,7732,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3521.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3200.97,3521.07,
OPIOID  ABUSE  &  DEPENDENCE,7733,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7007.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6370.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6370.4,7007.44,
OPIOID  ABUSE  &  DEPENDENCE,7734,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18099.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16453.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16453.75,18099.13,
COCAINE  ABUSE  &  DEPENDENCE,7741,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3177.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2888.33,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2888.33,3177.16,
COCAINE  ABUSE  &  DEPENDENCE,7742,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3529.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3208.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3208.86,3529.75,
COCAINE  ABUSE  &  DEPENDENCE,7743,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6317.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5742.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5742.97,6317.27,
COCAINE  ABUSE  &  DEPENDENCE,7744,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18275.03,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16613.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16613.66,18275.03,
1  ALCOHOL  ABUSE  &  DEPENDENCE,7751,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3286.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2988.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2988.01,3286.81,
2  ALCOHOL  ABUSE  &  DEPENDENCE,7752,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4680.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4255.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4255.06,4680.57,
3  ALCOHOL  ABUSE  &  DEPENDENCE,7753,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8029.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7299.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7299.71,8029.68,
ALCOHOL  ABUSE  &  DEPENDENCE,7754,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20793.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18903.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18903.24,20793.56,
OTHER  DRUG  ABUSE  &  DEPENDENCE,7761,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4253.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3867.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3867.13,4253.84,
OTHER  DRUG  ABUSE  &  DEPENDENCE,7762,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5075.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4614.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4614.31,5075.74,
OTHER  DRUG  ABUSE  &  DEPENDENCE,7763,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8726.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7933.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7933.6,8726.96,
OTHER  DRUG  ABUSE  8c  DEPENDENCE,7764,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13746.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12496.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12496.99,13746.69,
"1  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREATMEN""",7921,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14159.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12872.02,14159.22,
2  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREATMEN-,7922,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16358.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14871.19,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14871.19,16358.31,
3  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREATMENI,7923,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25124.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22840.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22840.64,25124.7,
4  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREATMEN,7924,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51837.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47124.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47124.73,51837.2,
1  MODERATELY  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  I,7931,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8543.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7767.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7767.24,8543.96,
2  MODERATELY  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS,7932,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12087.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10989.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10989.01,12087.91,
3  MODERATELY  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS,7933,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19303.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17548.71,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17548.71,19303.58,
4   MODERATELY  EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS,7934,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38193.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34721.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34721.67,38193.84,
1  NON-EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREA1,7941,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7315.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6650.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6650.05,7315.06,
2  NON-EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREA1,7942,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10203.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9275.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9275.94,10203.53,
NON-EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREA1,7943,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15743.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14312.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14312.6,15743.86,
NON-EXTENSIVE  OR  PROCEDURES  FOR  OTHER  COMPLICATIONS  OF  TREAll,7944,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32130.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29209.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29209.6,32130.56,
HEMORRHAGE  OR  HEMATOMA  DUE  TO  COMPLICATION,8101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4864.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4422.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4422.13,4864.34,
2  HEMORRHAGE  OR  HEMATOMA  DUE  TO  COMPLICATION,8102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6629.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6026.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6026.92,6629.61,
3  HEMORRHAGE  OR  HEMATOMA  DUE  TO  COMPLICATION,8103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11186.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10169.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10169.4,11186.34,
4  HEMORRHAGE  OR  HEMATOMA  DUE  TO  COMPLICATION,8104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20235.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18395.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18395.56,20235.12,
1  ALLERGIC  REACTIONS,8111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3084.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2804.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2804.44,3084.88,
2  ALLERGIC  REACTIONS,8112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4593.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4175.46,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4175.46,4593.01,
3  ALLERGIC  REACTIONS,8113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8806.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8006.02,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8006.02,8806.62,
4   ALLERGIC  REACTIONS,8114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19078.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17344.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17344.34,19078.77,
1  POISONING  OF  MEDICINAL  AGENTS,8121,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3521.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3201.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3201.69,3521.86,
2  POISONING  OF  MEDICINAL  AGENTS,8122,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5005.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4550.49,5005.54,
POISONING  OF  MEDICINAL  AGENTS,8123,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7326.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6660.81,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6660.81,7326.89,
POISONING  OF  MEDICINAL  AGENTS,8124,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13790.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12537.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12537.15,13790.87,
OTHER  COMPLICATIONS  OF  TREATMENT,8131,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5274.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4795.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4795.01,5274.51,
OTHER  COMPLICATIONS  OF  TREATMENT,8132,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6669.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6062.78,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6062.78,6669.06,
OTHER  COMPLICATIONS  OF  TREATMENT,8133,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10057.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9143.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9143.28,10057.61,
OTHER  COMPLICATIONS  OF  TREATMENT,8134,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20162.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18329.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18329.59,20162.55,
"OTHER  INJURY,  POISONING  &  TOXIC  EFFECT  DIAGNOSES",8151,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4082.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3711.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3711.52,4082.67,
"OTHER  INJURY,  POISONING  8c  TOXIC  EFFECT  DIAGNOSES",8152,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5744.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5222.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5222.38,5744.62,
"OTHER  INJURY,  POISONING  &  TOXIC  EFFECT  DIAGNOSES",8153,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10442.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9493.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9493.2,10442.52,
"OTHER  INJURY,  POISONING  8c  TOXIC  EFFECT  DIAGNOSES",8154,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28980.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26345.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26345.65,28980.22,
TOXIC  EFFECTS  OF  NON-MEDICINAL  SUBSTANCES,8161,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5022.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4566.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4566.26,5022.89,
TOXIC  EFFECTS  OF  NON-MEDICINAL  SUBSTANCES,8162,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5580.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5073.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5073.22,5580.54,
3  TOXIC  EFFECTS  OF  NON-MEDICINAL  SUBSTANCES,8163,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6706.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6096.48,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6096.48,6706.13,
4   TOXIC  EFFECTS  OF  NON-MEDICINAL  SUBSTANCES,8164,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13233.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12030.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12030.9,13233.99,
1  INTENTIONAL  SELF-HARM  &  ATTEMPTED  SUICIDE,8171,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3452.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3138.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3138.59,3452.45,
2  INTENTIONAL  SELF-HARM  &  ATTEMPTED  SUICIDE,8172,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4483.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4075.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4075.79,4483.37,
3  INTENTIONAL  SELF-HARM  &  ATTEMPTED  SUICIDE,8173,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7619.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6926.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6926.84,7619.52,
4   INTENTIONAL  SELF-HARM  &  ATTEMPTED  SUICIDE,8174,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15446.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14042.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14042.26,15446.49,
1  EXTENSIVE  3RD  DEGREE  BURNS  W  SKIN  GRAFT,8411,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42099.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38271.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38271.86,42099.05,
2  EXTENSIVE  3RD  DEGREE  BURNS  W  SKIN  GRAFT,8412,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,42825.49,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38932.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38932.26,42825.49,
3  EXTENSIVE  3RD  DEGREE  BURNS  W  SKIN  GRAFT,8413,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,65901.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59910.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,59910.7,65901.77,
4  EXTENSIVE  3RD  DEGREE  BURNS  W  SKIN  GRAFT,8414,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,139344.18,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126676.53,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,126676.53,139344.18,
1  BURNS  W  SKIN  GRAFT  EXCEPT  EXTENSIVE  3RD  DEGREE  BURNS,8421,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13282.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12074.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12074.64,13282.1,
2  BURNS  W  SKIN  GRAFT  EXCEPT  EXTENSIVE  3RD  DEGREE  BURNS,8422,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20701.27,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18819.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18819.34,20701.27,
BURNS  W  SKIN  GRAFT  EXCEPT  EXTENSIVE  3RD  DEGREE  BURNS,8423,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39362,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35783.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35783.64,39362,
BURNS  W  SKIN  GRAFT  EXCEPT  EXTENSIVE  3RD  DEGREE  BURNS,8424,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,86739.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78854.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,78854.09,86739.5,
EXTENSIVE  3RD  DEGREE  BURNS  W/O  SKIN  GRAFT,8431,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5937.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5398.06,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5398.06,5937.87,
2  EXTENSIVE  3RD  DEGREE  BURNS  W/O  SKIN  GRAFT,8432,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7281.14,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6619.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6619.22,7281.14,
3  EXTENSIVE  3RD  DEGREE  BURNS  W/O  SKIN  GRAFT,8433,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10750.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9773.58,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9773.58,10750.94,
4   EXTENSIVE  3RD  DEGREE  BURNS  W/O  SKIN  GRAFT,8434,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25772.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23429.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23429.35,25772.29,
1  PARTIAL  THICKNESS  BURNS  W/O  SKIN  GRAFT,8441,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3793.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3448.36,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3448.36,3793.2,
2  PARTIAL  THICKNESS  BURNS  W/O  SKIN  GRAFT,8442,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6064.86,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5513.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5513.51,6064.86,
3  PARTIAL  THICKNESS  BURNS  W/O  SKIN  GRAFT,8443,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10100.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9182,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9182,10100.2,
4  PARTIAL  THICKNESS  BURNS  W/O  SKIN  GRAFT,8444,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24340.67,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22127.88,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22127.88,24340.67,
"1  PROCEDURE  W  DIAG  OF  REHAB,  AFTERCARE  OR  0TH  CONTACT  W  HEALTF",8501,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16568.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15062.65,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15062.65,16568.92,
"2  PROCEDURE  W  DIAG  OF  REHAB,  AFTERCARE  OR  0TH  CONTACT  W  HEALTF",8502,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22099.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20090.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20090.7,22099.77,
"PROCEDURE  W  DIAG  OF  REHAB,  AFTERCARE  OR  0TH  CONTACT  W  HEALTF",8503,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29186.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26532.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26532.8,29186.08,
"PROCEDURE  W  DIAG  OF  REHAB,  AFTERCARE  OR  0TH  CONTACT  W  HEALTH",8504,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68879.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62617.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62617.61,68879.37,
REHABILITATION,8601,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4852.52,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4411.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4411.38,4852.52,
2  REHABILITATION,8602,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5239.01,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4762.74,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4762.74,5239.01,
3  REHABILITATION,8603,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8769.55,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7972.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7972.32,8769.55,
4 REHABILITATION,8604,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13624.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12385.85,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12385.85,13624.44,
"1  SIGNS,  SYMPTOMS  &  OTHER  FACTORS  INFLUENCING  HEALTH  STATUS",8611,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4675.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4250.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4250.76,4675.84,
"2  SIGNS,  SYMPTOMS  &  OTHER  FACTORS  INFLUENCING  HEALTH  STATUS",8612,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5648.38,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5134.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5134.89,5648.38,
"3  SIGNS,  SYMPTOMS  &  OTHER  FACTORS  INFLUENCING  HEALTH  STATUS",8613,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7964.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.2,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7240.2,7964.22,
"4   SIGNS,  SYMPTOMS  &  OTHER  FACTORS  INFLUENCING  HEALTH  STATUS",8614,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17301.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15728.8,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15728.8,17301.68,
1  OTHER  AFTERCARE  &  CONVALESCENCE,8621,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4971.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4519.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4519.64,4971.6,
2  OTHER  AFTERCARE  &  CONVALESCENCE,8622,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6233.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5666.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5666.96,6233.66,
3  OTHER  AFTERCARE  &  CONVALESCENCE,8623,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10430.7,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9482.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9482.45,10430.7,
4   OTHER  AFTERCARE  &  CONVALESCENCE,8624,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18136.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16488.16,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16488.16,18136.98,
1  NEONATAL  AFTERCARE,8631,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7951.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7228.72,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7228.72,7951.59,
2  NEONATAL  AFTERCARE,8632,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19630.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17845.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17845.57,19630.13,
3  NEONATAL  AFTERCARE,8633,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,45124.76,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41022.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41022.51,45124.76,
4 NEONATAL  AFTERCARE,8634,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,94596.45,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85996.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,85996.77,94596.45,
1  HIV  W  MULTIPLE  MAJOR  HIV  RELATED  CONDITIONS,8901,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7882.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7166.34,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7166.34,7882.97,
2  HIV  W  MULTIPLE  MAJOR  HIV  RELATED  CONDITIONS,8902,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8521.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7746.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7746.44,8521.08,
3  HIV  W  MULTIPLE  MAJOR  HIV  RELATED  CONDITIONS,8903,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11704.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10640.51,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10640.51,11704.56,
HIV  W  MULTIPLE  MAJOR  HIV  RELATED  CONDITIONS,8904,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25326.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23024.21,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23024.21,25326.63,
HIV  W  MAJOR  HIV  RELATED  CONDITION,8921,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5638.13,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5125.57,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5125.57,5638.13,
HIV  W  MAJOR  HIV  RELATED  CONDITION,8922,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6924.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6295.1,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6295.1,6924.61,
HIV  W  MAJOR  HIV  RELATED  CONDITION,8923,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9155.25,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8322.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8322.95,9155.25,
HIV  W  MAJOR  HIV  RELATED  CONDITION,8924,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15765.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14332.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14332.68,15765.95,
HIV  W  MULTIPLE  SIGNIFICANT  HIV  RELATED  CONDITIONS,8931,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4892.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4447.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4447.95,4892.75,
HIV  W  MULTIPLE  SIGNIFICANT  HIV  RELATED  CONDITIONS,8932,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6982.99,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6348.17,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6348.17,6982.99,
HIV  W  MULTIPLE  SIGNIFICANT  HIV  RELATED  CONDITIONS,8933,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9321.69,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.26,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8474.26,9321.69,
HIV  W  MULTIPLE  SIGNIFICANT  HIV  RELATED  CONDITIONS,8934,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16568.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15061.93,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15061.93,16568.12,
HIV  W  ONE  SIGNIF  HIV  COND  OR  W/O  SIGNIF  RELATED  COND,8941,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5332.09,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.35,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.35,5332.09,
HIV  W  ONE  SIGNIF  HIV  COND  OR  W/O  SIGNIF  RELATED  COND,8942,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6225.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5659.79,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5659.79,6225.77,
HIV  W  ONE  SIGNIF  HIV  COND  OR  W/O  SIGNIF  RELATED  COND,8943,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8115.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7377.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7377.87,8115.66,
4   HIV  W  ONE  SIGNIF  HIV  COND  OR  W/O  SIGNIF  RELATED  COND,8944,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11162.68,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10147.89,11162.68,
1  CRANIOTOMY  FOR  MULTIPLE  SIGNIFICANT  TRAUMA,9101,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24384.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22167.32,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22167.32,24384.05,
2  CRANIOTOMY  FOR  MULTIPLE  SIGNIFICANT  TRAUMA,9102,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26386.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23987.94,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,23987.94,26386.73,
3  CRANIOTOMY  FOR  MULTIPLE  SIGNIFICANT  TRAUMA,9103,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35986.07,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32714.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,32714.61,35986.07,
4   CRANIOTOMY  FOR  MULTIPLE  SIGNIFICANT  TRAUMA,9104,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66725.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60659.31,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,60659.31,66725.24,
1  EXTENSIVE  ABDOMINAL/THORACIC  PROCEDURES  FOR  MULT  SIGNIFICAN1,9111,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17204.66,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15640.6,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15640.6,17204.66,
2  EXTENSIVE  ABDOMINAL/THORACIC  PROCEDURES  FOR  MULT  SIGNIFICAN1,9112,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19215.24,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17468.4,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17468.4,19215.24,
EXTENSIVE  ABDOMINAL/THORACIC  PROCEDURES  FOR  MULT  SIGNIFICAN1,9113,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24400.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22182.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22182.37,24400.61,
EXTENSIVE  ABDOMINAL/THORACIC  PROCEDURES  FOR  MULT  SIGNIFICAN1I,9114,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57181.12,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51982.84,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51982.84,57181.12,
1  MUSCULOSKELETAL  &  OTHER  PROCEDURES  FOR  MULTIPLE  SIGNIFICANT,9121,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15806.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14369.96,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14369.96,15806.96,
2  MUSCULOSKELETAL  &  OTHER  PROCEDURES  FOR  MULTIPLE  SIGNIFICANT,9122,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17405,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15822.73,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15822.73,17405,
3  MUSCULOSKELETAL  &  OTHER  PROCEDURES  FOR  MULTIPLE  SIGNIFICANT,9123,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28088.91,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25535.37,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25535.37,28088.91,
4   MUSCULOSKELETAL  &  OTHER  PROCEDURES  FOR  MULTIPLE  SIGNIFICANT,9124,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,55623.3,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50566.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,50566.64,55623.3,
1  MULTIPLE  SIGNIFICANT  TRAUMA  W/O  O.R.  PROCEDURE,9301,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6788.95,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6171.77,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6171.77,6788.95,
2  MULTIPLE  SIGNIFICANT  TRAUMA  W/O  O.R.  PROCEDURE,9302,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8554.22,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7776.56,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7776.56,8554.22,
3  MULTIPLE  SIGNIFICANT  TRAUMA  W/O  O.R.  PROCEDURE,9303,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13679.64,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12436.04,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12436.04,13679.64,
MULTIPLE  SIGNIFICANT  TRAUMA  W/O  O.R.  PROCEDURE,9304,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29720.87,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27018.97,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27018.97,29720.87,
EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9501,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13318.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12107.63,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12107.63,13318.39,
2  EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9502,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18038.39,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16398.54,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16398.54,18038.39,
EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9503,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24458.98,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22235.44,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22235.44,24458.98,
EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9504,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,51573.75,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46885.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,46885.23,51573.75,
MODERATELY  EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNCI,9511,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10160.15,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9236.5,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9236.5,10160.15,
2  MODERATELY  EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNC,9512,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14538.61,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13216.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13216.92,14538.61,
3  MODERATELY  EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNC,9513,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21785.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19804.59,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19804.59,21785.05,
4   MODERATELY  EXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNC,9514,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43290.08,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39354.62,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,39354.62,43290.08,
NONEXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9521,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8622.05,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7838.23,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7838.23,8622.05,
NONEXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9522,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12258.28,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11143.89,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11143.89,12258.28,
NONEXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9523,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19701.9,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17910.82,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17910.82,19701.9,
NONEXTENSIVE  PROCEDURE  UNRELATED  TO  PRINCIPAL  DIAGNOSIS,9524,APR-DRG,,,,,Inpatient,,,,,,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41531.92,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37756.29,110,APR-DRG,,case rate,110% Medicaid APR-DRG,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37756.29,41531.92,